Health – Page 86 – artdiamondblog.com

“The Resistance from the Priesthood of Medicine Is at Its Height”

(p. 77) In December 2010 in Milwaukee, Wisconsin, Nicholas Volker, a five-year-old boy with a gastrointestinal condition that had not previously been seen, who had undergone over a hundred surgical operations and was almost constantly hospitalized and intermittently septic, was virtually on death’s door. But when his DNA sequence was determined, his doctors found the culprit mutation. That discovery led to the proper treatment, and now Nicholas is healthy and thriving. Even though this was only the first clearly documented case of the life-saving power of human genomics in medicine, (p. 78) few could now deny that the field was going to have a vital role in the future of medicine. Some would argue that the treatment led to an even bigger breakthrough: health insurance coverage of sequencing costs for select cases.
It took the better part of a decade from the completion of the first draft of the Human Genome Project for genomics to reach the clinic in such a dramatic way. To make treatment like Volker’s common will likely take more time still. Even if that’s the ultimate prize, the creative destruction of medicine still has various other, less comprehensive, genomic tools for us to use, based on investigations of things like single-nucleotide polymorphisms, the exome, and more. The material can be a bit heady, but it’s worth pushing through: these tools could effect not just dramatic corrections of faulty genes but a better, more scientific understanding of disease susceptibility and what drugs to take. Moreover, as they empower patients and democratize medicine, they make medical knowledge available to all and deep knowledge of ourselves available to each of us. Nevertheless, at this level, perhaps more than anywhere else in this ongoing medical revolution, the resistance from the priesthood of medicine is at its height. The fight might be tougher than the material, but in neither case can we afford to give up.

Source:
Topol, Eric. The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care. New York: Basic Books, 2012.

Health Inefficiencies Free-Ride on “Home Run Innovations”

The article quoted below is a useful antidote to those economists who sometimes seem to argue that health gains fully justify the rise in health costs.

(p. 645) In the United States, health care technology has contributed to rising survival rates, yet health care spending relative to GDP has also grown more rapidly than in any other country. We develop a model of patient demand and supplier behavior to explain these parallel trends in technology growth and cost growth. We show that health care productivity depends on the heterogeneity of treatment effects across patients, the shape of the health production function, and the cost structure of procedures such as MRIs with high fixed costs and low marginal costs. The model implies a typology of medical technology productivity: (I) highly cost-effective “home run” innovations with little chance of overuse, such as anti-retroviral therapy for HIV, (II) treatments highly effective for some but not for all (e.g., stents), and (III) “gray area” treatments with uncertain clinical value such as ICU days among chronically ill patients. Not surprisingly, countries adopting Category I and effective Category II treatments gain the greatest health improvements, while countries adopting ineffective Category II and Category III treatments experience the most rapid cost growth. Ultimately, economic and political resistance in the United States to ever-rising tax rates will likely slow cost growth, with uncertain effects on technology growth.

Source of abstract:
Chandra, Amitabh, and Jonathan Skinner. “Technology Growth and Expenditure Growth in Health Care.” Journal of Economic Literature 50, no. 3 (Sept. 2012): 645-80.

When Bibliometrics Are a Matter of Life and Death

(p. 51) . . . it is essential, if at all possible, to have a go-to physician expert and authority when one has a newly diagnosed, serious condition, such as a brain or, neurologic conditions like multiple sclerosis and Parkinson’s disease, heart valve abnormality. How do you find that individual doctor?
In order to leverage the Internet and gain access to state-of-the-art expertise, you need to identify the physician who conducts the leading research in the field. Let’s pick pancreatic cancer as an example of a serious condition that often proves to be rapidly fatal. The first step is to go to Google Scholar and find the top-cited articles for that condition by typing in “pancreatic cancer.” They are generally listed in order by descending number of citations. Look for the senior, last author of the articles. The last author of the top-listed paper in the Journal of Clinical Oncology from 1997 is Daniel D. Von Hoff, with over 2,000 citations (“cited by … ” appears at the end of each hit). Now you may have identified an expert. Enter “Daniel Von Hoff” into PubMed (www.ncbi.nlm.nih.gov/sites/pubmed) to see how many papers he has published: 567. Most are related to pancreatic cancer or cancer research.
(p. 52) Now go back to Google Scholar and enter his name, and you’ll see over 24,000 hits–this number includes papers that cite his work. There are some problems with these websites, since getting citations by other peer-reviewed publications takes time; if a breakthrough paper is published, it will be years to accumulate hundreds, if not thousands, of citations. Thus, the lag time or incubation phase of citations may result in missing a rising star. If it is a common name, there may be admixture of citations of different researchers with the same name, albeit different topics, so it is useful to enter in all elements including the middle initial and to scan the topic list to alleviate that problem. For perspective, a paper that has been cited 1,000 times by others is rare and would be considered a classic. In this example, the top paper by Von Hoff in 1997 is a long time ago, and he is no longer at the University of Texas, San Antonio-he moved to Phoenix, Arizona. How would you find that out? Look for Daniel D. Von Hoff using a search engine such as Google or Bing, and look up his profile on Wikipedia. Without any help from any doctor, you will have found the country’s leading authority on pancreatic cancer. And you will have also identified some backups at Johns Hopkins using the same methodology.

Source:
Topol, Eric. The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care. New York: Basic Books, 2012.
(Note: initial ellipsis added; parenthetical ellipsis in original.)

FDA and ACS Wrongly Endorsed Sunscreen with Retinyl Palmitate

Some consumers let their guard down on medical issues, assuming that the government Food and Drug Administration (FDA), and large incumbent bureaucratic non-profits, like the American Cancer Society (ACS), will protect them—it ain’t necessarily so. Caveat emptor should remain the rule for consumers.

(p. 39) Of note, one of the reasons for the lack of updating the rules and acknowledging UVA rays has been heavy pressure from sunscreen manufacturers, which include Johnson and Johnson (Neutrogena), Merck-Schering Plough (Coppertone), Proctor and Gamble (Olay), and L’Oreal. Interestingly, in Europe products that provide solid UVA protection have been available for years. The concerns run even deeper because many of the products (41 percent in the United States) contain a form of vitamin A known as retinyl palmitate, which has been associated with increased likelihood of skin cancer. There are, however, no randomized studies, but biological plausibility and the observational findings of a rising incidence of basal cell (p. 40) carcinoma and melanoma, despite the widespread use of sunscreens. In mid-2011, the FDA finally unveiled some new rules about sunscreen claims.

This issue really hit home when my wife brought out a tube of Neutrogena Ultra Sheer Dry-Tough SPF 30 Sunblock. It claims “Broad Spectrum UVNUVB Protection” despite repeatedly failing UVA tests. But the real eye-opener is to find the American Cancer Society logo on the front of the tube with the message “Help Block Out Skin Cancer.” Now what is the American Cancer Society logo doing on the tube of Neutrogena? The fine print on the bottom reads: “The American Cancer Society (ACS) and Neutrogena, working together to help prevent skin cancer, support the use of sunscreen. The ACS does not endorse any specific product. Neutrogena pays a royalty to the ACS for the use of its logo.”

Source:
Topol, Eric. The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care. New York: Basic Books, 2012.

The Kairos of Creative Destruction in Medicine

Wikipedia tells us that “Kairos” “is an ancient Greek word meaning the right or opportune moment (the supreme moment).”

(p. x) With a medical profession that is particularly incapable of making a transition to practicing individualized medicine, despite a new array of powerful tools, isn’t it time for consumers to drive this capability? The median of human beings is not the message. The revolution in technology that is based on the primacy of individuals mandates a revolution by consumers in order for new medicine to take hold.

Now you’ve probably thought “creative destruction” is a pretty harsh term to apply to medicine. But we desperately need medicine to he Schumpetered, to be radically transformed. We need the digital world to invade (p. xi) the medical cocoon and to exploit the newfound and exciting technological capabilities of digitizing human beings. Some will consider this to be a unique, opportune moment in medicine, a veritable once-in-a-lifetime Kairos.
This book is intended to arm consumers to move us forward.

Source:
Topol, Eric. The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care. New York: Basic Books, 2012.
(Note: italics in original.)

Instead of Fixing “Inadequate Schools,” Adderall Is Prescribed to “Struggling” Students

“Amanda Rocafort and her son Quintn in Woodstock, Ga. Quintn takes the medication Risperdal.” Source of caption and photo: online version of the NYT article quoted and cited below.

(p. A1) CANTON, Ga. — When Dr. Michael Anderson hears about his low-income patients struggling in elementary school, he usually gives them a taste of some powerful medicine: Adderall.

The pills boost focus and impulse control in children with attention deficit hyperactivity disorder. Although A.D.H.D is the diagnosis Dr. Anderson makes, he calls the disorder “made up” and “an excuse” to prescribe the pills to treat what he considers the children’s true ill — poor academic performance in inadequate schools.

For the full story, see:
ALAN SCHWARZ. “Attention Disorder or Not, Pills to Help in School.” The New York Times (Tues., October 9, 2012): A1 & A18.

Openness to Creative Destruction Will Speed Health Care Progress

Source of book image: http://si.wsj.net/public/resources/images/OB-RQ412_bkrvme_DV_20120202132402.jpg

Eric Topol has bucked the medical establishment before. In entries on August 20, 2006 and on December 26, 2006 on this blog, he was quoted as arguing that stents were being overused. Now he argues that the medical establishment is slowing progress that could reduce disability and extend life. He advocates the sequencing of each of our genomes and a medical revolution that will fine-tune treatment to our genomic differences.
Many agree with Topol’s view of the future of medicine, but many medical schools are neglecting teaching future doctors about the therapeutic implications of individual genomics.
Topol calls for the creative destruction of medical education and other medical institutions.
The early part of the book is weak because it discusses subjects on which Topol is not an expert—such as the history and applications of information technology. In these sections, he too often tediously explains the obvious and widely known. Sometimes in this section of the book, he is just wrong, as when (p. 14) he claims that Werner Sombart originated “creative destruction.”
After the early chapters the book comes into its own when Topol discusses medical advances and challenges. While his early prose may be aimed too low, his later prose may be aimed too high—but it is better to be talked up to than down to, and the best of the later chapters contain some fascinating descriptions of what is happening on the frontiers of medicine, and what could be happening if we change policies and institutions to make medicine more open to creative destruction.
In the following few weeks, I will be quoting several of the more important or thought-provoking passages.

Book discussed:
Topol, Eric. The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care. New York: Basic Books, 2012.

Garfield’s Doctors “Basically Tortured Him to Death”

Source of book image: http://rsirving.files.wordpress.com/2012/04/destinyrepublic.jpeg

(p. 15) Had Garfield been left where he lay, he might well have survived; the bullet failed to hit his spine or penetrate any vital organs. Instead, he was given over to the care of doctors, who basically tortured him to death over the next 11 weeks. Two of them repeatedly probed his wound with their unsterilized fingers and instruments before having him carted back to the White House on a hay-and-horsehair mattress.

There, control of the president was seized by a quack with the incredible name of Dr. Doctor Willard Bliss. Dr. Doctor Bliss insisted on stuffing Garfield with heavy meals and alcohol, which brought on protracted waves of vomiting. He and his assistants went on probing the wound several times a day, causing infections that burrowed enormous tunnels of pus throughout the president’s body.
Garfield’s medical “care” is one of the most fascinating, if appalling, parts of Millard’s narrative. Joseph Lister had been demonstrating for years how his theories on the prevention of infection could save lives and limbs, but American doctors largely ignored his advice, not wanting to “go to all the trouble” of washing hands and instruments, Millard writes, enamored of the macho trappings of their profession, the pus and blood and what they referred to fondly as the “good old surgical stink” of the operating room.
Further undermining the president’s recovery was his sickroom in the White House — then a rotting, vermin-ridden structure with broken sewage pipes. Outside, Washington was a pestilential stink hole; besides the first lady, four White House servants and Guiteau himself had contracted malaria. Hoping to save Garfield from the same, Bliss fed him large doses of quinine, causing more intestinal cramping.
The people rallied around their president even as his doctors failed him. The great Western explorer and geologist John Wesley Powell helped design America’s first air-conditioning system to relieve Garfield’s agony. Alexander Graham Bell worked tirelessly to invent a device that could locate the bullet. (It failed when Dr. Bliss insisted he search only the wrong side of Garfield’s torso.) Two thousand people worked overnight to lay 3,200 feet of railroad track, so the president might be taken to a cottage on the Jersey Shore. When the engine couldn’t make the grade, hundreds of men stepped forward to push his train up the final hill.
The president endured everything with amazing fortitude and patience, even remarking near the end, when he learned a fund was being taken up for his family: “How kind and thoughtful! What a generous people!”
“General Garfield died from malpractice,” Guiteau claimed, defending himself at his spectacle of a trial. This was true, but not enough to save Guiteau from the gallows.

For the full review, see:
KEVIN BAKER. “Death of a President.” The New York Times Book Review (Sun., October 2, 2011): 14-15.
(Note: the online version of the review has the date September 30, 2011, and has the title “The Doctors Who Killed a President.”)

The full reference for the book under review, is:
Millard, Candice. Destiny of the Republic: A Tale of Madness, Medicine and the Murder of a President. New York: Doubleday, 2011.

People “Reward the Providers of Dangerously Misleading Information”

(p. 262) As Nassim Taleb has argued, inadequate appreciation of the uncertainty of the environment inevitably leads economic agents to take risks they should avoid. However, optimism is highly valued, socially and in the market; people and firms reward the providers of dangerously misleading information more than they reward truth tellers. One of the lessons of the financial crisis that led to the Great Recession is that there are periods in which competition, among experts and among organizations, creates powerful forces that favor a collective blindness to risk and uncertainty.
The social and economic pressures that favor overconfidence are not (p. 263) restricted to financial forecasting. Other professionals must deal with the fact that an expert worthy of the name is expected to display high confidence. Philip Tetlock observed that the most overconfident experts were the most likely to be invited to strut their stuff in news shows. Overconfidence also appears to be endemic in medicine. A study of patients who died in the ICU compared autopsy results with the diagnosis that physicians had provided while the patients were still alive. Physicians also reported their confidence. The result: “clinicians who were ‘completely certain’ of the diagnosis antemortem were wrong 40% of the time.” Here again, expert overconfidence is encouraged by their clients: “Generally, it is considered a weakness and a sign of vulnerability for clinicians to appear unsure. Confidence is valued over uncertainty and there is a prevailing censure against disclosing uncertainty to patients.” Experts who acknowledge the full extent of their ignorance may expect to be replaced by more confident competitors, who are better able to gain the trust of clients. An unbiased appreciation of uncertainty is a cornerstone of rationality–but it is not what people and organizations want. Extreme uncertainty is paralyzing under dangerous circumstances, and the admission that one is merely guessing is especially unacceptable when the stakes are high. Acting on pretended knowledge is often the preferred solution.

Source:
Kahneman, Daniel. Thinking, Fast and Slow. New York: Farrar, Straus and Giroux, 2011.

Environmental “Witch-Hunt” Kills “Golden Rice”

(p. C4) Vitamin A deficiency affects the immune system, leading to illness and frequently to blindness. It probably causes more deaths than malaria, HIV or tuberculosis, killing as many people every single day as the Fukushima tsunami. It can be solved by eating green vegetables and meat, but for many poor Asians, who can afford only rice, that remains an impossible dream. To deal with the problem, “biofortification” with genetically modified food plants is 1/10th as costly as dietary supplements.
“Golden rice”–with two extra genes to make beta-carotene, the raw material for vitamin A–was a technical triumph, identical to ordinary rice except in color. Painstaking negotiations led to companies waiving their patent rights so the plant could be grown and regrown free by anybody.
Yet today, 14 years later, it still has not been licensed to growers anywhere in the world. The reason is regulatory red tape deliberately imposed to appease the opponents of genetic modification, which Adrian Dubock, head of the golden rice project, describes as “a witch-hunt for suspected theoretical environmental problems…[because] many activist NGOs thought that genetically engineered crops should be opposed as part of their anti-globalization agenda.”
It is surprising to find that an effective solution to the problem consistently rated by experts as the poor world’s highest priority has been stubbornly opposed by so many pressure groups supposedly acting on behalf of the poor.

For the full commentary, see:
MATT RIDLEY. “MIND & MATTER; Red Tape Hobbles a Harvest of Life-Saving Rice.” The Wall Street Journal (Sat., May 18, 2012): C4.
(Note: ellipsis in original.)
(Note: the online version of the article has the date May 18, 2012.)

In Cancer Treatment “a Breakthrough Moment”?

(p. A1) CHICAGO–Medical science efforts to harness the power of the immune system against cancer are beginning to bear fruit after decades of frustration, opening up a hopeful new front in the long battle against the disease.
In studies being presented Saturday, researchers said two experimental drugs by Bristol-Myers Squibb Co. . . . significantly shrank tumors in some patients with advanced skin, lung and kidney cancers.
Especially promising was that the drugs worked against several types of cancer, researchers said of the early findings. Most of the patients whose tumors responded significantly to the treatment saw long-term results.
. . .
(p. A2) Taken together, the findings are provoking excitement among researchers and the drug industry that immunotherapy has finally arrived as a viable cancer-fighting strategy.
“Those of us in the field really see this as a breakthrough moment,” said Suzanne Topalian, a researcher at Johns Hopkins School of Medicine and lead author of one of the studies. Both are being presented by Hopkins researchers at the annual meeting of the American Society of Clinical Oncology and published online by the New England Journal of Medicine.

For the full story, see:
RON WINSLOW. “New Cancer Drugs Use Body’s Own Defenses.” The Wall Street Journal (Sat., June 2, 2012): A1-A2.
(Note: ellipses added.)
(Note: the online version of the story has the date June 1, 2012.)