GlassHospital

Demystifying Medicine One Month at a Time

Category: research (page 2 of 7)

The Science of Medicine

Last week I told you of my admiration for Dr. Mona Hanna-Attisha, the Michigan pediatrician and epidemiologist whose strong research and advocacy was able to finally bring a shining light to the problem of lead in the water supply of Flint.

Continuing with a theme, I now bring you the story of Dr. Adriana Melo of Campina Grande, Brazil.

03-zika-doctor-adriana-melo.w245.h368Dr. Melo is an OB-GYN who subspecializes in Maternal-Fetal Medicine (MFM), the branch of obstetrics that deals with high-risk pregnancies.

She lives and works in northeast Brazil, which is less populous and more economically challenged than the southern, more well-known parts of the country (including Rio de Janeiro and Sao Paulo).

Dr. Melo noted an uptick in the number of fetuses with small heads on ultrasound — which is the main tool used by MFM doctors to diagnose babies in utero.

How much of an uptick? A rough look at the statistics shows ONE HUNDRED times the ‘normal’ rate of babies born with microcephaly, the medical name for the condition.

Dr. Melo had a suspicion that the mothers giving birth to these babies all had a common trait: they’d all told her that they’d had the characteristic rash associated with the mosquito-borne Zika virus.

When she tested the mothers for evidence of the Zika virus in their blood, the tests were negative. Not deterred, she convinced public health authorities to test the amniotic fluid of mothers carrying microcephalic fetuses. And indeed a strong correlation was found between exposure to Zika and microcephaly.

It’s this story of a doctor in a somewhat out-of-the-way place using her clinical insight to ‘prove’ a correlation which I find inspiring.

Dr. Melo could have been content to merely diagnose and treat these poor mothers and babies, perhaps simply ‘reporting up’ her findings on the increase in microcephaly. Instead, she decided to push against the inertia of daily medical practice because what she was seeing really bothered her — and as a mother of young children herself, she felt the urge to get to the bottom of the new trend.

If you follow health news, you no doubt have heard a lot about the Zika virus in the last few weeks, including warnings from both the CDC and the World Health Organization. As is often the case with warnings from these organizations, a certain amount of panic ensues — such as women in Latin America feeling that they’re being told not to get pregnant, for example.

I want to make it very clear that though there is a STONG ASSOCIATION between the rise in cases of Zika in the tropics of the Western Hemisphere and a concurrent rise in babies born with microcephaly, we must remember: Correlation does not equal causation. The public health agencies issuing travel and birth control warnings, while sounding dire, are making best guesses for us all to minimize our chances of harm. But drowned out in the response is the fact that we don’t yet know for certain that Zika is the cause of microcephaly. That work is ongoing.

For example, many experts think something else may be the cause — perhaps the use of dangerous pesticides in Brazil (that are banned elsewhere). That also sounds plausible since pesticides are used to “control the mosquito vector.” It’s entirely possible that microcephaly is occurring because of a chemical effect.

For now, we must wait and hope that science can show us the true cause of the uptick in microcephaly.

I also think it’s important to remind ourselves of two things about Zika virus: We’ve known about it since the 1940s, when it was discovered in Africa — so though if feels new, it’s really not. Secondly, at least for non-pregnant people, it only appears to cause mild flu-like symptoms and be a self-limited illness (not more than a few days at most).

My advice: Better to save your anxiety for the never-ending Presidential race.

Game Changer.

Well, 2016 is off and running. Though the markets seem in peril due to China’s economic cooling, the health care arena in the U.S continues to burn like a hot stove.

For one thing, a now-unified Republican Congress passed the 62nd or so attempted repeal of ObamaCare, which the President unsurprisingly vetoed. The new year will likely decide the fate of the Affordable Care Act — and whether it continues its evolution and improvement in providing coverage to more Americans and helping control health care costs, or whether it is substantially rolled back.

Whatever your position on the law, here are some incontestable facts about it:

  • marmotsdhThe law has survived two (2) different Supreme Court challenges.
  • More than 20 million Americans previously without insurance coverage now have it.
  • The percentage of uninsured Americans is the lowest since the government began tracking the statistic in 1972. [Percentages were much higher in the early 1960s before the passage of Medicare and Medicaid in 1965.]
  • Millions more are eligible to gain insurance through the law’s mechanisms, provided those people elect to sign up rather than pay a tax penalty.

But here’s what I find really interesting:

More than just a coverage law, the Affordable Care Act is also a health care delivery law. Parts of the statute are directed at improving how health care is delivered and how our menu(s) of options are developed and prioritized. Fundamentally, it’s reasonable to ask: If the U.S. spends the most in health care (both per capita and in aggregate), and our outcomes are worse than other nations (in measures like life expectancy, infant mortality, etc.), shouldn’t we seriously reconsider how we prioritize our health care spending?

CMS, the federal agency that administers Medicare and Medicaid announced this week its first ever pilot initiative to fund programs addressing social determinants of health: housing, food security, utilities, transportation. [Other key determinants not covered under this pilot are education and employment.]

This is a game changer because it’s the first time the biggest driver of health care services and innovation is directly attempting to address issues that undergird our collective poor health attainment. Rather than just continuing to pour money into “sick care” (i.e. where most of the spending in health care occurs), this initiative provides dollars “upstream” to see if together we can find ways to prevent both major and chronic illnesses.

Couple new initiatives like this with ongoing efforts to reform medical education, and one gets hopeful that we can change health care to become smarter, more compassionate, and achieve better results.

#MacLean15

IMG_0536Recently I attended the annual conference of the MacLean Center for Clinical Medical Ethics at the University of Chicago. I was a fellow there a decade ago, spending a year steeped in study of the history and mechanisms of making complicated medical choices and attempting to resolve seemingly irreconcilable choices.

The center began in the 1980s, and has trained nearly three decades worth of fellows. As such, the annual event brings back many alumni but also outside speakers and attendees from across not only the U.S and Canada, but also from Europe and Australia. The conference took place at the University’s Law School, where I snapped the accompanying photo of one of the Law School’s most noted former lecturers outside of Classroom V, which was apparently his favorite place to teach.

There were many interesting topics covered at the conference. Among them:

  • Persons donating kidneys are more likely to eventually need dialysis and transplant themselves, and should be informed of such. (Sounds intuitive, but had not been scientifically proven before.)
  • In spite of massive effort, compliance rates for hand washing in hospitals continues to hover near 30% of available opportunities.
  • Frustration with insurance companies approving expensive drugs for conditions like inflammatory bowel disease led one doctor-researcher to ask, “Do insurance companies have medical ethical standards?” (Apparently not; they only have ‘business’ ethical standards.) He used social media to positive effect for some of his patients to get them ‘restricted’ but indicated medication.
  • A physician with a strong humanist bent shared how his frustrations with the practice of modern medicine (productivity constraints, feeling more like a widget in a system than a professional) were put in context by a trainee of his undergoing excruciating treatment for cancer who maintained a wonderful attitude about his life despite his suffering.
  • Several sessions focused on the struggles of the most vulnerable — and providing care for them — children, elderly, veterans, the mentally ill.

That is only a sample of the presentations. Since the center and the conference are underwritten by benefactors, attendance is free and only requires registration.

People of the Book

51LnzMAiHuL._SY344_BO1,204,203,200_Doctors are a group that prize scientific evidence in plying our trade — whether making recommendations to our patients or arguing with each other about how to interpret and act upon our profession’s ever-growing body of research.

I find it pretty easy to lapse into the rationalization that “the latest evidence” is usually right, and therefore should heavily weight both our actions and our “knowledge base.”

But a new book challenges this rationalizing — pointing out that over the decades, many assumptions about best medical practices later come into question and are thrown out — a process known as “Medical Reversal.”

I blogged about this before, as several articles in this genre stood out to me. Now that line of research has been turned into a book: “Ending Medical Reversal,” by Vinay Prasad and Adam Cifu. I was delighted to be asked to review this book for Johns Hopkins Press, and glad to see that they’ve published it (in fact, they used a statement in my review as a blurb (!) on the book jacket).

If you like to know how medical knowledge gets disseminated, communicated, retracted, and paved over, then this will be an enjoyable read. The NYTimes just reviewed the book, with a recommend, only questioning the rather esoteric title, suggesting instead that the book be called “OOPS!” or “Are You Kidding Me?”

I like those.

*                         *                         *                          *                         *                         *

This past week I had the opportunity to meet the great Roz Chast, author of the award-winning graphic memoir “Can’t We Talk About Something More Pleasant?”

She visited the Tulsa City-County Library as part of a series of programs put on in conjunction with Clarehouse, a local not-for-profit hospice. The goal of the series is to increase awareness and dialogue about improving care for people at the end of life.dr john schumann 3

RIP: DFS (1930-2014)

Don Steiner died last week. You probably haven’t heard of him, unless you’re steeped in the lore of the University of Chicago or involved in the world of diabetes research.

Steiner is being remembered for discovering proinsulin, the hormonal precursor to insulin. As part of his work, he made the realization that proinsulin was made in the beta cells of the pancreas as two molecules bound together by a short molecule which came to be known as “c-peptide.” It’s not a stretch to say that his work was key in transitioning the mass manufacture of insulin away from grinding up the pancreases of cows and pigs to being able to manufacture pharmaceutical-grade insulin using modern technology.

Steiner was a throwback to a more innocent time in the world of biomedical research. As his Times obit states

steiner

Joe Stafford/UChicago

Some of [Steiner’s] research could have been patented, but Dr. Steiner never considered doing that, said Dr. Arthur Rubenstein, a professor of medicine at and a former dean of the medical school at the University of Pennsylvania, who studied under Dr. Steiner and collaborated with him.

“There it was, one of the really, really great discoveries, and there was no patent,” Dr. Rubenstein said.

That decision was part of a pattern. “He shared everything with everybody,” Dr. Rubenstein said. Dr. Steiner, he said, gave his students ideas and time, made them first authors on scientific publications that would advance their careers, and even shared materials and data with competitors who did not always credit his contributions.

This would never happen today. Universities have become more sophisticated about intellectual property, entrepreneurialism, and—let’s be honest—profits.

The story about Steiner’s openness reminded me of his contemporary, Professor Gene Goldwasser. Goldwasser, also of the University of Chicago, spent two decades unraveling the secrets of the hormone EPO (erythropoietin). He, too, could have patented his discoveries, but he thought it too important to share his work to move the science forward. Some say had he patented his molecular discovery he (and the university he worked for) would have made hundreds of millions of dollars.

I was lucky enough to spend time with Goldwasser near the end of his life. He introduced me to Professor Steiner on a couple of occasions. They were great friends. The two of them were part of a golden age in bioscience at the University of Chicago, the place where in 1942 the first sustained atomic chain reaction took place under Enrico Fermi.

I know that Goldwasser felt that since taxpayers (i.e. the federal government) had supported his research career, there was no doubt his discoveries ‘belonged to all of us.’ I’ve no doubt that Steiner felt the same way.

The two of them shared not only a love for science, but were ‘fiends for culture,’ supporting the arts—they were lovers of music, drama, and studio art.

Their deaths not only are a huge loss in Chicago, but for the whole world.

« Older posts Newer posts »

© 2019 GlassHospital

Theme by Anders NorenUp ↑