Archive for the ‘medicine’ Category

Obamacare = Medicaid

Friday, May 8th, 2015

emergency

I have been interested in health care reform for some time and have proposed a plan for reform. It is now too late for such a reform as Obamacare has engaged the political apparatus and sides have been taken. The Obamacare rollout was worse than anticipated and it was hoped that the Supreme Court would have mercy on the country, but that didn’t happen and it has been the law for two years.

What has it accomplished ? Well, the forecast drop in ER visits hasn’t happened. It also didn’t happen in Massachusetts when that plan took effect.

Wasn’t Obamacare supposed to solve the problem of people going to the ER for routine medical problems? We were told that if everyone had “healthcare” — either through the ACA exchanges or through Medicaid expansion — people would be able to go to their family doctors for routine care and emergency rooms would no longer be overrun by individuals who aren’t actually experiencing emergencies.

As it turns out, Medicaid patients can’t get appointments with physicians.

“America has severe primary care physician shortages, and many physicians will not accept Medicaid patients because Medicaid pays so inadequately,” said Michael Gerardi, MD, FAAP, FACEP, president of the ACEP.

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Myopia

Friday, April 24th, 2015

myopia

A couple of interesting articles about the increasing incidence of myopia in children.

Myopia isn’t an infectious disease, but it has reached nearly epidemic proportions in parts of Asia. In Taiwan, for example, the percentage of 7-year-old children suffering from nearsightedness increased from 5.8 percent in 1983 to 21 percent in 2000. An incredible 81 percent of Taiwanese 15-year-olds are myopic.

The first thought is that this is an Asian genetic thing. It isn’t.

In 2008 orthoptics professor Kathryn Rose found that only 3.3 percent of 6- and 7-year-olds of Chinese descent living in Sydney, Australia, suffered myopia, compared with 29.1 percent of those living in Singapore. The usual suspects, reading and time in front of an electronic screen, couldn’t account for the discrepancy. The Australian cohort read a few more books and spent slightly more time in front of the computer, but the Singaporean children watched a little more television. On the whole, the differences were small and probably canceled each other out. The most glaring difference between the groups was that the Australian kids spent 13.75 hours per week outdoors compared with a rather sad 3.05 hours for the children in Singapore.

This week the Wall Street Journal had more. There are some attempts to deal with the natural light effect.

Children in this small southern Chinese city sit and recite their vocabulary words in an experimental cube of a classroom built with translucent walls and ceilings. Sunlight lights up the room from all directions.

The goal of this unusual learning space: to test whether natural, bright light can help prevent nearsightedness, a problem for growing numbers of children, especially in Asia.

The schools have tried to get Chinese parents to send the kids outdoors more but it doesn’t seem to work.

And it isn’t limited to Asians.

In the U.S., the rate of nearsightedness in people 12 to 54 years old increased by nearly two-thirds between studies nearly three decades apart ending in 2004, to an estimated 41.6%, according to a National Eye Institute study.

But Asians with their focus on education are the most effected.

A full 80% of 4,798 Beijing teenagers tested as nearsighted in a study published in the journal PLOS One in March. Similar numbers plague teens in Singapore and Taiwan. In one 2012 survey in Seoul, nearly all of the 24,000 teenage males surveyed were nearsighted.

So, what to do ?

Though glasses can correct vision in most myopic children, many aren’t getting them. Sometimes this is because parents don’t know their children need glasses or don’t understand how important they are for education. Other times, cultural beliefs lead parents to discourage their children from wearing them, according to Nathan Congdon, professor at Queen’s University Belfast and senior adviser to Orbis International, a nonprofit focused on preventing blindness. Many parents believe glasses weaken the eyes—they don’t.

Getting kids to spend even small amounts of time outdoors makes a difference.

Why myopia rates have soared isn’t entirely clear, but one factor that keeps cropping up in research is how much time children spend outdoors. The longer they’re outside, the less likely they are to become nearsighted, according to more than a dozen studies in various countries world-wide.

One preliminary study of 2,000 children under review for publication showed a 23% reduction in myopia in the group of Chinese children who spent an additional 40 minutes more outside each day, according to Ian Morgan, one of the researchers involved in the study and a retired professor at Australian National University in Canberra. (He still conducts research with Sun Yat-sen University in the Chinese city of Guangzhou.)

That is a very significant effect of small changes in behavior. Now the researchers are trying something new.

Dr. Morgan, Dr. Congdon and a team from Sun Yat-sen are now testing, as reported recently in the science magazine Nature, a so-called bright-light classroom made of translucent plastic walls in Yangjiang to see if the children can focus and sit comfortably in the classroom. So far it appears the answer is yes.

In 2007, Donald Mutti and his colleagues at the Ohio State University College of Optometry in Columbus reported the results of a study that tracked more than 500 eight- and nine-year-olds in California who started out with healthy vision6. The team examined how the children spent their days, and “sort of as an afterthought at the time, we asked about sports and outdoorsy stuff”, says Mutti.

It was a good thing they did. After five years, one in five of the children had developed myopia, and the only environmental factor that was strongly associated with risk was time spent outdoors6. “We thought it was an odd finding,” recalls Mutti, “but it just kept coming up as we did the analyses.” A year later, Rose and her colleagues arrived at much the same conclusion in Australia7. After studying more than 4,000 children at Sydney primary and secondary schools for three years, they found that children who spent less time outside were at greater risk of developing myopia.

What is the mechanism ? Maybe it is this.

The leading hypothesis is that light stimulates the release of dopamine in the retina, and this neurotransmitter in turn blocks the elongation of the eye during development. The best evidence for the ‘light–dopamine’ hypothesis comes — again — from chicks. In 2010, Ashby and Schaeffel showed that injecting a dopamine-inhibiting drug called spiperone into chicks’ eyes could abolish the protective effect of bright light11.

Retinal dopamine is normally produced on a diurnal cycle — ramping up during the day — and it tells the eye to switch from rod-based, nighttime vision to cone-based, daytime vision. Researchers now suspect that under dim (typically indoor) lighting, the cycle is disrupted, with consequences for eye growth. “If our system does not get a strong enough diurnal rhythm, things go out of control,” says Ashby, who is now at the University of Canberra. “The system starts to get a bit noisy and noisy means that it just grows in its own irregular fashion.”

Another possible treatment is the use of atropine drops in the eye.

Atropine, a drug used for decades to dilate the pupils, appears to slow the progression of myopia once it has started, according to several randomized, controlled trials. But used daily at the typical concentration of 1%, there are side effects, most notably sensitivity to light, as well as difficulty focusing on up-close images.

In recent years, studies in Singapore and Taiwan found that a lower dose of atropine reduces myopia progression by 50% to 60% in children without those side effects, says Donald Tan, professor of ophthalmology at the Singapore National Eye Centre. He has spearheaded many of the studies. Large-scale trials on low-dose atropine are expected to start soon in Japan and in Europe, he says.

More than a century ago, Henry Edward Juler, a renowned British eye surgeon, offered similar advice. In 1904, he wrote in A Handbook of Ophthalmic Science and Practice that when “the myopia had become stationary, change of air — a sea voyage if possible — should be prescribed”.

More Biology

Saturday, December 20th, 2014

I have been posting some long comments at at Chicagoboyz, and decided to do them as post here. The topic is the future of technology.

I am pessimistic on molecular medicine for several reasons. I have gotten into two nasty debates on evolution at conservative web sites. One was at Ricochet and was nasty enough that I quit going there. There were something like 250 comments, of which about four were friendly. At Althouse, it was a bit better but still very negative, about 4 to 1. I let my membership at Ricochet expire and so can’t find the thread.

Found it with Google.

A sample of comments is here.

No disrespect Mike but I think you are suffering from the same problem that a lot of people suffer from. The inability to factor faith into the intellectual equation. It is possible to understand and embrace the science of evolution and apply the knowledge gleaned from it even if you aren’t 100% sure we have the story right.

I 100% believe the story of creation in the Bible, but I have no problem understand the evolution of the sickle cell trait. In the same way I have no problem believing Jesus brought Lazarus back from the dead or healed the server of a Roman centurion from miles away even though these things seen completely at odds with medical science.

That doesn’t even take into account the anti-GMO lefties who seem to be more accepting of human modification than with plants.

In both cases, I got into it by commenting that I would not write a letter of recommendation for a student applying to medical school who did not believe in evolution. I tried to make the point that I am not the king of medical school admissions but it was no help.

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Psychiatry and the “deinstitutionalism” movement.

Tuesday, November 4th, 2014

There is a piece in the City Journal this quarter about the New York state experience with psychotic citizens and the prison system. Years ago, I wrote a book about my experiences in medical school and still have some thoughts of publishing it as an e-baook. Chapter One included my own experience working in a psychiatric hospital before the changes took place that put the mentally ill on the streets.

In June of 1962 I was released from active duty. A place in the 1962 first year medical school class had been held for me, but I needed a job for the summer until classes resumed in September. I came across an ad in a Los Angeles paper for medical students to work at the Veteran’s Administration Hospital in West Los Angeles. I was a medical student, albeit one with only a month of medical school under my belt, and I responded to the ad. I got the job, which consisted of performing annual physical examinations on patients in the closed psychiatric ward of the VA Hospital in West Los Angeles. My first experience with patients then was with chronic schizophrenics in a VA hospital.

As I entered upon my new duties at the VA hospital I had more experience than one would expect of a one-month medical student because I had been a corpsman for three years (only one on active duty). Nonetheless, performing annual physicals on 200 psychotic adult men was a daunting task. The psychiatry attending staff and residents decided that they would not do these required physicals because they thought physical contact would interfere with their relationship with the patients. These were the days of Psychoanalysis in psychiatry and examining or even touching patients was considered harmful. They chose medical students to do the task, and I was hired along with a few others. I reported to Building 206 on the Sawtelle Veteran’s Administration Hospital campus about the 15th of June to start my job. Building 206 housed 200 patients, all but a few of whom were chronic schizophrenics. There was one elderly black gentleman who suffered from tertiary syphilis (also called “General Paresis of the Insane” in the old days) contracted during the First World War. He had been a Veteran’s Administration Hospital patient since about 1928. The remainder was from World War II and Korea. The second floor of the building was a locked ward where patients were not allowed out on the grounds without being accompanied by a staff member. There was even a locked room on that floor where patients were confined in strait jackets if they were too agitated to be free on the locked ward. The first floor patients were in an “open ward” where they were allowed to go to the canteen and to go about the grounds of the hospital but were not allowed off the hospital grounds without a pass. If someone left without a pass he had “eloped.” There was one building on the hospital campus with a higher level of security than Building 206, but these patients of mine were chronically psychotic and not allowed to wander about freely except when they were on pass. It was an interesting experience for a first year medical student.

The VA Psych hospital was called The Sawtelle Veterans Home at one time.

The VA Psych hospital was north of Wilshire and evidence of the psych hospital is not easy to find.

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Case #1 Ebola

Saturday, October 4th, 2014

The early information of the Ebola patients in Dallas seems to suggest that competence has not been high on the list of priorities. First, the patent seems to have known about his illness before he got on the plane to the US. He lied to the authorities in Liberia but that is not that unusual. All it takes is ibuprofen to evade the screening at the airport.

Second the treatment of the relatives Has finally become humane after days of cruel treatment including quarantine in a contaminated apartment.

The initial treatment was not a model of infectious disease protocol. Why he was sent home with a GI illness and a history of travel to Liberia is still not explained. My medical students are all told to take a history of travel with any GI illness symptom. It’s not clear who he saw but many ERs use Nurse practitioners or PAs to see ER patients.

He is not doing well and he seems to be declining. We will see how he does but his relatives are still in serious trouble. We are still in trouble.

The promised treatment program is still inadequate. Tomorrow will bring more bad news.

A CDC official said the agency realized that many hospitals remain confused and unsure about how they are supposed to react when a suspected patient shows up. The agency sent additional guidance to health-care facilities around the country this week, just as it has numerous times in recent months, on everything from training personnel to spot the symptoms of Ebola to using protective gear.

This is only the first case.

UPDATE: More news from Bookworm.

Ebola can transmit through people’s skin. It’s not enough to keep your hands away from your nose and mouth. If someone’s infected blood, vomit, fecal matter, semen, spit, or sweat just touches you, you can become infected. Even picking up a stained sheet can pass the infection. Additionally, scientists do not know how long the virus will survive on a surface once it’s become dehydrated. The current guess is that Ebola, unlike other viruses, can survive for quite a while away from its original host.

Oh oh. This explains the infection of hospital workers in Nigeria from urine.

The good news, if any, is this:

If patients get Western medicine that treats the symptoms — drugs to reduce fever and to control vomiting and diarrhea, proper treatment if the body goes into shock, and blood transfusions — the mortality rate is “only” 25% — which is still high, but is significantly lower than the 70%-90% morality in Africa, where patients get little to no treatment.

I will update this as news becomes available.

UPDATE #2

Now we have a possible case #2

A patient with Ebola-like symptoms is being treated at Howard University Hospital in Washington, D.C., a hospital spokesperson confirmed late Friday morning.

The patient had traveled to Nigeria recently.

That person has been admitted to the hospital in stable condition, and is being isolated. The medical team is working with the CDC and other authorities to monitor the patient’s condition.

“In an abundance of caution, we have activated the appropriate infection control protocols, including isolating the patient,” said hospital spokesperson Kerry-Ann Hamilton in a statement. “Our medical team continues to evaluate and monitor progress in close collaboration with the CDC and the Department of Health.”

No final word yet. Then, of course, we have the NBC case.

Thursday, news broke that a freelance NBC cameraman covering the outbreak in Monrovia, Liberia had tested positive for Ebola after experiencing symptoms of the disease.

The cameraman, Ashoka Mukpo, had been working with chief medical correspondent Dr. Nancy Snyderman. NBC News is flying Mukpo and the entire team back to the U.S. so Mukpo can be treated and the team can be quarantined for 21 days.

Is Ebola airborne ?

Saturday, September 13th, 2014

Ebola has become an uncontrolled epidemic in Africa. I have previously posted on Ebola elsewhere.

UPDATE: There is now a conclusion that Liberia and Sierra Leone are lost.

But Jonas Schmidt-Chanasit of the Bernhard Nocht Institute for Tropical Medicine in Hamburg told DW that he is losing hope, that Sierra Leone and Liberia will receive the neccessary aid in time. Those are two of the countries worst hit by the recent Ebola epidemic.
“The right time to get this epidemic under control in these countries has been missed,” he said. That time was May and June. “Now it will be much more difficult.”
Schmidt-Chanasit expects the virus will “become endemic” in this part of the world, if no massive assistence arrives.

This is from a German source. Our own CDC will not yet say this.

In the balance therefore, the probability is that the virus is not airborne — yet — but it is more dangerous than its predecessors. This would account for its ability to slip through the protocols designed for less deadly strains of the disease. It’s not World War E time, but it’s time to worry.

And: This may be a new strain with more virulence.

The results of full genetic sequencing suggest that the outbreak in Guinea isn’t related to others that have occurred elsewhere in Africa, according to an international team that published its findings online in the New England Journal of Medicine (NEJM). That report was from April 2014.

Now, we have more news. From 2012, we know transmission in animals may be airborne.

While primates develop systemic infection associated with immune dysregulation resulting in severe hemorrhagic fever, the EBOV infection in swine affects mainly respiratory tract, implicating a potential for airborne transmission of ZEBOV2, 6. Contact exposure is considered to be the most important route of infection with EBOV in primates7, although there are reports suggesting or suspecting aerosol transmission of EBOV from NHP to NHP8, 9, 10, or in humans based on epidemiological observations11. The present study was design to evaluate EBOV transmission from experimentally infected piglets to NHPs without direct contact.

The study of this potential explosive development showed:

The present study provides evidence that infected pigs can efficiently transmit ZEBOV to NHPs in conditions resembling farm setting. Our findings support the hypothesis that airborne transmission may contribute to ZEBOV spread, specifically from pigs to primates, and may need to be considered in assessing transmission from animals to humans in general.

Now we have more articles appearing about this.

The second possibility is one that virologists are loath to discuss openly but are definitely considering in private: that an Ebola virus could mutate to become transmissible through the air. You can now get Ebola only through direct contact with bodily fluids. But viruses like Ebola are notoriously sloppy in replicating, meaning the virus entering one person may be genetically different from the virus entering the next. The current Ebola virus’s hyper-evolution is unprecedented; there has been more human-to-human transmission in the past four months than most likely occurred in the last 500 to 1,000 years. Each new infection represents trillions of throws of the genetic dice.

If the New York Times is publishing this, somebody is worried.

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Maynard Brandsma

Tuesday, September 2nd, 2014

I was just thinking tonight about an amazing character I knew years ago. In 1972, I moved to Mission Viejo and began a surgical practice at Mission Hospital, now known as Mission Medical Center. When I arrived in December of 1972, I met an internist who had an amazing career and personal history. He was born in Holland and during World War II was supposedly a fighter pilot in the Dutch Air Force in what is now Indonesia. At the time it was the Dutch East Indies. He was also a physician at the time and was chief of staff at the hospital in Indonesia where another physician friend, Sergei Lockareff was born.

Maynard practiced as a physician in Santa Monica and was the personal physician for a number of movie stars, including Humphrey Bogart, Greer Garson and Carole Landis.

Life seemed very good indeed. But Bogie came home one day and told me that he’d run into an old co-star, Greer Garson.
Over lunch, she’d announced that she didn’t like the sound of his cough, and dragged him to see her doctor, Maynard Brandsma, at the Beverly Hills Clinic.

I was so used to Bogie’s cough that I never paid too much attention. He’d been off his food a little, but that wasn’t unusual. I should have realised at once that the mere fact that he’d consented to go with Greer to a doctor was indicative of something serious. Any time I’d ever mentioned a doctor to him, Bogie bristled.

Maynard discovered Bogart’s esophageal cancer and cared for him during that illness. Another physician friend, Burt Meyer, was the surgeon who operated on Bogart and who later said that the cancer was so small that he would never operate on another. If he couldn’t cure that one, there was none he could cure. Burt operated on John Wayne for his lung cancer with better luck.

Maynard was the physician who examined and treated the wife of David Niven for her fatal head injury, suffered when she fell down a flight of stairs in the dark at a Hollywood party.

When I came to Mission, Maynard had been there for several years. He had moved to Mission Viejo after marrying his second wife Mickie. He was active in practice and was kind of intimidating to a new surgeon. By that time, he was 65 years old but still very active. I remember that he tried to get me to join the Coto de Caza gun club, which was abruptly closed by the developer in 1991. At the time that Maynard was a member there was good quail shooting there but I couldn’t afford it.

He was quite the character. One night his telephone did not answer and the hospital asked the sheriffs to go to his house and let him know it was pout of order and they were trying to reach him. They knocked on his door at 3 AM and he came to the door with a .45 automatic held behind his back. Things were far less tense with the police in those days and they thought nothing of it.

The hospital was quite small at the time and Maynard was seeking a second career and life with his new wife. His career at St John’s Hospital in Santa Monica was spectacular in that he had been chief of staff and had a Hollywood practice, as well. One of his patients was John Ford and he made the diagnosis of Ford’s colon cancer that ultimately killed him.

Maynard was a good physician and continued to practice for a number of years after my arrival. Eventually, he and Mickie moved away and they are buried in Montana. He was a very colorful character and I remember him fondly.

Medicine is coming to be a government benefit.

Sunday, August 3rd, 2014

Obamacare is having serious trouble as I have discussed. The success stories, like California, are an example of what I have called Medicaid for All.

“It’s a total contradiction in terms to spend your public time castigating Medicaid as something that never should have been expanded for poor people and as a broken, problem-riddled system, and then turn around and complain about the length of time to enroll people,” said Sara Rosenbaum, a member of the Medicaid and CHIP Payment and Access Commission, which advises Congress.

Most of the new enrollees are Medicaid members and those enrolled in “private insurance” learn that they have severely restricted choice of doctor or hospital.

Now we have a new development.

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What next for health reform?

Saturday, July 26th, 2014

It looks to me that the Supreme Court will have little justification for continuing the Obamacare program as it exists. The Halbig decision should kill it off. It is clear that the IRS subsidies to federal exchange subscribers are illegal.

The only statement anyone has found in the legislative history that addresses this point comes from the Act’s lead author, who affirmed that Congress did intend to withhold tax credits in federal Exchanges. During a September 23, 2009, mark-up of his bill, which ultimately became the PPACA, Senate Finance Committee chairman Max Baucus (D-MT) refused to consider a Republican amendment regarding medical malpractice on the grounds it fell outside the Committee’s jurisdiction. Sen. John Ensign (R-NV) protested, asking how Baucus’ bill could do other things that lie outside the Committee’s jurisdiction, like direct states to create Exchanges. Baucus responded the bill creates tax credits, which are within its jurisdiction, and makes eligibility for those tax credits conditional on states creating Exchanges. Conditional necessarily means that Baucus intended to withhold tax credits in states that did not create their own Exchanges.

I just don’t see how the Court can ignore that history. The political left has been on a rant about Congressional intent since the decision was announced.

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An Update on Medical Reform

Monday, July 21st, 2014

Cash medical practice or, in the phrase favored by leftists critics, “Concierge Medicine,” seems to be growing.

Becker is shifting to a new style of practice, sometimes called concierge or retainer medicine. With the help of a company that has been helping physicians make such shifts for over 13 years, he will cease caring for a total of 2,500 patients and instead cut back to about 600. These patients will pay an annual fee of $1,650. In exchange, they will receive a two-hour annual visit with a complete physical exam, same-day appointments, 24-hour physician phone access, and personalized, web-based resources to promote wellness.

The article suggest that all these doctors choosing to drop insurance and Medicare are primary care. Many are but I know orthopedists and even general surgeons who are dropping all insurance.

The concierge model of practice is growing, and it is estimated that more than 4,000 U.S. physicians have adopted some variation of it. Most are general internists, with family practitioners second. It is attractive to physicians because they are relieved of much of the pressure to move patients through quickly, and they can devote more time to prevention and wellness.

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