The odds of having a history of each of the adverse cardiovascular events ranged from 2.21 to 4.18 times higher for patients receiving usual care at ERs compared to private doctors’ offices.
About 11% of participants who received their usual care in ERs had self-reported histories of diagnosed myocardial infarction, compared to 3% to 4% of participants at each of the other sites of care.
Contrary to popular wisdom, perhaps a drafty, energy-inefficient home is a worthwhile investment.
The problem in our homes is that there are multiple sources of gas and particle pollutants, and inadequate ventilation to reduce their impact.
Sometimes, the blogosphere just decides they’re going to discuss something in great detail. And now, with holiday travel upon us, we’re talking about the inane rules that airlines inflict upon passengers — especially the “turn off all electronic items that have off switches” rule at the beginning and end of flights.
Airborne toxic event
Longtime readers know my fondness of comparing the healthcare industry to the airline industry (based on similar goals of training, rituals of safety, and differing approaches to error, for starters).
Recently I’ve learned of a new intersection between medicine and aviation, when Delta chose to air ads to their captive cabin audience purchased by NVIC, the National Vaccine Information Center. The ads talk about staying healthy, maintaining good hygiene, and asking your doctor questions about the different flu shots available — to stay informed and keep all the options open.
Sounds … innocuous … right?
Sure, the CDC recommends the influenza vaccine as the single best defense against influenza deaths, though additional hygiene measures can help. But what’s the harm in asking questions of your doctor? Being informed?
Well, during the three-minute informercial, the NVIC website URL is shown. Their site is the opposite of information — a mixture of pseudoscience and innuendo, laced with bromides about patriotism and personal freedom.
I recently flew Delta and didn’t see (or recall seeing) this ad, though I do remember a loud car commercial right after takeoff, that I couldn’t stop, or quiet. Inflight advertising is said to be unusually effective at prompting recall among passengers, well after landing. Since a fair number of people report some upper respiratory issues after flying, I’ve got to admit the NVIC initiative is well-planned.
But dangerous. In the words of AAP president, Dr. Robert Block:
The AAP and many other child health organizations have worked hard to protect children and their families from unfounded and unscientific misinformation regarding vaccine safety. The influenza vaccine is safe and effective.
By providing advertising space to an organization like the NVIC, which opposes the nation’s recommended childhood immunization schedule and promotes the unscientific practice of delaying or skipping vaccines altogether, you are putting the lives of children at risk, leaving them unprotected from vaccine-preventable diseases. Diseases like influenza can have serious consequences. From September 2010 to August 2011, 115 children died from influenza disease, most of whom were unvaccinated.
A petition is circulating to ask Delta to stop putting their passengers at risk. For their part, Delta has said that they’ll change their ad purchasing policy, and the NVIC ads will only run until the end of the month. Wolfram Alpha suggests that, at about 200,000 passengers a day, that’s another three million viewings of the informercial.
I rounded the daily passenger rates up slightly, for the Thanksgiving rush. Maybe, though, we could round it down — #dontflydelta is trending on Twitter.
At the recent BWELA conference social health track, a bunch of us were talking about ways healthcare providers could affect positive change, in a media sphere where stories, novelty and fear usually trump statistics and uncontroversial, boring truth. This sounds like just the opportunity we were looking for — pushing for a measurable outcome (Delta stopping the ads early), fighting pseudoscience with evidence-based recommendations, and using social networks for a decidedly anti-viral purpose.
Signal in the sky
Notable figures such as Atul Gawande and Captain Sullenburger have, when discussing safety in medicine, drawn comparisons from the world of airline operations. Lots of people, actually, have made comparisons to these disparate fields.
If healthcare were more like aviation, the thinking goes, there would be fewer errors, greater transparency, and more uniform ways of doing things (and thus, presumably, lower costs). Gawande and Sully both talk about the egos of doctors, who view checklists as beneath them, who view their patients and practice as worthy of exceptions to guideline-based practice, who view their gestalt as superior to cookbooks and calculators.
No doubt, that’s part of the problem. But consider: New York magazine publishes a list of top doctors, but not top pilots. Lots of people brag about the acclaimed specialist they see, but no one brags about the pilot that they’ve booked for their trip to Paris. I think society’s expectations of physicians have never been in line with their expectations of air travel. The relationship between passenger and pilot is nothing like the relationship between patient and doctor, except that we rely on pilots and doctors to get us from point A to point B safely and smoothly.
US healthcare has maddening inefficiencies and rituals. But so, too, do airlines. I’m not even talking about TSA security theater (at least, not this time). Just consider the flight attendant preamble about using your seat as a flotation device in the event of a water landing, or the rules about electronics below 10,000 feet. These always seemed to me to be put in place by cautious administrators, years or decades ago, with a “better safe than sorry” rationale that’s hard to study or rescind, once put in place.
These speeches and restrictions always reminded me of the over-the-top, out-of-date rules about cell phones in hospitals. Sure, there’s one confirmed case that I’m aware of, years ago, where a mobile phone caused an IV infusion pump to malfunction. But it never seemed reasonable to extrapolate from that event, to banning personal communications at a time when patients and families are most inclined to get in touch.
Recently, the IATA issued a report on passenger-generated electronic interference with flight systems. Via TechCrunch:
The reported incidents were based on 125 airlines’ responses submitted between 2003 and 2009, noting that flight controls, autopilot, auto-thrust equipment, landing gear, and the communications kit were all allegedly affected by electronics use. Of course, not one of the seventy-five incidents were verified to be caused by electronic devices. Instead, the IATA reports that crew-members and pilots believed that electronics were the culprits in those cases.
In one instance, with two laptops being used nearby, the plane’s clock spun backwards and GPS readings began going off. In another example, altitude details were jumbled until the pilot asked passengers to turn off their gizmos. A Boeing advisor, Dave Carson, believes that the signals radiating from portable electronics can mess with sensors hidden in the passenger areas of a plane, and that those signals are far stronger than what Boeing considers acceptable during a flight.
I didn’t know some sensors were in the passenger area, where nearby device signals could interfere. Still, the article goes on to say a true cause/effect relationship between portable electronic devices and malfunctioning sensors has not been demonstrated by any of these IATA incidents.
What I found particularly interesting were the outraged comments, in response to the “scofflow” writer who admitted to keeping his phone on during landing. He was attacked for jeopardizing the lives of everyone on every plane he’s flown on. With 4000 flights a day in the US alone, and a lot of forgetful or sleeping passengers on each flight, I have a hard time believing that electronic interference poses any measurable risk. Even if all 125 citations over 6 years were really due to electronic interference, there were still no “bad outcomes” (to borrow from medical QA parlance) and the event rate, as commenters point out, was approaches zero and is far less than the odds of being struck by lightning.
Would these same outraged commenters angrily force a patient’s family member to hang up their mobile phone, if they saw them talking in the ED near a stretcher? Would they yell at a car driver who’s not wearing a seatbelt? Or do these commenters feel people who keep their devices on during plane takeoffs and landings are not just jeopardizing themselves, but perhaps the commenters as well?
This seems like yet another example of our attitudes and behaviors toward risks being poorly aligned to the actual danger. It’s more David Ropiek’s territory — though I’m sure Sullenbuger and Gawande would agree, getting the public’s perceptions to match the true hazards in aviation would make air travel a good deal more smooth and productive.
As for healthcare, it seems almost impossible to calculate how much money, time, and stress would be saved if patients’ risk perceptions were brought into better agreement with true health risks. Yet I’m more optimistic that the culture of aviation — with its transparency, uniformity, and lack of ego — is more likely to lead to progressive policy changes and successful public education, when compared to the culture of medicine.
Into a void we filled
I had a bunch of difficult shifts midweek last week and a lot of charts to complete, afterward. That, plus some other obligations, and I had fallen behind on emails — to say nothing of the news. So while I had heard a little bit about the earthquake in Haiti, I hadn’t really reflected on it.
Gmail had grouped the following messages last week from CNN — all sent within a few hours of each other — into a thread:
- CNN Breaking News: Hundreds of thousands of people have died in Haiti’s earthquake, the prime minister told CNN today.
- CNN Breaking News: President Rene Preval tells CNN that Haiti lacks capacity to hospitalize quake victims, asks for medical aid.
- CNN Breaking News: R+B singer Teddy Pendergrass has died at age 59, CNN has confirmed.
So forgive me, I knew something terrible had happened but I was having difficulty putting it into context.
This isn’t necessarily new territory. But, much like with Katrina, the enormity really only sinks in, for me, when I read physician’s accounts from the front lines. Something about comparing the challenges of working in my electronic ED with the endless supplies, state-of-the-art equipment, and an army of readily available specialists, to what these doctors are going through, conveys the horror more than a thousand breaking news updates or footage of crumpled buildings.
Some informative, and responsible, medical accounts are available online (1,2).
Here’s a dispatch from a former colleague with ties to the area:
My husband and I hitchhiked it to port au prince from the domincan republic; the devastation is of incredible magnitude; [X] and I both have family here; his father was pulled from the rubble alive after having been trapped for 16 hours; fractured ribs hand and leg ; his brother and stepmother killed; we are still looking for 2 nephews; [X] and I stay on opposite sides of town since food and water are scarce; we are helping our families to ration; at night we sleep on the roads the only safe place since after shocks are still being felt daily; hospitals have turned away thousands so I care for whomever I can in the meantime; I delivered a baby on the sidewalk this morning; please send this email out to our colleagues and ask them to send whatever resources they can; the various teams deployed have still not covered a large portion of the city that is in need of assistance; I have still not been able to get in contact with my medical mission group for lack of communication.
People have been bellyaching about disaster journalism cliches for close to 40 years, but the physician-as-reporter is a new wrinkle that’s coming under some scrutiny. From my perspective, I find the physician dispatches very helpful for contextualizing the disaster — at least, until these doctors’ heroics start to become the focus of the story, instead of the lens from which to view it.
Inside the Beltway
Last year I blogged about Nathan’s Hot Dog eating contest. This year, I gave some thought to attending this spectacle of competitive eating (these plans were laid to rest the night before, when I enganged in the spectacle of competitive drinking).
Anyway, it doesn’t look like I missed too much. The same guy, Takeru Kobayashi, won again (though last year, he was frequently called by his nickname, “the Tsunami.” Not so much, this year).
Also unchanged: the dearth of scientific inquiry into this … sport. I mean, it’s been over twenty years since competitive race-walking was examined in detail — is that any more of a sport than competitive eating? Which activity is of more relevance to the obese American taxpayer?
All I can really find on the matter is this press release from the International Federation of Competitive Eating:
The November 2003 Popular Science addresses the tendency for thinner, in-shape gurgitators to beat heavier eaters in competition. Many intuitively believe that a larger individual has more room to hold food, but this is not the case. The magazine states that the size of the stomach at rest is inconsequential and that the ability for the stomach to expand is all that matters.
This is the conclusion reached by former world champion hot dog eater Edward Krachie in his 1998 scholarly journal article, “CAN ABDOMINAL FAT ACT AS A RESTRICTIVE AGENT ON STOMACH EXPANSION? An Exploration of the Impact of Adipose Tissue on Competitive Eating.” In his article, Krachie goes a step further and proves that the stomach of a heavier eater is prevented from expanding by a “belt of fat.”
The IFOCE and Edward Krachie submitted his piece to numerous academic journals including the New England Journal of Medicine. Sadly, all journals rejected his piece.
Sadly, Popular Science doesn’t really conclude the ‘belt of fat’ theory is correct. The reporter just asserts it, and goes on to talk about satiety signaling. The entire piece is not much longer than the IFOCE press release.
I think there’s plenty of room for more … data. Granted, I have an appetite for this stuff, but I think it’s worthy of extra helping from the scientific community. Because the few morsels of information we have now are hard to digest (as are these puns. I’m sorry.)
Krachie and company are arguing, essentially, that a belly of fat is more compressive than skin and muscle are distensible. I’m not convinced. I wouldn’t be surprised if the thin eating champs were born with weak pyloric sphincters, or exhibit higher capacity for smooth muscle relaxation. But until we start doing some barium swallows and endoscopies on these people, we’re just guessing.
Sooner or later, the reward money for these contests will prompt some competitors to fund their own clandestine research. And it would be a shame if these athletes were smeared with allegations of shady practices. Let’s keep the research open and freely available — let science have a seat at the table.
There was a neat article in the Boston Sunday Globe about American Hypomania. Yeah, it sounds like the latest craze, but a new book suggests it may have been going on for centuries:
In his new book “The Hypomanic Edge: The Link Between (A Little) Craziness And (A Lot of) Success In America” (Simon & Schuster), John Gartner contends not only that most of today’s successful entrepreneurs and businesspeople are hypomanic, but that many of our history’s leading figures, such as Alexander Hamilton, Andrew Carnegie, and Henry Ford, had the condition as well. The United States has more hypomanics than other countries, Gartner claims, and these people are largely responsible for the nation’s power and prosperity.
I remember learning about hypomania in the context of bipolar disease (manic-depression) in med school. Many of my classmates suspected they were hypomanic, or would need to be in order to graduate. Indeed, when you read the DSM-IV criteria for a hypomanic episode, it doesn’t sound half bad:
A distinct period of persistently elevated, expansive or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood…
…inflated self-esteem or grandiosity, decreased need for sleep (e.g., feels rested after only 3 hours of sleep)… flight of ideas or subjective experience that thoughts are racing…increase in goal-directed activity (at work, at school, or sexually)…
…The mood disturbance not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.
Sounds great, right? Well, I’m leaving out the undesirable features — distractability, irresponsible spending sprees, pressured speech — and condensing the APA legalese. It’s worth noting that, according to DSM, hypomania differs from full-blown mania only in that it can last just four days (mania requires a week) and that it doesn’t markedly impair functioning. That’s it. Follow the link above to see the rest, and learn how hypomanic episodes are a component of bipolar disorders.
It’s sufficient to say that preclinical med students aren’t the only people a little enamored with this disease. Even psychiatrists with a lot more experience treating bipolars think there’s something attractive about hypomania. It’s a small step from that, to assigning hypomania a role in making this nation great. But Dr. Kay Jamison, who herself is bipolar and has some fond memories of it, sounds aword of caution:
“Certainly there have been studies, long before his book, suggesting that there is a disproportionate rate of bipolar illness in immigrant populations, which is not surprising, really, when you think about the energy and the optimism and impulsiveness that drives people to immigrate,” she said in a recent telephone interview. “Now, does that mean that most Americans are hypomanic? No, that means - at least from my point of view - that a very real minority may be hypomanic, though perhaps a very important minority.”
Gertner apparently acknowledged that his book has no reasonable proof, just a provocative correlation. He elaborates:
“What I’m doing is putting certain things together, drawing an inference,” he says. “I’m saying: ‘Look, isn’t it interesting that the countries that have been havens for immigrants also have the highest rates of bipolar disorder? And isn’t it interesting that those are the countries that have the highest rates of new company creation?’ Yes, it could be coincidental - but in science, we say that the simplest explanation is usually the right one.”
It seems far simpler, to me, to say the following: the American system, with its lack of tradition, its relatively trustworthy institutions, and its extensive natural resources, encouraged the citizenry to take risks. Many did, leading to an unparalleled prosperity. Their wealthy decendants are now able to obtain psychiatric diagnoses that their counterparts in the Old Country cannot, and thus Americans lead the world in a number of disorders, including bipolar.
Jamison thinks that immigrants tended to have bipolar traits, compared to those left behind. But really, why not obsessive-compulsive traits? After all, one would need to be meticulous about planning to leave home, and those traits would serve one well in American business. And I wouldn’t be surprised if Americans lead the world in OCD diagnoses, too. But no one’s yet ascribed our economic state to that disease — perhaps it’s not as glamorous.
Anyway, any attempt to prove this hypomania hypothesis will be tough. It’s easy enough to measure spending habits, and bankruptcies, but hard to attribute that to hypomania when there are so many external forces involved. Same with hours slept (Americans do work more and sleep less than others), and frequency of sex (Durex says we’re #1). But again, is U.S. culture reinforcing these behaviors, or hypomanic behavior creating the culture?
They’d have an easier time explaining our high oil consumption with the obsessive-compulsive fear of public transportation. Much easier to study. I really think someone should look into this. I would, but I have too many other ideas to follow up on right now…
Truth and / or Beauty
The Boston Globe magazine today surveys new developments in the interface between science and art. Harvey Blume’s article includes a talk with a Harvard particle physicist, Eric Heller, who tinkers with his subatomic flow diagrams with photoshop (with startling effectiveness).
Blume also interviews MIT’s Felice Frankel, who’s carfeul to call her scientific images a “craft” and not “art”:
“What’s primary for me about my photographs,” she said, “is that they communicate scientific information. If by chance they also happen to be beautiful, I’m very happy about that. But I feel I’m revealing the beauty that’s already there.”
…Frankel believes that abstraction is a useful element of scientific photographs. “I think a lot of my images are successful because they are abstract,” she explained. “That allows the viewer to participate.” As she describes it, abstraction is a sort of come-on, “a seduction” that prepares the viewer for “another layer of meaning” — a bedrock scientific layer that, in the case of microcantilevers, involves the physics of microelectrical systems. For her, abstract beauty is not an end in itself; it leads viewers to the nuts and bolts of scientific truths that underlie the image, and then it peels away — leaving, she hopes, a readiness to recognize other such representations of nature.
Frankel’s insistence on — almost a fiercely protective attitude toward — scientific truth, makes her impatient with artists who ransack science for imagery and metaphor without taking time to understand it. “I get angry,” she says, “at artists who create one-liners, who take a sentence from a textbook and make an installation out of it.”
I appreciate her stance. Yet these one-liners might at work with in a different new science-art book Blume mentions:
In her recent book “The Molecular Gaze: Art in the Genetic Age,” coauthored with Dorothy Nelkin, [Suzanne] Anker looks at disconcerting outcomes, real or imagined, of the biological revolution — for example, a mouse engineered to grow a human ear on its back. This trick was pulled off several years ago by researchers at the University of Massachusetts at Amherst, who later harvested the tissue in order to replace damaged tissue on the ear of a child….
Anker discusses the mouse with a human ear as an example of what is known among biologists — and their fellow travelers in the arts — as transgenics, the cutting and pasting together of elements from two different beings to produce a third. She notes that in Greek mythology, that third was known as a chimera. She also points out that the technique of cutting and pasting was much in vogue among early 20th-century artists, such as Picasso and the Dadaists. “With the advent of the 20th century,” Anker explained, “new ways of looking at the world arose in parallel in the arts and in science.”
So it doesn’t really matter that UMass researchers weren’t thinking about Greek myth or art history when they grew an ear on that mouse. Now that humans can read and rewrite genetic code much as we do computer code, biology may well be the source for the next iconic image. If so, it may not be anything like the graceful double helix.
The author is incorrect on some of the facts — the UMass scientists were at the Worcester campus, not Amherst. And, as far as I know, the engineered ear was a proof-of-concept and was not re-implanted in a human.
But Anker, an art history professor, might be an example of what Frankel was worried about. Why include the mouse with a human ear (shown below) in a book on molecular biology? The human cartilage cells were mixed into the scaffold ex vivo and inserted into the mouse surgically, subcutaneously (the mouse acted as an incubator). Molecular genetics isn’t involved at all, unless you count the use of a nude mouse (which has a defective immune system, unable to reject the human chondrocytes). So why is it in her book on molecular biology?
I don’t have the book, so I don’t know if they give it the appropriate caveat. One molecular biologist seems to have liked it. The image they probably used is shown below —though the original 1995 CNN health brief has another another iconic image (mice do certain things when they’re frightened).
But calling this mouse a “chimera” is misleading — the term should be reserved for true genetically engineered chimeras. Otherwise, you could say I’m a chimera because I’ve got some cat fur on my lap.
The mouse with a human ear could have been photographed a hundred years ago, if someone had shaved a rodent and slipped an ear under its skin. In other words, the significance of the UMass photo isn’t that mice can sprout new parts, but that we can grow cartilage in certain shapes. Yet the under-informed have latched onto this image as heralding the apocalypse.
Stephen Milloy has tried to enlighten people about this issue in the past. The fact that it’s still misunderstood, almost a decade later, implies his work isn’t done. And that the image should be discussed as art, comparable to Picasso’s minotaurs, is just specious.
Not too many people are going to hang up a photo of this mouse in their living rooms. But someday, someone whose arthritic cartilage was replaced by these techniques might be able to walk over to Anker’s office and discuss the real significance of the mouse experiment. That’s the truth, and the beauty, of the UMass photo.
Update! Harvey Blume responds:
as to the question of transgenics, though you’re clearly right, this mouse was not a product of genetic reprogramming (& i hope i did not imply it was), anker does, in fact, discuss it in that context, though she would probably agree with you fully that she was using that term — and the term “chimera” — loosely to make her point. she then goes on talk about phenomena that are transgenic in the technical sense. i think she’s simply trying to open our minds to the idea.