Month: October 2018

Drone Ambulances to the Rescue

http://bit.ly/2DaRcDt

How innovative technology is serving needs in rural health emergencies.

Remoteness is what makes family worry about us. It’s true at any age — from a daughter who sets off on a weekend hike into the deep woods to a couple who chooses to age in place in the country with only deer, songbirds and cicadas to keep them company.

But what happens when disaster strikes? According to a recent analysis of over 1.8 million 911 calls, callers in rural areas wait twice as long for an ambulance (on average) than elsewhere. That’s a 13-minute wait in the country vs. a six minute wait in the city or suburbs. Ten percent of folks in rural areas had to wait a full 30 minutes for an ambulance to arrive.

Where Drone Technology Comes In

A Mississippi-based team of doctors is working on a telemedicine technology that could get emergency care to rural areas faster. It’s an aerial ambulance: a drone named HiRO, which stands for Health Integrated Rescue Operations. The team is working on how to make the drone simpler and easier to use — easy enough so that people with no medical knowledge can use it, even when they’re in the middle of a crisis situation.

“The inspiration for using drone-based technology [were] individuals [who] could not reach or communicate with their frail, elderly loved ones due to downed power lines and trees,” said Italo Subbarao, an emergency medicine specialist who came up with the idea for HiRO after a severe tornado hit Hattiesburg, Miss. “First responders saw the messages and responded appropriately, but it took time.”

With the potential to integrate into local emergency 911 systems, each drone carries a medical kit that, when opened on the ground, can help bystanders — family members, neighbors or even you — provide simple medical care until emergency help arrives.

In addition to medicine and supplies stored in small bins that can be unlocked remotely, the drone’s medical kit contains an augmented reality interface that acts as a direct link to a remote, on-call doctor. Once you put the googles on, the doctor can see what you see and help provide medical care.

“We have designed many drone and telemedical package prototypes in the past four years,” said Guy Paul Cooper, Jr., who developed the drone with Subbarao as a medical student at William Carey University College of Osteopathic Medicine.

Cooper and Subbarao say the kits can vary from two to 20 pounds, depending on their purpose. The heaviest kits are meant for mass-casualty events (bioterrorism, mass shootings) and disasters that displace or endanger many people (earthquakes, hurricanes). Smaller kits are more appropriate for search-and-rescue missions in remote areas, including wilderness emergencies.

Stop concocting unscientific excuses for ignoring brain injuries from football

http://bit.ly/2EO15ss

110/111 is a curious kind of number — both potentially misleading and yet highly informative. Using these case reports to estimate how widespread CTE and its hallmark symptoms of mental decline and mood disturbances will be over the next several decades is tricky because the sample isnot representative; the 111 whose families sought autopsies for their next-of-kin tend to include those players who suspected they might have CTE because of symptoms they suffered during retirement.

Unfortunately, advocates on both sides are desperately misusing the 110/111 statistic. A few claim we will eventually learn that a “shockingly high percentage” of all NFL players will develop CTE, but this may over-rely on the skewed nature of the first 111 autopsies.

Critics lacking public health training are routinely making four illogical claims to “manufacture doubt” about this emerging issue.

First, I was buffeted with repeated claims that “some players never developed CTE despite long careers.” I hope it’s obvious that this is a completely useless fact. A risk factor never has to result in disease or injury among everyone for it to cause grave harm in a few or in many victims; that’s the very definition of “risk” (as opposed to certainty).

Imagine the claim that “smoking can’t cause lung cancer because I heard of someone who smoked for 60 years and died in a car crash” and the derision that would, or at least should, dismiss that fallacy. Similarly, our draft OSHA study was criticized because we didn’t mention the mirror-image observation — that it may be possible to develop CTE without ever having experienced repeated head trauma. Again, change this utterance to “smoking can’t cause lung cancer because radon can,” and one should shudder at the illogic.

Besides, it’s not even clear that a single human being has ever developed CTE without some history of head trauma: the Mayo Clinic examined 264 specimens from a brain bank, and found CTE in 21 of the 66 persons who had been contact-sport athletes, but not in even a single one of 198 matched control subjects without contact-sport experiences.

Other skeptics, using two similar spasms of illogic, actually argue that although CTE is associated with devastating symptoms, the brain lesions themselves may be “tiny abnormalities [that] might not have any specific clinical significance.” Again, anecdotes about a specific person with CTE lesions and no symptoms, or the opposite fact that many people can have similar symptoms without CTE lesions, are just noise, not signals of anything relevant.

And it turns out, we can learn much about the true risk of CTE among football players by starting with, though not accepting at face value, the series of 110 case reports. We can readily estimate thelowest possible risk, simply by exploring the unrealistic best-case scenario that not a single additional CTE case will ever be found among the rest of the players who were in the League at the same time as the 110 were.

Using individual player data from the NFL on the number of his team’s snaps each player was on the field for, and on the length of his career in the League, I estimated that there was a total of about 12,000 player-careers worth of on-field activity (about 26,000 different players suited up during this time period, but many of them played only occasionally and in a very few games). So 110 cases out of 12,000 players yields a best-case risk of 0.0092, or just under a 1 percent risk.

A 1-in-100 chance (at the bare minimum) of a grave disease caused by environment or occupation is a huge risk that any law or regulation would deem unacceptable. The Supreme Court instructed OSHA in 1980 that occupational disease risks above one chance per thousand must be worthy of regulation, and Congress has instructed the EPA in various laws to regulate cancer and other risks exceeding one chance per million.

What, then, could OSHA do to reduce this significant risk of disease, in football and in other occupations (logging, commercial driving, the military) where repeated head trauma is commonplace? OSHA could propose regulatory limits for the cumulative head-trauma forces workers could undergo, just as it has regulated various chemicals based on case series of as few as seven workers afflicted with cancer or sterility, and having a common exposure.

Observations From ICU Patients We Thought Were Asleep but Were Not

http://bit.ly/2D5aeLq

This is an audio recording that is 25 minutes long….

Download MP3           Subscribe to Podcast

What if the patient you are managing in the ICU is not asleep when you thought they were? Patients relate their very disturbing stories about what they experienced while in an ICU and their treating clinicians thought they were asleep.

Major study: Drug overdoses over a 38-year period reveal hidden trends

This is appalling. The increase of 9 times in overdose deaths is in the rate, not the numbers. Since there are more people now than in 1980, the total number of deaths is much more than 9 times what it was in 1980. So much for the war on drugs…

http://bit.ly/2EKbYeD

It’s just the current cycle that involves opiates, but methamphetamine, cocaine, and others have caused the trajectory of overdoses to head the same direction.

  • It appears that overdoses are increasing exponentially, no matter the drug itself
  • If the study bears out, it means that even reducing opiates will not slow the trajectory.
  • The causes of these trends remain obscure, but near the end of the write-up about the study, a hint might be apparent

A new study has just been published in Science.Org magazine detailing the progression of addiction in the United States from 1979 to 2016.

Named “Changing dynamics of the drug overdose epidemic in the United States from 1979 through 2016,” it records the deaths from 600,000 overdoses during that 38-year period.

The results are more disturbing because one fact emerges: no matter the drug of choice for those who overdosed, or even the demographic backgrounds of those who overdosed, the mortality rate has increased every year since 1979.
Even more alarming: Even if, for example, the current opioid crises begins to be dealt with, the trajectory is such that deaths from that same drug would not lessen.

Indeed, more than 70,000 died from overdoses in 2017, and nearly 70% of those are/were from heroin, opioids, and fentanyl, according to the Centers for Disease Control and Prevention.

From the abstract:

“Better understanding of the dynamics of the current U.S. overdose epidemic may aid in the development of more effective prevention and control strategies. We analyzed records of 599,255 deaths from 1979 through 2016 from the National Vital Statistics System in which accidental drug poisoning was identified as the main cause of death. By examining all available data on accidental poisoning deaths back to 1979 and showing that the overall 38-year curve is exponential, we provide evidence that the current wave of opioid overdose deaths (due to prescription opioids, heroin, and fentanyl) may just be the latest manifestation of a more fundamental longer-term process. The 38+ year smooth exponential curve of total U.S. annual accidental drug poisoning deaths is a composite of multiple distinctive subepidemics of different drugs (primarily prescription opioids, heroin, methadone, synthetic opioids, cocaine, and methamphetamine), each with its own specific demographic and geographic characteristics.”

Near the end of the study, one of the key items that stands out is that “Sociological and psychological ‘pull’ forces may be operative to accelerate demand, such as despair, loss of purpose, and dissolution of communities.”

In other words, the loss of good jobs with benefits, as well as neighborhoods where people felt like they lived among an actual community, are impacting overdoses and addiction.

 

The Isolation of Being Deaf in Prison

http://bit.ly/2D7dPJ7

“I didn’t have a way to communicate. And they basically just flipped me the bird.”

When I was in state prison in Georgia in 2013, I heard about a class called “Motivation for Change.” I think it had to do with changing your mindset. I’m not actually sure, though, because I was never able to take it. On the first day, the classroom was full, and the teacher was asking everybody’s name. When my turn came, I had to write my name on a piece of paper and give it to a guy to speak it for me. The teacher wrote me a message on a piece of paper: “Are you deaf?”

“Yes, I’m deaf,” I said.

Then she told me to leave the room. I waited outside for a few minutes, and the teacher came out and said, “Sorry, the class is not open to deaf individuals. Go back to the dorm.”

I was infuriated. I asked several other deaf guys in the prison about it, and they said the same thing happened to them. From that point forward, I started filing grievances. They kept denying them, of course. Every other class—the basic computer class, vocational training, a reentry program—I would get there, they would realize I was deaf, and they would kick me out. It felt like every time I asked for a service, they were like, fuck you, no you can’t have that. I was just asking for basic needs; I didn’t have a way to communicate. And they basically just flipped me the bird.

While I was in prison they had no American Sign Language (ASL) interpreters. None of the staff knew sign language, not the doctors or the nurses, the mental health department, the administration, the chaplain, the mail room. Nobody. In the barbershop, in the chow hall, I couldn’t communicate with the other inmates. When I was assaulted, I couldn’t use the phone to call the Prison Rape Elimination Act (a federal law meant to prevent sexual assault in prison) hotline to report what happened. And when they finally sent an interviewer, there was no interpreter. Pretty much everywhere I went, there was no access to ASL. Really, it was deprivation.

I met several other deaf people while I was incarcerated. But we were all in separate dorms. I would have liked to meet with them and sign and catch up. But I was isolated. They housed us sometimes with blind folks, which for me made communication impossible. They couldn’t see my signs or gestures, and I couldn’t hear them. They finally celled me with another deaf inmate for about a year. It was pretty great, to be able to communicate with someone. But then he got released, and they put me with another blind person.

When I met with the prison doctor, I explained that I needed a sign language interpreter during the appointment. They told me no, we’d have to write back and forth. The doctor asked me to read his lips. But when I encounter a new person, I can’t really read their lips. And I don’t have a high literacy level, so it’s pretty difficult for me to write in English. I mean, my language is ASL. That’s how I communicate on a daily basis. Because I had no way to explain what was going on, I stopped going to the doctor.

My health got worse. I came to find out later that I had cancer. When I went to the hospital to have it removed, the doctor did bring an interpreter and they explained everything in sign language. I didn’t understand, why couldn’t the prison have done that in the first place? When I got back to prison, I had a lot of questions about the medicines I was supposed to take. But I couldn’t ask anyone.

Mathematica Develops Safe Use of Opioids Measure

http://bit.ly/2EMMnlm

As the nation continues to grapple with the opioid epidemic, numerous federal organizations are focusing on reducing unintentional drug overdoses. Emerging evidence shows that adverse drug events because of concurrent prescribing are a serious problem. Every day, more than 115 Americans die after overdosing on opioids. In fact, according to the National Institutes on Drug Abuse, concurrent use of benzodiazepines with opioids was present in more than 30 percent of fatal overdoses, but many people continue to be prescribed both drugs simultaneously. Although no national hospital-level measure of the problem exists, according to the Veterans Health Administration, implementing a measure to assess the concurrent prescribing of opioids and benzodiazepines via its Opioid Safety Initiative has helped improve patient safety in veteran health facilities.

To help measure nationwide rates of concurrent prescribing, Mathematica developed the Safe Use of Opioids – Concurrent Prescribing electronic clinical quality measure on behalf of the Centers for Medicare & Medicaid Services. This measure assesses the percentage of adult patients who were prescribed two or more opioids or an opioid and benzodiazepine concurrently after a hospital discharge. The measure aims to reduce preventable mortality and the costs associated with adverse events related to concurrent opioid and benzodiazepine use by doing the following:

(1) Encouraging providers to identify patients with concurrent prescriptions of opioids or opioids and benzodiazepines

(2) Discouraging providers from prescribing two or more opioids or opioids and benzodiazepines concurrently whenever possible

“Developing this measure can raise providers’ awareness of the adverse effects from prescription opioid use,” explained Cindy Cullen, associate director at Mathematica. “In addition to averting potentially tragic outcomes, this opioids co-prescribing measure might also help reduce health care costs.”

The measure aligns with the 2016 Centers for Disease Control Guidelines for Prescribing Opioids for Chronic Pain and opioid prescribing guidelines issued by several state agencies and professional societies. These organizations’ guidelines support the recommendation to avoid concurrently prescribing multiple opioids or opioids and benzodiazepines whenever possible, as the combination of these medications could foster opioid-induced respiratory depression. The National Quality Forum’s Patient Safety Committee endorsed this measure in May 2018.

How does stress affect the brain?

http://bit.ly/2D6FUAe

The stress hormone affects memory

In their study, the researchers worked with participants with an average age of 49 and no diagnosis of dementia.

At baseline, the investigators asked each participant to undergo a psychological exam. They also assessed each participant’s memory and thinking abilities. For the purpose of the study, they assessed these abilities again after an average period of 8 years.

Furthermore, at the beginning of the study, all the volunteers provided blood samples. The team collected them in the morning, after an appropriate fasting period, so that the blood test results would be accurate.

Specifically, the researchers were interested in measuring the participants’ levels of blood cortisol, which is a hormone released chiefly in response to stress. After assessing cortisol levels, the investigators divided the participants into groups according to their results.

The researchers found that people with high levels of blood cortisol had much poorer memory when compared with peers with normal cortisol levels. Importantly, impaired memory was present in these individuals even before obvious symptoms of memory loss set in.

These results remained consistent even after the investigators had adjusted for relevant modifying factors, such as age, sex, smoking habit, and body mass index (BMI).

“Cortisol affects many different functions,” notes study author Dr. Justin B. Echouffo-Tcheugui, from Harvard Medical School, “so it is important to fully investigate how high levels of the hormone may affect the brain.”

“[S]o it’s important for people to find ways to reduce stress, such as getting enough sleep, engaging in moderate exercise, incorporating relaxation techniques into their daily lives, or asking their doctor about their cortisol levels and taking a cortisol-reducing medication if needed.”

Dr. Justin B. Echouffo-Tcheugui

IL-12/23 Blocker Offers Long-Term Benefits in SLE

Lupus treatment has had such a difficult improvement trajectory that I’m posting this despite its technical challenges….

http://bit.ly/2D64vVY

The monoclonal antibody ustekinumab (Stelara) showed sustained clinical benefits for systemic lupus erythematosus (SLE) through 1 year and may offer a new therapeutic option, according to a researcher here.

At week 24, the SLE Responder Index-4 (SRI4) response rate was achieved by 61.7% of patients randomized to receive ustekinumab compared with 33.3% of those given placebo, a difference of 29% (P=0.0057), reported Ronald van Vollenhoven, MD, of the Amsterdam Rheumatology and Immunology Center in the Netherlands, at the American College of Rheumatology annual meeting.

Ustekinumab inhibits the interleukin (IL)-12/23 pathways, both of which have been implicated in the incompletely understood pathogenesis of SLE. This monoclonal antibody has been approved for use in psoriasis, psoriatic arthritis, and Crohn’s disease.

The last agent to be approved for use in SLE was belimumab (Benlysta) in 2011, and that was the first drug to be approved in half a century. “Drug development has been very bittersweet in lupus,” said Susan Manzi, MD, who is co-director of the Lupus Center of Excellence, Allegheny Health Network, in Pittsburgh. “But ustekinumab looks like a promising treatment,” she told MedPage Today.

The number of patients who experienced a 30% or more improvement over baseline on the physician global assessment was 67.9% at week 24 and rose slightly to 75% at 1 year, while the percentages with an improvement of 50% or more in the number of joints with pain and inflammation remained at 86.5% at both time points. A more pronounced improvement was seen on the Cutaneous Lupus Erythematosus Disease Area and Severity Index, with improvements of 50% or more being seen in 53.1% at week 24 and in 68.6% at 1 year.

More than 60% of patients had sustained responses at 1 year, “and that’s good news,” Manzi commented. “What you don’t want to see is that they get better but then lose the response at 1 year,” she said in an interview.

Triggers, Facilitators and Aggravators: A New Hypothesis of Parkinson’s disease

http://bit.ly/2EHShEv

Parkinson’s disease remains one of the most elusive problems in medical science. Despite all the progress the field has made in recent years, in the vast majority of cases we still don’t know how it starts, what effects its development, and why it looks and feels so different from person to person. More importantly, after billions of dollars and countless hours spent in labs all around the world, we still don’t have any therapies that can modify disease progression.

In a paper just released in Trends in Neuroscience authored by Dr. Michaela Johnson, myself (Benjamin Stecher), Prof. Viviane Labrie, Prof. Lena Brundin and Prof. Patrik Brundin, we have proposed a possible explanation for our inability to make sense of PD.

We believe that part of the reason is that we have spent decades studying Parkinson’s as though it were a single disease with a single cause. To this day labs researching PD still do all that they can to reduce the amount of variability in their models to try and study this as if it were one disease. But walk into any room of people with PD and you will see a wide variety of different symptoms, from tremor to shuffled gait to rigidity to stooped posture to frozen faces, to some unique combination of all of the above. And, if you talk to them about their disease you would hear about chronic pain, sleep disorders, speech problems, hallucinations and much more. How can one disease possibly explain all this variety?

What we propose is that this is not one disease, but rather a cluster of different disorders that have been lumped together under the broad label of Parkinson’s disease. But we are not the first to suggest that Parkinson’s is an umbrella term for a number of disorders. What we propose that is new is that we believe the factors that lead to these diseases can be divided into three categories which we have called triggers, facilitators and aggravators. These factors correspond with different stages in one’s disease and categorize the chain of events that cause Parkinson’s disease and its progression.

‘Triggers’ are the spark that kicks things off. They often take place decades before symptoms develop, and may start in the gut or the nose following an exposure to certain pesticides or infections. However, most people exposed to these triggers will never develop Parkinson’s disease because they don’t have a ‘facilitator’. Facilitators enable the initial trigger to cause further damage, examples include chronic inflammation or certain genetic mutations. If triggers are the spark, facilitators fan the flames. Finally, in order for this harmful process to really snowball an ‘aggravator’ is needed. Aggravators, as the name implies, aggravate the disease process and enable it to cause further damage and spread through the brain.

Note that these three stages do not have hard boundaries between them and some factors may fall into more than one category. Also, there are likely a large number of different triggers, facilitators, and aggravators. This variety may explain why we see so many differences in people with Parkinson’s disease as there may be dozens, if not hundreds, of different combinations that each result in a different set of symptoms and unique disease progression.

This categorization of Parkinson’s disease into three time-dependent phases has important implications for how we treat Parkinson’s disease. If we want to stop the disease early on then we ought to consider targeting triggers or facilitators. But for those that have already developed symptoms the most effective therapies could be those that silence the aggravators of this disease.

How free Lyft rides can dramatically improve life for senior citizens

http://bit.ly/2D1uoWE

On-demand car services can drastically improve the health of senior citizens, according to new preliminary data.

At the USC’s 2018 Body Computing Conference this past Friday, researchers showed how unlimited free Lyft rides can improve quality of life by a whopping 90% for seniors. The research was part of a pilot program announced last fall between Lyft and the University of Southern California Center for Body Computing, which aimed to study and connect senior citizens with transportation. In collaboration with UnitedHealthcare, the AARP Foundation gave a $1 million grant to the Keck Medicine of USC to test the impact of providing free Lyft rides on the health of elderly USC patients within the greater Los Angeles area.

The goal was to see whether accessible transportation greatly affected later-in-life healthcare, socialization, and activity levels. While the final study will not be published until early next year, researchers released preliminary data about its current progress.

“It’s not just missing doctors’ appointments,” Leslie Saxon, executive director of the USC Center for Body Computing, previously told Fast Company. “What really determines survival in an aging population is socialization–it’s any trip out of the house, and how active you are. That is the No. 1 determinant of basically who lives and who dies.”

Several million senior citizens miss medical appointments each year due to a lack of accessible and affordable transportation, with no-show rates hovering at 30% for sub-specialty doctor appointments, according to a 2016 study. Transportation for America (T4 America) found that more than half of the U.S. non-driving population age 65 and over stays home on any given day because they don’t have transportation. They make fewer trips to the doctor (15%), to shop or eat out (59%), and for social, family, and religious activities (65%) than drivers in the same age group.