What Are The Chances?

I was told a story about a person who was watching House and saw a case where a patient had heart palpitations when anyone put pressure on his abdomen. The patient on House had a pheochromocytoma.

This person went into her doctor's office and claimed that she too had a pheochromocytoma and described her symptoms and how they were similar to the case she saw on House.

I'm guessing 99% of the time when a patient presents at their doctor's office with a diagnosis they came too while watching a fictional tv show...they are wrong. This is even more likely when the diagnosis is as incredibly rare as a pheochromocytoma. There are endocrinologists who go their entire career without seeing a SINGLE case of pheochromocytoma.

Turns out this woman was right and she did have this incredibly rare disease. Seriously, what are the chances?

Hackers Guide to H1N1

I came across a guide to hacking influenza. It creates an impressive analogy comparing DNA to hard disk memory, RNA to RAM, and amino acids to pixels.

The guide discusses how to theoretically hack influenza, making the current strain of H1N1 substantially more dangerous. The post goes on to describe how influenza may well figure out how to perform the aforementioned hack on itself. However, I suspect that if that particular genetic modification made influenza more infectious, it would have already happened by now. If influenza was more infectious, it would infect more people (obviously!), and this would make it more evolutionarily fit because it would be passing on its genes at a higher rate. Thus, since we don't see the hack in the real world, it may be because that particular genetic change makes the influenza less infectious. This same phenomena is seen in HIV. HIV can become resistant to medication, which seems like a genetic advantage, but sometimes when medication is stopped, the HIV infection loses its resistance to the drugs. This is because the non-resistant HIV strain is more evolutionarily fit than the resistant strain and out-competes the resistant strain if it is not hampered by medication. (If this makes you want to stop your HIV meds...DON'T...Go talk to your doctor first!!!)

The guide describes how influenza is made up of genetic compartments and co-infection of a host by two strains of influenza can lead to the creation of novel influenza strains.

Consider what happens when a host is infected by two types of Influenza at the same time. If the genes were stored as a single piece of DNA, there would be little opportunity for the genes between the two types to shuffle. However, because Influenza stores its genes as 8 separate snippets, the snippets mix freely inside the infected cell, and are randomly shuffled into virus packets as they emerge. Thus, if you are unlucky enough to get two strains of flu at once, the result is a potentially novel strain of flu, as RNA strands are copied, mixed and picked out of the metaphorical hat and then packed into virus particles. This process is elegant in that the same mechanism allows for mixing of an arbitrary number of strains in a single host: if you can infect a cell with three or four types of influenza at once, the result is an even wilder variation of flu particles.

This mechanism for genetic variation leads to the most dangerous influenza outbreaks. Imagine two strains of influenza, strain A infects humans and pigs and strain B infects pigs only. Strain A is relatively harmless to humans because we have been exposed to it for a long time and our immune systems have learned how to fight it. Strain B is harmless to humans because it does not contain the required proteins to infect us. However, if a pig was infected by strain A and strain B and the strains shared genetic information, then a new strain, strain C, may be created sharing genetic components from both strain A and strain B. Strain C can be especially dangerous because it may have proteins from strain A that make it infectious to humans, but the proteins from strain B are completely unrecognized by the human immune system, meaning we have little immune defence against strain C. This is what happened with swine flu, avian flu, and the Spanish flu.

Another interesting point brought up in the guide is using influenza as a biological weapon. Theoretically a very scary and dangerous possibility. However, it would be ridiculously difficult to control a weapon like that. Influenza can rapidly spread across the globe, even when the entire world is prepared and trying to stop it. A "surprise attack" with influenza would probably be very difficult to contain and the attacker would be putting himself in grave danger too!

Can You Recognize Primary Care When You See It?

Wired has an article discussing the market advantage of cheap, simple solutions over more expensive, feature rich products. The thesis of this argument is that we consumers prefer the quick, easier option most of the time and only rarely desire the more detailed, fancy choice. Their first example describes how photography enthusiasts may demand the more powerful DSLR cameras, but the average person prefers the simple point and shoot cameras for their ease of use and lower price point.

Another example they describe is the new Kaiser Permanente "microclinics". Kaiser Permanente is described as

the largest not-for-profit medical organization in the country, Kaiser has long relied on a simple strategy of building complete, self-sustaining hospitals—employing 50 doctors or more—in each region it serves.

These microclinics are run by two doctors and set up in strip malls. They share electronic medical records with larger regional Kaiser Permanente hospitals, but do not contain a radiology department, pharmacy, or any additional features you would expect from a hospital. The wired article reports that

What they found is that the system performed very well. Two doctors working out of a microclinic could meet 80 percent of a typical patient's needs. With a hi-def video conferencing add-on, members could even link to a nearby hospital for a quick consult with a specialist. Patients would still need to travel to a full-size facility for major trauma, surgery, or access to expensive diagnostic equipment, but those are situations that arise infrequently.

This microclinic is being heralded as an amazing step to reducing costs and simplifying health care for patients. However, I don't understand how this is different from primary care? Aren't these "microclinics" simply doing the job of a family physician? Family physicians are easeier to access than specialists in the hospital (or at least they should be!). They provide preventative care and establish a long term relationship with their patients. They treat the average patient's needs and consult with specialists in the scenarios that are beyond their professional scope. This is the role of a general practitioner. They are vital to our health care system, but I don't think the general public sees their importance. Patients sometimes even view their family physicians as obstacles to reaching specialists who are the "real doctors". This could not be further from the truth.

I strongly believe that strengthening primary care will reduce overall costs of health care, but I think primary care needs to do a better job of marketing themselves so the public understand their value. Otherwise, you get articles like this, that praise Kaiser Permanente for re-inventing the wheel.

Need Up-To-Date Research...Now?

The Public Library of Science has released a new website, PLoS Currents, to rapidly share research pertaining to influenza in response to global fears regarding H1N1.

The website is a joint venture with google that allows researchers to present their results to the world while side-stepping the lengthy publishing process. The research articles are looked over by expert moderators; however, the articles are not peer-reviewed in detail (peer-review is usually the rate determining step for publishing). Peer-review allows fellow researchers in the same field criticize the methodology, analysis, results, and conclusions of a research project. It is a check and balance in the scientific community. Peer-review ensures that an unjust conclusion that may incite unnecessary fear is not released to the general public.

However, the peer-review process certainly delays the distribution of scientific knowledge. A delay that may have disastrous consequences in the presence of a global pandemic.

I'm interested in seeing if the lack of a peer-review process results in PLoS Currents doing more harm than good with regards to rapidly spreading scientific knowledge. The PLoS openly states that results on their Currents website should be considered preliminary and they do point out that the articles have not been peer-reviewed, however, readers may not heed this warning. I believe that a hybrid publication system, involving immediate publication and peer-review, would be a huge win for everyone; I just hope it works.

Ice Water Recovery

Ice water recovery is a method of exercise recovery used by many elite athletes. UFC fighter, Tito Ortiz, and Jenna Jameson provide an example in this video.

A good discussion about ice water recovery and the scientific theory behind it can be found in this article at Shark Fitness. To be honest, I haven't gone through the sources cited in the article, but some of the logic doesn't make sense at first glance. For example, the article states that ice baths are thought to,

Constrict blood vessels and flush waste products, like lactic acid, out of the affected tissues

How does that make sense? The ice bath will surely constrict blood vessels, but how does it "flush waste products"? If the blood vessels are constricted, then the blood will have a harder time leaving the tissue. The blood transports the waste through your body, so if it can't leave your muscle tissue, the waste won't leave either.

Discrepancies like this make me very skeptical about the recovery value of ice baths. As the article says, most studies regarding ice water recovery offer inconclusive or contradictory findings. I would really hate to go through all that if it doesn't really help!

In Response To "Is it fair to compare American health care with systems in Europe or Canada?"

I found an interesting article on KevinMD written by Ralph Silverman, a colorectal surgeon who blogs at The Colon Doctor.

Dr. Silverman discusses his thoughts on comparing American health care with systems in Europe and Canada. He attributes America's lower life expectancy, compared to Canada and Europe to a lack of healthy living, as opposed to a broken health care system. Saying,

American patients...are more obese than patients in other countries. We eat a diet high in fat and carbohydrate content. As a population, we smoke like there’s no tomorrow. We drive everywhere we go and don’t get any exercise. Instead of exercising to control our blood pressure or diabetes, we sit on the couch and take a pill. We eat ice cream and cake, and then take some insulin to bring down our sugar levels

I agree with Dr. Silverman because preventative care has been shown to be the best way to improve patients' quality of life. However, earlier in the article, Dr. Silverman explains that American's shouldn't expect universal health care just because Canadians and Europeans have universal health care,

It is true that those countries [Canada and Europe] do have universal health care, but is it a fair comparison?

Who does Canada rely on to defend its borders? When the Germans invaded France in World War II who stormed the beaches at Normandy? The point is, these countries rely on the United States for security when peace is compromised. America allocates trillions of dollars to defend both itself and the rest of the world. No other country does this. That money could easily be used for universal health care.

Discussing the "these countries rely on the United States for security when peace is compromised" issue would taint this post with a political slant that has nothing to do with the fallacy of Dr. Silverman's argument, so I will leave it alone. However, the crux of Dr. Silverman's argument in the above quote is that America could easily provide universal health care, but it must spend that money on other expenditures, like defence. Thus, American's should not expect the same health care that Canadians and Europeans receive because Canadians and Europeans have fewer financial burdens, allowing them to spend more on universal health care.

Reuters illustrates the argument against Dr. Silverman's statement quite nicely.

Here is a comparison of the United States' health care costs versus those of selected other countries in 2006:

UNITED STATES: 15.9 pct of GDP, $6,657 per capita

BRAZIL: 7.9 pct of GDP, $371 per capita

CANADA: 9.7 pct of GDP, $3,430 per capita

CHINA: 4.7 pct of GDP, $81 per capita

FRANCE: 11.1 pct of GDP, $3,807 per capita

GERMANY: 10.7 pct of GDP, $3,628 per capita

INDIA: 5.0 pct of GDP, $36 per capita

ISRAEL: 7.9 pct of GDP, $1,533 per capita

JAPAN: 8.2 pct of GDP, $2,936 per capita

MEXICO: 6.4 pct of GDP, $474 per capita

SOUTH AFRICA: 8.7 pct of GDP, $437 per capita

SWEDEN: 8.9 pct of GDP, $3,598 per capita

RUSSIAN FEDERATION: 5.2 pct of GDP, $277 per capita

UNITED KINGDOM: 8.2 pct of GDP, $3,064 per capita

America probably does spend much more money on defence than Canada and Europe. However, that does not help the argument against universal health care. The countries that offer their citizens universal health care (e.g. Canada) spend significantly less per capita on health care than the United States. The American health care system is broken and needs to be reorganized. People aren't lobbying for more money to be thrown at the problem. They are lobbying for a more intelligent system.

Again, living healthy is paramount and pushing Americans to clean up their diets and improve their attitudes about exercise is very important, maybe even more important than health care reform. However, claiming that America can't offer universal health care because it spends so much money on defence just doesn't add up.

The Unfortunate Truth About Developing New Treatments

Our health has improved significantly due to advancements in medicine. We now live longer, better lives than we ever did before; however, most of these improvements took advantage of the sick and desperate.

Whenever a new drug, therapy, or treatment is developed, it must go through several phases of testing to ensure that it is effective, safe, and we understand its side effects. To achieve the most accurate results possible, we perform double blind testing. This form of testing involves at least two drugs, the new drug being tested and either the drug that is currently used to treat the disease or a placebo. Multiple drugs are required to provide a comparison to judge the new drugs efficacy.
Double blind testing avoids biased result because neither the patient nor the physician know which drug the patient is taking.

Thus, once a patient decides to participate in a clinical drug trial, there is approximately a 50% chance that the patient will be given either a placebo or an old drug that is known to be ineffective. With more pathogenic illnesses this can severely reduce a patients quality of life or even result in their death.

Normally the results of these studies are closely watched and if the investigators notice that one treatment method is significantly better than another they often switch all patients to the superior treatment. However, the patients on the inferior treatment will have already suffered significantly.

This means that many advancements in medicine required taking advantage of the desperation of very ill patients. If these patients were not desperate enough to go through clinical trials (wherein they may have been given a placebo), then the treatments would never have been tested and thus never approved for general use. Unfortunately, this is still the best method of treatment approval available to us today. Hopefully one day we will be able to perform robust drug testing without requiring patients to suffer phase 3 clinical trials...but that doesn't seem possible in the near future.