Today in Ebola

This is big news that 43 people in Texas were recently declared free of Ebola.  This includes the dead man’s fiance, her family, and many caregivers!  Ebola is scary is hell, but this just further shows that it is not actually easy to catch.  The man’s fiance didn’t get it, damnit!  And yet you’ve got people afraid to leave their house or worried that they are on the same cruise ship as somebody completely asymptomatic who carefully handled a blood sample in a lab.  Get a grip already.

Love, love, love the response of this Cleveland man:

AKRON, Ohio — Peter Pattakos spent 20 minutes Saturday in an Akron bridal shop, getting fitted for a tux for his friend’s wedding. Thursday, his friend sent a text message, telling him that Ebola patient Amber Joy Vinson had been in the store around the same time…

Pattakos, 36, a Cleveland attorney who lives in Bath Township, called the health department, which told him to call back if he exhibits any Ebola symptoms. He called a doctor, who told him not to worry.

“I didn’t exchange any bodily fluids with anyone, so I’m not worried about it,” he said. “I’m much more likely to be mistakenly killed by a police officer in this country than to be killed by Ebola, even if you were in the same bridal shop.” [emphasis mine]

A post from Seth Masket on the potential electoral fallout .  It’s just so pathetic to hear Republicans with an incoherent chorus of “Isis, Ebola, and Terrorists, of my,” though I fear it may work:

It’s possible that the current Ebola scare is undermining American’s sense of security and well-being, even while not directly threatening their lives. It’s also possible that this sense of insecurity has become politicized in Americans’ minds, such that they—consciously or unconsciously—blame Obama for the climate of fear and will punish Democrats for it in the election. But what beyond that? Will they credit or punish Democrats for Obama’s handling of the situation? Will they turn to Republicans to protect them during times of crisis?

I honestly don’t expect a particularly large political impact, but to the degree there is one, I think people are scared and unhappy and that is pretty much always the president’s “fault.”  I was pretty happy with my quote in this article:

But is Ebola a legitimate campaign issue or are campaigns engaging in fear mongering? Steven Greene, a professor of political science at NC State University, says it’s a little bit of both.

“I think there are very important issues of public policies related to Ebola that we should have a mature discussion about, but the truth is we don’t have mature discussion about anything in the campaign season so whatever political discussion about this is most likely going to be fear mongering,” Greene said.

Though, I actually don’t think we can have a mature policy discussion outside of election season either.

And lastly, have you wondered why you are not hearing at all from the Surgeon General during all this?  It’s because we don’t have one.  Why don’t we have one?  Because the nominee is under the impression that not only do people kill people, guns kill people.  Obviously he is unqualified for the job and Republicans are right to block him:

On Sunday, Meet the Press host Chuck Todd asked Senator Roy Blunt (R-MO) about the NRA’s role in blocking Murthy’s confirmation, but the Republican senator dismissed the question outright.

Blunt blamed the vacancy on President Obama and Senate Majority Leader Harry Reid (D-NV), who has yet to put Murthy’s nomination to a full vote, and dismissed questions about the National Rifle Association’s efforts to block the nominee.

“The NRA said they were going to score the vote and suddenly everybody froze him,” said Chuck Todd. “That seems a little petty in hindsight, does it not?”

“Well, the president really ought to nominate people that can be confirmed to these jobs, and frankly then we should confirm them, there’s no question about that,” replied Blunt.

Earlier this year, the NRA launched a campaign to derail Murthy’s nomination because he voiced support for expanding background checks for gun purchases. His comments that gun violence was a public health concern raised the ire of the gun lobby and conservative lawmakers despite the fact that every major medical association — and several former Surgeons General under Republican presidents — shared the same view.

Once again it’s the NRA’s America and we’re just living in it.  Public health be damned (though, that’s already pretty obvious when looks at attitudes towards needless gun deaths).

Quick hits (part II)

Sorry these are a little late today.  Spent more time than anticipated watching the terrific Notre Dame vs. Florida State game last night.

1) Really interesting Vanity Fair article that give an account on this Ebola outbreak– unlike all the others- became an epidemic.

2) On a somewhat related note, a FB friend shared this story from last year of how an extremely dangerous bacteria was nearly impossible for the NIH to eradicate from it’s research hospital.  With plenty of scary stuff about the future of antibiotic resistant bacteria.

3) Heck, let’s stick with a theme.  Here’s a Yahoo! story about a robot that uses ultraviolet light to disinfect rooms (the CDC used a robot that filled rooms with hydrogen peroxide gas).

4) Alright, let’s just keep going here.  James Surowiecki putting everything in perspective and reminding us we should be way more scared of the annual flu.

5) A Tennessee woman involved in manufacturing meth got 6 years added to her sentence for being pregnant at the time.  Hmmm, that just doesn’t seem right in a variety of ways.

6) We could use better data on charter schools.

7) True tales from the making of Princess Bride.  Much to my dismay, my 8-year old son refused to like it because of the title.  My almost 4 daughter liked it even though it was over her head.

8) Teenagers should so not be interrogated without a parent or a lawyer.  It is a legal travesty that this happens all the time.  I’ve told David never to talk to the police without a parent.  Never.

9) Garrett Epps on the “undue burden” standard from Casey and how courts are increasingly ignoring it.

10) Republican Congressmen are intent on cutting NSF funding based solely on the title of research.

11) How modern pork production is bad for pigs and not so good for workers, either.

12) NYT Magazine feature on how billionaires are becoming their own political parties.

Quick hits (part I)

1) The New Yorker’s Maria Konnikova on Walter Mischel (the marshmallow self control guy)

2) Really interesting NYT profile of super-far-right Kansas Secretary of State, Kris Kobach

3) That would be so awesome if the ability to effectively grow Alzheimer’s brain cells in the lab actually leads us much more quickly to a cure or effective prevention.

4) So there was a Wire reunion and you can watch it.

5) Vox says this attack ad makes the Willie Horton ad look tame.  I think they are right.  To add insult to injury, the Republicans actually put this policy in place.

6) On what grade level of reading ability are presidents’ speeches over time.

7) Did the pro-life movement actually lead to more single moms?  Maybe.

8) Interesting Ozy piece on how cancer may ultimately be an ineradicable part of life.  Actually reminded me of one of my favorite science fiction works ever, Robert Sawyer’s Calculating God, in which the nature of cancer plays a fundamental role.

9) The keyboards from early IBM PC’s (my dad had one) were simply the awesomest.

10) James Surowiecki on the capitalism and streaming entertainment services.

11) Loved this description of Curb Your Enthusiasm from a recent Larry David appearance:

“ ‘Curb’ is about what’s beneath the surface of social intercourse, the things we think about and can’t say,” David told Remnick. “I’m normal. If I said the things he does”—he, of course, being the Larry David who goes around eating his in-laws’ manger scene, inviting a sex offender to a Seder, and teaching kids how to draw swastikas—“I’d be beaten up. He’s a sociopath!” A pause. “But I’m thinking them!”

So is everyone else, and that’s the brilliance of “Curb.” The show exists to prove how thin the veneer of social custom and courtesy really is, and to reveal the inner sociopath that we are supposed, at all costs, to suppress.

12) 538 looks at which diet will help you lose the most weight.  Easy, the one that is easiest for you to stay on.

13) How to get the right kind of sleep depending upon what your test the next day will be on.  Seriously.

14) Really liked this TNR piece on how judges should respond to burdensome laws on the right to vote and the right to abortion when legislators are so clearly lying about their actual intent:

But if courts cannot, and should not, prove deliberate discrimination, they can still apply objective balancing tests, to weigh the benefits of a law against its costs. When they do, the relevant question changes: judges no longer ask whether a legislature’s motivation was to limit abortion or to protect patient safety, but whether such a law can be justified by a reasonable person who takes both values seriously. In an important sense, this inquiry is far less fraught and far more coherentno mind-reading necessary.

15) Andrew Sullivan on the latest out of the Vatican

Why I medicate my kids with medicines that don’t work

Placebo effect!  And a topic I’ve hit many times.  Great summary on the power of the placebo effect by Austin Frakt in the Upshot.  I love how he starts be telling his story of being in the ER and telling his nurse to just tell him she’s putting an opiate in his IV whether it is true or not.  Plus more good stuff:

In comparing a treatment with a placebo, we should also keep in mind that the placebo is not the same thing as the absence of treatment. In research settings, placebos are specifically designed to mimic treatment without the hypothesized few “active” ingredients or procedural steps. They still include a lot of components of care. (Another form of clinical trial is to compare one treatment with another or with “usual” care — the care that would be given in the absence of the treatment being tested.)…

The question addressed by placebo-controlled trials is whether the second effect — the placebo effect that operates only through belief — is the only effect of a given treatment. Does the “active” part of the treatment do anything more? The possibility that placebos cure is therefore acknowledged and built into placebo-controlled study designs…

Taking two placebo pills (e.g., sugar pills) relieves more pain or provides a greater stimulative effect or is more sedating or heals stomach ulcers more quickly (depending on the study) than taking just one…

If placebos were always the same as no treatment, then the following findings, most of which are summarized by the emergency physician David Newman in his book “Hippocrates’ Shadow,” would be hard to explain:

■ Placebo pills with a brand name printed on them are more effective at pain reduction than the same pills without the brand name.

■ Placebo pills with a brand name printed on them are more effective at pain reduction than the same pills without the brand name.

■ Patients who faithfully take placebo medication for cholesterol reduction survive longer than those who skip doses.

■ Though sham acupuncture reduces migraines as much as real acupuncture, both reduce migraines far more than no treatment at all.

■ Measurements of increased endorphins — our bodies’ natural pain relievers — have been associated with placebos’ ability to reduce pain.

Anyway, with my youngest son, Evan, suffering from quite the cough this week it got me to thinking about how I always give him cough syrup even though I know the evidence is clear that it is no better than a placebo.  The thing is, no better than a placebo does not mean no better than no treatment.  I don’t know if anybody has every looked at the placebo effect in kids in adults, but my intuition suggests it is even stronger in kids (as anybody who has ever kissed a boo-boo knows).  Thus, I will keep giving my kids medicine that might not actually work because there’s a lot to be said for the placebo effect and I don’t actually have any sugar pills.

When to treat

Really, really loved this Wired article about a physician who insists on being relentlessly empirical and evidence-based in determining the best course of treatment for his patients.  So much of our medical treatment is entirely unnecessary (as nicely detailed in the terrific book, Overtreated).  David Newman bases much of his practice of medicine based on a concept called NNT:

Developed by a trio of epidemiologists back in the ’80s, the NNT describes how many people would need to take a drug for one person to benefit. (The NNT for antibiotics in a case of acute bronchitis is effectively infinity, because the medicine is no better at curing the illness than a placebo.)

Consider a couple other examples: If your kid is throwing up and you take her to the hospital, she might get a drug called Zofran. The NNT for that is 5, meaning that only five kids need to take Zofran for one of them to stop throwing up. And if you look at Zofran’s “number needed to harm” (the number of people who would need to take a drug for one to have a bad side effect) the answer is … well, there really isn’t one—no one has a significant side effect.

Now, say you’re pushing 50. You’re healthy, but your doctor suggests you start taking a baby aspirin. Just in case, you know? That NNT is 2,000. That’s how many people have to take a daily aspirin for one (nonfatal) heart attack to be prevented. Statistically speaking: Not especially helpful.

They don’t have the NNT here for the PSA, but I’m damn sure it’s not good.  I think I have a favorite new medical care statistic (replacing mortality amenable to health care).  Check that– the article doesn’t have the PSA NNT, but I went over to the awesome NNT website and started playing around.  The NNT for the PSA is infinite (no benefit) whereas the number needed to harm is 5.  Um, yeah, no PSA.  Meanwhile, one of my friends just started warfarin for atrial fibrillation, and that gets the green light.  (NNT of 25).

Anyway, back to Wired, because there was more of the article worth sharing:

Newman has just arrived at work in the emergency department where he’s an attending physician, and he’s giving his residents the “Three Networks” spiel.

“ABC, always be closing. You want to be moving patients back home or into the hospital for treatment. At the ER, the front door is always open, but if the back door is closed, and you have people mounting up, things get missed, heart attacks occur, sepsis gets worse, and people die. Always be closing.” Then comes NBC, never be consulting—don’t call specialists if you can avoid it. Then CBS, close before signoff. There’s good evidence that medical errors are more likely to occur with handoffs. Discharge your cases before the end of your shift to avoid these errors, he tells his charges…

Newman wants to use science to protect his patients from treatments that are not justified by research and evidence, and he wants to impart that science to young medical residents. So he’s constantly grilling them on the assumptions that underlie their recommendations and diagnoses…

Habits—whether based on old literature, biased studies, or just educated hunches that get ingrained in protocol—die hard.

Indeed, more than 90 percent of doctors believe that their colleagues practice this kind of “defensive medicine,” according to a survey published in the Archives of Internal Medicine. You do what’s done because it is considered to be the so-called standard of care. And not adhering to the standard of care can be considered negligence if something goes wrong and you get sued for malpractice. The unfortunate result of this contorted logic, according to the Institute of Medicine, a policy research organization, is that the US spent $210 billion on unnecessary services in 2011 (some 8.4 percent of the more than $2.5 trillion we spend annually on health care), and untold numbers of patients are subjected to pain, anxiety, and even death as a result. The NNT could help prevent a lot of that suffering—physical, mental, and financial…

If Newman’s site continues to expand beyond its current number of about 200 write-ups, and if the NNT were included with every published article about a treatment, the result would be happier, healthier patients and less waste in our health care system.

Great stuff.  This won’t be easy because we are talking about changing a culture, and that’s never easy.  But we all stand to benefit if we do.  And given how much of health care expenses are paid by the government, there’s potentially a big role for public policy in making this happen (we could start with no Medicare reimbursement for red-light treatments).

Today in Ebola

Very interesting perspective on over-reaction to Ebola from a physician in Slate:

So what’s the problem with a little overvigilance? The answer lies in systemic capacity.

Every day, well more than 50,000 transatlantic passengers arrive at the New York metropolitan area’s airports. If any of these passengers become sick, they appear to be fair game for the spectacle we saw in Newark and Los Angeles.

Moreover, we are entering flu season. The previous three months have been the lowest of the year for emergency department visits for flu-like illnesses, as is usual during the summer months. Last year the number of ER visits for flu-like illnesses in New York City swelled sixfold during the height of the flu season, from a low of fewer than 80 visits per day to a zenith of nearly 500 visits per day.

If the Ebola detection system continues to widen its net during flu season and to provide airborne isolation precautions for suspected Ebola patients following the spectacular example the CDC has set in public, we will quickly fill the approximately 200 negative-pressure airborne isolation rooms in New York City emergency departments. This will make it harder to isolate patients who truly require these facilities—including the hundreds of laboratory-confirmed cases of airborne diseases tuberculosis, varicella, and measles we treat annually.

The new case in Texas underscores this point: We need to focus on properly adhering to prevention techniques that we know decrease the spread of this disease. We should not add burdensome extras that look good for the media, do nothing for safety, and scare other patients away who need immediate medical evaluation…

Currently, many of your top doctors and health care policy leaders are doing a poor job of distinguishing between systemic readiness and panic. I invite laypeople to encourage their health care providers and government agency leaders to remember this crucial distinction, both for this current epidemic as well as the inevitable next one.

I gotta say, it’s pretty scary that a health care worker in Dallas who was using all the proper equipment still got sick.  But we sure cannot afford to treat everyone who comes into the hospital with a fever or flu-like symptoms as if they have Ebola.

Would we have an Ebola vaccine

if NIH funding hadn’t been cut?  The Director thinks so.  First, the chart:

francis collins

Dr. Francis Collins, the head of the National Institutes of Health, said that a decade of stagnant spending has “slowed down” research on all items, including vaccinations for infectious diseases. As a result, he said, the international community has been left playing catch-up on a potentially avoidable humanitarian catastrophe.

“NIH has been working on Ebola vaccines since 2001. It’s not like we suddenly woke up and thought, ‘Oh my gosh, we should have something ready here,'” Collins told The Huffington Post on Friday. “Frankly, if we had not gone through our 10-year slide in research support, we probably would have had a vaccine in time for this that would’ve gone through clinical trials and would have been ready.”

It’s not just the production of a vaccine that has been hampered by money shortfalls. Collins also said that some therapeutics to fight Ebola “were on a slower track than would’ve been ideal, or that would have happened if we had been on a stable research support trajectory.”

“We would have been a year or two ahead of where we are, which would have made all the difference,” he said.

But, hey, why worry about funding something as trifling as public health when there are millionaires who need to pay less in taxes and battleships to be built.


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