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.

Quick hits (part II)

1) John Dickerson on how fundraising emails encapsulate everything wrong with politics:

Perhaps it’s effective, but there’s a larger point to be made about political fundraising emails: They are a bouillon cube of all that is awful about American politics—the grasping for money, the neediness, the phony plays on your emotion, the baiting, and reduction of anything complex into its most incendiary form. What makes these emails bad is not the breadth of their insult—you can opt out of receiving them, which makes them easier to avoid than a television commercial—but what it says about the people who send them. Here’s the short version: They think you’re stupid.

2) Personally, I love Common Core math.  I love that my boys are asked not just to apply algorithms, but actually understand what they are doing and really think about math.  Here’s a nice Vox post explaining the virtues of this approach.  Also, so embarrassed to admit I missed this math problem (but I am so inside the box I don’t even know I’m in the box).

3) This piece by Sahsa Issenberg about changing minds on gay marriage and what they may tell us about changing minds on abortion was really fascinating.  Long, but worth it.

4) Amy Davidson on Texas’ abortion law nicely takes about the “not a large fraction” argument.  And TNR’s Jen Gunter looks at the patient safety argument.

5) Yeah, so our kids totally need grit and persistence.  We just haven’t quite figured out how we are supposed to teach them.

6) In case you haven’t seen this alternate ending to Titanic that’s gone viral.  It truly is awful.

7) So love this Onion headline:

Yard Sign With Candidate’s Name On It Electrifies Congressional Race

8) Paul Waldman on our failure to actually learn in our dealings in the Middle East.

9) Sharing your chocolate makes it taste better.

10) Sensationalist coverage of foreign policy makes Americans more hawkish.

11) Adam Gopnik on the power of images in terrorism.

12) This Onion headline so captures some awkward experiences I’ve had:

Coworkers Each Putting In Herculean Effort To Sustain Conversation For Entire Commute

13) Of course teachers should have serious apprenticeships rather than just 6 weeks of student teaching.  Let’s do this.

14) Awesome interactive Smithsonian feature on the Anthropocene era we are living in.

15) The latest in the Post’s terrific series on the abhorrent police practice of stealing innocent people’s cash because, you know, drug dealers use cash, too.


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