Links for Tuesday, November 21, 2017: more on the new HTN guideline, Gymnastics coaches throwing robot shade, the last iron lungs, Germany bans smartwatches, and Raymond Chandler hated US healthcare

Thoughtful post on the new HTN guideline by Dr. Allen Brett

Representative quote: "Consider, for example, a healthy white 65-year-old male nonsmoker with a BP of 130/80 mm Hg, total cholesterol level of 160 mg/dL, HDL cholesterol of 60 mg/dL, LDL cholesterol of 80 mg/dL, and fasting blood glucose of 80 mg/dL — all favorable numbers. The calculator estimates his 10-year CV risk to be 10.1%, making him eligible for BP-lowering medication under the new guideline. To my knowledge, no compelling evidence exists to support drug therapy for this person."

A gymnastics coach says the Boston Dynamics robot flip was a 3.5/5.0

'In a back salto, says Mazloum, “you want to be able to go as high as you can, and you want to be able to land as close to where you take off as possible.” To do that, the gymnast has to squat, throw her arms up by her ears so her body is a straight line (in gymnast-speak, opening the shoulder angle and the hip), then contract into a “closed” position again. By these standards, Atlas’ trick is “not the cleanest flip,” explains Mazloum.

Here’s Mazloum’s critique: Atlas didn’t quite get to that open position, “so it didn’t really get the full vertical that we look for. That’s why it went backwards a little bit.”'

The last of the iron lungs

Get your kids vaccinated for polio, folks.

Germany has banned smartwatches for kids

If I understand this correctly, it is not because smartwatches cause kids to be distracted monsters (although I don't doubt that that statement is at least a little bit true). The decision stems from the capability of bad guys to hack in and monitor the location of little Dick and Jane:

You have to wonder who thought attaching a low-cost, internet-enabled microphone and a GPS tracker to a kid would be a good idea in the first place. Almost none of the companies offering these “toys” implement reasonable security standards, nor do they typically promise that the data they collect—from your children—won’t be used be used for marketing purposes. If there ever was a time to actually sit down and read the terms and conditions, this was it.
Get your shit together, parents.

Asking parents to destroy them might be a bit of an overreaction, though.

Raymond Chandler paints a dark picture of American healthcare in a newly-discovered story

The title, "It’s All Right – He Only Died," sounds like the title of a video residencies would show interns to convince them that quality improvement and patient safety are part of their job.

The doctor who turned away the patient, Chandler writes, had “disgrace[d] himself as a person, as a healer, as a saviour of life, as a man required by his profession never to turn aside from anyone his long-acquired skill might help or save”.

 

Links for Wednesday, November 15, 2017: the new definition of hypertension, preventing bike accidents by driving, podcast brain-fry, and webside manner

Your new definition of hypertension is....130/90 mmHg

I remember an anthropologist in college making fun of an economist, saying the economists never changed the questions on tests, only the answers. This seems like that. But the guideline includes more organizations than I can shake a stick at:

orgs.PNG

So it has consensus going for it, I guess. And I like that it makes HTN treatment more like cholesterol treatment: initiation and targets are linked to 10-year vascular disease risk, which can be calculated here.

With a risk >/=10%, you get drugs if your BP is 130/80 mmHg or above. With a risk <10%, and you get lifestyle management alone. Everyone gets drugs at 140/90 mmHg:

HTN algorithm.PNG

"90 percent of bike accidents could be prevented by buying a car like a normal person."

I LOL'ed. 

Are podcasts frying my brain? Are they worse than silence?

I'm on board for recommendations on sleep. If we could get by with less sleep than ~7-8 hours, I figure Mother Nature would have mutated the need out of us long ago. But even though I'm a social media skeptic, I just can't quite bring myself to think that podcasts are bad for me. Maybe I love them too much. But humans are social animals, and in many cases we're put in situations where social interaction just isn't practical. Podcasts fill some of that gap for me. And I agree that the reason podcasts light up people's brains on fMRI is because fMRI is so boring to begin with:

“One of the problems you have in MRI experiments is oftentimes they are very boring,” Gallant said on Freakonomics. “If you put somebody in an MRI scanner, which is a very uncomfortable place to be, and then you flash a word at them every five seconds for an hour, they get bored out of their skull.”

To me, an apt, potentially enlightening, comparison is podcast listening versus phone calls. We know that even hands-free phone calls for drivers radically decrease the quality of driving. Listening to music is associated with no such risk, and neither is talking to a passenger in the car. So is driving while podcasting (DWP) more like hands-free driving, or is it more like driving with music? If you're futzing around with your device trying to find a podcast you like, it's clearly dangerous. That's one reason I absolutely despise Apple's new podcast app, which won't just play podcasts in series like the old app did. I have to pull over to start a new podcast if I'm in the gas-powered wheelchair. But if you don't need to touch your device to play the sound, it seems more like music. On the other hand, podcasts can't shut up when the traffic gets bad or warn you you're about to hit somebody like a passenger can. Sigh. I don't know if I'm talking myself into something or out of something at this point. 

We need to teach medical students "webside" manner

I've done a fair amount of telemedicine, all with Vigilias. (I think I was the first doc to ever see a patient on their platform). The practice is closer to in-person medicine than you think. But there are some tricks, as the article points out:

"It sounds strange, but when you're on camera all your actions are magnified," Krupinski says. Sitting six feet away from your doctor, in person, you might not mind or notice her slouching, fidgeting, or gesticulating. But a webcam's intimate vantage point augments these actions in ways that patients can find distracting or off-putting. "You take a sip of coffee and your mug takes up the whole screen, and all they hear is the sound of you slurping," she says. "Or you turn away to make a note, and now all your patient sees is your shoulder. Maybe you disappear from the frame entirely."

And this one is the hardest to get used to:

To appear as though they're making eye contact, clinicians are taught to look not at the patient on their screen, but directly into their device's webcam.

I had other little quirks in my telemedicine days: I had to move my studio to the basement because of complaints about the neighbor's dog barking in the background. And at the beginning I only "dressed" from the waist up, since patients would never see me below the waist. But I found that it made me self-conscious. I needed to have some kind of uniform on to feel like a doctor. 

Links for Tuesday, November 7, 2017: hacking the genome, ammonia in the NFL, and community health workers for hypertension

Body hacker Josiah Zayner wants us all to use CRISPR to modify our bodies

And give ourselves cancer. I think he forgot the cancer part. From author Rowan Jacobsen:

"Let’s be clear: don’t try this at home! Although hundreds of gene-therapy trials are under way, and many experts believe they will eventually transform almost every aspect of human health, few have been proven safe. When you start scrambling your DNA, very bad things can happen. You can get cancer. Your immune system can attack the unfamiliar DNA, as happened when an 18-year-old with a rare metabolic disorder died during a University of Pennsylvania gene-therapy trial in 1999."

You may recall a link I posted to this guy giving himself a DIY fecal transplant. I'll give him an A+ for marketing. You can't beat the name Gut Hack:

NFL players have decided (not recently, it seems) that inhaling ammonia is performance-enhancing

Instead of something sinister, though, what the widespread use of smelling salts really reveals is the increasingly bizarre culture created by the NFL's (win-at-all-costs pressure cooker. Extreme parity, the minuscule margin of error, the constant threat of injury and million-dollar stakes all push players to exploit any shortcut, no matter how weird, gross or pitiful. More than a century ago in major league baseball, players like Hall of Fame pitcher Pud Galvin thought consuming ground-up monkey testicles was the answer (seriously). A decade ago, football found deer antler spray. Now it's smelling salts.

Not coke, but smelling salts in a cup. I think I would actually prefer ground-up monkey testicles.

More evidence that community health workers improve the care of certain patient populations

(paywall, but the abstract is free)

The proportion of patients with controlled hypertension increased from 17.0% at baseline to 72.9% at 18 months in the intervention group and from 17.6% to 52.2% in the usual care group; the difference in the increase was 20.6% (95% CI, 15.4%-25.9%; P < .001).

 

"The greatest favor you can do is...put away your phone."

Sherry Turkle from the MIT Media Lab talks about the frequency she hears people say they'd "rather text than talk." People say they feel less vulnerable when they text than they feel in a face-to-face conversation. I agree. I feel less vulnerable texting, too. 

So don't be a phone worm. When I was in medical school in the late '90s, I remember classmates making fun of a woman in our class who was pathologically attached to her cell phone. We'd all just learned the word "pathologic," and our family members were already asking us for medical advice, so we all felt comfortable making the diagnosis. Anyway, hers was the phone that would ring its Nokia ringtone multiple times a day to interrupt class back when this was still a novel occurrence:

In the year 2017, I'm not sure she'd even hit the average cell phone use. Recently, at my kids' gymnastics lesson, I was flanked by two women on cell phones. The first one sat to my right, bouncing off my shoulder as she sat. I forgave her for this, because she couldn't see me past the smartphone glued to her left ear. Then she proceeded to scream intermittently at two kids who were not in the gymnastics class, all while never removing the phone from her ear. I didn't blame the kids for being wound up; it was after school, and they were stuck in a building watching a sister when they would've undoubtedly preferred to be outside on the playground. But she couldn't be bothered to interrupt what seemed like a very non-urgent conversation.

I moved to a quieter place, sacrificing my chair for the floor. Then, three feet away, a second person started talking at full voice on her cell phone, telling the unfortunate listener on the other end repeatedly how pissed she'd been earlier in the day. Keep in mind, it was sunny and 66 degrees outside. Either person stepping outside to take her call would have been healthful and humane. But both women, insofar as my amateur observational skills could tell, sat in the middle of a crowded room and talked on their phones for the duration of the one-hour practice, save for the intermittent screaming at their kids. One child actually begged lady number two not to talk on the phone anymore, and was told to "zip it." A third man, who I assume was also a parent, broke his phone conversation only to tell a toddler to "stop fucking around." The toddler did not heed his instruction, and the man was soon sufficiently lost in his talking and texting to allow, shall we say, ample f'ing around, toddler-style. 

Sherry Turkle doesn't get into this directly in the brief video above, but this is all consistent with her observations that technology is killing social skills. We collectively show decreased empathy and a decreased ability for self-reflection. A big part of my job is handling sometimes delicate negotiations within clinics or within medical systems or between payers and doctors. In those situations, vulnerability is key. If the interested parties can't look one another in the eye and feel insecure and feel like their decisions impact the other people around the table, we get nowhere. 

Don't get me wrong. I've taken my share of calls and texts in crowds. But I've felt like an asshole almost every time. So to keep from being a hypocrite, I've set my phone to no alerts for messages or emails, and I frequently put it on sleep mode, meaning it won't ring unless an immediate family member or neighbor calls (I figure the neighbors have the best view of my house burning down). And though I've occasionally feared that this would kill my productivity, I'm fairly certain now that it does the opposite. I'm more productive the more time I spend apart from my device. People think email is urgent, for example. According to psychologist Dan Ariely, it's not. Yuval Noah Harari, author of some incredible work including Sapiens, meditates for two hours a day. And the astonishingly productive computer scientist and self-help writer Cal Newport is "indifferent" to his smartphone, still subscribes to paper newspapers, and only upgraded from a flip phone because his wife guilted him into it when they had their first baby. 

So here's a challenge for this week: Go outside your phone (comfort) zone. The next time you're standing in line waiting for something to happen, or watching your kids jump on the trampoline, or between innings at a softball game, or waiting for a movie to start, leave your phone in your pocket. Better yet, take it to whatever vehicle brought you to the game (except your skateboard; skateboards are a bad place to store a phone). It'll be hard to do, but you have the strength. Concentrate on your breathing. Once you've safely stowed the phone away, look at the others around you. You might have to work for some eye contact, because they probably aren't following the same rules you are. While you're gyrating around trying to get them to look at you, think about their stories. It'll give you something to ask them about. If they won't talk to you, make like Yuval Harari and make this time your meditation. If you're not the meditative sort, think about what you want to accomplish with the rest of the day. Make a mental plan. For a few minutes, don't be a phone drone.

See also: CRANK UP THE BASSHOW ELSE CAN YOU CRANK UP THE BASS?SOCIAL MEDIA IS A SET OF COMMON PLATFORMS TO DRAW OUT OUR WORST TENDENCIES, HAVE SMARTPHONES DESTROYED A GENERATION?