Links for Wednesday, September 5, 2018: docs are nervous about weight loss meds, risky low-carb diets, why I'm not a pediatrician, and continuity of care is good

Why don't more docs prescribe weight loss medications?

Speculation: 1) cost (and by extension, prior authorization requests); 2) residual fear from fen-phen, as one of the docs interviewed alluded to. We can surely put this to bed, since the current crop of meds has been on the market much longer than fen-phen had been when its harm was revealed; 3) nihilism. Five percent weight loss is meaningful from a medical perspective, but unless the doc is consciously, prospectively measuring outcomes like blood pressure, lipids, and fasting sugars, it won't knock her socks off. Patients won't be thanking her for getting them ready for bikini season; and 4) the old Risk Evaluation and Mitigation Strategy (REMS) for Qsymia was such a PIA that it scarred some docs to prescribing these meds.

Can we stick a fork in low-carbohydrate diets? (Ba Dum Tss)

What's a 32% increase in mortality among friends? Investigators (in a study that, to my knowledge, has not yet been published, so caveat emptor) found an association between the lowest quartiles of carbohydrate intake and death:

 NHANES data. Model 1 is unadjusted for other risk factors. Model 2 is adjusted. These are ugly, ugly numbers. 

NHANES data. Model 1 is unadjusted for other risk factors. Model 2 is adjusted. These are ugly, ugly numbers. 

Remember: we can't draw causality from this. There is some chance that people who are sick and more likely to die from heart disease, cancer, or stroke are more likely to adopt low-carbohydrate diets. But it doesn't seem likely. The people at highest risk in this study were those over age 55 and "non-obese."

Reason # 1,001 I'm not a pediatrician:

Can. Not. Do. It.

Special shout-out to the 100 cell phone text alerts during the video. 

If lack of continuity is a mark against telemedicine, then it's a mark against the hospitalist model in general

Links for Tuesday, August 21, 2018: patients love good news. And weed. Patients love weed.

Patients liked a blood pressure app better because it was inaccurate

If I were to pick a single study that wraps all my angst about medicine up into a tidy bow, it would be this one:

"...user enjoyment and likelihood of future BP monitoring were negatively associated with higher-than-expected reported systolic BP. These data suggest reassuring app results from an inaccurate BP-measuring app may have improved user experience, which may have led to more positive user reviews and greater sales."

A better writer could hold forth on how doctors (and devices?) are so bad at giving negative but meaningful information to patients that patients simply avoid the process altogether, leading patients to seek a relationship with their doctors that more resembles that between a shaman and a subject than that of a modern, informed, dynamic doctor-patient exchange of information.

*head explodes*

Dr. Robert Badgett, on seeing this study, reminded me of a quote by Voltaire:

"The art of medicine consists in amusing the patient while nature cures the disease."

I certainly feel like I'm in the entertainment business some days.

With wider availability of cannabis comes wider use and wider abuse

"Public-health experts worry about the increasingly potent options available, and the striking number of constant users. 'Cannabis is potentially a real public-health problem,' said Mark A. R. Kleiman, a professor of public policy at New York University. 'It wasn’t obvious to me 25 years ago, when 9 percent of self-reported cannabis users over the last month reported daily or near-daily use. I always was prepared to say, ‘No, it’s not a very abusable drug. Nine percent of anybody will do something stupid.’ But that number is now [something like] 40 percent."

I knew guys in college who were stereotypical "potheads," and I think my bias at the time was that all but a few of them would be reined in by the relative difficulty of getting the drug (not that it was difficult). Now that the reins are off, we're stuck addressing possible solutions to the problem. This is not an argument for going back to hard-core criminalization. As Annie Lowrey points out, the US still arrests more people for marijuana offenses than it does for all violent crimes combined. That seems, shall we say, excessive. 

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).