I'll tell you what you do. You put them in an envelope and send them Astronomers Without Borders, who will forward them to school children around the world so that they can see eclipses in the future:
Explore Scientific
621 Madison Street,
Springdale, AR 72762
(link and address via All Hail the Black Market)
Galega officinalis, the poisonous plant from which guanides were isolated. (Wikipedia Creative Commons)
It may promise a lot of things, but until I see RCT data, I'm not convinced that we should put an old anti-malarial drug in the water. Metformin, I mean. And that RCT would be the TAME Study. Observational studies of metformin and cancer have been promising, but...
In two controlled trials involving patients with advanced pancreatic cancer, a notoriously difficult cancer to treat, metformin failed to provide any benefit.
So I'll hold out ultimate judgement until after the TAME Study. But this smells a little like 20 years ago when pharma invented osteopenia to sell bisphosphonates, and then tried to encourage "prophylactic" treatment of even osteopenia. (metformin link via marginalrevolution.com)
Brown cane sugar -- a combination of sugar and molasses, both inherent in the sugarcane plant -- is produced naturally as part of the process of refining white cane sugar by the traditional method, crystallization.
Brown sugar from C & H Sugar Co. and other cane refiners uses the process, but beet sugar is different. It's made by refining the sugar all the way to the final white granular stage, stripping off all the molasses because beet molasses is unfit for human consumption (it's recycled as cattle feed). Then cane molasses is added back into the sugar through a process called "painting."
Painting coats the granules but does not necessarily penetrate them -- the molasses can sometimes be rubbed right off.
As with white sugar, these different types of sugars act differently in the kitchen.
The best medical analogy for this seems to be the auto-substitution of in-class medications by insurance formularies. Detemir substituted for glargine, for example.
The folks at 80,000 hours think so, noting that the number of people whose lives will be extended by a single doctor is low, or "pretty modest," as they say:
This analysis confirms the contentions above: physician density is negatively correlated with burden of disease16; the social determinants of health explain more of the variance in health outcomes than physician density17; there are steeply diminishing returns between increases in physician density and decreases in burden of disease16. Further, the ‘bottom line’ figures (which are likely optimistic) suggest an additional doctor adds four health years for every year they work. This is a lot less than can be accomplished through even modest donations to effective charities, and so suggests the ‘direct impact’ of medicine is pretty modest.18
(link from slatestarcodex.com)
I saw, early in the morning, the sun diminish against a backdrop of sky. I saw a circular piece of that sky appear, suddenly detached, blackened, and backlighted; from nowhere it came and overlapped the sun. It did not look like the moon. It was enormous and black. If I had not read that it was the moon, I could have seen the sight a hundred times and never thought of the moon once.
To be fair: I don't know a lot about this literature at all, but I suspect that the same claim could be made of many interventions, dietary and otherwise, were the data known. The more money you have, the healthier you are in general. (link via kottke.org)
I need to investigate this further. The thrust of this article--that knowing our risky mutations doesn't make us behave any differently--flies in the face of some data I've presented in the past.
I remain convinced that eating food that looks like food, in the Michael Pollan sense, is generally what we should all be doing. Like most ventures that people look to capitalize on, though, it has been taken too far: see the "influencers" in this article that actually make themselves sick with adherence to an irrationally vegetable-based, uncooked diet. (link via longform.org)
I've had several conversations with fellow docs about the NBER paper from last week showing a relationship between medical school rank and narcotic prescriptions. Naturally, the responses I got were pretty skeptical. A recurrent theme I ran across was that the authors didn't pay enough attention to practice setting.
1. Higher-ranked medical schools tend to produce more students who eventually land in academia, often at higher-ranked medical schools or residency programs.
2. Because of the culture of those high-performing places, characterized by greater access to subspecialists, a slower pace of practice, the presence of trainees to keep you honest and whatnot, you practice more conservatively and without fear of patients firing you for not giving them narcotic prescriptions.
3. Perhaps people graduating from lesser-ranked schools end up in private practice, where there is more pressure to write a narcotic prescription to all those patients with back pain, just to keep them from 1) firing you, and 2) telling all their friends and family what a crappy, uncaring doctor you are.
4. So the speculated end result is that people graduating from higher-ranked medical schools end up writing fewer narcotic prescriptions than their peers from lower-ranked schools.
I pointed out to several people that the study took into account specialty and location; the relationship held for people in the same specialty and same county. The investigators pontificated on practice setting (noting that DO graduates often take care of a more rural, white population, for instance). But they didn't control for it. So I held my hands up ¯\_(ツ)_/¯ and moved on with my life.
But then I listened to a segment about it on the Weeds podcast today (start at 1:01:25):
UPDATE: I'm having some trouble embedding the audio, so if you can't get it to play, go here: http://bit.ly/2uLk2lY
Sarah, Ezra, and Matthew made note that the relationship held within the same clinic, so I re-visited the paper. I found this:
Check the footnote. *slaps forehead*
So the investigators did account for practice setting, but since it was hidden in a footnote, I missed it.
The take-home from this paper is still kind of hard to identify. I'm not in favor of necessarily checking the LinkedIn page of every doctor you see to check what med school she went to, but there is clearly some kind of relationship between the culture of medical schools and the prescribing behavior of graduates.
Could you eat these delicious-looking river horses? I didn't think so. (photo by TiggerT on flickr)
"The idea was to import hippopotamuses from Africa, set them in the swamplands along the Gulf Coast, and raise them for food. The idea was to turn America into a nation of hippo ranchers."
The fact that we don't have hippos living in the Mississippi River eating water hyacinths and being harvested for meat is no tragedy; introduced species have a rough history in America, as anyone in Hawaii can tell you. But as author John Mooallem notes, the fact that we no longer live in an America where kinda-sorta crazy ideas like this can be debated non-ironically is kind of sad. (link from longform.org)
Notice the 2016 link. But it sounds as though 2017 was no different. Link from globalcyclingnetwork.com
"Air pollution is believed to be a contributing factor in some 9,000 deaths in the UK capital alone annually.
According to a story published in The Times today £383,000 of taxpayers’ money has been spent by Government ministers on fighting efforts to clean up the UK’s air. Despite this, Britain recently announced plans to ban the sale of petrol and diesel cars by 2040 following a similar commitment in France."
This essay makes me so happy. It's a joyful, self-deprecating account of learning to ride a pennyfarthing, complete with copious use of Pond's Extract. But this essay makes me so sad. It's better than anything I'll ever write, and Mark Twain didn't even try to publish it. Sigh. Link from bikesnobnyc.blogspot.com.
That's where my mind went when I read this. The immediate application for CRISPR technology in animals may be to reduce their production of greenhouse gases, or decrease their carcinogenicity. But for now, organ transplantation seems to be where it's at, for obvious reasons:
Doctors won’t have to do much persuasion, however, to get patients to accept organs from another species. “There is so much desperation among people on transplant lists, and 20 a day are dying as they wait,” said Dr. Adam Griesemer, a xenotransplantation researcher and transplant surgeon at Columbia University Medical Center. “This could be a path to a transplant for them. Colleagues keep asking me when we’re going to do it.”
Link from kottke.org
I'll be honest. I didn't even know this was controversial.
Although I'm told that "wellness" is being replaced by "well-being" in the worksite lexicon.
Problem: public transportation is associated with improved health outcomes, but in places like Wichita, the least-congested city in America, it's a tough sell.
You read that headline right: investigators in an NBER paper found that docs who went to a lower US News-ranked school are more likely to write narcotic prescriptions, and the ones who write narcotic prescriptions are likely to write for more drugs, depending on the ranking of their school. And lordy, those osteopathic schools:
US News publishes several rankings, in topics from research to primary care to women's health. For this paper, the investigators used the "research" ranking, which is difficult to translate into medical student bedside education. After all, some of my best teachers in med school hadn't published a paper in a decade.
Several other take-home points from this. First, at first glance general practitioners write a ton of narcotic prescriptions; their rate on the y-axis is roughly double the overall physician population's. But when you consider that primary care docs perform well over half of all the visits delivered, that number of narc prescriptions looks less impressive.
Second, the effect size, if you're willing to take a leap and go straight to the idea that the quality of research at your medical school somehow has a causative effect on how many hydrocodone prescriptions you write, is huge. Using Harvard as the index school, the schools in the eighties and nineties have graduating docs writing three times as many prescriptions.
My first thought when I read this was that docs who went to lower-ranked schools may end up on places where they're more compelled to write narcotic prescriptions: places with high poverty, or a large blue-collar workforce, for instance. But the investigators accounted for that, and found that the relationship persisted even within the same county:
I can't help but try to apply this research to myself, even though I'm an endocrinologist and therefore mostly shielded from the narcotic game, and even though I see relatively few patients nowadays. But here we go. I attended the University of Kansas, which is comfortably ensconced in a tie at number 65 on the research list:
Oof. Medical school got a lot more expensive in the last couple decades.
So where would I live in the narc prescribing graph?
Riiiiiiiiight about there. It's a wonder I'm not a bonafide narcotic prescribing machine.
What's unsaid in this list is that KU has three campuses (two at the time of my training). And it further goes without saying that the training in Wichita, Salina, or Kansas City may have subtle differences that would lead to slightly different physician performance or behavior. Furthermore, it would be interesting to see the research repeated with residency or fellowship training as the independent variable, since those are the years when trainees really fall into a groove of prescribing habits. If I were held to the standard of my internship with a University of Washington program, I'd be compared to the folks at the skinny end of the graph:
Go dawgs.
But if my fellowship training at UNC-Chapel Hill were the standard, I'd be in a nice, comfortable happy medium between the narc-crazed sixties and the narc-stingy pre-teens:
The take-home from this isn't that we should all check our doctors' CVs before we go see them, in fear of them hooking us on oxycodone. It's just that schools who inhabit the lower tiers of medical research need to do a better job of teaching narcotic prescribing.
And obviously, the take-home for patients is to be very, very careful about requesting narcotics for pain. They don't work as well as we think they do, and the potential for harm is huge.
I found this link, fwiw, via marginalrevolution.com
Image from Wikipedia (public domain)
This is reminiscent of the way Banting and Best handled insulin:
"...the first “sale” of insulin was for just $3 (Canadian), not for a vial, but the very intellectual property of the drug itself. Frederick Banting, Charles Best, and James Collip, the team that first discovered and refined insulin therapy, agreed to receive $1 each in exchange for giving their patent rights to the Board of Governors of the University of Toronto in 1923.
This was a bold move, and not without controversy at the time, according to an article posted by the University of Toronto Centre for Innovation Law and Policy. At the turn of the 20th century, it was considered beneath scientists and universities to patent medical innovation at all. However, Banting and company believed that they needed to patent their formulation of insulin to stop pharmaceutical companies from rushing to patent an inferior, less potent form of the drug. The university immediately gave pharmaceutical companies the right to manufacture insulin, royalty-free, and to improve upon the formulation and patent any subsequent improvements."
If only we saw such responsibility and modesty from drug manufacturers now.
But back to Laennec: it is strange that we continue to venerate the stethoscope 200 years after its invention, especially when we have rapidly evolving, already far superior equipment in the form of handheld ultrasound. As the folks at 99 percent invisible note, docs no longer routinely carry reflex hammers or pinwheels, but they still overwhelmingly carry stethoscopes. I do not. You can't auscultate an adrenal tumor, you know what I'm saying? Bedside ultrasounds are the future, period. They'll just reach full market penetration sooner in the US than in developing countries.
Brad Stulberg pontificates on why endurance sports are so popular among high-income people.
"...data collected in 2015 by USA Triathlon shows that the median income for triathletes is $126,000, with about 80 percent either working in white-collar jobs—professions such medicine, law, and accounting—or currently enrolled as students."
Once upon a time, and still for a shrinking older population, golf was the sport that signaled wealth. But now, with the fuzziness that surrounds the measurement of effectiveness in the knowledge economy, endurance sports give white-collar workers a simple, quantitative way to measure progress. You run/swim/bike/ski faster or slower than you did the last time, period. And the pain doesn't hurt (pun intended):
“By flooding the consciousness with gnawing unpleasantness, pain provides a temporary relief from the burdens of self-awareness,” write the researchers. “When leaving marks and wounds, pain helps consumers create the story of a fulfilled life. In a context of decreased physicality, [obstacle course races] play a major role in selling pain to the saturated selves of knowledge workers, who use pain as a way to simultaneously escape reflexivity and craft their life narrative.”
Link from marginalrevolution.com
Answer: it's complicated.
A pharmacist finds a cache of drugs, unopened, all 30-40 years past their expiration date. He has them tested by a toxicologist. The result? All of the drugs--all of them--are still useable.
Link from foodpolitics.com
There's more progress yet to be made, obviously.
Financial health is a big part of health that we tend to forget about.
The short story "Baster" by Jeffrey Eugenides, was featured on this week's New Yorker Fiction podcast. It is in his collection of short stories Fresh Complaint, to be released this fall. "Baster" was adapted into the movie The Switch with Jason Bateman and Jennifer Aniston, but only the first half of the movie, where Wally obsesses over Kassie's impending insemination and eventually switches his own specimen for her better-looking donor's, is drawn from the story. The rest of the movie, dealing with Wally's growing affection for his neurotic son and his eventual confession, are new.
It tells the story of consanguinous parents of a child born with 5-alpha reductase deficiency, a hormonal disorder in which male children do not make enough of the active male hormone dihydrotestosterone.
The red line is the enzyme defect we're talking about here. Image from Wikipedia.
This causes them to be very feminized at birth, with a micropenis and undescended testicles. They were often raised female before the disorder was well-known. But at the onset of puberty, people with the disorder suddenly and sometimes dramatically get male features. Callie (later Cal) is the narrator, and his gender identity evolves in parallel with the family's experience in immigrating from Asia Minor to Detroit, then to San Francisco. It's fantastic.
It starts off with one of the main protagonists, Josef Kavalier, escaping to New York from Prague, Czechoslovakia by being concealed inside the coffin of the Golem of Prague, a clay mannequin, by his magic teacher, Kornblum. The giant clay mannequin is clothed in the suit of a giant obtained from a deceased patient of Josef's endocrinologist father. It's the first of several escapes by Joe in the book (first from Nazi Europe, then from poverty, then from Antarctica, then from loneliness). The book concludes with (spoiler alert) Sammy, his best friend and cousin, escaping from life as a closeted homosexual. Haunting book.
Even if we all continued to eat poultry, pork, and fish. Beef is that carbon-heavy. Related: the economic value of giving up meat and see James Hamblin below.
I literally gasped when I saw this pic of the Col du Galibier.
If you're not the listening type, you can read the transcript here.