Sunday, August 30, 2015

Oliver Sacks Dies at 82; Neurologist and Author Explored the Brain’s Quirks - The New York Times


Oliver Sacks as portrayed by Robin Williams in   "The Awakening"

Oliver Sacks Dies at 82; Neurologist and Author Explored the Brain’s Quirks - The New York Times

Mental Health Access in Critical Condition



Jamycheal Mitchell, 24, had been held in Virginia jail without bail for nearly four months, accused of stealing a Mountain Dew, Snickers bar and a Zebra Cake was found dead on the floor of his jail cell 







after spending almost four months behind bars without bail for stealing groceries worth $5.
Jamycheal Mitchell, who had mental health problems, was discovered lying on the floor of his cell by guards early last Wednesday, according to authorities. While his body is still awaiting an autopsy, senior prison officials said his death was not being treated as suspicious.
“As of right now it is deemed ‘natural causes’,” Natasha Perry, the master jail officer at the Hampton Roads regional jail in Portsmouth, said of his death in an interview. Perry said there were no obvious outward signs of injury to the 24-year-old’s body. Portsmouth police are looking into the death.
Mitchell’s family said they believed he starved to death after refusing meals and medication at the jail, where he was being held on misdemeanour charges of petty larceny and trespassing. A clerk at Portsmouth district court said Mitchell was accused of stealing a bottle of Mountain Dew, a Snickers bar and a Zebra Cake worth a total of $5 from a 7-Eleven.
“His body failed,” said Roxanne Adams, Mitchell’s aunt. “It is extraordinary. The person I saw deceased was not even the same person.” Adams, who is a registered nurse, said Mitchell had practically no muscle mass left by the time of his death.
Except for a brief item stating that an inmate had been found dead, the story of Mitchell’s death has not been covered by local media in Virginia, and is reported for the first time here.
Adams said in an interview that her nephew had bipolar disorder and schizophrenia for about five years. Nicknamed Weezy, he lived with his mother Sonia and had been unable to hold down work. “He just chain-smoked and made people laugh,” said Adams. “He never did anything serious, never harmed anybody.”
Officials said that after his arrest, Mitchell was taken to Portsmouth city jail, where he stayed for almost three weeks before being transferred across the city to the regional jail on 11 May.
Ten days after that, the court clerk said, Judge Morton Whitlow ruled Mitchell was not competent to stand trial and ordered that he be transferred to Eastern State hospital, a state-run mental health facility in Williamsburg, for treatment.
The clerk said that typically in such cases “we do an order to restore the defendant to competence, send it to the hospital, and when the hospital has a bed, we do a transportation order, and he’s taken to the hospital.” Whitlow reiterated the order on 31 July and was due to review the case again on 4 September, according to the clerk.
But the hospital said it had no vacancy and the 24-year-old was therefore detained in jail until his death on 19 August, according to Adams, Mitchell’s aunt, who said she had tried to assist the hospitalisation process herself but was left frustrated.
Except for a brief item stating that an inmate had been found dead, the story of Mitchell’s death has not been covered by local media in Virginia, and is reported for the first time here.
Adams said in an interview that her nephew had bipolar disorder and schizophrenia for about five years. Nicknamed Weezy, he lived with his mother Sonia and had been unable to hold down work. “He just chain-smoked and made people laugh,” said Adams. “He never did anything serious, never harmed anybody.”
Officials said that after his arrest, Mitchell was taken to Portsmouth city jail, where he stayed for almost three weeks before being transferred across the city to the regional jail on 11 May.
Ten days after that, the court clerk said, Judge Morton Whitlow ruled Mitchell was not competent to stand trial and ordered that he be transferred to Eastern State hospital, a state-run mental health facility in Williamsburg, for treatment.
The clerk said that typically in such cases “we do an order to restore the defendant to competence, send it to the hospital, and when the hospital has a bed, we do a transportation order, and he’s taken to the hospital.” Whitlow reiterated the order on 31 July and was due to review the case again on 4 September, according to the clerk.
But the hospital said it had no vacancy and the 24-year-old was therefore detained in jail until his death on 19 August, according to Adams, Mitchell’s aunt, who said she had tried to assist the hospitalisation process herself but was left frustrated.




Young black man jailed since April for alleged $5 theft found dead in cell | US news | The Guardian

Tuesday, August 25, 2015

New breed of paramedics treats patients before emergencies occur - LA Times

When  does a paramedic become a independent health care provider. The line between physicians, nurses, physicians assistance is  becoming blurred as the future of health care evolves.



Paramedic Jacob Modglin parks on a palm-lined street in Oxnard and jumps out of his ambulance. 
He is prepared for any kind of emergency.
But his patient is standing in the driveway of a one-story house, holding a thermos, and smiling. It's time for his 8 p.m. appointment.
Modglin is part of a new cadre of "community paramedics" working in a dozen pilot programs across California. Their jobs are to treat patients before they get sick enough to need emergency care.
Many insurance companies and healthcare providers are seeking to curb spending by focusing on the small number of patients who drive the majority of costs. These so-called super-utilizers often have chronic conditions or other social problems that keep sending them to hospital emergency rooms and racking up big bills.
A patient who visits an emergency room unnecessarily or is repeatedly admitted to a hospital, for instance, could be suffering from a chronic medical condition, or may not be able to afford medicine, or may be too frail to go pick up fresh food — or all of the above.
That makes it difficult to know how to assist these patients. But California healthcare leaders hope these specially trained community paramedics can help.
"There's a missing link in the chain here and we don't know what that is, but we're trying to find out," said Dr. Steven Rottman, medical director of the UCLA Center for Prehospital Care, which trained the community paramedics.
Willl this become the next standard of care ?  

In Ventura County, Modglin administers tuberculosis medicine to infected patients. Health officials there are worried about the illness — especially some cases that appear drug-resistant — and believe paramedics are in the best position to help stop its spread by providing patients with pills each day at their homes.

This may be useful during times when paramedics are idle, however sudden emergency 911 calls may divert these first responders to a timely  call.  Using paramedic-firemen seems to be a shortcut that will fail.

In addition to that who reimburses for the preventive medicine care?  Is this a public service ordinarily paid for by the taxpayer. Does the insurance company save money by  cost shifting to the tax payers?

Chatting under a fruit tree in the house's frontyard, they also talk about the patient's diabetes and the medicine that controls his high blood pressure. Modglin takes a look at the man's knee, because he slipped and fell earlier in the day.
"Not only do I administer his TB medicine, but I'm here to make sure his overall health is good," Modglin said.
Ventura County runs the tuberculosis program and another that sends paramedics to the homes of hospice patients.
Los Angeles County has two initiatives as well, gearing up next month. In one, community paramedics in Glendale will visit patients with congestive heart failure within three days of their discharge from the hospital. They will try to make sure those patients — who typically have high readmission rates — are following their doctors' recommendations and living in an environment that's conducive to recovery.
With the advent of telemedicine it may allow physician supervision of first responders, much like first responders who communicate with an emergency  room in  transit as they treat a critically ill patient, such as in shock or in cardiac arrest.
As this concept spread there should be a careful evaluation. In 2017, researchers from UC San Francisco will evaluate the programs' success.
California's modern version of these emergency responders originated with a pilot program in Los Angeles County in the late 1960s as people started to take note of a high number of cardiac arrest deaths occurring outside hospitals. In 1970, California became the first state in the nation to allow paramedics to perform advanced medical life support.
But these days, Glendale paramedic Todd Tucker estimates that 10% to 20% of his calls aren't medical emergencies.
"We get called for you-name-it," said the Glendale fire captain, who's part of both Los Angeles County pilot programs. 










New breed of paramedics treats patients before emergencies occur - LA Times

Monday, August 24, 2015

Doctors' Virtual Consults With Patients To Double By 2020 - Forbes

Thanks to expanding health insurance coverage, the number of virtual video consultations between primary health care providers and their patients will double in five years in the U.S., fueling the nation’s telehealth boom, according to a new analysis.

A new report from information and analytics firm IHS says video consultations will jump overall to nearly 27 million in the U.S. market, driven by the primary care market where insurance coverage is rapidly widening. IHS  projects there will be cumulative annual growth of nearly 25% a year over the next five years to 5.4 million video consultations between primary care providers and their patients by 2020 from this year’s 2 million video consultations, IHS says.  “We’ve seen growth in reimbursement,” Roeen Roashan, medical technology analyst with IHS said in an interview.  “There’s no doubt payers are focused on virtual consultations. They are really pushing it.”

There are  however certain caveats, which include whether your insurer covers this type of virtual visit. In reality they are so inexpensive that many people would not even think about using their  health insurance, especially if it does not count as a 'deductible expense'..The swinging door is still open for change.  

State medical boards are 'waffleing' on the new virtual visit.   Previously a clinician had to examine a person before making a diagnosis or treatment. This was assumed to a real visit. Now that we have virtual visits the standard of care must be re-visited. Certainly not all conditions will require a real visit, however for good care, some conditions patients must still be seen. A virtual visit could serve as the first step to make an appointment.


Health plans see a way for patients to get high quality care from a physician and the potential to avoid a more expensive trip to a hospital emergency room. It also may be a way to get a quick answer from a doctor about an existing treatment regimen.

“We’ve seen growth in reimbursement,” Roeen Roashan, medical technology analyst with IHS said in an interview.  “There’s no doubt payers are focused on virtual consultations. They are really pushing it.”

 To be sure, major health plans like Aetna (AET), Anthem (ANTM), Cigna (CI) and UnitedHealth (UNH) are expanding coverage and offering more options to employer clients.

Total numbers of virtual consults is growing 10% a year with 16.6 million this year with growth projected to hit 26.9 million including consultations with specialists in many fields including mental health and dermatology. Specialty consultations are projected to jump from 14.5 million to 21.5 million, IHS figures show.
Much, however, needs to be done to meld virtual consultations into the health care system, analysts say, as the Affordable Care Act and insurers move providers to a more coordinated approach that is value-based and moves away from traditional fee-for-service medicine.
“Even though more and more people use online urgent care for $49, there won’t necessarily be an improvement of healthcare until providers integrate virtual consultations as part of their care delivery,” Roashan says. “This will allow a much more intimate experience and most likely at a lower cost than $49. We’ve seen large providers providing complimentary virtual consults for their patient population, and . . . that’s the model we need to see more of.”

What is interesting is that payors are at the forefront of the medical economy promoting virtual medicine because overall it will save money. The data will be analyzed and hopefully the savings will be apparent. 















Doctors' Virtual Consults With Patients To Double By 2020 - Forbes

Friday, August 21, 2015

Coca Cola Announces it's Spending Plan for Research on Obesity




In a series of events mirroring that of the 'Tobacco Wars" of the 1980s Coca Cola revealed it's funding of research studies into the causes of obesity. The research they are funding has a preordained outcome, as Coca-Cola has stated obesity is not due to high caloric intakes, but to lack of exercise.  

Although there was indisputable scientific evidence of the effects of tobacco smoking on lung cancer, big tobacco denied the causative effects of  tobacco.

Coke Tries to Sugarcoat the Truth on Calories
By paying experts who side with them, the company is trying to divert attention from products that contribute to obesity, heart disease and diabetes.

During the past two years New York City placed a ban on containers of soda greater than 16 ounces.  Big tobacco,  feeling the heat, began a campaign to  defend it's huge profits based upon addictive drinking of high sugar content drinks.  Coca-cola was not the only target of the ban on 'super-size' drinks.

In an opinion article published online in The Wall Street Journal on Wednesday, Muhtar Kent, chief executive of Coca-Cola, also said the company would assemble a panel of independent advisers on its financial support for academic research.
“As we continue to learn, it is my hope that our critics will receive us with an open mind,” Mr. Kent wrote. “At times we will agree and at times we will passionately disagree.”
A front-page article in The New York Times this month revealed the financial ties between Coke and the Global Energy Balance Network, a nonprofit advocacy group that contends people worry too much about what they eat and not enough about how much they exercise.


RELATED COVERAGE

Coca-Cola provided seed money for the group, and its vice president, Steven Blair, appeared in a video in which he chastised “the media” for blaming overconsumption of fast food and sugary drinks for the country’s high rates of obesitydiabetes and heart disease. In the video, Dr. Blair said, “There’s really virtually no compelling evidence that that, in fact, is the cause.”
On Thursday, however, Dr. Blair posted a statement on Global Energy’s website, saying he had asked the group to remove his video. “I regret that a statement I made in this video has been used by some to brand G.E.B.N. as a network focusing only on physical activity,” the statement said. “This is not true and never has been true. From the beginning the mission of G.E.B.N. has been to study the science of energy balance, which involves both diet and physical activity.”
Marion Nestle, a professor of nutrition, food studies and public health at New York University, said it often was hard to determine the origins of research funding, so the decision by Coke to increase disclosure of its investment would be helpful.

“But what he didn’t say was, ‘We’re going to stop fighting soda taxes and limits on soda sales,’” said Dr. Nestle, whose new book, “Soda Politics: Taking on Big Soda and Winning,” will be published this fall. 


She noted that Coca-Cola had underwritten studies critical of the National Health and Nutrition Examination Survey, known as Nhanes, a program of the Centers for Disease Control and Prevention that uses information about what people are eating. The data is collected from 5,000 households around the country throughout the year and combined with information from physical examinations.
In 2013, a paper co-written by Dr. Blair was published on PLOS One, an online peer-reviewed scientific journal, that questioned the validity of the data collected in Nhanes. PLOS One later added a correction to the report, noting Coca-Cola’s financial support for the research.
“Nhanes is the basis of the epidemiological studies that demonstrate an association between consumption of soft drinks and obesity and diabetes,” Dr. Nestle said. “Coke has embarked on a systematic effort over the years to discredit Nhanes and therefore those studies.”

Consumers often look for alternative drinks  and turn to other brands, which imply lower caloric content and 'healthy'  Surprisingly many of them are high calorie drinks as well.

Marketing is slick, often false (euphemistically) and often downright fraudulent.


100 Calories


180 calories


233 Calories








200 calories

No One would argue the lowest calorie drink is



Coca-cola may receive unwarranted attention, because like tobacco (Marlboro, Camels, Virginia Slims, Lucky Strike, there are many other sugary brands, such as Starbucks ( a favorite for millenials)

References:

Consumption of Sugar Drinks in the United States, 2005–2008Cynthia L. Ogden, Ph.D., M.R.P.; Brian K. Kit, M.D., M.P.H.; Margaret D. Carroll, M.S.P.H.; and Sohyun Park, Ph.D., M.S

Fact Sheet: Sugary Drink Supersizing And The Obesity Epidemic








Trending: Coca-Cola Funds Scientists Who Shift Blame for Obesity Away From Bad Diets - gmlevinmd@gmail.com - Gmail

Monday, August 17, 2015

Five Drugs in the Polypill

Technology and the pressure of cost containment and improving patient compliance are resulting in an interest in developing a pill with 3,4, or even 5 drug combinations.  There are however some obstacles for this advance in poly-pharmacology.


Patients often are not compliant with treatment recommendations, even for one medication.  As more medications are prescribed compliance deteriorates further.



If a safe, inexpensive, once-a-day pill could substantially reduce the risk of myocardial infarction (MI) or stroke, would people want it? Most would probably say yes because MI and stroke are the first and third leading causes of death, respectively, in the United States.1 It is likely that many employers, health plans, and payers would also say yes because MI and stroke cost the US economy more than $300 billion annually in health care expenditures and lost productivity.2



Improving adherence by simplifying drug regimens and reducing their cost could have far-reaching consequences. In 2003, Wald and Law3 proposed to combine 3 half-dose antihypertensive agents, an intermediate-dose statin, low-dose aspirin, and folic acid into a once per day polypill for primary and secondary prevention of cardiovascular disease. Based on epidemiological models, they estimated that daily use by individuals aged 55 years or older could reduce the incidence of MI and stroke by more than 80%.3
The 4 drugs in the current version of the polypill have long histories of safe use. Although all 4 are frequently prescribed in the United States, the US Food and Drug Administration (FDA) has not approved combining them in a single pill. It has, however, authorized approximately 50 two-drug pills for hypertension.4 Recently, an FDA advisory committee expressed cautious support for using the polypill for secondary prevention of MI and stroke in patients who are unlikely to be closely monitored by a physician. It did not address the larger question of primary prevention.5
Although the polypill could produce substantial public health benefits, people in the United States are unlikely to find out anytime soon. This is because the pill’s price is so low (≤$1 per tablet) and the cost of the large clinical trials required for FDA approval is so high, it is unattractive to investors. The inventor’s dilemma is that creating a product that improves health is not enough; the product must also be able to generate a healthy return on investment. In the United States, the surest way to generate a healthy return on investment is to increase health care spending, not reduce it.
In reality advances in drug delivery systems will be very important for pubic health reasons, compliance and cost reduction.  It will require some creative and innovative for financing drug development costs.  The technology is ready, can we afford it ?  We need innovative venture capitalists.  It is doubtful whether the Affordable Care Act will nourish this embryonic technology.  What can be done?


First, to inspire innovators, federal agencies and philanthropies should commit a larger share of their research budgets to high-risk, high-reward science. Second, to entice inventors to address challenging problems, there could be greater use of prizes (eg, cash for the first inventor who creates a drug or device that meets a specific need).

Third, to ensure that low-cost, high-value discoveries reach the market, patent buyouts could be offered. This could increase the likelihood that these products are commercialized and offered at prices sufficiently low to encourage widespread adoption.

Fourth, to give inventors access to the capital required to bring a cost-lowering technology to market, a public-interest investment fund could be established. The public-interest investment fund would seek out promising products that are not attractive to conventional investors, and replenish its coffers with shared savings from successful inventions.

Fifth, to streamline the regulatory approval process, the FDA could be authorized to use existing mechanisms, such as fast-track or breakthrough therapy authority, to expedite review of cost-lowering technologies. This would require expanding the FDA’s mission beyond safety and efficacy to address costs.
What is the actual cost to develop a new medication ? The California Biomedical Research Association outlines the process
The studies are spread out from 2010 to 2015 and the increases have been substantial during this period. Keep in mind that reports from pharma are used to justify the high costs of drugs.
In addition the costs vary greatly among disease categories and the category of the drug.  Some drugs are a variation of one already approved, while others are in new classes such as oncology drugs designed as antibodies to cancer cells.  Variations in cost estimates suggest that policymakers should not use a single number to characterize drug costs. It is important to also be aware that different drug types might have substantially different actual costs of clinical trials. Therefore, the estimated variation in drug costs could be higher or lower, depending on whether the correlation between actual costs, success probabilities, and durations is positive or negative. As discussed below, recent work suggests that HIV/AIDS drugs have high clinical costs.


Poly drug combinations are made of already approved drugs for single use, and development costs may be far less. 





JAMA Network | JAMA | Effects of a Fixed-Dose Combination Strategy on Adherence and Risk Factors in Patients With or at High Risk of CVD:  The UMPIRE Randomized Clinical Trial

Meaningful Use....What the AMA has to say about Meaningful Use

October 1, 2015 is fast approaching. That is the deadline for providers to adopt ICD-10.  In addition to that requirement Meaningful Use continues to be a bane on providers.  Physicians perceive meaningful use as less than meaningful when resources could be better used to improve EHR usability rather than  some bureaucratic bloat/.

Meaningful Use (MU) isn't working, and now the government wants to move forward with Stage 3 implementation. But if it's not fixed, that could lead to less time with patients, less innovation and costly penalties if physicians are unable to comply. Currently physician participation in MU Stage 2 sits at less than 10 percent, compared to the 80 percent adoption of EHRs.

Recently Rep. Renee Ellmers, R-N.C., introduced H.R. 3309, the "Flex IT 2 Act." This legislation would provide much needed flexibility in the MU program and enhance electronic health records (EHRs) to improve patient care and access to health information. The bill also addresses key interoperability challenges by ensuring certified EHR systems are capable of sending, receiving and seamlessly incorporating patient data.

At a recent AMA town hall meeting on EHRs and MU, the response from physicians was overwhelming: MU is not working, and physicians cannot move to a learning health system unless they have the tools to do so. They need state-of-the-art technology that can interoperate with other systems and providers.
In Washington, D.C., August means one thing—congressional recess. 


Some of the reflections spoken about at the AMA meeting:

     80% of physicians are using EHR
     Rather than improving efficient patient care, the current state of EHR design interferes with the
     goal of improving patient relationships. 
     The current administration continues to push forward with more meaningful use requirements instead
     of correcting what does not contribute to patient care.

     The proposals to change from procedural based reimbursement to value will require EHR modification
     to integrate with the proposed changes of health reform.

     The AMA's goals are to have physicians play a key role in improving patient care, improve                            interoperability, and eliminate the digital silos that have replaced paper silos.

     
     Please take advantage of this time when your members of Congress are back at home: Email or call (888) 434-6200 to be connected with their district offices, and urge them to cosponsor H.R. 3309 today!


To learn more about MU and to share your story, please visit: breaktheredtape.org






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