Monday, October 31, 2016

The Importance of Sex Differences in Disease and Health

Precision medicine is driving innovation and research  into the differences between boys and girls other than the obvious external appearances and internal organs.


Population health studies already reveal differences in the proclivity of diseases to effect the genders, and also their responses to drugs. This was apparent in heart disease,  and responses to medications.





Even though the observation that men and women are different is arguably as old as human life, women have been included in clinical trials for only a few decades. Women have a unique physiology and their experience of illness, and responses to therapeutic interventions are often significantly different from those of men. Recent regulations from the National Institutes of Health requiring grant applicants to consider sex as a variable in biomedical research are a welcome development.1 However, despite increasing evidence that an individual’s sex is one the most important modulators of disease risk and response to treatment, consideration of the patient’s sex in clinical decision making (including the choice of diagnostic tests, medications, and other treatments) is often lacking. This is surprising given the increasing interest in precision medicine, which should begin with attention to sex differences in medicine.
Sexual Dimorphism in Response to Drugs


Many medications are metabolized differently in women than men due to variances in body size and distribution volumes, sex hormone levels, activity of enzymes, and effects of routes of excretion on sex-specific responses to drugs.2
What is the impact of the differences between having two X chromosomes, or one X and one Y chromosome.  The new tools of genomics, computer power and the drive toward less expensive and more effective diagnostic and therapeutic modalities are creating a synergy that may prove to yield some surprising secrets.  The secrets are only now becoming exposed.
Sex Differences in Cardiovascular Disease
Arrhythmias, particularly atrial fibrillation, have different consequences for women, who have higher mortality, more symptoms, and higher rates of recurrence following ablation procedures.2 Women have a higher risk of atrial fibrillation–associated stroke than men (25% vs 10%) and experience significantly higher mortality after stroke (25% vs 19% at 6 months).2,7Women's unique electrophysiology (which produces a longer cQT interval than that of men) increases the risk of drug-related torsades de pointes (TdP)8,9; risk of TdP associated with sotalol is higher among women than men (4.1% vs 1.0%). The observed vs expected prevalence ratio for TdP associated with amiodarone, dofetilide, and azimilide is at least twice as high among women as it is in men.9
Coronary Artery Disease


Hypertension, dyslipidemia, smoking, diabetes, and obesity account for 80% of risk of acute MI in both sexes, but presence of diabetes is associated with a 6-fold increase in women's risk of coronary artery disease (CAD), from 107 per 100 000 person-years to 651 per 100 000 person-years vs a 3-fold risk among men with diabetes (Box).2,10 Moreover, women with diabetes and CAD have a 3-fold increased risk of heart failure; men with diabetes have minimal increase in risk.2 
Timely diagnosis of MI is often delayed in women because of their different symptom complex (shortness of breath, unusual fatigue, sleep disturbances, indigestion, and anxiety; almost one-half may not report chest discomfort). 
Read the entire story here:
The Importance of Sex Differences in Disease and Health | Cardiology | JAMA | The JAMA Network

Saturday, October 29, 2016

IT'S ALL ABOUT NETWORKING

The topic is germane to the changes in our world today, not just in health care.

The Seventh Sense, written by Joshua Cooper Ramo offers an explanation and an open ended question about Endless terror. Refugee waves. An unfix-able global economy. Surprising election results. New billion-dollar fortunes. Miracle medical advances. What if they were all connected? What if you could understand why? 

Beyond the aspects of how and why lies the simple fact that change is inevitable,no matter what time period we examine. Looking backward from the present globalization, health care revolution, digital/internet revolution, the industrial revolution, 

The next generation of revolutionary leaders is a continuing  stream of bright, creative, and out of the box peoples. Linked in describes the 2016 LinkedIn Next Wave. Not surprisingly there are some from the health care sphere , notably three physicians.

Linkedin identified ten people in health care as thought leaders and exceptional networkers.

Dr. Loren Robinson

Dr. David Mou
Co-founder and medical director, Valera Health
Elizabeth Asa  CEO, 3Derm Systems

Zoe Barr  Founder and CEO, ZappRx

The list mentions ten innovators

In a recent book, The Seventh Sense, called this instinct to connect a whole new skill—really a sensibility that marks success now. I mean an ability to look at the world, see connection, and use it. It’s a skill that can be learned. And it is what will mark the winners and losers of our age when we look back several decades from now. What the data tells us about the Next Wave leaders is something I think we all know by instinct now anyhow: Success and connection are really the same thing now.

Much of the criteria for a mention in the New Wave is related to the power of their network. Of course this selection is highly biased by their presence on social media. This new metric is foreign to most established businesses, However it has gained traction among young professionals and must not be ignored.

In reality networking has become essential, health maintenance organizations, group medical practice, large health systems, accountable care organizations. The  impetus to network is also  being driven by visions from CMS and the Department of Health and Human Services.

Many of these new networks are unproven and promoted on the basis of cost containment, quality  assurance, and regulatory processes.

Some of these networks will not suceed.  Early evidence indicates an inability to be self-sustaining without government  support, and questionable metrics for measuring success.



Friday, October 28, 2016

How Your Doctor's Politics Affects Your Health Care -- And What You Can Do About It

It seems timely to discuss what politics has done to your health.  It has certainly affected your first amendment rights. It flies in the face of the bill of rights, and the declaration of independence.  No doubt few of our leaders have read either of those cherished documents.  If you have not reviewed the I highly recommend it. To my knowledge no one as cancelled the pledges, nor suspended those rights, which we all cherish.

Paul Hseih M.D., a praciticng internal medicine physician speaks:




Does your doctor’s politics affect his or her medical advice?
Although I would like to think not, a recent study by Yale researchers Eitan Hersh and Matthew Goldenberg has shown the opposite. They’ve published some eye-opening results in a recent research paper, “Democratic and Republican physicians provide different care on politicized health issues”:
We linked the records of over 20,000 primary care physicians in 29 US states to a voter registration database, obtaining the physicians’ political party affiliations. We then surveyed a sample of Democratic and Republican primary care physicians. Respondents evaluated nine patient vignettes, three of which addressed especially politicized health issues (marijuana, abortion, and firearm storage).
Their results were interesting. For most issues, the physician’s political leanings did not affect their treatment. But for three specific issues, the doctor’s political leanings did — abortion, marijuana, and guns.

With respect to the first two issues:
Faced with a woman who wasn’t currently pregnant but had undergone two abortions earlier in life, Republican doctors were twice as likely as their Democratic counterparts to say they’d discourage any future abortions and 35 percent more likely to discuss so-called mental health aspects of abortion…
Faced with a man who uses recreational marijuana three times a week, Republican doctors were 64 percent more likely to say they’d discuss marijuana’s legal risks and 47 percent more likely to urge them to cut back than Democratic doctors.


I cover health care and economics from a free-market perspective.  
Does your doctor’s politics affect his or her medical advice?
Although I would like to think not, a recent study by Yale researchers Eitan Hersh and Matthew Goldenberg has shown the opposite. They’ve published some eye-opening results in a recent research paper, “Democratic and Republican physicians provide different care on politicized health issues”:
We linked the records of over 20,000 primary care physicians in 29 US states to a voter registration database, obtaining the physicians’ political party affiliations. We then surveyed a sample of Democratic and Republican primary care physicians. Respondents evaluated nine patient vignettes, three of which addressed especially politicized health issues (marijuana, abortion, and firearm storage).
Their results were interesting. For most issues, the physician’s political leanings did not affect their treatment. But for three specific issues, the doctor’s political leanings did — abortion, marijuana, and guns.

With respect to the first two issues,  Faced with a woman who wasn’t currently pregnant but had undergone two abortions earlier in life, Republican doctors were twice as likely as their Democratic counterparts to say they’d discourage any future abortions and 35 percent more likely to discuss so-called mental health aspects of abortion  Faced with a man who uses recreational marijuana three times a week, Republican doctors were 64 percent more likely to say they’d discuss marijuana’s legal risks and 47 percent more likely to urge them to cut back than Democratic doctors.


As a physician and a gun owner, I was especially interested in how political affiliation affected doctors’ treatment of patients who owned guns:  When it came to firearms stored in patients’ homes, Democratic physicians expressed far more concern than Republicans. However, Republicans doctors were more likely to actually talk with patients about storing guns safely in the home, despite being far less concerned about the issue overall…

In contrast to abortion, marijuana use, and gun ownership, doctors’ political affiliation did notaffect their treatment of other issues such as depression, alcohol abuse, or riding a motorcycle without a helmet.









How Your Doctor's Politics Affects Your Health Care -- And What You Can Do About It

Friday, October 21, 2016

Primary care doctors are staying out of the fight against opioids

During the past six months public health officials have labelled the overuse of opiod pain killers and opiod dependence (addiction)  It amounts to a larger problem than diabetes mellitus. It may very well be the greatest Population Management challenge.

Paradoxically opioid abuse has worsened since many state medical licensing boards now issue CME requirements for physicians to obtain CME regarding opioid prescription for re-licensure.  Is this a statistical oddity ?  Several years ago a rating scale from 1-10 was recommended to quantify patient  pain.  How bad is your pain?  It is mostly a subjetive statement b a patient. A 10 is the worst pain you have ever experienced, affecting thought or movement This measures intensity but ignores duration of pain which can be as important as the level of pain.

The scarcity of doctors trained to deal with addiction is acute, and the issue resonates in cities and towns across the country, where roughly 20,000 people die annually from opioid-related overdoses. In the face of one of the country’s most pressing and fastest-growing public health crises, few primary care doctors treat substance abuse disorders, even though they are uniquely positioned to recognize problems and help patients before it’s too late.
Instead, many primary care doctors follow an old script: Refer patients to addiction centers and Narcotics Anonymous, and move on.
The scarcity of doctors trained to deal with addiction may be particularly acute in EspaƱola, but the issue resonates in cities and towns across the country, where roughly 20,000 people die annually from opioid-related overdoses. In the face of one of the country’s most pressing and fastest-growing public health crises, few primary care doctors treat substance abuse disorders, even though they are uniquely positioned to recognize problems and help patients before it’s too late.
Instead, many primary care doctors follow an old script: Refer patients to addiction centers and Narcotics Anonymous, and move on.

“We’re just watching the ship sink, even though we have the pumps to easily keep the water out,” said Dr. R. Corey Waller, an addiction-treatment specialist who leads the advocacy division of the American Society of Addiction Medicine, or ASAM.

FACT SHEET: Obama Administration Announces Public and Private Sector Efforts to Address Prescription Drug Abuse and Heroin Use




Primary care doctors are staying out of the fight against opioids

Thursday, October 20, 2016

(28) National Eye Health Education Program (NEHEP)




Join us and learn more about diabetic eye disease.  Health Train Express is pleased to be a sponsor as well as a proponent of managing diabetic eye disease.

The progress in treatment of early diabetic retinopathy has  improved immeasurably.

A key component for diabetics is to monitor your blood sugars.  An annual eye examination or an annual fundus  photo of the retina  will often find undiagnosed diabetic retinopathy.  This can be accomplished by your regular vision provider, optometrist or ophthalmologist. An annual fundus screening using photography provides an excellent means for screening and it provides a permanent record for comparison from year to year. Often the earliest changes from diabetic retinopathy are not symptomatic. Diabetics who experience blurring of vision may have the earliest form of macular edema.  Any diabetic who has vision problems or changes in vision should be examined immediately.

The treatment of late diabetic retinopathy (proliferative) has evolved from laser photocoagulatioin to medical drug therapy using intraocular inhibitors of new vessel growth (Avastin).  This new treatment minimizes retinal damage and often restores lost vision.

The NEHEP provides an excellent presentation, which was featured on 'Facetime'. In this video Dr Emily Chu a prominent eye research scientist at the National Eye Institute..

The progress has been amazing.  When I began my ophthalmology practice in 1975 most patients with proliferative diabetes were blind within five years.  It was very disheartening.

Today there is no reasnn why anyone with diabetes should go blind from diabetes.

Sam Omar,,M.D. a fellow ophthalmologist has this to say,

" During my training at UCLA in 1997 I was speaking to one of my mentors Dr Straatsma. I was particularly excited one day because I had assisted the retina fellow in repairing a detachment for a patient. My mentor had told me when he was in training in the late sixties he had attempted to surgical reattachment repair for a detached retina and was unsuccessful in three out of three patients. Those patients all went on to becoming permanently blind. Fast forward - 2015 the technology has improved so much in my short life span of Ophthalmology over the past 20 years. The first picture shows a retina specifically the central retina detached with fluid floating underneath it that's the black in the lower part of the picture. The next picture shows the retina completely reattached so perfectly that the organization of the photoreceptors and the retinal pigment epithelial cells is entirely intact. There is normal organization of the retinal layers and the retina is set up perfectly to heal and function properly. This repair was done by a particularly skillful surgeon. Technology is everywhere and I even used it to dictate this Facebook post with no mistakes in all of the above technical terms."








(28) National Eye Health Education Program (NEHEP)

Sunday, October 16, 2016

Lessons I’ve Learned from Patricia Bath, MD F.A.A.O.

The title seems ordinary enough, but hidden in it's meaning is the life of the first woman ophthalmologist of color.  One who broke through  'the glass ceiling' as early as 1974.

For those who speak of breaking through a glass ceiling for women.....you are a bit late !  Medicine however offers an undeniable metric for advancement, achievement and dedication. In other disciplines such as business financial measures, leadership ability or political persuasion are more amorphous measures for a 'glass ceiling.

Patricia Bath's career path runs very similar to Ben Carson, MD (former Presidential candidate for President of the United States. She was born in poverty, and went to what some would call a second rate School of Medicine.  That was the last step in 'second rate' institutions. From there she was accepted to a major world class ophthalmology training program, eventually earning faculty status.



For me as the average white male  American I don't think I can fully appreciate her journey. With all the   privilege of being white I still had challenges pursuing my education. The competition to become accepted to medical school is extremely high,  the competition to be accepted into an ophthalmology training program is even more intense, and becoming the chair of an ophthalmology training program one of those 'never events' we speak of in complications of surgery.

The graphic below  succinctly maps her progress to recognition

The Career path of Patricia Bath M.D. F.A.A.O.



Her inspirational thoughts will fuel the desire of many more women and men of color.

When she chould not  penetrate an impregnable barrier, she went around it,  preferring to not waste energy  and to pursue her own interest.  All of which is evident from her outcome.

My favorite motivational saying is "Believe in one-self"  Ask  few for opinions (be sure who you ask in t he first place.  Don't listen to negative answers.  Remain committed to your goals. Find people who believe in  you and will assist you, or at least not stand in your way.

I salute all the 'suffragettes who strive to improve humanity with their standards, goals.

This post gave me great pleasure, one of the most enjoyable as well as satisfying, to recognize a great physician (ophthalmologist)  I have written (in my humble opinion)







Gary M. Levin M.D. F.A.A.O.





more.......





Lessons I’ve Learned

How Government Solved the Health Care Crisis - Animation

The Lodge and Fraternal Society Model for Health Care was the forebearer of our present dilemna, of inadequate access to health care.  Those who do not know history are doomed to repeat it.

Government solved the last crisis !

How Government Solved the Health Care Crisis




Family Practitioner Awarded Family Physician of the Year

Family medicine has always been at the heart of medicine. If you ask a patient they willl usually say 'Our family doctor is .....  It bespeaks much of the complexity of credentials, board certification and the rest of it. Most patients are not that aware of what all those diplomas are on the wall. And with  the general training all young physicians obtain, and are licensed as MDs in all states, not as a specialist most MDs are capable of handling routine complaints and treat simple disorders. If they can't then they should not be practicing medicine (in my opinion)

My perspective may be a bit skewed by the fact that I did general medicine after internship in t he Navy and practiced family medicine for three years afterward.  When I had a major heart surgery, I relinquished my scalpel for several years, returning to family medicine with a colleage who  used to refer to me.

This announcement caught my eye and is well worth recognition.
******************************************************************************************************


At just 11 years old, Karen Smith, M.D., went on the trip of a lifetime.



Smith's mother wanted to visit Walt Disney World with her children. In 1972, the family made the trip to Orlando, Fla., and it's where a young Smith learned the power of imagination, belief and creativity. Walt Disney's famous saying, "If you can dream it, you can do it," resonated with her.
Smith's mother died from sarcoidosis not long after the trip, but the memories they created inspired her daughter to pursue a career of medical service.
"It's amazing what a mother can instill in her children," Smith told AAFP News. "Those memories are in us, and those memories are what have allowed me to do what I've done … with the grace of God."
For her efforts, Smith has been named the Academy's 2017 Family Physician of the Year. The award recognizes a family physician who stands out among his or her colleagues for providing compassionate and comprehensive care, enhancing the quality of the community, and acting as a credible role model. Today, 43 years after her first trip to Orlando, Smith has returned to the city to accept this award during the AAFP Family Medicine Experience.
Another example of the unsung, underpaid, overwhelmed primary care internists, pediatricians and family medicine physicians...In today's world primary care providers take a residency as long as most other specialtlies.  


STORY HIGHLIGHTS
  • Karen Smith, M.D., of Raeford, N.C., has been named the 2017 Family Physician of the Year.
  • The award recognizes a family physician who stands out among his or her colleagues for providing compassionate and comprehensive care, enhancing the quality of the community, and acting as a credible role model. 
  • After more than two decades in rural practice, Smith says she still is driven by the power of touch -- physical, emotional and spiritual.
























Compassion, Imagination and Belief Inspired 2017 FPOY

Tuesday, October 11, 2016

How those pharmacy coupons may increase your health care costs


How drug coupons 'undermine' payers' efforts to limit healthcare costs


Consumer drug vouchers for pricey pharmaceuticals--like Mylan’s EpiPen--may lead to market failures that dissolve the incentive for powerful pharmaceutical firms to reduce prescription drug prices, hurting payers' cost-control efforts.


Here are five ways, according to a article published in the Annals of Internal Medicine, that vouchers to help offset the cost of drugs like EpiPens interrupts the proper functioning of the market--and subsequently contributes to higher future healthcare costs:

  • Co-pay assistance placates “public outcry.” Public pressure, such as articles about the high cost of EpiPens, seemed to be correlated with a “reduction in the magnitude” of price hikes by Mylan, the authors note. Appeasing consumer anger can circumvent such processes, and therefore lessen pressure on companies like Mylan to reduce prices.  
  • The vouchers subvert insurers' strategies to limit healthcare utilization for low-premium, high-deductible enrollees. Low-premium, high out-of-pocket expense health insurance plans shift the burden of healthcare utilization onto consumers, nudging them to use fewer healthcare services--which lower total healthcare expenditures. The co-pay assistance programs “undermine” this effort, pressuring insurers to increase premiums across the board, the authors say.
  • They create an artificial price distortion. High prices are supposed to encourage consumer shrewdness in the marketplace, according to the authors, which theoretically should “include scrutiny” of product price and quality. The researchers thus conclude copay coupons “keep patients from acting as consumers,” reducing the incentive for consumers to factor price into their decisions and further decreasing the incentive for pharmaceutical firms to lower their prices.
  • The tactic handcuffs insurers’ leverage during negotiation with drug companies. Insurers that reach price concession agreements with drug producers reflect this in their formulary tiers with lower out-of-pocket costs--and vice versa for manufacturers that insist on high prices. Pharmaceutical companies like Mylan, which offered patients $300 coupons, are able to sidestep this mechanism by keeping out-of-pocket expenses lower for consumers when insurers aim to keep them high.
  • Co-pay assistance programs don’t live up to their promises.Pharmaceutical companies don’t provide financial assistance to all filled prescriptions, only for patients who haven’t hit their deductible to have their insurer prescription benefit kick in. Insurers can’t ascertain payments made by patients versus those covered by the co-pay coupons, ultimately helping patients hit out-of-pocket maximums quicker. For specialty drugs that can cost up to $10,000 per month, insurers can be left to foot the bill much earlier in the year.

Medicare Part D spending on EpiPens grew more than 1,150 percent over a seven-year period from 2007 to 2014 while the number of beneficiaries receiving the treatment increased a disproportionate 164 percent. The ensuing public frustration resulted in CEO Heather Bresch to testifying at a Senate hearing to defend the 400 to 500 percent price hikes.

Most health cost containment programs just shift the burden or cost to another segment of the health industry.  There is one big pot, which we must all share. And the partcipants do not play fair.

Thanks to Fierce Health Care Payer for most of this article.