HEALTH TRAIN EXPRESS
Mission: To promulgate health education across the internet:
Follow or subscribe to Health Train Express as well as Digital Health Space for all the updates for health policy, reform, public health issues. Health Train Express is published several times a week.Subscribe and receive an email alert each time it is published. Health Train Express has been published since 2006.
Previously on a routine history taking there were several categories of organization, ranging from chief complaint, present illness, family history, past medical history, review of systems.and social history I remember memorizing those categories and the questions in each category. Regardless of what a patient complained about it was standard to perform this standardized method of taking a history.
In today's world the Social determinants of health include socioeconomic, familial structure, health insurance coverage and other sociological factors, religion, community, social networks and more.
Remarkable advances in medical science, clinical care, and therapeutics over the last 60 years have established the current understanding of the “nature” side of disease. The “nurture” components of disease also have been explored, revealing strong associations between social support and health outcomes. However, prior investigations into social determinants have often been limited by self-reported information based on reductionist instruments with standardized responses. Moreover, social determinants are complex, and entail networks and behaviors that are best revealed by what actually occurs in life, rather than the perception of these complex relationships. Individual and network data available within social platforms therefore have the potential to elucidate the understanding of social determinants of health and could offer measurable, actionable insights into how disease can be prevented. To date, only limited direct links between medical and complex social network data have been made.
Corresponding Author: Freddy Abnousi, MD, MBA, MSc, Facebook Inc, 1 Hacker Way, Menlo Park, CA 94025 (abnousi@fb.com).
In this Viewpoint, Harlan Krumholz and colleagues discuss the promise that social media data hold for helping researchers better understand social determinants of health, and the challenges that must be overcome to reliably link social network data to clinical and health outcomes.
The roots of interest in social determinants of health can be traced back in part to the World Health Organization (WHO), which, in 1946, notably defined health as “complete physical, mental, and social well-being.”3 Since then, a number of national and international efforts have increased awareness of the field, such as the WHO’s Commission on Social Determinants of Health and initiatives by the MacArthur and Robert Wood Johnson Foundations.4-6 From a research perspective, numerous studies have shown associations between social determinants of health and life expectancy. While these studies reflect the overall importance of social determinants of health in relation to health outcomes, an important limitation of current research on social determinants of health is that many of the identified factors, such as income and education, cannot easily be changed.8 This is in part because of a lack of granularity in understanding the person and his/her community, compounded by the potential flaws introduced by survey self-reported social/behavioral variables as opposed to observed factors. Access to information that captures the habits, behaviors, and networks of individuals has been limited in the existing body of work as these parameters relate to health outcomes. As such, it is not surprising that actionable variables continue to be elusive.
Better approaches are needed for accessing information about observed habits, behaviors, and networks to foundationally understand their relationship with health and health outcomes. Despite the exponential increase in the role of social media in the daily life of individuals around the world over the last decade, most studies have not directly evaluated social variables from social network sources in relation to clinical outcomes.
Evaluating social network data in combination with increasingly available digital health care data (such as from large, national clinical registry programs or electronic health records) could lead to novel, more nuanced understanding of social and behavioral variables that account for the interplay of the individual and the network in relation to health outcomes. These may transform the traditionally held social determinants of health, including education, income, housing, and community, to encompass a more granular tech-influenced definition, ranging from simple factors, such as numbers of online friends, to complex social biomarkers, such as timing, frequency, content, and patterns of posts and degree of integration with online communities. With data related to millions of users, network effects may amplify the total range of patterns and associations.
These aspects lean toward 'population health' measures. this kind of research also harbors potential risk and clear challenges. As was done for the Human Genome Project, the first step will be to establish the legal and ethical framework for this endeavor. Social network data raise unique challenges to deidentification beyond the typical demographic identifiers. For example, when an individual posts a simple phrase, the exact composition of words used can become a form of identification in its own right; developing the techniques to de identify this kind of data will require thoughtful approaches. In addition, a combination of physical and software-driven isolation needs to tightly control access to the data. Concurrently, investment in research towards the creation of “synthetic data sets” (ie, data sets that maintain associations but have the original data removed) may serve to advance security and privacy for the next iteration of this research.Some authors have even suggested the use of social media as a measure for social determinants. For those not familiar with the standards of health care professionals this would be a dangerous measurement.
Facebook has had serious privacy violations in the breast cancer group Thousands of women who carry mutations in the genes BRCA1 and BRCA2 and joined ‘private’ Facebook groups recently learned that their groups were vulnerable to a Chrome plug-in that allowed marketers to discover group members’ names and other private health information. That Chrome plug-in has since been removed from this, and apparently all other private groups, but has left a deep scar in the BRCA community’s trust in Facebook.
Safeguards have been put in place for Facebook which include removing the chrome extension grouply.io. This extension allowed for mass harvesting of group members data.
The bottom line is that these methods are not yet ready for prime-time and should carefully be investigated until ethical and legal matters are addressed and codified.
Can we become Green doctors and patients? Our current focus on health reform has been to make it more efficient and less costly. Our country shares two statistics that are shameful. . We suffer with the highest costs globally, and we are one of the most polluting country in the world.
The term "eco-health' also refers to the effect of our environment on personal well-being.
The United States spends more on health care than any other country, with costs approaching 18% of the gross domestic product (GDP). Prior studies estimated that approximately 30% of health care spending may be considered waste. Despite efforts to reduce overtreatment, improve care, and address overpayment, it is likely that substantial waste in US health care spending remains.
This review used the framework of 6 domains of waste that guided previous work (failure of care delivery, failure of care coordination, overtreatment or low-value care, pricing failure, fraud and abuse, The estimated annual savings from these interventions ranged from $22.8 billion to $30.8 billion.) administrative complexity)2,3 and added estimates of the cost of low-value care to the “overtreatment” domain (Table 1).
Low-value care was defined as services that provide no or minimal benefit to a patient in a specific clinical situation.15 In addition to new evidence on the cost of waste, evidence regarding cost-saving interventions was reviewed to provide estimates of potential waste reduction in each domain if those successful interventions were scaled.
Two articles addressed cost of waste from administrative complexity (Table 2), and no articles were identified that addressed savings from interventions. The estimated total annual cost of waste in this category was $265.6 billion.
This review of the current literature of the cost of waste in the US health care system and evidence about projected savings from interventions that reduce waste suggests that the estimated total costs of waste and potential savings from interventions that address waste are as high as $760 billion to $935 billion and $191 billion to $282 billion, respectively. These estimates represent approximately 25% of total health care expenditures in the United States, which have been projected to be $3.82 trillion for 2019.
Patients and providers alike must learn about and question why their physician orders a test or a treatment. Both are subject to commercial marketing practice and competition amongst laboratories, imaging services, hospitals, clinics and pharma for their share of the marketplace.
In addition to financially going Green, a focus on minimizing pollution, increasing recycling, and improved energy efficiency are of paramount importance. While other industries are giving attention and resources to these issues, health care has not. Cogeneration and alternate sources of energy have been ignored by hospitals and large medical clinics. There is little competition from medical device manufacturers about energy efficiency of their products.
By issuing an Executive order the administration intends to bypass Congress's powers for health care just as he did for border and immigration. His order includes 'sweeping" changes many of which could effect America's healthcare. It is a carrot and stick approach to gain acceptance by physicians and patients. It would reduce massive bureaucracy and regulation and at the same time drastically reduce reimbursement to providers.
“Since Day One, this administration has worked to undermine access to care and quality of care for patients. The president’s latest Executive Order suggests changes regarding scope of practice that would also have disastrous effects for patients. We must ensure that every American, regardless of age or economic status, has access to a trained physician who can provide the highest level of care. We agree that medical professionals should be able to practice at the top of their license but care must be supervised by a physician who is highly trained and ultimately responsible. Expanding access to care should not come at the expense of patient safety and we will not support unequal standards of care for patients from different economic backgrounds.”
It strips away a differential reimbursement algorithm which pays physicians differently than nurse practitioners or physicians assistants. The new regulation would pay a uniform amount to a second level provider equating their expertise with that of a an accredited licensed M.D. (or a specialist).
It merges disparate functions of the FDA and HHS in an attempt to legislate increased efficiency and decrease reimbursement.
It would prohibit any legal action by a person or organization to hinder the implementation of said executive order.
Para: 12:3 in General Provisions.
"This order is not intended to, and does not, create any right or benefit, substantive or procedural, enforceable at law or in equity by any party against the United States, its departments, agencies, or entities, its officers, employees, or agents, or any other person."
Attribution is given to FDA, HHS, CMA. Statements outisde ".." are those of the author and do not represent any other organizational entities. The author has no financial interest in other health care entities and owns no shares of medical, Pharma or business corporations
Why do hackers target healthcare data? Hospitals need to spend more and pay attention to cybersecurity in order to prevent data breaches.
Did you know that more than 25 percent of all data breaches that occur in a given year affect hospitals and healthcare facilities? Why is healthcare data a target for hackers?
Research from 2018 suggests that health data is the second most at-risk type of information after social security numbers. In 2019, there have been more than 25 million patient records affected.
It’s also very important to point out that out of all hospital data breaches, 53 percent originated within the establishment itself. What’s even more troublesome is the fact that for most hospitals, more than a month passed from the initial hack attack/breach to its detection.
Why are healthcare facilities vulnerable and what makes hackers target such institutions? Why are health security challenges becoming more difficult to address every single year?
The conclusion reached was that hospitals were severely lacking in data security measures due to the lack of funding, the lack of appropriate staffing, no employee training pertaining to the best data security practices, improper organizational structure, the overall lack of a security policy and the lack of security audit procedures.
Why Do Hackers Target Hospitals?
The research quoted in the introduction suggests that over 15 million patient records were breached in 2018. The number of affected records has nearly tripled over the course of a single year – from slightly over 5.5 million records in 2017 to over 15 million records in 2018.
There are several reasons why hackers are so keen on accessing healthcare facility and patient information.
Patient data can easily be sold off, which is the number one reason why healthcare facilities are subjected to so many hack attacks.
Health records and other patient-related information are hugely demanded on the black market. In some instances, hackers are even capable of selling the information back to the hospital itself. Needless to say, they generate massive profits from such “transactions.”
In essence, hackers can make money from patient data through blackmail or by selling such records to the highest bidder.
Hackers can also utilize the information of high profile patients. In 2017, for example, hackers breached the network of a major plastic surgery clinic in London. It was a high profile case that included information from numerous celebrity clients. That information consisted of pictures, medical records, addresses, and even sensitive financial data. Such information can easily be applied to fraudulent activities, stalking, and harassment. Finally, hackers target medical facilities because they lag behind in the introduction of security measures. Bank and financial networks, for example, are heavily protected. This isn’t the case for medical facilities. Many of them don’t have the resources to introduce the latest safety measures and to make sure that patient information is properly protected.
Ways in Which Hospital Data Breaches Occur
A hospital’s database can be breached in several distinctive ways.
The first and easiest available option is the so-called social hacking. It involves getting credentials (user names and passwords, for example) from one of the individuals that have legitimate access to the network.
It’s very easy for someone to impersonate an IT company rep who needs to do maintenance, hence is looking for credentials information.
The second and a bit more challenging option involves the use of brute force to access the network in a completely unauthorized way.
Security experiments show that the second data breach method isn’t that difficult to utilize.
Healthcare Data Protection: Best Practices
Data security solutions are becoming more readily available today. Cloud-based technologies are scalable and cost-efficient. They allow for better protection through encryption, access monitoring and the logging of unusual activity.
A shift in mindset is needed for healthcare facility managers and administrators to see the cost-efficiency of database safety solutions. Until recently, these were perceived as too costly and only attainable within the framework of a large medical facility.
Educating staff members is even more important. As already illustrated by some of the examples, many hack attacks and security breaches are the results of negligence or complete unawareness of safety protocols.
Any IT security program within the healthcare framework should have a big focus on staff training. Many people are still unaware of how hack attacks occur, what’s phishing, malware or ransomware. When such threats become easy to identify, they also become easy to circumvent.
Good hospital data protection practices should also focus on the establishment of a secure wireless network, the encryption of portable devices and even the introduction of physical security controls like locking file cabinets (to protect paper-based data) and installing security cameras.
Hospital Security Necessitates a Thorough Approach. Workforce training and management is a requirement for all covered entities under the HIPAA Security Rule.
Making hospital data more secure isn’t about the introduction of a single measure. A thorough approach will be required to eliminate vulnerabilities from the network itself and to reduce the risk of human error.
Ransomware, external threats, and advanced persistent threats are a few of the key healthcare data security and healthcare IT infrastructure dangers.
1. Ransomware
2. Outside Threats (human)
3. Advanced Persistent Threats (APTs) – Theft of IT and Corporate Data
4. Distributed Denial of Service (DDoS) Attack
The importance of information management in the healthcare context cannot be underestimated. While digitization is simplifying the management of larger information volumes than ever before, it also contributes to potentially disastrous security risks. The need for healthcare-focused security solutions and staff training courses is only going to grow in the years to come. While current statistics don’t pay an optimistic picture, technological advancements and higher levels of awareness will hopefully change the situation for the better in the near future.
Healthcare employees must undergo regular and comprehensive training so organizations can better avoid potential data security threats.
Eighty percent of health IT executives and professionals said that employee security awareness is their greatest data security concern, according to a survey conducted by HIMSS Analytics and sponsored by Level 3 Communications, Inc.
There is a shortage of adequately trained cybersecurity experts. There are over 300,000 job positions available that remained unfilled A variety of solutions have been suggested, from retraining already employed personnel in cybersecurity, to Filling Healthcare Security Staffing Gaps with Virtual CISOs, Students. The staffing shortage has hit the healthcare sector hardest: 79 percent of healthcare organizations find it difficult to recruit security staff, Ponemon reported. V-CISOS Virtual CISOs, or vCISOs, are quickly becoming a sound method for effectively closing security staffing gaps. These cybersecurity leaders are offsite and are commonly shared between several organizations. On the surface, the move could seem risky: the leader is off-site and shares security time with other providers. Those concerns are valid. But for smaller organizations that may not need a full-time security leader or that may reside in an area where it’s difficult to attract top security talent, a V-CISO can be more than effective at providing the necessary security policies, procedures, and support.
Synoptek, CynnergisTek, Pivot Point Security, and a host of others offer these virtual roles, which can be tailored to meet the needs of an organization. Hospitals often struggle to find and retain security leaders who have the skillset to manage the complexity of the healthcare environment, Hewitt explained. Even with outside recruiting, there’s a moderate amount of movement in CISO roles. Resources also add to the challenge, as many can’t afford to retain top talent. VCISOs can fill that gap, while providing elements a traditional CISO cannot. “For mid- to small-sized providers, you can clearly see that a vCISO may be an advantage because, number one, they probably can’t afford additional training. But they can take that money and go with a vCISO, which will be shared across two to five hospital districts or providers. There’s an economy of scale.” What should an employee do if they suspect a breach in cyber security
Attribution is given to the following publications and/or organizations for the content herein.
Obesity is very difficult to cure or treat. Research is exploring the road to being overweight. New concepts are emerging
My own concepts and observations led me to believe it was highly associated with lower-income populations. This may be falsely attributed to my analysis that Walmart provides low-cost food and other household items. The two ethnicities I have observed are Hispanic and African-Americans specifically and not all people of color. My demographic is based upon "The Walmart demographic" I have been to Walmart's in many regions of the United States, and it seems to be true in all regions.
We have all been faced with the aisle jams caused by people who take up an inordinate amount of floor space.
The obesity epidemic continues relentlessly across the globe, despite the increasing attention being paid to it. The latest CDC statistics (as of 2016) show that 39.6% of adult Americans are obese, with every state having a rate of >20%. This is an increase from 2011 – 34.9%. In fact, the trend has accelerated. The same is true worldwide. As of 2016, there were 650 million obese adults worldwide. This is no longer a problem of just industrialized nations, and obesity can occur alongside malnutrition. The figures have tripled since 1975.
Despite these alarming numbers, there remains a fringe of “obesity denial”, which I first discussed in 2011. There are two main elements to this denial. The first is the notion that people are not really getting fatter, that it is just a trick of statistics. This is clearly not true, as the trends over the last 8 years further demonstrate. Second, there is the notion that overweight and obesity may exist, but are not in and of themselves unhealthy. This is also not true but takes a bit more data to unpack.
The counterclaim is that obesity correlates with other things that are unhealthy, such as a poor diet, lower socioeconomic status, and less access to health care, but is not an independent risk factor for the disease. This is the “fat but fit” hypothesis. This has always been a minority opinion among experts, but a plausible interpretation of the data, resulting in some controversy. This is because the data, by necessity, is observational. You cannot make people get fat to see if they are more likely to die from the disease. Correlational data leaves the door open for multiple interpretations of cause and effect.
At this point, however, I think we can say that the data is in. The “fat but fit” hypothesis is all but dead. Multiple large studies have reasonably isolated obesity as an independent risk factor. A 2018 study in the European Heart Journal looked at almost 300,000 people prospectively. They first evaluated them for their metabolic health – diabetes, blood pressure, cholesterol – and then tracked their health over four years. They found that waist size was an independent risk factor for heart disease and strokes. Further, there was a “dose-response” effect – the bigger your waist, the higher your risk.
Further, being overweight is an independent risk factor for other things which themselves carry a further risk – such as sleep apnea, diabetes, certain cancers, and arthritis.
A recent study also shows this risk extends to younger age groups. Specifically, tracking of cancer rates over the last decade show a shift in obesity-related cancers to younger age groups.
In this cross-sectional study of 2,665,574 incident obesity-associated cancer cases and 3,448,126 incident non–obesity-associated cancer cases from 2000 to 2016, the percentage of individuals diagnosed with incident obesity-associated cancers increased in younger age groups, with some of the greatest increases observed for liver and thyroid cancers (all sex- and race/ethnicity-specific strata), gallbladder and other biliary cancers (non-Hispanic black men and women and Hispanic men), and uterine cancer (in Hispanic women in the 50- to 64-year age group).
We show that, contrary to the dominant paradigm, more than 55% of the global rise in mean BMI from 1985 to 2017—and more than 80% in some low- and middle-income regions—was due to increases in BMI in a rural area
The one thing about which there is general agreement is that the epidemic cannot be understood simply through the lens of individual behavior. This is a public health issue, relating to societal factors. A lot of blame focuses on the fast-food industry. Over the last 30 years, the average calorie content of a fast food meal has increased (along with salt and fat content). There is also a focus on “food deserts” – locations that lack sufficient access to fresh fruits and vegetables. There is some debate about the role of a sedentary lifestyle, although it seems the evidence supports the conclusion that obesity is largely due to excessive caloric intake.
Overweight and obesity is a complex behavior problem without a known consistently effective solution. The primary problem may be that we evolved in an environment that was calorie-restricted and now we have access to calorie abundance. The food industry competes with increasingly tasty products, and that means more calories. Health and dieting fads have apparently not been helping.
What is likely necessary is a significant change in the culture of food, but that is not something that is easily changed, or really in the power of any one organization or institution to change. That is why we debate endlessly about the causes and solutions to the obesity epidemic, while the numbers continue to worsen and even accelerate.
Climate change is a health emergency. As physicians, we regularly see the ways in which it’s already damaging the health of our patients.
A few examples from our practices: We have seen a 12-year-old boy forced to quit his beloved baseball team because air pollution is now so extreme that simply being on the baseball field makes him sick. A 30-year-old woman whose asthma is exacerbated so extremely by poor air quality and smoke exposure that she needed multiple rounds of oral steroids — which led to weight gain and worsened her depression. A mother who couldn’t sleep at night because every time she closed her eyes she relived the night she and her young children were evacuated and then lost their home to extreme flooding. An 80-year-old man whose chronic obstructive pulmonary disease worsened dramatically after his exposure to wildfire smoke, to the point where he could no longer help care for his grandchildren.
This is already happening. And this is just the beginning.
Protesters block traffic on California Street as part of the Global Climate Strike in San Francisco on Sept. 25.
Severe weather will cause more injuries and fatalities. Worsening air pollution caused by increased temperatures and smoke exposure will result in more severe exacerbations of asthma and heart disease. Rising temperatures are already causing dehydration, heatstroke, and heat-related death, especially in children and the elderly. Tropical storms are larger, more intense with higher wind velocity and greater rainfall. Forests are migrating as average temperatures change (either increasing or decreasing)
The extent of infectious diseases such as Zika, malaria, and dengue fever will increase, putting hundreds of thousands of more people at risk of these diseases. Seasonal allergies will become more severe and last year-round.
The mental health and sense of well-being of all people will be severely compromised. The most vulnerable among us — the youngest, the poorest, and the most disenfranchised — will be hurt the most.
As physicians, we take an oath to treat disease and prevent human suffering. Our office waiting rooms are already filling up with patients whose health and lives are being irreversibly damaged by climate change. The medicines we have at our disposal are not strong enough.
Simply put, we will not be able to treat the disease caused by climate change.
We are also excited and galvanized. Four million people worldwide and 400,000 people in the U.S. took to the streets to demand action on Sept. 20. Many more partook in conferences and strikes this past week. Greta Thunberg has becoming a household name.
The message is clear: we must cut our greenhouse gas emissions as quickly as possible to prevent catastrophic human sickness, suffering and premature deaths.
The key question is, what can we do?
Regardless of what you believe, a climate change naysayer or a 'greenie" commonsense reveals at how the earth looked from space 200 years ago, or now with the view from the international space station, the lights on earth reveal a transformation. The earth is alight with a glow that was not present before. Any populated area has been transformed at night by lights produced by energy from mostly fossil fuels.
First, every person alive right now needs to understand that this is about our health and futures generations (ie, your descendants) Climate change is making us sick and will only make us sicker.
Is it all in your head? Of course, it is. Your brain is where you think and feel. It is all biochemistry. It is also electrical. Medicine is just beginning to understand the process, due to the relatively recent addition of specialized imaging. It is now possible to see what is occurring in the brain by monitoring glucose uptake and locating the exact areas that "light up" when thinking, feeling, moving, or sensing our surroundings.
The irony of “it’s all in your head” is that although this phrase is often used inappropriately and dismissively, it is technically correct. The problem does indeed lie within the head. More specifically, it lies within the brain and its complex networks that we are just beginning to understand. Over the past 10 years, neuroimaging research studies have consistently identified brain abnormalities in patients with medically unexplained symptoms—yes, biologically based changes in the activity and connections of brain regions, such as the amygdala, prefrontal cortex, temporal-parietal junction, and other structures.1 These brain circuit abnormalities provide physiological explanations for once mysterious links between regions implicated in emotional processing and the generation of “physical” symptoms (eg, pain, fatigue, weakness). Jean-Martin Charcot, MD, a famous 19th-century French neurologist and early pioneer of this field, reportedly insisted that a “functional lesion” would be found when microscopes were sufficiently powerful.2 Well, our microscopes are getting better, and we are now starting to see evidence of the predicted functional or software disruptions in the brain.
We still do not fully understand what causes these software problems; however, recent research suggests a multifactorial etiology, including genetic predisposition, environmental risk factors (eg, childhood adverse events), and psychological stressors.
In the case of gastrointestinal disorders, we know that the GI system's neurologic system is equivalent to a second brain, in terms of weight and size. Our head brain is connected directly to the gut-brain by the Vagus nerve
The Clinical Encounter
Based on such attitudes, a typical physician-patient interaction may proceed as follows: (1) the physician provides a rundown of normal investigations, (2) the patient is told they have no known medical diagnoses, (3) a brief awkward exchange occurs, and (4) little further explanation, guidance, resources, or facilitation of an appropriate referral process is given. Even if the infamous phrase is not explicitly stated, this sequence leaves the patient to infer for themselves that it must be all in their head. Unfortunately, they do not perceive this as, “I have a real dysfunction of networks in my brain,” but instead understandably conclude that “they think I’m crazy” or “faking it.”4 Sometimes, patients may hear the distant utterance of, “Maybe you should see a psychiatrist,” as they exit the office door, but in this context, such advice is rarely productive.
Many of these patients can be so offended by this encounter that they quickly seek multiple second opinions and subsequent rounds of pricey and unnecessary investigations. Depending on the jurisdiction and medical record system, the original physician may be completely unaware of these additional rounds of care. Mounting negative and invalidating clinical interactions can become a source of distress and cause medical trauma. At this point, patients often either fall through the cracks or stumble on a fringe medical specialist or alternative medicine practitioner who may offer the “physical” diagnosis they’ve been yearning for. This could include a growing list of unsubstantiated metabolic deficiencies, infectious disorders, or autoimmune hypersensitivities. Anecdotally, the most common current example seems to be the diagnosis of chronic Lyme disease by unvalidated assays.5 Let me be clear that many of these practitioners are well-intentioned and can offer holistic approaches that medicine could learn a lot from. However, there appears to be a subset that takes advantage of these patients’ desire for “physical” diagnosis and exploit their vulnerabilities.
For the patient, receiving such a concrete, “organic” diagnosis often quells mounting anxiety, which in itself could be partially therapeutic. However, now wedded to their given diagnosis with no knowledge of their actual software problem, patients do not see a need to address underlying factors that may be contributing to their disorder nor do they receive the multidisciplinary care that they may so badly need. The saddest part of this epidemic is that if addressed early, these symptoms may be reversible; however, with delays to proper diagnosis and management, prognosis worsens considerably.
Included below are several helpful video programs of patients with FND.
Unfortunately, physicians trained in another era often used the term "conversion disorder" as a wastebasket term for a disorder that could not be measured with laboratory testing. Modern neuroscience and diagnostic imaging and soon biological markers will help make a diagnosis.
Research builds on the Sound Health Initiative, an NIH-Kennedy Center partnership in association with the National Endowment for the Arts.
"There is so much we still don’t know about the effects of music in health broadly, and this partnership aims to explore this uncharted territory."
-Dr. Francis Collins, NIH Director
The National Institutes of Health has awarded $20 million over five years to support the first research projects of the Sound Health initiative to explore the potential of music for treating a wide range of conditions resulting from neurological and other disorders. The National Endowment for the Arts contributed funds toward these awards. While music therapy has been in practice for many years, Sound Health research aims to advance our understanding of music’s mechanism of action in the brain and how it may be applied more broadly to treat symptoms of disorders such as Parkinson’s disease, stroke, chronic pain and many more. The research will also seek to understand the effect of music on the developing brain of children.
“We know that the beat of a metronome can steady the gait of someone with Parkinson’s disease, for example, but we don’t fully understand how that happens,” said NIH Director Francis S. Collins, M.D., Ph.D. “If we can pinpoint in the brain how music therapy works through the use of imaging and biomarkers, the hope is that we can improve its effectiveness and apply it more broadly to improve the lives of millions of people who suffer from neurological and other disorders.”
Through a series of workshops beginning in January 2017 that involved neuroscientists, music therapists, and supporters of both biomedical research and the arts, NIH developed the Sound Health research plan that informed today’s grant awards. With funding from 10 NIH institutes, centers and offices, Sound Health awardees will:
Investigate the impact of music and singing on the walking ability and gait of people with Parkinson’s disease and older adults, and how these methods influence the brain.
Study how repeated exposure to music — including songs stuck in your head sometimes referred to as earworms — contribute to the creation and consolidation of memories, and how music serves as a cue for retrieving associated memories even when memory structures of the brain involved in effortful memory retrieval are damaged, as in Alzheimer’s disease.
Analyze data from longitudinal studies that define growth curves of brain and behavior from childhood to adulthood to learn how brains are shaped by music and how musical training affects attention, executive function, social/emotional functioning, and language skills.
Examine mechanisms underlying the effects of music intervention on improving early speech and later language learning for developing infants, specifically those at-risk for speech and language disorders.
Assess the effects of active music interventions on multiple biomarkers to provide a more holistic understanding of how active music interventions work to mitigate cancer-related stress and its potential to improve immune function.
Study musical rhythm synchronization as a mechanism of healthy social development and how that is disrupted in children with an autism spectrum disorder, with the goal of developing music interventions for social communication.
Want To Reduce Suicides? Follow The Data — To Medical Offices, Motels And Even Animal Shelters
On Kimberly Repp’s office wall is a sign in Latin: Hic locus est ubi mors gaudet succurrere vitae. This is a place where the dead delight in helping the living.
For medical examiners, it’s a mission. Their job is to investigate deaths and learn from them, for the benefit of us all. Repp, however, isn’t a medical examiner; she’s a Ph.D. microbiologist. And as the epidemiologist for Washington County in Oregon, she was accustomed to studying infectious diseases like flu or norovirus outbreaks among the living.
But in 2012 she was asked by county officials to look at suicide. The request led her into the world of death investigations, and it also appears to have led to something remarkable: In this suburban county of 600,000 just west of Portland, the suicide rate now is going down. It’s remarkable because national suicide rates have risen despite decades-long efforts to reverse the deadly trend.
Northern California’s Humboldt County, where the suicide rate is higher than the statewide average, has begun implementing a system like Repp’s. Officials there have identified several unexpected locations, including public parks and motels, where people have died by suicide. They can now turn those sad facts into action plans.
In addition to place, certain life events precipitate suicidal ideation. Loss of a pet, rates were highest among older white men.
Loss of a pet was linked to evictions when patients can no longer house or care for a pet.
IF YOU NEED HELP
If you or someone you know is thinking about suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255, or use the online Lifeline Chat, both available 24 hours a day, seven days a week.
JAMA. Published online September 18, 2019. doi:10.1001/jama.2019.14732
In this Medical News article, experts discuss sensitive ways to tell older adults that they no longer need cancer screening when their life expectancy is less than 10 years.
Finding the Right Words to Stop Cancer Screening in Older Adults
During her geriatric medicine fellowship in 2012, Nancy Schoenborn, MD, took notice of the American Geriatrics Society’s new guideline on caring for older adults with multimorbidity. Its advice for clinicians to incorporate prognosis into their clinical decision-making “really made a lot of sense to me…and it was supported by evidence,” said Schoenborn, an associate professor in the Division of Geriatric Medicine and Gerontology at the Johns Hopkins School of Medicine.
But when she considered how physicians should implement that advice, she didn’t have the words for it. Literally. “[I]t wasn’t clear how we should talk about it,” she said. The issue was particularly salient in cancer screening guidelines, which often use the life expectancy of fewer than 10 years as the time to stop screening. Especially in primary care settings, where most cancer screening takes place, Schoenborn struggled with how physicians should tell healthy older patients they no longer need a mammogram, prostate-specific antigen test, or other routine cancer screening.
“If they pointed to the [guideline] and said, ‘Look, it says don’t screen if you have less than 10 years to live,’…that’s not going to go over very well,” she said. So Schoenborn went straight to the front lines. She and her colleagues interviewed older adults and primary care clinicians about how to discuss life expectancy in clinical decision-making and stopping cancer screening. In their most recent study, the investigators compared perspectives from both sides.
The study’s “good news is that there are several common themes that both the physicians and the patients agreed upon,” said Alexia Torke, MD, associate professor of medicine at the Indiana University School of Medicine, who has published research on cancer screening cessation. “That provides a good, brief framework for starting off this conversation,” added Torke, who wasn’t involved in the study.
Benefits vs Harms
Clinicians and older adults agree that talks about stopping cancer screening should include a discussion of the benefits and harms. “Every screening test has risks,” noted Elizabeth Eckstrom, MD, MPH, chief of geriatrics at the Oregon Health & Science University. “Mammography is a perfect example because there are so many false-positives. [W]ith colonoscopy…you could perforate the colon at a time when the person should never have had the procedure in the first place.”
When they’re armed with information about the pros and cons of screening, older adults in the study said the decision on whether to have the test should be their own. Clinicians agreed. Said one clinician who was interviewed: “I tell them that we are a team, so I explain the information and…then I leave it up to them.” But if older patients forgo screening, they also don’t want to feel that they’re receiving less care. “I would not want to just [stop screening] and then just not do anything else,” an older adult in the study said.
Perhaps the chief worry among clinicians was that by suggesting it’s time to stop cancer screenings, patients could become angry and feel their physician was giving up on them. “That was really a major concern and barrier” for clinicians, Schoenborn said. Added Eckstrom: “It’s a big deal emotionally for a lot of doctors.”
But older patients said they wouldn’t think badly of their physician for suggesting it’s time to stop screening. “They were actually not as reluctant as the doctors thought,” Schoenborn noted. “Many of them were willing, some had already stopped, and if they trusted their doctor it was not necessarily perceived as a negative thing.” In fact, patients in the study hoped clinicians would find that perception reassuring, she added.
Focusing on other health priorities “hopefully would give [clinicians] some place to start to have that conversation,” Schoenborn said. Eckstrom also has another strategy. “Sometimes I say, ‘You get to graduate from cancer screening; it’s a good thing. You don’t need this anymore,’” she explained. Some of her patients are relieved to learn they no longer need cancer screening tests. “Who wants another colonoscopy in their 80s?” she said.
Decades of public health messages have emphasized the importance of cancer screening. “We have these very clear, consistent messages that sit on the side of a [mailbox] or on a billboard: get your colonoscopy,” Torke said.
Clinicians and patients get into the routine of regular screening, and advocacy groups sport pink ribbons to encourage mammograms. “There is a lot of emotional attachment to doing that,” Schoenborn said. “It’s part of being a good citizen.”
But the time may be ripe for a “more public health approach to raise awareness in the public that stopping screening can be the right thing,” she added. “Maybe a first step is just to raise awareness that it’s not something we all have to do until we die.
From. JAMA, September 20, 2019 Elizabeth Thomas, DO1; Jennifer Milton, RN, MBA1; Francisco G. Cigarroa, MD
The effect of kidney disease on the nation’s health is significant and expensive. Kidney disease affects more than 30 million individuals in the United States and is recognized as the 10th leading cause of premature mortality. 2 Patients receiving dialysis who are younger than 80 years are expected to live less than one-third as long as their counterparts without ESKD.2 The estimated cost of Medicare spending for beneficiaries with chronic kidney disease and ESKD exceeded $114 billion in 2016.
Prevention, treatment, and research are essential strategies in the management of patients with kidney disease and are highlighted in the 3 goals of the executive order. The aim of the first and second goals is to reduce the burden of renal disease over time, whereas the third goal will provide the most immediate benefit for patients with ESKD. This goal focuses on deceased donors and living donors for kidney transplantation.
In the United States, the waiting list for a kidney is about 100,000 people. Alternatives for ESRD are renal dialysis, cadaver donors, and living donors. The success and survival rates are high in both cases, with rates approaching 85-95%. A living kidney donor yields the highest success and duration.
Attracting suitable donors include organ donation promotion through a choice listed on driver license cards, public service announcements, and joining the National Kidney Registry or register at your local hospital, medical university or by calling
Kidney donation is an amazing gift but is also major surgery involving:
Medical tests that will require at least one full day at the hospital.
1 – 3 days in the hospital after surgery.
Typically 2 – 4 weeks off work for recovery.
There are means to offset the loss of income for donors who have an income of less than 62,000 per annum.
The most successful kidney donors are immediate family members related by blood, such as brothers, sisters, cousins or close aunts and uncles. Gender has no determining effect.
Efforts to improve the live kidney donor program should include:
The Advancing American Kidney Health Executive Order serves as a framework for furhter improvement in the Live Kidney Donor programs.
More
New Online
Views 0 Citations 0
9
Viewpoint
September 20, 2019
The Advancing American Kidney Health Executive Order
An Opportunity to Enhance Organ Donation
Elizabeth Thomas, DO1; Jennifer Milton, RN, MBA1; Francisco G. Cigarroa, MD1
Author Affiliations Article Information
JAMA. Published online September 20, 2019. doi:10.1001/jama.2019.14500
author interview icon Interviews
Audio Interview (23:35)
The Advancing American Kidney Health Executive Order
On July 10, 2019, President Trump signed an executive order to launch “Advancing American Kidney Health,” an outline of policy priorities centered on advancing 3 main goals: (1) preventing kidney failure whenever possible through better diagnosis, treatment, and incentives for preventive care; (2) increasing patient choice through affordable alternative treatments for end-stage kidney disease (ESKD) by encouraging higher-value care, educating patients on treatment alternatives, and encouraging the development of artificial kidneys; and (3) increasing access to kidney transplantation by modernizing the organ recovery and transplantation systems and updating outmoded and counterproductive regulations.1
The effect of kidney disease on the nation’s health is significant and expensive. Kidney disease affects more than 30 million individuals in the United States and is recognized as the 10th leading cause of premature mortality.2 Patients receiving dialysis who are younger than 80 years are expected to live less than one-third as long as their counterparts without ESKD.2 The estimated cost of Medicare spending for beneficiaries with chronic kidney disease and ESKD exceeded $114 billion in 2016.2
Prevention, treatment, and research are essential strategies in the management of patients with kidney disease and are highlighted in the 3 goals of the executive order. The aim of the first and second goals is to reduce the burden of renal disease over time, whereas the third goal will provide the most immediate benefit for patients with ESKD. This goal focuses on deceased donors and living donors for kidney transplantation.
Regarding deceased donation, the executive order introduces strategies to improve the use of organs from deceased donors, but more can be done. For example, increasing the number of registered donors is critical to augmenting organ donation. Donor registries allow individuals to register their legally binding decision to donate rather than leaving the decision to their surrogate decision-maker. Data suggest that the most effective donation authorization strategy for the United States is to build on the current opt-in system and to increase the number of registered donors from 54% to more than 75%, considering that the majority of residents indicate they would donate their organs.3 This percentage increase would increase available organs for donation and could save thousands of lives. Moreover, educational campaigns, such as the establishment of RegisterMe.org and registration via the iPhone Health app, could substantially increase the number of registered donors. In addition, hospitals must ensure donor registrations are honored through staff and physician education as well as quality reviews and process improvements focused on root causes of any failure to proceed with procurement of organs from a medically suitable and registered organ donor.
Another important endeavor with the capacity to increase potential transplants involves how to better allocate kidneys from individuals with unique risks such as those (1) with a high kidney donor profile index (KDPI), (2) at increased risk for transmitting HIV, hepatitis B virus, or hepatitis C virus (HCV) (risk designated by the US Public Health Service), and (3) from donors infected with HCV. The KDPI is a numerical measure that combines 10 donor factors to summarize into a single number the quality of deceased donor kidneys relative to other recovered kidneys. It is a useful index, but should not be used in isolation because transplantation outcomes are dependent on variables from both the donor and recipient.
To decrease the number of organs not being used because of a high KDPI, transplantation programs would benefit from access to high-quality biopsies with prompt interpretations by experienced pathologists and ex-vivo perfusion to better characterize the quality of the kidneys and better predict outcome. For increased risk donors as defined by the Public Health Service, the standard use of nucleic acid testing minimizes the risk of unknowingly exposing a recipient to infections such as HCV and HIV. The estimated window period of risk (the time between acquisition of infection and serological detectability) with nucleic acid testing for HCV ranged from 0.027 to 32.4 per 10 000 donors and the window period of risk for HIV infection ranged from 0.04 to 4.9 per 10 000 donors based on the types of at-risk behaviors of the donor.4,5
Known HCV-positive donor organs can be given to HCV-negative recipients with informed consent, given the availability of antiviral therapies that achieve undetectable levels of HCV in 95% to 100% of patients with HCV infection after 12 to 24 weeks of treatment. Physicians and patients should understand the benefits of good organ function far outweigh the risks of infection in the majority of cases, given the effectiveness of nucleic acid testing and antiviral therapies. Although the Centers for Medicare & Medicaid Services and the United Network for Organ Sharing encourage transplantation centers to expand the use of these organs within the context of considering the benefits and risks to the patient, increasing the reimbursement by payers for using these organs would most likely incentivize their use and offset the higher costs of patient care and monitoring required after transplantation.
Living donors offer the most promising option for increasing the number of successful kidney transplants. The 5-year survival rate for patients receiving a kidney graft from a living donor is 85% on average vs 75% from a deceased donor, and the 10-year graft survival rate is 65% vs 48%, respectively.6 A living donor graft is less likely to develop delayed graft function that affects the overall quality and longevity of the transplanted kidney.6 Recipients of living kidney donors also do not have to wait for their transplant, whereas those without a living donor wait 5 years on average for their transplant. Similarly, recipients of living donor kidneys can avoid starting dialysis in most cases, will not accumulate the morbidities that accompany kidney disease or dialysis over time, maintain a higher quality of life, all of which reduce the costs to the health care system and Medicare spending. Estimated health care system costs are more than $89 000 per patient per year once dialysis has begun.7 By maximizing living donor transplants, more deceased donor organs will be available to patients who do not have a living donor.
Why are more living kidney donor transplants and other living donor organ transplants (such as liver) not occurring? The primary reasons are (1) recipient’s and donor’s incomplete knowledge of the adverse effects of kidney disease or another end-stage organ disease; (2) inadequate education regarding the safety and recovery of the surgical procedure; and (3) the concern for incurring debt and potential for long-term health risks.
Public health campaigns to communicate the importance and safety of living kidney donation are needed. Based on United Network for Organ Sharing requirements and policies, the living donor evaluation is extremely thorough and continually prioritizes the safety and well-being of the donor, both at the time of donation and for any estimated future risks. The perioperative mortality for donor nephrectomy is 3.1 per 10 000 donors.8 The estimated cumulative incidence of ESKD at 20 years after a donation is 50.9 per 10 000 donors.9 The absolute risk of developing ESKD is slightly higher among donors who are younger at donation (38.0 vs 41.0 years), black, male, obese (body mass index >30), is a first-degree relative of the transplant recipient, and who are less likely to live in a wealthy neighborhood, but this risk is still at less than 1%.10 Long-term survival among donors and healthy comparison patients is similar.8
The expansions in charitable assistance described in the executive order could serve to reduce the burden of lost wages, travel expenses, and other costs living donors encounter. It is imperative that federal donor-directed policies are put into place such that qualified and willing living donors are not disincentivized based on potential financial hardships related to donation, concerns about loss of employment, and apprehensions about increased health insurance premiums or loss of coverage after donation. These disincentives are not hypothetical but real. In some cases, inadequate post-donation coverage offered by the recipient’s insurance and limited donor insurance plans has led to the loss of otherwise qualified donors to provide life-saving grafts to their intended recipients. Although insurers may have effective coverage for preoperative evaluation and donation, they may have limited or no coverage for routine care required after donation, including federally mandated follow-up, and limited or no coverage for complications related to organ donation. Routine post-donation care is usually inexpensive, and complications are rare, so the lack of coverage is illogical and unacceptable.
The need to better support living donors is important not only to reduce the burden of end-stage organ failure but also from the obligation of the community to support those generous individuals willing to be donors. Their gift is a sacrifice that deserves gratitude. There should be federal protection against loss of employment and consistency among all private payer insurance companies to cover any donor-related health care costs to a living donor for 1 year after organ donation. Options under Medicare should exist to reimburse unpaid medical expenses after donation not covered by private payers. Private insurance or federal funding should be provided to donors for all reasonable travel and accommodations related to donation. Federal mandates should protect living donors from having the status of a preexisting condition simply due to their donor status. This kind of support would allow many willing donors to realize their desire to donate and it could provide life-saving organs to recipients in need.
This Viewpoint uses provisions in President Trump’s 2019 American Kidney Health Executive order calling for an increase in access to kidney transplantation to discuss strategies to increase deceased and living donor pools, improve the allocation of organs from higher-risk donors, and support the...
