Motor Vehicle Crashes: A Leading Cause of Death for Children. Of the children who were killed in a crash, 36% were not buckled up. Parents and caregivers can make a lifesaving difference by ensuring that their children are properly buckled on every trip. 
Age Restraint use (like car seat, booster seat, or seat belt use) varies by age. Restraint use typically decreases as children get older. In a study from 2021 where researchers observed children riding in cars, they found: <1% of children under age 1 were not buckled up, 6% of children 1–3 years old were not buckled up, 11% of children 4–7 years old were not buckled up, and 13% of children 8–12 years old were not buckled up.3
Being unrestrained in a vehicle increases the risk of being killed in a crash. In a study from 2023 using fatal crash data, researchers found: 30% of 0–3-year-olds killed in crashes were not buckled up and 36%§ of 8–12-year-olds killed in crashes were not buckled up.
Also, among children who are buckled up in child restraints, many graduate too soon to the next stage of child passenger safety. An example is when children stop using a booster seat before the seat belt fits them correctly. Age-appropriate restraint use typically decreases as children get older. Race and ethnicity American Indian and Alaska Native children and Black children are more likely to be killed in a crash than White children. Child passenger death rates were highest among American Indian and Alaska Native children (2.67 per 100,000 population), followed by Black children (1.96), according to combined data from 2015–2019. Several studies also indicate that it is more common for Black children, Hispanic children and American Indian and Alaska Native children to travel unrestrained or improperly restrained when compared with White children. 21% of Black children, 15% of Hispanic children, and 7% of White children ages 4–7 years were not buckled up, according to a study in 2021 where researchers observed children riding in cars. There are likely many reasons for these differences, including access to affordable car seats and booster seats and differences in culture and perceptions related to car seat and booster seat use. Rural versus urban location Children in rural areas are typically at higher risk of being killed in a crash. According to combined data from 2015–2019: Child passenger death rates were highest in the most rural counties (4.5 per 100,000 population) and lowest in the most urban counties (0.9). Death rates among children who were not using age-appropriate restraints were highest in the most rural counties (2.9 per 100,000 population) and lowest in the most urban counties (0.5). Studies also indicate that children in rural areas are more likely to be incorrectly restrained than children in urban areas. A multistate study using data from car seat check events found that child restraint misuse was more common in rural locations (91%) than in urban locations (83%).Similar to racial and ethnic disparities, there are likely several factors for these differences. Alcohol-impaired driving Alcohol-impaired driving is a major threat to all road users, including child passengers. In 2021, 25% of deaths among child passengers (ages 14 and younger) involved an alcohol-impaired driver. Among all child passengers (ages 14 and younger) who were killed in crashes, a higher proportion of those riding with alcohol-impaired drivers were unrestrained (43%) compared with children riding with drivers who had no alcohol in their system (38%).
Driver seat belt use Restraint use among children is associated with their driver’s seat belt use. In 2021, 69% of child passengers ages 14 and younger killed in crashes who rode with unbuckled drivers were also not buckled up, compared with 26% of children riding with buckled drivers. Researchers who observed adults and children riding in cars in 2021 found that 95% of children ages 7 and younger who were driven by a buckled driver were restrained, compared with 77% of children driven by an unbuckled driver. Many other studies assessing different child age groups or specific geographic locations have also found strong associations between unrestrained drivers and unrestrained child passengers. Car seat and booster seat misuse Car seats and booster seats are often used incorrectly, which can make them less effective. Researchers who observed children riding in cars in a 2011 study estimated that 46% of car seats and booster seats are used incorrectly in a way that could reduce their effectiveness.22–24 Car seat misuse estimates are even higher at 59% when booster seats are excluded.
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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.
Friday, September 22, 2023
Emergency Message System
Thursday, September 21, 2023
Compensium of Unpublished Health Train Express Articles
These are previously unpublished articles from September 2016 until current (September 22, 2023)
I unknowingly accumulated these drafts during the past years. Sometimes I will look at them and don't even remember writing them... Does anyone else have this experience? Am I brain-damaged?
https://draft.blogger.com/blog/post/edit/1928170677546195443/7695180941023409286
https://draft.blogger.com/blog/post/edit/1928170677546195443/2985923747823633413
https://draft.blogger.com/blog/post/edit/1928170677546195443/6864373290720454374
https://draft.blogger.com/blog/post/edit/1928170677546195443/451197192291627646
https://draft.blogger.com/blog/post/edit/1928170677546195443/4723515906286209104
https://draft.blogger.com/blog/post/edit/1928170677546195443/6352283569341904365
https://draft.blogger.com/blog/post/edit/1928170677546195443/8563191770624462465
https://draft.blogger.com/blog/post/edit/1928170677546195443/3426109235947992328
https://draft.blogger.com/blog/post/edit/1928170677546195443/8154004737906066492#
I will be posting additional memories. Stay tuned
Giving up the knife: Saying goodbye to surgery
This year, I stopped doing surgery — giving up the knife, so to speak. It wasn’t an easy decision to make. I’ve been a surgeon for 32 years since graduating from medical school. It’s been a distinct part of who I am for most of my life.
This doesn’t mean I’ve retired. I’m still practicing in a clinic-based setting and still do procedures in the office. I just no longer operate in hospitals or ambulatory surgery centers. And because of this, I no longer must take call for the hospitals and their emergency rooms (which are required to have surgical privileges at a hospital). In the past few years, seeing patients in the office occupied most of my work week anyway.
And yet now, the time spent in the office is less harried and more engaging. I’m more in the moment with the person in front of me, without that overhanging sense of dread that comes with the unknown — an unexpected complication in a post-op patient, a call from one of the ERs, the hospital or the transfer center.
Office encounters have been more rewarding. Besides a patient’s medical problems, I’m more inclined to see their intangible qualities, aspects of their nature that can be intensely interesting or downright humorous.
I do miss the OR. I miss the people in the OR. Though we’ve faced a torrent of scary, pee-in-the-pants situations as any surgical team is bound to face, much of the time was quite pleasant and fun. Yeah, surgery can be a real kick-in-the-pants. That’s the reason I became a surgeon.
I miss some of the more challenging surgeries when actively treating a patient with cancer was the ultimate high of my surgical profession. But I gradually gave up some of the more complicated and lengthy surgeries some years ago. Part of this was the stamina of my youth had dwindled– some of those cases took six to eight or more hours of continuous operating with no break. More importantly, more fellowship-trained surgeons nowadays are sub-specialized with more experience. It was best for the patient to be treated by these folks, even if it meant traveling three or more hours to get there. All the other ENTs in our area have done the same.
I was the sole “old-timer” still in private practice. All the other ENT doctors in our area are employed by a large hospital system with a huge referral base. My surgical volume was far lower than my hospital-employed colleagues, which didn’t bother me since I was getting older. Yet last year, I was the only ENT taking call for all three of our area hospitals. I could’ve been employed by a hospital, earning much more while relinquishing the business of running a practice, but the loss of autonomy wasn’t worth the trade-off.
I wasn’t unhappy about making less than my peers. There was no dire need for more money. What’s the endpoint with money anyway? How much annual income is really enough? My wife and I always budgeted our expenses and were able to save each year while regularly contributing to our kids’ college funds, even during the leanest years. We stuck by a strategic plan for savings and investing and nearly met our financial retirement goals before I decided to stop doing surgery. Our quality of life was not adversely affected. Additional money would not have changed our lifestyle.
Stopping surgery and no longer taking calls from the hospitals was the right thing to do at the right time. I eventually felt the stress evaporate, replaced by an enhanced peace of mind. I see this not as an end but as another stage in life’s journey. But I’m not ready to retire yet.
After giving a lecture earlier this month, a third-year medical student came up to me. He was interested in pursuing ENT, his reasons being a good blend of clinic and surgery — some of the same reasons I chose this calling. He said that aside from tonsillectomies, and nasal and ear procedures, he wasn’t aware we did surgeries such as thyroidectomies, parotidectomies, neck dissections, and the like, which fascinated him even more.
He asked how one gets to that point doing such intricate surgery. I had that same fascination back when I was a lost third-year med student, not knowing what field of medicine to choose. The epiphany came during a series of lectures from a few of the ENT attendings, one of whom was a head and neck surgeon who later became my mentor (Bruce Campbell, MD). Like a slobbering, tail-wagging dog, I approached him and asked the same questions. I chose ENT and never looked back. It has been — and continues to be — a most fascinating and rewarding career.
Saying goodbye to surgery is a pivotal and bittersweet milestone, but I look back at my surgical career with fondness and satisfaction. And despite no longer performing surgery in the OR, I still want to treat patients until I am unable to do so.
Following are a few lines from a speech to the graduating class of residents I was asked to give this year, which speaks to this very point:
At this stage in my career, I still want to keep going. I still think of medicine as an adventure. I still find joy in our profession. I still learn; I learn from all of you. It’s been 27 years since I finished my residency, and I reflect back with a sense of satisfaction and pride and no regrets. Though I look forward to one day retiring, I’m hesitant to do so since what we do is so meaningful, absorbing, and worthwhile that I don’t want my professional journey to end. That’s by choice. Being a doctor is a part of who I am, embedded in my DNA. And hopefully, it is with you.
#259 - Women's sexual health: Why it matters, what can go wrong, and how to fix it | Sharon Parish, M.D. - Peter Attia
Women’s sexual health: Why it matters, what can go wrong, and how to fix it | Sharon Parish, M.D.
We discuss:
Sharon’s interest in sexual medicine and the current state of the field [3:00];
How hormones change in women over time and how that impacts sexual function [8:15];
Changes after childbirth and its impact on sexual function [11:00];
The role of metabolic health and systemic vascular health in sexual health [20:15];
Conditions associated with decreased sexual function and the importance of sexual health for overall well-being [26:15];
Sexual dysfunction case study #1: A 41-year-old mother of two, the sexual response cycle, and the difference between arousal and desire [38:45];
Medications that may reduce sexual desire [49:45];
The effect of birth control pills on sexual desire [56:30];
The importance of testosterone in women for sexual function and desire, and why the FDA hasn’t approved exogenous testosterone as a therapeutic [1:01:15];
Challenges faced by physicians who are open to prescribing off-label testosterone for women, and Sharon’s approach in managing this aspect with her patients [1:14:30];
A hypothetical treatment plan for the patient in case study #1 [1:26:45];
The role of DHEA (a precursor to testosterone) in female sexual health [1:32:15];
Case study #2: A 30-year-old woman with anorgasmia (inability to orgasm) [1:38:30];
Resources for helping women and their partners to enhance the pleasure experienced during sex, overcome anxiety, and increase desire [1:51:30];
Two drugs for premenopausal women with low desire [1:59:30];
Why treatments are potentially underutilized for both desire and genitourinary syndrome of menopause [2:13:15];
Case study #3: A menopausal woman with symptoms [2:19:00];
Addressing the misguided fears around hormone replacement therapy and cancer [2:24:15];
Symptoms and treatment of genitourinary syndrome of menopause [2:32:45];
Age 65 and beyond, and resources for finding a provider [2:37:30]; and
More.
Journal of Medical Internet Research - Virtual Reality Treatment for Chronic Low Back Pain
CVS recieves stern warning from FDA
Hello!
Wednesday, September 20, 2023
Why is the CDC recommending mRNA COVID19 jabs for everyone?
The saddest defense yet of the insane US decision to push more mRNA on everyone
American epidemiologists are feeling defensive. They’re embarrassed that people have figured out the new American push for mRNA Covid jabs doesn’t match what the rest of the world is doing. As you may know, most countries are not recommending COVID boosters for most healthy adults under 65 this fall. Meanwhile, the United States is pushing shots on six-month-old infants as well as healthy teenagers (!) and adults.
So why is the United States so far out of step?
The U.S. has a broad recommendation for the fall Covid-19 vaccine, while the U.K. has a more targeted policy. This conversation is bleeding into flu vaccines and COVID-19 isolation and testing policies, as similar contrasts exist.
COVID-19 Fall 2023 vaccine eligibility across four countries.
It’s fair to wonder why. We are all high-income countries. We all have the same vaccines. We are all looking at the same data. How could public health officials come to different conclusions across countries?
One word: landscape.
The health landscape is entirely different from country to country. Because of this, we should expect country-level policy decisions to vary. How we approach health threats on a population level will be different because the threat’s implications are different.
The U.S. healthcare system is subpar.
U.S. healthcare is hard to access, has poor administrative efficiency, and lacks equity. In 2021, the Commonwealth Fund compared the healthcare systems of 11 high-income countries, using measures such as access to care, equity, and health outcomes. The U.S. had the worst healthcare system performance: an overall ranking of 11 out of 11. This means that if someone gets sick, it’s hard to get help. And, as we’ve seen throughout the pandemic, it’s harder for certain groups than others. This means we need to do even more in the U.S. to prevent infectious diseases and their poor outcomes, including hospitalization and death, than in other high-income countries.
U.S. health insurance is mostly voluntary. Even if someone gets to a doctor, Americans have a patchwork of coverage to pay for the costs. This differs from other high-income countries as shown below.
Basic primary health coverage, 2016 or the latest available. Source: “Health Systems Characteristics” OECD Health, 2018. This means that a bigger net needs to be cast, ideally across the whole population, when it comes to providing lower-cost interventions, like a vaccine, so we can avoid people having to go to the doctor in the first place. CDC estimates that, compared with giving the fall COVID-19 vaccine to only those aged 65 or older, universal vaccination will prevent an additional 200,000 hospitalizations and 15,000 deaths. There are also significant differences between countries in who will buy COVID-19 vaccines this fall:
U.S.: CDC recommendations determine who pays for the vaccine. By providing universal recommendations, the following happens:
Private insurance companies and public insurers (i.e., Medicaid and Medicare) buy vaccines for all their enrollees;
The Bridge Program—a $1.1 billion new public-private partnership—will pay for uninsured adults;
It will now be included in the federally funded Vaccines for Children— a program that provides vaccines “at no cost to children who might otherwise be vaccinated because of inability to pay.”
U.K.: Has a single-payer system funded by taxation, so it decided not to pay for the vaccine for everyone, giving it instead to those at high risk of severe disease, based on cost-benefit considerations.
U.S. healthcare capacity is lower than average.
The U.S. also doesn’t have much wiggle room in hospitals. The Commonwealth Fund found the U.S. had 2.8 hospital beds per 1,000 population, lower than the OECD average of 4.3. (Notice that the U.K. also has low capacity). In other words, we need to work harder to keep people out of the hospital so we have enough beds for non-preventable medical needs. Pre-pandemic, our hospitals would reach capacity during just a bad flu season.
The U.S. safety net is unacceptable.
If someone gets sick in the U.S., there isn’t the same level of support as in our peer high-income nations. For example, we don’t have federally guaranteed sick pay. This means people are more likely to go to work sick and spread viruses. The International Labor Forum summarized it nicely in several graphs.
U.S. health status is poorer.
Taken together, Americans have worse health than their counterparts. In one study, they had worse health across all 16 health outcomes than their English counterparts. This stark disparity is particularly relevant to infectious diseases like COVID-19 that exacerbate underlying health conditions.
Adjusted Risk Ratios (ARRs) for US-England Health Differences at Ages 55 to 64 Years for 2008-2016. Source: JAMA 2020. In the decisions this fall, the CDC noted that “the vast majority of the U.S. population has an underlying condition that would qualify under a risk-based recommendation.”
Bottom line
The U.S. has much less wiggle room to mess up than other countries because we have worse healthcare access, less social support, less healthcare capacity, and worse health. Casting a larger net, such as universal vaccine recommendations for COVID-19, is more necessary than in other countries.
Keep this in mind when it comes to cross-country comparisons.
Dr. Gavin Yamey is the Hymowitz Professor of Global Health in the Duke Global Health Institute, a Professor of Public Policy in the Duke Sanford School of Public Policy, and Director of Duke University’s Center for Policy Impact in Global Health.
“Your Local Epidemiologist (YLE)” is written by Dr. Katelyn Jetelina, M.P.H. Ph.D.—an epidemiologist, wife, and mom of two little girls. During the day, she is a senior scientific consultant to several organizations. At night, she writes this newsletter. Her main goal is to “translate” the ever-evolving public health world so that people will be well-equipped to make evidence-based decisions. This newsletter is free, thanks to the generous support of fellow YLE community members. To support this effort, subscribe below:
YouTube Is Wiping Safety Content on COVID-19 Vaccines
Tuesday, September 19, 2023
California’s Medical Board Can’t Pay Its Bills, but Doctors Resist Proposed Fixes
California doctors and state lawmakers are squaring off once again over the future of the Medical Board of California, which is responsible for licensing and disciplining doctors and has been criticized by patient advocates for years for being too lax.
A bill before the legislature would significantly increase the fees doctors pay to fund the medical board, which says it hasn’t had the budget to carry out its mission properly. It would also mandate new procedures for investigating complaints.
Patient advocates say the board, which oversees about 150,000 physicians and surgeons with active licenses in the state, is hamstrung by a lack of funding and clunky processes, and that its shortcomings pose a risk to the public by allowing bad doctors to continue practicing. The board opened only about 1,000 investigations out of nearly 10,000 complaints last year, according to its 2022 annual report.
But the California Medical Association, which represents physicians, is again fighting proposed increases in the fee, which was unchanged for more than a decade before being raised in 2021 after a contentious debate. Now lawmakers want to boost the license renewal fee to $1,289 every two years, up from $863 currently.
The doctors’ lobby largely defeated the 2021 efforts to strengthen the board, and critics say the group is trying to whittle away the board’s power by depriving it of funding.
The legislation, sponsored by Sen. Richard Roth, a Riverside Democrat, would also require board staff to interview patients or families before closing their complaints, create a unit to better facilitate communications, and improve efficiency by changing procedures and adjusting standards of evidence for investigations.
Another provision would allow patients and relatives to make a statement during the investigation about how a doctor’s negligence or misconduct affected them — similar to crime victims speaking during a sentencing hearing in criminal court.
The bill faces a pivotal vote in the state Assembly’s Appropriations Committee this month.
Most California licensing boards are funded through license fees. Currently, dentists pay $668 for a two-year license renewal, plus other permitting fees such as $325 for general anesthesia or $650 for oral surgery. Attorneys actively practicing in California pay $510 annually.
But the medical association insisted in a memo that it “cannot agree to a fee increase of nearly 50% that will primarily go toward building a multimillion-dollar reserve fund and future programs for the Medical Board.”
“If the bill is passed in its current form, it would have vast, negative impacts on the practice of medicine and health care delivery in California,” it added.
George Soares, a legislative advocate for the California Medical Association, told lawmakers last month that the association would be willing to accept a fee increase, but that $1,289 is too much — more than double the national average for state medical licenses. A July working paper from the National Bureau of Economic Research found that physicians’ annual earnings average $350,000 across the U.S.
The medical board supports the bill and says a fee hike is needed to cover operations, repay millions of dollars in loans, and establish a three-month reserve. Over the past two years, the Department of Consumer Affairs, which is responsible for the operations of the medical board and other licensing boards, has had to backfill the board’s $79 million budget, using a total of $18 million in loans from Bureau of Automotive Repair license fees to cover the gap.
“The simple reality is that the board is not able to pay its bills,” a spokesperson for the medical board read from a joint statement from Randy Hawkins, the vice president of the board, and Richard Thorp, a former president of the California Medical Association and current member of the board, at a committee hearing last month.
“We are physicians in private practice, and this fee increase will impact us personally, albeit at an increased cost of less than $20 per month,” the statement read. “We do not see this as a burden but rather as an investment into the organization that helps ensure that physicians have the confidence of the patients that we are privileged to treat.”
Roth points out that the medical board, which is composed of eight physicians and seven members of the public, has little control over staffing costs. Its 169 employees work for the state and are covered by labor agreements negotiated by statewide employee unions.
Consumer advocates say the opposition from the doctors’ lobby is part of a years-long effort to weaken the board and deprive it of adequate funding.
The licensing fees for the California Medical Board are already double the amount charged in other states. The cost of living is higher in California. A large part of the CMB overhead is the salaries for its staffing controlled by the state legislature. (180) These salaries are controlled by employment unions.
A report about the medical board’s operations conducted by a consulting firm that serves as the enforcement monitor for the board, Alexan RPM Inc., underscored the board’s financial challenges and recommended adopting automatic annual fee increases tied to the consumer price index, or something similar. Some lawmakers suggested the fees could be determined on a sliding scale based on doctors’ income.
Critics have complained for years that the medical board doesn’t hold doctors accountable often enough. Families that file complaints against doctors frequently go years without updates on the status of investigations, and often aren’t told why when their complaints are rejected.
“This is kind of the culmination of two things: patient advocacy trying to make changes and a few years of very recent, direct pushes by the legislature,” said Carmen Balber, the executive director of Consumer Watchdog, a consumer and patient advocacy organization.
The California Medical Association has already blunted some aspects of the bill, including securing the removal of a provision to add two more members of the public to the board, which would have made it a public-member majority instead of its current physician majority.
The association is also opposed to a provision currently in the bill that would lower the standard of proof for disciplining doctors in instances besides those in which they could lose their licenses.
Tracy Dominguez, a Bakersfield resident whose daughter, Demi, and grandson, Malakhi, died in 2019 from complications of severe preeclampsia, is among those advocating for reforms.
One of the physicians who treated Dominguez’s daughter prior to her death had already been accused by the medical board of gross negligence that led to the death of a young mother, according to medical board documents. Advocates at Consumer Watchdog allege his negligence had already caused death or permanent injury of other mothers and babies he treated, and that he was already banned from practicing in some hospitals at the time he treated Demi Dominguez but had been allowed to keep his license.
Tracy Dominguez said she hopes changing evidentiary standards and strengthening the medical board overall “will put dangerous doctors away.”
And a chance to provide a victim impact statement would be important for families hurt by medical neglect, she added. It would be “an opportunity for them to hear from the family, directly — to know that she was a person, not just a number.”
ADDENDUM: SB
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