Vol. 215 June 15, 2019 Sometimes Even Good News is “Fake” News

June 16, 2019

A lesson in evaluation of a cost-reducing health care program:
a learned, scientific critique of a controversial Medicare reimbursement program.

 

“The Hospital Readmissions Reduction Program (HRRP) was established in 2010 by the Centers for Medicare and Medicaid Services (CMS) with a “goal of reducing ‘preventable’ re-hospitalizations by imposing financial penalties on hospitals with higher-than-expected readmission rates in the 30 days after a hospital discharge”. This was one of several new “Pay For Performance” (PFP) programs aimed at lowering federal health care costs by tying Medicare reimbursement to hospitals, physicians, and even home care agencies to the use of more appropriate (read “lower cost”) medical care delivery settings.

After implementation of the HRRP, hospital readmission rates did decrease nationwide for the targeted diagnoses of heart failure, acute myocardial infarction, and pneumonia. So, the federal government ended up reimbursing less money to those hospitals that had higher-then-expected “preventable” patient readmission rates . “Great!”, said some policy makers, “it saved us some money. Let’s expand the program to ALL conditions treated in the hospital.”

“Whoa”, said by a group of research physicians from Harvard and Washington University Medical Schools, both known as liberal academic institutions, ”let’s look at the data.”

  1. The proportion of patients that returned to the hospital within 30 days after discharge actually did NOT change.
    .        .Patients returned to the hospital within 30 days after discharge for care, BUT they weren’t “readmitted”. Instead a significant number of those returning to the hospital were treated for up to 3 days in Observation Beds/Units or overnight in an Emergency Room bed. HRRP did not measure use of Observation Units or overnight stays in the ER. No wonder the “readmission” rates went down.
  2. If a patient dies within 30 days after hospital discharge they obviously can’t be “readmitted”.
    .         .The HRRP statistics did not measure mortality rates. A hospital keeping sicker patients alive by readmitting them for appropriate care rate might have the better outcomes, i.e. a lower death rate, but it would be penalized for having a higher readmission rate. In fact, the financial penalties for higher readmission rates under HRRP are much higher than the penalties for a higher death rate under Hospital Value-Based Purchasing program (HVBP), another federal PFP program.
  3. “Risk adjustment” of patient illness severity is notoriously varied and difficult to standardize.
    .          . “Risk-adjusting” of illness severity, for example, recording the different illness severity between the heart failure patient on two drugs and slightly swollen ankles versus the patient on multiple heart drugs for decompensated heart failure, is very difficult to standardize. Some of the early enthusiasm for HRRP and its reported improvement of risk-adjusted readmission rates may have been the result of improved medical record coding of co-existing conditions. (This is well-known as “gaming the system”, legal and even ethical, sort of like taking advantage of tax code loopholes, but it does nothing to improve the quality of care.)
  4. Social risk factors like patient poverty and poor community resources like lack of public transportation and diminished access to primary care were omitted from risk-adjustment factors.
    .          .Safety-net hospitals (those in poor areas) can be penalized under HRRP as a result of such factors. “The evidence that social risk factors influence readmission rates is incontrovertible.”
  5. HRRP may even have increased the death rates for patients with heart failure.
    .          .Four independent studies showed that the death rates for patients with heart failure INCREASED significantly after implementation of HRRP. The increase was concentrated among the patients who were NOT readmitted, suggesting that the use of ER beds and Observation Units “may adversely affect patients who would benefit from higher-level care.” Two other studies found different results which suggested that HRRP was more beneficIal to patients with acute heart conditions rather than patients with chronic heart failure.The three authors urge several steps to correct what they consider a faulty, positive evaluation of HRRP before jumping into expanding the program to ALL patients admitted to a hospital. This failure to correctly evaluate HRRP “underscores the consequences of implementing national policies after [evaluation that does not include] a control group.”They also urge “policymakers to seek input from frontline clinicians and patients who understand the real-world effects of HRRP. . . . If HRRP is improved it might be transformed from a regressive penalty program to a progressive program that improves patient care.”

    Q.E.D.

    Reference:
    “The Hospital Readmissions Reduction Program—Time for a Reboot”, Drs. Wadhera, Yeh, and Maddox, NEJM 380;24 June 13, 2019.

Advertisements

Vol. 211 April 15, 2019 A Modest Proposal To Eradicate Measles In The U.S.

April 15, 2019

Measles was declared “eradicated” in 2000. Since then we have had unexpected U.S. measles outbreaks in 2014 and presently we are breaking all records for new cases (78 cases just this very week). In 2014 there were 667 cases of measles in Amish country of Ohio. Since January 1, 2019 the U.S. has had 465 cases in 19 states.

For those of us who are used to hearing big numbers every day—size of the national debt, baseball player salaries, number of immigrants pounding on our door, etc.—these numbers don’t sound very compelling. BUT, measles is a preventable disease. One measles vaccine shot protects the recipient 93% of the time. When you add the second shot years later the individual’s protection goes to 97%. 

 Measles, the most infectious disease we know, can cause debilitating encephalitis (brain swelling), pneumonia, and, very rarely in the U.S., death in both infants and adults. Madagascar is not so lucky. Because of its poverty Madagascar has a vaccination rate of only 58% despite the population’s desire for vaccination. They had 1200 deaths in the115,000 who got measles last year. Europe had 41,000 measles cases in 2018. A community vaccination rate of 90-95% is necessary for effective “herd immunity” in which the vaccinated keep the un-vaccinated safe just be reducing their chances of exposure.

You are not likely to be exposed to a case of Madagascar measles, but if you happen to be in the Williamsburg section of Brooklyn, or Rockland County, NY, or  Portland, Washington, or near Sacremento, California, you may be exposed. These four hot spots of current measles outbreak apparently share an unintended consequence of easy-access global travel.  Unvaccinated Orthodox Jews returning from the September annual Hasidic Pilgrimage from Israel to Uman, Ukraine unexpectedly brought measles back to their unvaccinated, ultra-orthodox Jewish U.S. communities.

There is no aversion to vaccination in the Bible, the Quran, or even Sanskrit texts. It is speculated that these communities have low measles vaccination rates because of “anxiety about science”, “concern about risks of new technology”, and, especially in Soviet emigres, “distrust of the government”. 

In 1896 a Jewish man in Britain refused vaccination contending that it was against his religion. The prosecutor, also Jewish, asked the opinion of the Chief Rabbi of Britain who answered, “Hogwash.” The London court agreed.

Anti-vaxxers don’t respond to facts, They reject scientific data. They are apparently immune to dreaded stories about sick, dying children but appear to believe dreaded stories of assumed vaccine reactions. The mayor of New York City has declared a public health emergency and wants to fine any Williamsburg orthodox Jew who refuse the measles vaccine $1000. He has threatened to even close non-compliant Yeshivas. Rockland County tried to bar unvaccinated persons from public places including . . . gasp, . . . malls! A judge with a cooler head put that on hold.

After reading about the British 1896 court case a modest proposal just sprang out of my head: We should sue an anti-vaxxer, the parent of an unvaccinated child, for civil damages!

It has been recently and repeatedly affirmed that one way to get things done in America, to effect change, is to sue somebody—your spouse, your neighbor, the police, the National Enquirer, the President, whomever. 

So, all we have to do is wait until an unvaccinated child with measles exposes a vaccinated child. Since we know that the measles vaccine is not truly 100%  effective, the vaccinated child has a small chance (probably 3% – 7%) of getting measles. If the vaccinated child now with measles develops the more common complication of pneumonia, or the rare one of encephalitis, or the even rarer one of death, his or her parents could sue the unvaccinated child’s parents for all present and future medical bills, loss of school days, future loss of income due to brain damage, loss of companionship, and other compelling emotional stresses dear to personal injury lawyers. If encephalitis were the complication, the huge jury award would be enough to get the attention of even the most adamant anti-vaxxers. They would learn that their stance is not just a risk to society; it could be a large monetary risk to them personally.

References:
1. “A Modest Proposal”, Jonathan Swift, 1729 


Vol. 207 February 1, 2019 Things That Threaten

February 1, 2019

With our President and our own intelligence agencies currently in public disagreement about our greatest threats (Southern border migrants {Tweets} VS China, Russia, and North Korea {“Worldwide Threat Assessment”} ), it seems an appropriate time to list again some of the things that might threaten us from a medical point of view.  I last did this on February 1, 2010.

Repeats from 2010:

Watching TV – increase chance of a cardiac death by 18%, increase chance of obesity in children by 5%. 

Tanning Booths – Increase chance of malignant melanoma by 75%; 20 minutes in the booth equals 5 hours in the sun.

Cell phone use in cars – Increase risk of accident by 400%

Toys – 13,663 head injuries in children from toys seen in an ER in 2005; 251,000 toy injuries seen in ERs in 2018; 41% (102,910) were injuries of face or head.

Sleep apnea in truck drivers – Sleep apnea increases the chance of a driving accident by about 100%; 17% of truck drivers have sleep apnea

Brain cancer from cell phones– no evidence for it in 2010; “maybe” in 2019; very heavy users over 10 years in Sweden had an increased incidence of acoustic neuroma (non-cancerous growth on hearing nerve).

Contaminated herbal supplements – more studies continue to find supplements with incorrectly labeled ingredients and/or unlabeled contaminants. Most of these supplements are for sexual enhancements, body building, or weight loss.  

Vaping of nicotine products – “Unknown risks” noted in August 1, 2009; Still unknown over the long term, but of more concern because of the alarming explosion of use by junior high students and 21% of twelfth-graders.( an increase of 1.3 million teens just since 2017) (NEJM 2018 Dec 17)

New threats:

Gun Violence – I am surprised that this wasn’t in my 2010 list since it seems like we have been talking about this threat for years, but it was before the Sandy Hook and Stoneman Douglas school massacres . Wikipedia has a handy list of 122 world-wide school massacres by country, dates, number killed, etc. Do you remember what the auto industry said in the past regarding proposed laws requiring seat belts? – “Cars don’t kill people; people kill people.” I don’t either. Someone must have made that up to make a point. Check my two previous blogs (2015 and 2018) for the comparison of “the frog sitting in the gradually heating up water” with our pace of achieving gun safety. (“By Degrees”, Markerelli.com)

Climate Change – Extreme weather events and raging wildfires in California have caused some to label climate change as a “Health Emergency”. Accompanying an article describing the stress on emergency medical care resources and the significant contribution to air pollution caused by the California wildfires, a lead editorial in the New England Journal of Medicine stated: “Climate change is already adversely affecting human health and health systems, and projected climate change is expected to alter the geographic range and burden of a variety of climate-sensitive health outcomes and to affect the functioning of public health and health care systems.”  

Large Gathering in Any Public Place – During a break in the interminable Boston TV coverage of the Patriots prior to Super Bowl LIII one channel showed a segment on the security planned for the Mercedes Benz Stadium in Atlanta. It was impressive; ten miles of fencing, prohibition of drones, helicopter fly-overs, fully-armed policemen, and more-fully-armed soldiers (always shown walking in pairs). Nothing new to us since September 11th. Just another reminder, but now at least we realize it is not actually foreign “terrorists” that have caused the most havoc in our country.

Enough about threats. Any good news?

Salt-free diet not necessary for heart failure patients- A review of 9 studies showed “a paucity of evidence supporting low-sodium diets for patients with heart failure”. The recommended first step is to “… retreat from an unbridled and potentially harmful insistence on rigorous sodium restriction” in these patients. (JAMA Internal Med 2018 Dec; 178)

Vitamin D supplements of no benefit to preventing cancer or cardiovascular disease –A study of 25,800 participants over 50 years old followed for 5 years showed that daily 2000 IU of Vitamin D “did not keep the doctor away” compared to placebo. This is good news for people spending money on vitamin D supplements for this purpose. (NEJM January 3, 2019:380;1)

Omega-3 Fatty Acids (“fish oil”) of no benefit in preventing cardiovascular disease – Ditto  (JAMA Cardiology March 2018; 3)

Stand-up desks at work reduces sitting times – See “Watching TV” above, but unfortunately there are no studies that standing does anything but improve psychological well being of the worker with some work-related benefits.  When arising from the sitting position, the authors recommended doing some physical activity. Standing alone is not any healthier. (BMJ 2018 Oct10:363)


Vol. 203 November 15, 2018 Recent Updates

November 15, 2018

Hub thumbnail 2015

Unsafe Toys for Christmas 2018
World Against Toys Causing Harm or W.A.T.C.H. has just released its 5th annual list of “worst toys for the holiday season” picked for their potential cause of choking, eye injury, or other safety hazard. In 2016 there were 240,000 toy-related injuries. During 2014 to 2016 there were 35 toy-related deaths. The top ten worst toys this year include:

  • Nickelodeon Nella Princess Sleeptime Pet Pillow – choking and suffocation (“DO NOT USE IN CRIB”)
  • Nerf Praxis Blaster- “rapid fire” projectiles could cause eye injuries
  • Marvel Black Panther Slash Claw – “it can actually slash”
  • Power Range Ninja Superstar Blade – “plastic chain saw that can actually cut”
  • Cabbage Patch Dance Time Doll – choking (Is nothing sacred?!)
  • Stomp Ultra Rocket – “fires up to 200 ft. in the air if not stopped by an eye”

Lower Your Prostate Cancer Risk by Riding a Bicycle
Men who did long-term vigorous exercise like biking, swimming, or running had a 25-30% less chance of developing advanced or lethal prostatic cancer. Exercise even lowered the risk for those men who have a specific genetic subtype of prostatic cancer seen in half of the deaths. “The influence of insulin, growth factors, and other metabolic factors” is thought to be the link between exercise and the lower risk according to this Harvard School of Public Health study of 49,000 healthy men between 1986 and 2012.

Many Nutritional Supplements Include Contaminants
Half of U.S, adults take some sort of nutritional supplements spending about $30 billion annually, and the FDA is prohibited by law to evaluate supplements for safety or efficacy PRIOR to marketing. The FDA can issue post-marketing warnings about adulterants. One study from 2007 to 2016 identified 776 supplements, mostly for sexual enhancements, weight loss, or muscle building, with either adverse events or consumer complaints,. Of the 28 products that had received two or more “FDA warnings” 19 continued to be sold. In another study of 21 supplements with “FDA warnings” because of one or more unapproved stimulants, 12 were still available in 2007 and 9 of the 12 still contained the same stimulants. Q.E.D.; FDA warnings have little effect in protecting consumers from potentially harmful effects of contaminants in nutritional supplements.

Does Drinking More Water Reduce Bladder Infections in Women?
Yes, if they had 3 or more bladder infections in the previous year and are drinking LESS than the recommended 1500 ml. (4 water bottles) a day. If they doubled the amount of water to 3000 ml. (8 water bottles) a day the reoccurrence of a bladder infection is reduced from 3.2 a year to 1.7 a year (at least in Bulgarian women). If they were already drinking over the 1500 ml. minimum a day increasing the amount had no effect on recurrence. [All the U.S. women I know, at least in Barnstable county, take a bottle of water with them when they’re just going to the post office.]

One-half of Obese Adolescents Started Being Overweight When 3 – 5 Years Old (at least in 50,000 healthy German children)
Most of the children who were obese at age 6 were obese as adolescents. Rates of obesity were higher in children with overweight or obese mothers. “It is an ominous sign that the number of American children with the most recalcitrant forms of obesity has increased progressively during the past 10 years.” This study suggests that physicians should start nutritional counseling if exaggerated weight gain occurs after age 2! (NEJM October 4, 2018)

Do Not Use Infant Walkers
Despite the fact that the American Academy of Pediatrics has long called for infant walkers to be banned in the U.S. as they are in Canada, infant walkers are still sold here. An average of 9,000 infants a year under 15 months of age are treated in our ERs with head or neck injuries when infant walkers go down household stairs with an infant in them. The AAP says that “there is no advantage of the walker to the infant and parents should not use them.”

A Chilling Aftermath of Our Latest Gun Violence
A friend of mine has a brother who worships at that Pittsburgh synagogue. He was not there for the October massacre, but sat Shemira (literally a bodyguard) for a member who was. After Shemira the brother called my friend to say that he had bought a gun and obtained a carry permit. My friend was incredulous, and asked him, “When are YOU going to carry a gun?” His brother’s answer, “Only when I pray”.

A Prayer for Our Times
The mid-term elections are over, but the political hyperbole and acrimony, especially from the President to the press, is not. On Veterans’ Day we sang “America the Beautiful” in church, and I was struck by the relevance of the unappreciated second verse:

“America! America! mend thine every flaw,
Confirm thy soul in self-control, thy liberty in law.”

Have a Happy Thanksgiving.


Vol. 201 October 15, 2018 Medical Facts and Fantasies?

October 15, 2018

Hub thumbnail 2015A baby aspirin a day does not necessarily keep the doctor away.
Daily low dose (81 mg. or a baby tablet) aspirin protects you from having your SECOND heart attack, not your first one. Another recent study confirmed that aspirin gives no such protection to someone who has a normal heart history. A baby aspirin is of NO benefit for primary cardiovascular disease prevention. (Despite these repeated studies many of us continue on our merry way of taking a daily baby aspirin in hopes of preventing “the big one.” )

Ritalin is apparently better than nothing . . . and lots of other things.
ADHD (Attention-Deficit-Hyperactivity-Disorder) in school children is not helped much by non-drug therapy. A 2011 review of 54 studies showed little lasting effectiveness of neurofeedback, child behavioral training, parent training, cognitive behavioral (“talk”) therapy, dietary changes, or herbal and Omega fatty acid supplements when compared to the usual psychostimulant drugs like Ritalin. (This lack of evidence of any benefits from non-drug treatment of this common condition is disappointing. The reviewers themselves call for additional studies.)

There’s An App For It – Among things that your smartphone can do are:

  • Record and transmit a electrocardiogram of your heart rate and rhythm.
  • Ask questions to determine whether you are slipping into a depression, and send a text message to your therapist.
  • Have a trained counselor call you within an hour of you opening up a bluetooth equipped HIV self-test kit to interpret the results for you.
  • Adjust the volume and sound characteristics of the hearing aid in your ear.
  • Operate an automatic pill dispenser filled with your daily medications.
  • Give you a “text neck”. The 60 degree angle of your neck as you text puts about 60 pounds of strain on your spine. (That’s the equivalent of 4 bowling balls).
  • Measure, record, and transmit your blood pressure or blood glucose level.
  • Give you an inaccurate pulse oximetry reading if using a non-FDA approved monitoring app. (In fact, the FDA faced with the existence of about 400,000 health and wellness apps has decided to review 20 apps a year that are directly related to gathering and transmitting clinical data. – FitBits are not included in that category)

Got your flu shot yet?
This year the CDC is recommending the quadrivalent flu vaccine for everyone over 6 months old who does not have a medical contraindication. No particular vaccine brand is recommended over the others. People with egg allergies can safely receive any of the vaccines. ( The Bill and Melinda Gates Foundation is pouring money into research efforts to reduce the potential effects of one of their greatest fear, another flu pandemic.)

Parents know best.
Children sleep better if fed earlier in life. Official pediatric policy used be to start solids at 6 months. Many parents think that starting at 3 months causes longer sleep periods and less sleep problems. A study of 1300 breast-fed infants in England and Wales showed that the parents are right. Duh! (Pediatricians used to recommend starting certain solid foods at even a later age because of potential food allergies. That is no longer true.)

The “other shoe” on probiotics.
The current wisdom that “probiotics are harmless and can benefit everyone” is not necessarily true. The exploding volume of research on our “microbiome” (the bacteria in our intestines) reveals that the bacterial mix in our intestines is unique to each individual (like a fingerprint) and is “good” for us in its natural state. Probiotics can change that mix, and one study shows that some of us have guts that are not only “resistant” to probiotics, but that alteration of our natural mix by probiotics could delay recovery from some illnesses.

Why your visit to your doctor’s office isn’t the same as the “old days”.
It is estimated that a typical primary care physician needs 22 hours a day to address all of the preventive, acute, and chronic needs of an average patient panel of 2,500 patients. This includes all of the insurance-prescribed, electronically embedded (in the electronic medical record – EMR) quality measures tied to the reimbursement of the physician. (This is one reason we patients are filling out more questionnaires, clicking on more boxes on a screen, and spending more time with nurse practitioners and physician assistants when we go to the doctor’s office. “The doc can’t do it all any more.”)

Watch out. More un-immunized children are on their way to school.
A 2017 CDC telephone survey indicates that about 100,000 children in the U.S. born in 2015 and 2016 have not received vaccination against the 14 disease for which shots are recommended. This is an increase from a similar study of children born in 2011.

Too fat? Just take a pill. . . A new kind of pill.
A capsule with a long thin plastic tube is swallowed by the patient. Once in the stomach air is pushed down the thin plastic tube, the capsule expands into a balloon filling 1/3 of the stomach, the patient has sensation of having a full stomach, and the thin tube breaks off and is withdrawn. In about three months the stomach balloon disintegrates, deflates, and is passed out in the stool. It has been approved in Europe and is being tested in the U.S. hoping for FDA approval in 2020. Another start-up company is hoping that their capsule filled with gel that expands in the stomach juices and accomplishes the same thing will also be approved. ( The gel-filled capsule is a bit of deja vu for me. As a chubby pre-teen trying to lose weight, I remember taking a tablespoon of “weight-loss powder” a half-hour before a meal, waiting to let it expand in my stomach, and feeling less hungry  so I ate less. I forget its name, but I do clearly remember the time I was in a particular hurry, ate too soon after the dose, and promptly emptied my over-filling stomach onto my shoes.)

A timely tip for women.
With all the surprise disclosures of “good men” exhibiting past sexual harassment acts and even sexual assaults, how can a woman feel confident that the man she is with is not the aggressive type? A recent study suggests you can just look at his hands. The shorter the index finger is compared to the ring finger, the more aggressive the man may be. This is from a study of 300 Canadian men and women. No correlation of personality to finger lengths was found in women. Researchers associate this finding with “the amount of testosterone that babies are exposed to in utero”. ( Or could it be related to being born North of the 49th parallel?! )


Vol. 200 October 1, 2018 “Memories Are Made Of This” (apologies to Dean Martin)

October 1, 2018

Hub thumbnail 2015

The man [or woman] with a clear conscience probably has a poor memory. ~Author Unknown

 

 

He said. She said. Which one has the correct memory? That’s a very good question . . . and there are a variety of answers.

Before the memory is made, of course, perception has to occur. As the police, lawyers, and judges know, perceptions of the same event can vary considerably between witnesses. Much has been written about the unreliability and inaccuracy of eyewitnesses to a crime. Extreme stress during a criminal act, presence of weapons, brief time durations, racial disparities, and lack of significant physical characteristics are some of the causes of much different perceptions. But some of it is due to how our brain works.

As an example of perceptual differences in viewing even non-stressful events click here and watch a video of an attentiveness test. It is a variation of the famous 1999 “Invisible Gorilla” perception test.

In the recent confirmation hearing of a Supreme Court judge dominating our current media only the two principals will be telling their story. Since he denies the event as described by her, and no eyewitness is available, we are back to the reliability of memories.

Memories are thought to be reconstructed like a puzzle rather than being played back like a videotape. Other people questioning the memory, challenging details, asking for repeated retelling (as in the “telephone” party game), or unintentionally giving non-verbal clues can actually alter how the puzzle is reconstructed. Police line-ups as a way of identifying criminals has long thought to be rife with such errors.

False memories have intentionally been created in experiments where researchers present to a number of adults four stories of their own early childhood. Three are true memories. The false story contains some true, irrelevant, but known to the reader, details provided by relatives. Each adult is asked to add any other details they can remember to the stories. In the end one-third of the adults believed that the false memory was true. In follow-up interviews 25% still felt that the false memory was true. This, of course, was a highly structured, experimental manipulation not easily mimicked in real life, but it shows that false memories can be created by outside influences.

Mitchell Garabedian, the lawyer that represented victims of Catholic clergy sexual abuse feels that victims often come forward because they feel obligated to for the sake of others. He also notes that both persons believe wholeheartedly that their memory is true, so that both will appear to be equally credible. (1)  This suggests that lie detector test results are irrelevant to characterizing memories as either true or false.

The debate about whether recovered memory in child abuse cases is false or true flared to a peak in the 1990’s. “Recent debates between differing schools of scientific thought, fueled by the media and by lay organizations with varied political agendas, have left the public confused and misinformed regarding the nature of traumatic memories” – ( this was writtenin in 1994!)  In an effort to reconcile the differences of scientific opinion of recovery memory in child abuse cases, a national symposium of all kinds of experts with all kinds of theories was convened in 2012. It did not produce a consensus, but it did produce a 255 page book that you are welcome to read.  (Full disclosure by my true memory: I did not read the whole thing)

“Emotional arousal appears to increase the likelihood of memory consolidation during the retention (storage) stage of memory (the process of creating a permanent record of information). A number of studies show that over time, memories for neutral stimuli decrease but memories for arousing stimuli remain the same or improve. Others have discovered that memory enhancements for emotional information tend to be greater after longer delays than after relatively short ones. This delayed effect is consistent with the proposal that emotionally arousing memories are more likely to be converted into a relatively permanent trace, whereas memories for non-arousing events are more vulnerable to disruption. Several studies have demonstrated that the presentation of emotionally arousing stimuli (compared to neutral stimuli) results in enhanced memory for central details (details central to the appearance or meaning of the emotional stimuli) and impaired memory for peripheral details.  A few studies have even found that emotionally arousing stimuli enhance memory only after a delay.”

We know from PTSD studies that traumatic memories can be either haunting or forgotten. Traumatic memories that are a single event, involve an adult victim, and receive validation and support are more apt to be retained as a “continuous memory”. (i.e.; a rape, assault) Trauma that is repetitive, involving a child victim, and is followed by denial and secrecy is more apt to produce “disassociation/amnesia” (i.e.; incest, abuse, torture).

After reading this you may still be uncertain about who has the correct memory, as well as being undecided about whether the Senate Judicial Committee hearing was a kangaroo court or not. “A kangaroo court is a judicial tribunal or assembly that blatantly disregards recognized standards of law or justice, and often carries little or no official standing in the territory within which it resides. The term may also apply to a court held by a legitimate judicial authority who intentionally disregards the court’s legal or ethical obligations. A kangaroo court is often held to give the appearance of a fair and just trial, even though the verdict has in reality already been decided before the trial has begun. This could be because of the biases of the decision-maker, or because the structure and operation of the forum result in an inferior brand of adjudication.”

HAVE A NICE DAY! If you do, please make sure to remember it.

References:
1. Boston Globe, Sept 23, 2018, B2, Steve Annear

 


Vol. 199 September 15, 2018 Nature vs. Nurture . . . an update

September 15, 2018

Hub thumbnail 2015

“The closer scientists get to understanding the impact of individual genes,
the smaller that impact seems to be.”
– Evan Horowitz, Boston Globe, 9/11/18,C1

The discussion about what influences our upbringing the most, the environment (“nurture”) or our genes (“nature”), has been going on for decades. Sets of twins, particularly comparison of fraternal twins (two genetically different people born at the same time) and identical twins (two genetically identical people born at the same time), have been the subjects of much research trying to tease out the answer to which has the most influence. Why is one twin smarter than the other? Why does one love football and the other the violin? Why do they have the same walk, the same tastes in clothing, and the same gestures, but one has no sense of humor and the other is the class clown?

Despite the revelations in the recent movie, “Three Identical Strangers, many ethical and scientifically-rigorous twin studies have added a great deal of insight into the nature vs. nurture conundrum, and the discussion continues in the absence of consensus. The completion of the human genome project in 2003 was heralded as an historic step in finally settling this question. The hope was that, at last, we would be able to correlate a specific gene, or maybe just two or three genes, with a human characteristic, a human condition, and even a human disease.

In a recent study of the human genome, researchers found 1,271 different genes that seemed to improve educational outcomes. However, the cumulative effect of these educationally significant genes explained only about 11-13% of real world, actual educational attainment. (1) In a separate study by other researchers, the role of inherited genes in height, obesity, and education seemed to have much less influence than previously estimated . . . and a drastically much smaller role than suggested by twin studies. The influence of genes was highest for height (55%) and lowest for years of schooling (17%). The gene effect on cholesterol level was about 31% and the gene effect on determining your body mass index (BMI) was 29%.(2) There is no single “fat gene.”

One group of researchers suggested that perhaps the genes of the parents that are NOT passed to their offspring are important. What if the parents’ genes made them “slightly more attentive to kids and more willing to sacrifice their own happiness for the benefit of the kids”? Perhaps that could result in those children receiving a richer education. They suggested calling this influence of the parents’ genes on the children’s environment “genetic nurture”. (Thanks a lot for mudding the waters some more!)

There is no doubt that the genes we inherit from our parents influence our health and longevity. The adage, “To enjoy a long life, pick your parents right”, was dramatically brought home to me one day in the hospital cafeteria many years ago. A dozen of us physicians were discussing over lunch the pros and cons of a new study that daily baby aspirin could prevent some heart attacks, and different opinions about this brand new data were being voiced. A cardiologist espousing the strong genetic influence on heart disease interrupted our lively discussion with the question, “How many of you can call your father on the phone right now?” Only three could.

So the discussion of nature vs. nurture continues despite our growing knowledge of the human genome, but we have nothing to worry about as long as we have picked our parents right.

References
1. Nature Genetics, July 2018, as reported in Boston Globe, September 11, 2018
2. Ibid


%d bloggers like this: