Vol. 179 October 15, 2017 What About Stem Cells?

October 15, 2017

 

At this moment, the full promise of stem cell research remains unknown, and it should not be overstated. But scientists believe these tiny cells may have the potential to help us understand, and possibly cure, some of our most devastating diseases and conditions.  But that potential will not reveal itself on its own. Medical miracles do not happen simply by accident. They result from painstaking and costly research — from years of lonely trial and error, much of which never bears fruit — and from a government willing to support that work.

BARACK OBAMA, remarks at signing of Stem Cell Executive Order, March 9, 2009

Our stem cells  can renew themselves AND are capable of transforming into a wide variety of different tissue types comprising essential  organs. It is this last property that has excited both medical researchers looking for new therapies as well as people opposed to abortion or concerned about the potential threat of human cloning.  Stem cells are not to be confused with the STEM curriculum movement advocating since 2001 for the integrated study of Science, Technology, Engineering, and Mathematics at every grade level to prepare our children for future jobs. Obviously, we will need more STEM graduates to develop more stem cell therapies.

Stem cells were first grown from human embryonic tissue in 1998 after decades of mouse embryo research. The initial source of these embryonic stem cells was fetal tissue from spontaneous miscarriages, unused fertilized embryos from in vivo fertility clinics, or elective abortions. The association with abortions prompted President Bush in 2001 to impose severe federal restrictions on fetal tissue research. In 2009 President Obama lifted those restrictions in response to persist pleas from many medical scientists. With the lifting of those federal restrictions several states have subsequently launched their own legal opposition to use of fetal tissue for research. A rich source of stem cells is umbilical cord blood collected from live babies at the time of delivery. Private cord blood banking (in case your child develops leukemia and needs some stem cells for bone marrow transplant at a later age) continues to be a thriving business. (Ad disclaimer: “No babies were harmed in the making of this tissue culture.”)

Stem cells can also be derived from adult or mature tissue like skin, fat, muscle, and even teeth (dental pulp). These adult or somatic stem  cells are not pluri-potential; they can only grow into the same or very similar tissue as their source. They have less potential impact for new broad-based medical therapies. There are few stem cells in adult tissue, and they are more difficult to extract and grow in tissue culture. The repair of damaged knee cartilage with cartilage/bone stem cells injected by arthroscope is an example of a current stem cell therapy. A very recent article about injecting heart stem cells directly into heart muscle damaged by infarction suggests a new, potential therapy for patients with congestive heart failure following an MI.

So what’s the buzz all about? The FDA recently cracked down on several stem cell clinics suspected of “peddling unproven and dangerous” products  to “vulnerable patients” for treatment of cancer, diabetes, Parkinson’s, stroke, and other neurological diseases.  The patients are “vulnerable”, of course, because they have diseases for which current medicine has no cure. ( The Stem Cell of America website  claims success with 4,000 patients at their Mexican treatment center; “cost of treatment depends on individual case evaluation”; dozens of positive research articles about stem cell treatments are listed… all in mice). I personally know parents who took their brain-damaged child to China at great expense on several occasions for injections of stem cells into their child’s spinal fluid with no success in regenerating nerve tissue. Stem cell therapy is administered intravenously, intranasally (for brain disease), or directly into a target organ. In another recent report, three elderly Florida women receiving treatment for deteriorating vision were blinded by injection of stem cells into their eyeballs.

So, many significant risks with few proven benefits so far. Where do we go from here? How can we evaluate this new therapy? The U.K. created the National Institute of Health and Clinical Excellence as part of their National Health Service. They leave out the “H” and call it “NICE” for short. Its purpose is to evaluate new medical technology, including new therapies, for both quality (benefits) and cost (risks and expense) as compared to current technology. Reviews of its work are positive.

We have no such evaluating body in the U.S. The FDA evaluates new drugs. The CDC evaluates new vaccines. No one agency has the responsibility to evaluate new medical technology, i.e. “Does the very expensive PET scan improve patient outcomes compared to MRI/CT scans?” Different professional societies have their views and publish their data. The Office of Technology Assessment (OTA) was established in 1972 to advise Congress, but spent its time and energy on non-medical issues (acid rain, etc.) and was abolished in 1995 during Regan’s administration. The ACA (Obamacare) created a Center for Innovation within the Center of Medicare and Medicaid to support, evaluate, and promulgate new ways of providing medical services. Funding of its budget budget of a billion dollars a year for ten years was delayed. Its impact so far is negligible, and its fate is unknown.

Stem cell research may seem like small potatoes compared to climate change and potential nuclear war in the context of our currently anti-fact, unpredictable, and often inconsistent federal government, but the return on investment in stem cell therapy research could be quite big.
Lets make “American Science Great Again.”

 

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Vol. 178 October 1, 2017 What is Single-Payer Health Insurance?

October 1, 2017

Now that Bernie Sanders is again firing up the discussion about single-payer health insurance, it might be a good idea to review this complex issue. So, here’s a short self-test for you to gauge your understanding of what Bernie, and a lot of other people, are talking about.  The correct answers are supplied right away, so you won’t stay confused for long. Since this is an internet-based test, YOUR ANSWERS, of course, WILL BE COMPLETELY ANONYMOUS. Nothing will  be recorded by NSA , Equifax, or the Russians.

 

“Single-payer” means:

  1. socialized medicine
  2. 100% of health care costs are paid for with taxes
  3. Pop-Pop picks up the dinner bill for everyone
  4. none of the above

Answer: 4. none of the above – In socialized medicine health care facilities and providers are owned by the government. “Socialized medicine” is a pejorative term which is now irrelevant since at least 70% of U.S. healthcare costs are already met by tax dollars  from Medicare, Medicaid, or the Veterans Administration. “Single-payer” is just an insurance scheme for public or privately owned services. In countries with universal health care insurance 77%-87% of costs are met by taxes. In the U.K. private insurance pays for about 13%. Pop-Pop gladly picks up the dinner bill for his children, but health insurance is still on them.

The number of countries with universal health insurance are:

  1.  1
  2.  2
  3.  3
  4. 58

Answer: 4. 58 – Germany in 1883, France in 1945, UK in 1946, Australia in 1975, Canada in 1984, Israel in 1995.

A basic tenet of single-payer insurance is that everyone will be covered without regard to income level:

  1. true
  2. false
  3. true, but …

Answer: 3. True, but … it will take years to bring everyone in the U.S. under “Medicare For All”.  Each year or so another decade of ages will be added to the coverage. States will need to coordinate their income-based Medicaid programs with “Medicare For All”.  Some states could request and receive waivers from the national program. Etc., etc., as incrementally we always go.

Universal health care insurance in other countries is administered:

  1. nationally
  2. regionally
  3. locally (municipalities)
  4. all of the above

Answer: 4. all of the above – Germany has 1100 public and private “sickness funds” with a national standard level of coverage. In the Netherlands health insurance is administered by municipalities that levy local taxes to pay the costs. This  apparently enhances transparency and both taxpayer and patient satisfaction. Conclusion: If you have seen one system of universal health coverage, you have seen ONE. By the way, isn’t “sickness fund” a much more honest name for insurance which pays for medical care and does not necessarily buy “health”. (Leave it to the Germans to say it like it is).

Universal health insurance is based on which basic insurance principles:

  1. spread the risk over the greatest number of people
  2. use education and regulation (i.e.. fire laws) to reduce the highest risks of loss
  3. if you win (stay healthy), you “lose” (your premiums). If you “lose” (get sick), you win (care is paid for)
  4. use excess premium revenue to build fancy office buildings and pay for expensive lobbyists .

Answer: 1-3 (see subsequent question for further information on #4)

Single payer health insurance will cost less to administer than our present system:

  1. true
  2. false
  3. true, but …

Answer: 3. true, but… maybe not as much reduction as we hope. Administrative costs for the individual provider will probably remain the same because “meaningful criteria” compliance, complex diagnostic coding, need for medical necessity justification, and need for data showing that quality is not being eroded will continue to require significant personnel time and computer capability. Remember also that Medicare is currently administered in large part by “fiscal intermediaries” like Blue Cross. That probably won’t change. Some predict that because of continued pressure on a single-payer to reduce costs, it may, if fact,  get even more complicated for providers to get paid for their services. Of course, the huge consumer advertising, employer marketing, and lobbying expenses of private health insurance companies will be greatly reduced when the market share of private insurance is reduced to 10-15% as has occurred in other countries. If only we could get Visa to run Medicare’s fraud protection system!

Why not “Medicaid For All”;  could individual states institute universal health insurance so that we wouldn’t have to wait for a national consensus?

  1. no
  2. yes
  3. yes, but…

Answer: 3. Yes, but … the hallmark of universal health insurance in other countries is a consistent standard of coverage for all residents. Medicaid programs are state-specific and coverage is extremely variable, as is provider payments. If you see one, you have seen one. Attempts to waive the Obamacare national standards by those wishing to repeal it spotlighted the potential glaring inequities. But, Massachusetts has done it for 90% of its population, and there are bills in its legislature to do it for all. California is attempting to do it. Most California families and businesses, a University of Massachusetts study has said, would pay less for health care than they do now, even with the new taxes, because they would no longer pay premiums, deductibles or co-pays. As Samantha Bee recently noted: “You don’t have to be racist anymore to believe in States’ Rights .”

Why is a single-payer sometimes described as a “double-edged sword”?

  1.  a single-payer could have much greater negotiating leverage with both suppliers (drug companies) and providers (doctors and hospitals)
  2. a single-payer would be perched on the sharpest edge of the cost-quality equation
  3. the standardization of payments by a single-payer could dampen innovation and hamper medical progress
  4. all of the above

Answer: 4. all of the above – More leverage against the drug companies is “good”. More leverage against the providers could be “bad”.  Despite studies that show that good quality care is less costly, many still see a dichotomy between cost and quality. Concern about hampering innovation (“new ways of doing things”) with excessive standardization (“the old ways”) was one reason Obamacare created a Center for Innovation within Medicare as part of the ACA .

Who is in favor of single-payer health insurance?

  1. 60% of those polled
  2. 38% of those polled
  3. depends on the nature of the poll
  4.  all of the above

Answer: 4. all of the above – The 60% in favor of single-payer health insurance dropped to 38% when the question was tied to one about increased taxes. The most recent Harris-Harvard poll (9/17/17) showed that 52% were in favor of single-payer insurance. 69% believe that it would provide more coverage, including 54% of Republicans. . Most of the other questions about a governmental single-payer were 50/50 pro and con. Some physicians, hospitals, and other providers are in favor of single-payer insurance.

What are some of the barriers to implementing single-payer, universal health insurance in the U.S.?:

What does President Trump think?:

 


Vol. 175 August 1, 2017 Trump Turmoil From a Medical Perspective

August 1, 2017

President Trump is not my patient.
I am not President Trump’s doctor.

Neither is Leonard L. Glass, MD, MPH, Board Certified psychiatrist and psychoanalyst, Associate Professor of Psychiatry Harvard Medical School, McLean Hospital Senior Attending Physician , medical ethicist, and Distinguished Life Fellow of the American Psychiatric Association (APA).

After clearly making those two statements above, Dr. Glass resigned his 40+ year membership in the APA because the APA recently reaffirmed and expanded its statement that it is unethical for any psychiatrist to make any statement about the mental state of public figures who they have NOT examined in person, i.e. who are not their “patient”.  It is called the Goldwater Rule and was  implemented by the APA Ethics Committee in 1964 after FACT Magazine lost a libel suit over their published poll of psychiatrists of the “mental state” of Senator Barry Goldwater as a candidate for president.  “Superimposing the time-honored doctor-patient relationship onto public, political discourse, where there is no doctor-patient relationship is intrusive, improper, and self-defeating”. (1)

HIPPA regulations about patient confidentiality aside for the moment, Dr. Glass feels that since orthopedic surgeons can explain to us the mechanics of an ACL tear and its treatment in a Patriots linebacker, and radiation therapists can give us chapter and verse about Senator Ted Kennedy’s positron treatment for brain cancer, forbidding an experienced professional observer of behavior to comment on the observed behavior of a public figure is ridiculous. He makes no pretense of “making a diagnosis”, and explicitly refrains from that.

Having stated that he disagrees with the APA Goldwater Rule, Dr. Glass goes on to give his insightful views of the observed behaviors, nay the copiously observed videotape and real-time audio behaviors, of a prominent public figure, President Trump. (Please notice the respect I am showing by not referring to him as “the Donald”.)

Dr. Glass first cites the US Army’s Field Manual for Leadership’s list of “criteria for leadership” as an objective means to evaluate capacity for effective leadership. The criteria are:
Trust
Discipline
Self-control
Judgment
Critical thinking
Self-awareness
Empathy.

Dr. Glass’s then offers his “plausible ways of understanding Trump’s aberrant behavior.”

  • “Trump’s continual boasting and proclamation of great confidence in his ability to solve complex problems suggest bluster and posturing to disguise insecurity.”
  • “His inability to tolerate divergent opinions and his lashing out impulsively at those who differ from him demonstrate an impulsivity that could interfere with processing important new data that runs contrary to his prior opinions.”
  • “His vindictiveness and ridicule of vulnerable groups [and individuals] point to a lack of empathy and compulsive need to prop up his self-worth at the expense of others.”
  • “His assertions of strength and power, paired with repeated complaints of being victimized, suggest fears of exposure as small and inadequate.”
  • “His numerous self-contradictions and shifts of position without acknowledgement of prior misjudgments betoken an erratic, unstable, and unreliable mind-set in which chaotic emotional needs are constantly swamping his capacity for deliberative, thoughtful problem-solving.”

Dr. Glass finishes with “These are psychological hypotheses aimed at helping us make sense of mercurial and aberrant behavior without getting into diagnosis .”

Now if you don’t consider President Trump’s behavior as aberrant, or at least as unusual, for a President, then you stopped reading this blog a while back.

One of the reasons I think that President Trump is so unusual was recently clarified for me by a couple of linguists interviewed on radio. They who have been studying his speeches for some time. “He speaks like people ordinarily do.” They mean that he is a bit rambling, sometimes quickly changes subjects, repeatedly emphases favorite or strongly held thoughts, and even injects profanity for effect. They go on to say that “ordinary language” is meant to be spoken, not read. It doesn’t necessarily read well as the written word. Understanding it often depends a lot on physical cues like voice modulation, facial expression, and body language. The linguists noted that his speech pattern is one way Trump has such an appeal for some. “He doesn’t talk like a politician.”

I am no fan of politick-speak, and I don’t consider myself to be an elitist (though at least one of my children would tell me that as a relatively affluent older white male, I fit the definition). But I do expect Presidents to speak like a President; with some eloquence, with some consistency of content and syntax, and hopefully with a greater vision than I have, so I can be inspired or challenged.

My late, sweet, gentle, very-short Irish Catholic mother-in-law’s most damning and infrequently-used dismissal of a person was “They’re ordinary”. I never thought that I would ever quote her in a blog, BUT ….

References:
1. “Let psychiatrists talk about Trump’s mental state,” Leonard L. Glass, Boston Globe, July 31, 2017, pg.A9.


Vol. 174 July 15, 2017 Dumb Government and Smart Guns

July 15, 2017

Gun violence injuries and deaths in the U.S. is a public health crisis.”   – AMA

Gun violence kills roughly 30,000 Americans each year, about as many people as car accidents. The federal government has been restricted in gathering and analyzing gun violence data since 1996 when a CDC study linked the presence of a gun in the house with an increased risk of homicide. The NRA responded with a successful lobbying effort to pass the restriction that the CDC may not use any money allocated to it for “activities that advocate or promote gun control.” It stripped $2.6 million from the CDC budget for firearm injury research. After the Newton School shooting in 2012 Obama issued an Executive Order (one of his relatively few) commanding the CDC to renew their research into gun violence and requested Congress to allocate $10 million for that. Congress never did, and research never resumed.

The NRA has also successfully limited the federal government’s ability to trace guns involved in crimes, “crime gun-tracing”. Some states have developed data bases of crime-gun tracing to identify sources of and reduce illegal gun trafficking. Massachusetts established crime-gun tracing in 2014, but has not published a meaningful analysis of the data which might lead to some action. The 2017 Massachusetts legislature has inserted into their budget proposal a request that the governor produce such an analytical report.

Doctors, particularly pediatricians, are keenly aware of the dangers of having guns in the  house. 90% of accidental gun injuries to children happen in a home with a gun. The American Academy of Pediatrics has explicitly recommended that pediatricians routinely ask gun-safety questions during health and wellness visits. But in 2011, Florida passed a “Privacy of Firearm Owners” law levying $10,000 fines and loss of medical license to any pediatrician that inquired about the presence of firearms in the house. The law was upheld by a Florida state court in 2014 based on “2nd Amendment infringement”. The law was just struck down this year by a Federal Appeals Court that ruled that “there was no evidence that the law infringed on the Second Amendment.” By the way, the Affordable Care Act (aka Obamacare… remember Obamacare?) specifically prohibits physicians from keeping records on gun ownership. an assurance to any paranoid, conspiracy-theory-believing gun owner that docs were now not in league with big government. (see “Docs vs. Glocks”, Scientific American, August 2015. pg. 10)

The solutions to gun violence deaths are mostly focussed on mass shootings including either/or/and:
1. eliminate mental illness,
2. eliminate terrorists,
3. eliminate humane treatment (put water boarding video of terrorists on You Tube),
4. eliminate Muslims,
5. eliminate political correctness  (utter the words “Radical Islam Terrorists” which Obama refused to say (sic.) (1)

The truth is that “mass shootings”, though a big part of media attention, are a small part of the  30,000 annual gun death toll. 62% of  gun deaths are due to suicides committed with guns that DO NOT BELONG to the victim (particularly among the young). Criminals steal about 250,000 guns per year. 1.7 million children live in homes with unlocked, loaded firearms. (2)

The NRA consistently raises the spectrum of the need for the home owner to have a means of self-defense, but a gun is 22 times more likely to be used in a criminal assault, an accidental death or injury, a suicide attempt, or a homicide than it is for self-defense. 61% of gun homicides are by people who know each other.(3)

Making a gun as smart as an iPhone is one way to prevent to a large portion of gun injuries and deaths. Previous attempts to develop such a smart gun have been fraught with problems, have been actively boycotted by gun manufacturers, and have been opposed by gun advocates and the NRA. Kai Kloepfer, a 15-year-old high school student in Colorado, in response to the Aurora theater shooting near his home, started a science project in 2015  to design a pistol that will only fire when a sensor in the grip recognizes the fingerprint of the owner. His project won awards, and Kloepfer delayed his entrance to MIT for a year when he got a grant to develop a working model of such a smart gun. By 2017 he successfully built and demonstrated a smart pistol. The gun takes 1 second to unlock, its battery lasts a year, a light indicates the battery status, and a second light indicates it is unlocked and ready to fire. Neither a child nor a thief can fire the gun. The owner may store up to 10 “authorized user” fingerprints (like for a spouse or domestic partner ). The smart gun is smart enough to NOT  connect with the internet, so it can not be hacked or hijacked.

The NRA response has been predictable: “NRA does not oppose new technological developments in firearms; however, we are opposed to government mandates that require the use of expensive, unreliable features, such as grips that would read your fingerprints before the gun will fire.”(2)

Hey, at least the NRA didn’t evoke the 2nd Amendment argument. That is progress!  Technology can deal with “expensive” and “unreliable”. Technology is far faster to upgrade than the Constitution.

References:
1. “A Nation Captive To The Gun”, Garry Wills, Boston Globe 6/15/2016
2. “The Future of Everything”, Wall Street Journal, 2017, Geoffrey Fowler
3. Journal of Trauma and Acute Care Surgery, 1998

 

 


Vol. 172 June 1, 2017 Why Republicans Dislike Obamacare (simplified)

June 2, 2017

“You pays yer money,
and you takes yer choice.”

 

 

The #1 reason is that the Affordable Care Act (ACA) expanded health insurance to at least 23 million voters in the name of Obama, a Democrat.

The #2 reason is that Obamacare is costing the federal government more than the Congressional Budget Office (CBO) predicted.

That is because more of the uninsured enrolled in Medicaid than predicted and less than predicted bought policies through the health insurance exchanges. I am sure that there are all sorts of complex economic reasons for that, but to my mind it seems pretty simple.  If Medicare is the Gold Card of health insurance, Medicaid is at least the Silver Card.  The Medicaid card is accepted by all hospitals and ERs (by law) and many physician specialists. Even some behavioral health services can be paid for with the card. Medicaid insurance is always state-funded, and each state develops their own program.”If you know one Medicaid program, you know just one Medicaid program.”

Obamacare increased federal subsidies to states that expanded people’s eligibility ( i.e.; by raising eligible income levels) for Medicaid insurance. Federal subsidies existed for the first few years, but Medicaid costs would eventually be borne by the individual states’ taxpayers. If you are the Republican governor of a state running for reelection every four years you’re probably not enthusiastic about that. However, one Republican Governor ( Romney of Massachusetts) had already expanded that state’s Medicaid eligibility to achieve nearly 100% insured. The present Republican Governor (Baker of Massachusetts) will be very unhappy if he loses the federal subsidies to Medicaid under Trumpcare.

Health insurance exchanges were supposed to recruit into the health insurance risk pool a lot of healthy young people not covered by employer-based plans. These healthy young people would need less health care than their elders, so their premiums would be a “net plus revenue” to the insurance companies. When that “net revenue” did not appear as large as expected several companies withdrew from the exchanges with much media attention. The “individual mandate” tax which was supposed to “incentivize” the uninsured to buy policies through the exchanges was apparently too low to work.

So, the essential elements of the Republican “replacement” of Obamacare are to:
1) roll back federally subsidized Medicaid expansion and
2) do away with the health insurance exchanges with their federal subsidy of premiums and the associated “individual mandate”.

Of course, Republicans propose to keep the more popular benefits like required coverage for pre-existing conditions and coverage for children up to age 26 living at home. Obamacare also established a new standard definition of “essential benefits” such as pregnancy and other maternal benefits and put a maximum cap on premiums for the elderly. One Republican proposal would define pregnancy as a “preexisting condition” and deny coverage. Watch for further developments in evolving Senate proposals.

The predictions of the CBO in the past (since Nixon created it on the way out the Oval Office door) have been more nearly correct than those of most other agencies and organizations. It’s reputation as bipartisan and objective remains intact. The publication of Republican “replacements” before the CBO’s analysis could be carried out clearly hurt the credibility of their proposals.

Multiple evidence-based studies and the experience of all other developed countries with government-based health insurance (does NOT have to be a “single payer”) have shown that providing universal health insurance in the long run saves money;
-by providing access to medical care for all citizens,
-by enhancing the cost-effective introduction of new technology,
-and by rationalizing the resource allocation of a defined budget.

We have a history of difficulty in taking the long view. For example, the initial enthusiasm for preventative/wellness programs exhibited by the early HMOs eroded considerably when they realized that the policy holder might not be with the same insurance company when the time came years later to reap the benefits of good health (less medical care expenses).  Certainly Governors, congressmen, and other public officials with short 2, 4, or 8-year terms have little incentive to always appreciate the long-term cost benefits down the road. (“No regulations to fight against climate change” comes to mind)

So as “they”say, being either the British magazine Punch in 1846 or Mark Twain in 1884 in “Huckleberry Finn”,
“You pays yer money, and you takes yer choice.” 


Vol. 171 May 15, 2017 Medical Updates (Real News)

May 15, 2017

 

“The Only Thing That Is Constant Is Change -”― Heraclitus

 

 


Those TV ads work … for the drug companies.
A study of the effectiveness of TV ads (Direct-to-Consumer Advertising or DTCA) for prescribed testosterone supplements (no effectiveness in men without endocrine disease) in 75 regional markets from 2009 to 2013 showed that the addition of ONE TV ad per household per month for 4 years was associated with an increase in new blood tests of testosterone level, new prescriptions with blood level testing, and new prescriptions without any blood level testing. About 2% of the middle-aged men in this study of 17 million men received a testosterone prescription. (JAMA,Mar 21, 2017)

In other news, the British Medical Journal published a study of over 900,000 men which showed that those taking testosterone were 63% more likely to develop potentially fatal blood clots in the legs or lungs during the first six months of taking it. (BMJ, Nov. 13, 2016)

Vitamin D gets an “F”.
Vitamin D supplements became very much in vogue when some studies suggested that people with low blood levels had a higher risk of cardiovascular disease. BUT, in New Zealand 2500 adults were given 1000 units of vitamin D once a month and a matched group of 2500 were given placebo. The vitamin D blood level doubled in the supplemented adults, but at the end of 3 years both groups had identical rates of adverse cardiovascular events (12%). (JAMA Cardiol Apr 5, 2017)

PSA testing -“D” or “C”? It depends.
In 2012 the U.S. Preventative Services Task Force (USPSTF) gave the PSA blood test screening for prostate cancer a “D” – (not recommended) because of false positives leading to unnecessary procedures and treatment, and the fact that PSA screening prevented less than 1 prostate cancer-related death per 1000 men screened.

In 2017 the USPSTF is upgrading that “D” to a “C” (maybe a small benefit) but only for men aged 55-69. (Dare we call it a “gentlemen’s C” ?) The “D” remains for those over 70. This upgrade for the younger men is based mostly on the emergence of the “active surveillance” option to immediate surgery or radiation for positive PSA tests and biopsy. The USPSTF strongly recommends that physicians 1) explain all the risks and benefits of PSA testing to men from 55-69, 2) be aware of the patient’s “values and preferences”, and 3) practice effective “joint decision-making” with the patient. (J Watch General Medicine May 15, 2017)

In other news, a Michigan study of 431 men with localized prostate cancer discovered by PSA testing and confirmed by biopsy who opted for “active surveillance” rather than immediate surgery or radiation showed that only 31% actually followed the complete “active surveillance” protocol. (PSA testing every 6 months and annual repeat biopsy.) Another 31% complied with just the PSA test repeats, but not the biopsy. 22% did neither repeat PSA tests nor biopsy. Outcomes were not measured in this study, (J Urol Mar 2017)

Aspirin may get a third “A”
Aspirin is well-known to relieve pain, reduce inflammation, reduce fever, and reduce blood clotting. It does that by inhibiting the production of prostaglandins, a hormone-like substance in play in all those conditions. In 2000 scientists discovered that aspirin also increases our production of resolvins which also reduce our inflammatory response. We make resolvins from Omega-3 fatty acid precursors (hence the contemporary popularity of fish oil).

Investigators are very interested in a newly defined, third effect of aspirin which is unrelated to its role in anti-inflammation – aspirin’s interference in the ability of cancer cells to metastasize. Cancer cells apparently need to be coated with clumps of platelets in order to survive their trip through the blood stream to distal sites. In mice, aspirin’s anti-platelet action (the “reducing blood clots” function) has been found to interfere with platelet clumping around the cancer cell and successful migration of the cancer cells through blood vessels is inhibited. (Scientific American May 2017)

Trying to avoid sugary beverages? Don’t jump to diet soda.
A 10 year study monitoring 4000 people without diabetes for strokes and cognitive decline found that people who drank diet soda every day were three times more likely to develop strokes and dementia. In a separate study people who drank more juices and more sugar-sweetened soda than others were more likely to have poorer memory and smaller brains on MRI imaging than the other people. The researchers state clearly that this is not a cause and effect situation, just an “association”. (Stroke April 24, 2017)
“More research is needed.” Of course.
“Water is best.”

Bilingual brains remember their first language, even when they can’t speak it!
Korean-born adults who were adopted by Dutch families before the age of six and who did not speak nor understand Korean were better at distinguishing between the sound contrasts of the Korean language and could pronounce the Korean sounds much better than those Dutch adults who had no exposure to the Korean language as children. This better discrimination of sounds is not genetically based because numerous studies have shown that all infants are capable of reproducing all the sounds of all languages. “Remarkably, what we learn before we can even speak stays with us for decades.” (Duh!) (Royal Society Open Science, Mar 2017)

No federal money to study pistols or pot.
According to David Hemenway, Professor of Health Policy, Harvard School of Public Health, an average of 300 people get shot in the U.S. each day. One-third of them die. Twenty years ago the CDC funded about $2.6 million a year (“a small amount”) for firearms research. Now that funding is ZERO. Since 2006 Congress has pprohibited the CDC from gathering any gun-related statistics and developing a gun-related data base, but there is apparently no formal, official prohibition for funding gun-issue research,; just the CDC’s desire to “stay out of congressional crosshairs”.

NIH apparently has the same reticence. In the past 40 years over 486 NIH grants have been awarded in the areas of cholera, diphtheria, polio, and rabies which have caused 2000 deaths in the U.S. Over the same 40 years while 4 million people were shot in the U.S. , NIH has awarded 3 gun-issue research awards. (Note: this period of time is during the relatively scientific-friendly Clinton, Bush, and Obama administrations .)

Marijuana is still classified by the FDA and the DEA as a Schedule I substance which prevents any clinical trial or study of its medicinal benefits. Medicinal marijuana must have FDA required “drug development” studies to get off Schedule I, and those studies are virtually impossible while it is on Schedule I. (Note: current Attorney General Jeff Sessions said in April 2016: “Good people don’t smoke marijuana”) (Scientific American May 2017)


Vol. 169 April 15, 2017 “Free-market Health Care Doesn’t Work”

April 17, 2017

“Nobody knew health care could be so complicated.”
-Donald Trump 2/27/17

Stephen Colbert responded with: “There was at least one person who knew that it was complicated, that tall, thin, greying guy who used to be in your office, Donald.”

Of course, there are lots of people who know how complicated it is. One of them is my old boss, Jim Lyons, founder and past-CEO of Cape Cod Healthcare, Inc. He is retired now and hasn’t lost his knack of making sense of the morass. He did just that in a recent Op Ed piece in the Cape Cod Times, and I’m shamelessly plagiarizing parts of it (in bold) for today’s blog.

“The fallacy [of the health care debate] is that necessary healthcare services is a free-market choice, as with buying a car, a house, or a kitchen table. If you have a stroke, break your hip or have an automobile accident [you don’t make] the same free-market choice for service”.

You could argue that if you want an elective procedure like a new knee, a new hip, or cancer treatment there is the opportunity for more choice, and that is true. Just take a look at the burgeoning advertising budgets of competing medical centers. The say they are competing on “quality”, and they are competing for your dollar, or more nearly correct the insurance company’s and the federal Medicare dollar. So far, in no U.S. health care market region has this “competition” led to lower costs. We recently wrote about the growing “lower-cost” market of medical tourism.

The two biggest reasons that health care costs keep rising are 1) we are all living longer and 2) better medical technology (both electronic and “better living through chemistry”).

 “New technology in health care almost always results in increased costs. In industry, new technology often lowers the cost of production. This is not the case for health care innovations.”

In fact, The Hastings Center estimates that 50% of our increasing health care costs is due to new technology. MRI exams have replaced  CT scans and other x-ray procedures in many instances, even in mammography; coronary surgery is being replaced in some instances by “simpler” medical devices inserted through a blood vessel; newer drugs with marginally better effects for heart disease and cancer are selling at much higher prices; PET scans are becoming the standard of care in certain cancer treatment protocols, etc.

Many years ago I remember the responses of a delegation of physicians and administrators from Great Britain who were touring American medical centers looking at our health care facilities. They were impressed, of course, with the MRIs and cardiac surgery units in Boston, but they “were just like what we had in London.” But, then they saw the same facilities in Worcester, Springfield, even Winchester and Burlington, and impossibly, Cape Cod, and they were impressed.

Efforts to control health care costs continue to be futile. “Republicare” was a political disaster and only attained a 17% approval rate in public polls. “Medicare For All” which calls for an incremental extension of Medicare coverage to those below 65 years of age has been in the House of Representatives (HR 676) since 2015. In Massachusetts there are now no less than four separate bills in the legislature calling for a single-payer Medicare For All in Massachusetts.

“One reason that it’s probably not politically possible to make a change to a single-payer system at this time is the more than 1,000 great buildings for servicing health insurance companies all over the country, full of many workers, many executives, and billions of forms.”

“Whether health care is a privilege or a right, we have made such great progress in the past 50 years that I don’t want to see any new health care plan that slows or reverses our progress. Please remember, health care is not a free-market choice like many of our other important decisions.”


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