We can say that people search after to beat the death since they have existed.Well,how much we can resist the death? What is the limit for our body to resist the deadly effects? Scientists had wondered this too and they had tried to measure that how much resistance of people is against to death.
They had shared the results with National Geographic readers in december 2009 release of the magazine.There is also too marginal events.For example,in last december,in Minnesota state of USA, a woman had fallen down over the ice and she had not been able to stand up again because of her arthritis.This woman who was 64 years old,had stayed over the ice for hours.
Over all also her heart had stopped because her body heat had decreased under 21 degree.Of course ,That part you have read is not interesting part of the event.The doctors who treated the woman who was almost died,had succeeded to have her heart to beat again,and they had provided Mrs.Duluth to live as a healthy person
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UPMC Fouls Another One Off
It's almost World Series time in the US, so here's a baseball story,courtesy the Pittsburgh Business Times,
University of Pittsburgh Medical Center lobbyist Leslie McCombs used Pittsburgh Pirates baseball tickets purchased by UPMC’s insurance arm to entertain film executives and others to promote the creation of a state film tax credit, according to the State Ethics Commission.
The commission fined McCombs $5,025 for failing to promptly register as a lobbyist for Lions Gate Entertainment Corp. and omitting a daytime phone number in registering as a lobbyist for UPMC, according to a commission ruling reached on July 22. The confidential decision was disclosed Sept. 9 by The Associated Press.
McCombs, who works for UPMC as a consultant, received permission from UPMC President and CEO Jeffrey Romoff to lobby on behalf of Lions Gate, which she described in a February 2007 e-mail to him as the, 'largest independent producer and distributor of motion pictures and television in the country.'
Romoff cleared her work with Lions Gate after consulting with UPMC legal counsel and assured by McCombs in the e-mail that, 'UPMC signs will be prominently featured throughout the (‘Kill Pit’ television) series.'
Filming for the eight-part miniseries, which was renamed 'The Kill Point,' began in March 2007 in Pittsburgh. Gov. Ed Rendell signed the Film Production Tax Credit bill into law in July 2007, which provided for a 25 percent film tax credit to offset production expenses.
Also,
From 2005 to 2006, McCombs was director of public relations for UPMC Health Plan, a for-profit subsidiary of the nonprofit hospital network. She was then named senior consultant with UPMC’s government relations department.
The State Ethics Commission lists 18 baseball games where McCombs treated Lions Gate and government officials using UPMC tickets.
In addition, she attended a June 15, 2007, matchup against the Chicago White Sox with Rendell and his wife, Marjorie, and Romoff and his wife, Stefania, according to the commission.
It’s not clear from the commission report whose interests McCombs was representing at that game, but Rendell later reimbursed $960 for the tickets to the five games that he attended, which was returned to the health plan.
In 2007, UPMC Health Plan bought $61,440 worth of Pittsburgh Pirates tickets, which were available to employees of the insurer 'in the performance of their duties,' the report states. The sum included a $20,000 seat license.
So did you get all that? The director of public relations for the UPMC Health Plan, the managed care subsidiary of UPMC, a large academic medical center, lobbied the state governor for the enactment of a tax credit for television and movie production, partially so that the UPMC logo would appear in a television series, and entertained the governor using a few of the more than $60,000 worth of baseball tickets the medical center purchased for employee use. Amidst the complication, the public relations director violated state lobbying rules. None of these shenanigans had anything directly to do with health care, or medical education and research. The only conceivable advantage accruing to the institution would be the appearance of the UPMC logo in a television series. But most likely everyone had good times at the ball game.
This story again suggests that managers of health care organization are more focused on playing marketing and political games than on health care, and generally are more focused on benefiting themselves than upholding their organizations' mission. The amounts of money involved in this case may be small, but do not underestimate the collective effects on health care access, cost and quality of managers who have their eyes on the wrong balls.
UPMC has provided grist for the Health Care Renewal mill before, see earlier posts
Sunscreen and Melanoma
Melanoma is the most deadly type of skin cancer, accounting for most skin cancer deaths in the US. As Ross pointed out in the comments section of the last post, there is an association between severe sunburn at a young age and later development of melanoma. Darker-skinned people are also more resistant to melanoma. The association isn't complete, however, since melanoma sometimes occurs on the soles of the feet and even in the intestine. This may be due to the fact that there are several types of melanoma, potentially with different causes.
Another thing that associates with melanoma is the use of sunscreen above a latitude of 40 degrees from the equator. In the Northern hemisphere, 40 degrees draws a line between New York city and Beijing. A recent found consistently that sunscreen users above 40 degrees are at a higher risk of melanoma than people who don't use sunscreen, even when differences in skin color are taken into account. Wearing sunscreen decreased melanoma risk in studies closer to the equator. It sounds confusing, but it makes sense once you know a little bit more about UV rays, sunscreen and the biology of melanoma.
The UV light that reaches the Earth's surface is composed of UVA (longer) and UVB (shorter) wavelengths. UVB causes sunburn, while they both cause tanning. Sunscreen blocks UVB, preventing burns, but most brands only weakly block UVA. Sunscreen allows a person to spend more time in the sun than they would otherwise, and attenuates tanning. Tanning is a protective response (among several) by the skin that protects it against both UVA and UVB. Burning is a protective response that tells you to get out of the sun. The result of diminishing both is that sunblock tends to increase a person's exposure to UVA rays.
It turns out that UVA rays are more with melanoma than UVB rays, and typical sunscreen melanoma in laboratory animals. It's also worth mentioning that sunscreen does prevent more common (and less lethal) types of skin cancer.
Modern tanning beds produce a lot of UVA and not much UVB, in an attempt to deliver the maximum tan without causing a burn. Putting on sunscreen essentially does the same thing: gives you a large dose of UVA without much UVB.
The authors of the meta-analysis suggest an explanation for the fact that the association changes at 40 degrees of latitude: populations further from the equator tend to have lighter skin. Melanin blocks UVA very effectively, and the pre-tan melanin of someone with olive skin is enough to block most of the UVA that sunscreen lets through. The fair-skinned among us don't have that luxury, so our melanocytes get bombarded by UVA, leading to melanoma. This may explain the incredible rise in melanoma incidence in the US in the last 35 years, as people have also increased the use of sunscreen. It may also have to do with tanning beds, since melanoma incidence has risen particularly in women.
In my opinion, the best way to treat your skin is to tan gradually, without burning. Use clothing and a wide-brimmed hat if you think you'll be in the sun past your burn threshold. If you want to use sunscreen, make sure it blocks UVA effectively. Don't rely on the manufacturer's word; look at the ingredients list. It should contain at least one of the following: titanium dioxide, zinc oxide, avobenzone (Parsol 1789), Mexoryl SX (Tinosorb). It's best if it's also paraben-free.
Fortunately, as an external cancer, melanoma is easy to diagnose. If caught early, it can be removed without any trouble. If caught a bit later, surgeons may have to remove lymph nodes, which makes your face look like John McCain's. Later than that and you're probably a goner. If you have any questions about a growth, especially one with irregular borders that's getting larger, ask your doctor about it immediately!
Health Care Information Technology, Hospital Responsibilities, and Joint Commission Standards"
My letter "Health Care Information Technology, Hospital Responsibilities, and Joint Commission Standards" was published in JAMA yesterday.
... these stipulations [hold harmless and gag clauses in contracts] further instantiate my observation that health IT lacks the rigor of medical science itself, its major Achilles heel.
Dr Silverstein's letter adds context to our Commentary on HIT vendors' self-protective "hold harmless" clauses while introducing an important discussion about hospitals' and vendors' possible violations of Joint Commission standards. We agree with Silverstein about the misapplication of the standard business software contracting model.
The AMIA response piece concluded:
"While we support increased transparency around error disclosure, the belief that the best approach to increase the safety and effectiveness of EHR systems is by legal regulation of system vendors is misplaced. Such an approach would stifle innovation and not achieve the desired goals. At a minimum equal attention needs to be given to the role that provider organizations bring to configuration, management and oversight of the software and related processes."
July 23 addendum:
Dr. Koppel has forwarded to me a letter he and Mr. Kreda submitted to AMIA in response to AMIA's aforementioned critique of his March 2009 JAMA "Hold Harmless Clause" article. Koppel and Kreda's letter, "On the AMIA Response to Commentary in JAMA by Ross Koppel and David Kreda" can be read (MS Word .doc format).
Highlights:
Read the whole thing at the link above. (I placed Koppel and Kreda's response to AMIA on my faculty server. The response, to the best of my knowledge, was not published by AMIA itself.)
... Where the AMIA authors disagree with us is the emphasis placed on errors produced in the coupling. [The coupling of healthcare organization and software, i.e., alterations and customizations beyond the control of the software vendor - ed.] We say a vast number or errors are generated in the marriage. But they say we have essentially ignored how many errors are created by doctors and hospitals seeking to consummate their relationship with HIT systems in situ ...
... A brief recap of our JAMA commentary seems in order. We wrote about: (1) the HIT vendor “non-disclosure” clauses that prevent clinicians from sharing information about errors generated from faulty software; (2) the clauses that remove all vendor responsibility for errors in their systems – and place all responsibility on clinicians and hospitals (the “hold harmless/learned intermediary” clauses); (3) the need to protect vendors from responsibilities for errors introduced when hospitals implement HIT or when untrained or incompetent clinicians use the HIT; and (4) the need for more balanced contracts that are fair to clinicians and hospitals ...
... Given that we addressed the non-software issues we are said to have ignored, we are not sure why our JAMA commentary earned the response it received on official AMIA letterhead. We hope, therefore that this letter can further a longer conversation about the many ways to make clinical IT software and its implementation better. Nonetheless, we stand by our statement that the imbalance in incentives we described in our JAMA Commentary is a structural obstacle that on balance hurts improving the clinical part of clinical IT.
Profit Hospital Systems
about how buy-outs of not-for-profit hospital systems by private equity firms seemed to be a new fashion in health care. Since then, new doubts have been raised about whether this is a good idea.
Detroit Medical Center, Vanguard Health, and the Blackstone Group
Letters to the Detroit Free Press raised concerns,
As a nonprofit corporation, DMC's mission is to provide quality health care to the community. Management is accountable to Detroit area citizens and health care consumers, not to profit-motivated investors.
As a private, for-profit corporation, its mission will be to provide profit for its shareholders. Management will be accountable to shareholders and will be rewarded in relation to the rate of return on their investments.
Also, the Free Press reported that a coalition of local not-for-profit organizations challenged the legality of the proposed sale,
The sale of the Detroit Medical Center to a for-profit Nashville company violates state law and raises issues about whether poor patients who depend on the DMC will be assured of care for years to come, three nonprofit Michigan organizations said today.
Marjorie Mitchell, executive director of Michigan Universal Health Care Network, said the organizations e-mailed today a three-page list of concerns about the sale to Michigan Attorney General Mike Cox.
Mitchell testified briefly today at the Detroit City Council about the issue and distributed the letter. The two other nonprofit organizations signing the letter were Metropolitan Organizing Strategy Enabling Strength, or Moses, an organization of community and religious leaders active on health issues, and Michigan Legal Services, a Detroit legal aid organization. The three groups called themselves the Coalition to Protect Detroit Health Care.
Citing a provision in state law, the letter said Michigan law is clear that nonprofit companies should not 'permit assets … to be used, conveyed or distributed for non-charitable purposes.'
'The mission of a for-profit is to serve the stockholders,' the letter to Cox said. The letter said it is the opinion of the three groups that the purchase by Vanguard of the DMC 'violates Michigan’s nonprofit corporation statute.'
The three organizations asked Cox to hold public meetings to answer questions about the impact of the proposed sale on the health of Detroiters, particularly uninsured people.
The groups also have questions about how the DMC’s $140-million charitable assets will be used as well as concerns that use of state Renaissance Zone money would benefit a for-profit company.
Caritas Christi Health Care and Cerberus Capital Management
Boston Globe news articles that Cerberus failed recently not only in its management of Chrysler, but of GMAC (now also bailed out by the US government), its management is secretive even for the opaque world of private equity, and it hasrunning "large medical systems."
A letter by Dr Arnold Relman, distinguished former editor of the New England Journal of Medicine,
Cerberus promises to keep the present hospital management, add much money beyond the purchase price toward the operation and improvement of the hospitals, maintain charity support, and not sell the system — for three years. After that, who knows? Cerberus follows its own interests, and it will take money out of the community, not contribute to it.
As a close observer of the for-profit hospital industry ever since its beginnings, I predict that Cerberus will sell to another business sooner or later, and the initial promises will be forgotten. That’s what happened at Framingham’s MetroWest Hospital.
Control over the kinds of medical services provided by the hospital would be lost. Unprofitable services such as pediatrics, obstetrics, and outpatient psychiatry would disappear. Business-owned hospitals will resist major reforms to control medical costs or reorganize a community’s medical services in the public interest.
Caritas Christi ran an advertisement in local papers that referred to Cerberus as its new "financial sponsor," suggesting that the company was going to give a still not-for-profit health care system a grant, quite different from what was really proposed, which was that Cerberus would become the owner of a formerly not for-profit health care system, thus rendering it into a privately held, for-profit system. One wonders why the public relations people thought they needed to spin the deal thus.
Finally, the Boston Globe current Caritas Christi CEO Dr Ralph de la Torre, who apparently negotiated a deal that would leave him "as chief executive of Caritas, while also putting him in charge of acquiring other hospitals for Cerberus." But the article raised questions about what sort of leader he would be. It characterized him as transformed "from doctor to dealmaker," who now "stands to win a much bigger payout." Worse, it suggested that winning, as evidenced by making more money than anyone else, rather than access to quality patient care, is his prime motivation.
He used to say, ‘It’s not about the money, but that’s one way people keep score.’
In addition, Dr De la Torre has now so transformed into a CEO that "he let his medical license lapse."
Summary
Let me note some people think that the notion that how much money one makes should be considered a "score," and that he who dies with the most money wins, was one of the central reasons for the global financial collapse. For example, Nancy Rapoportsome New Year's resolutions for corporate boards (in 2008!), including:
I will remind myself and my colleagues that the level of CEO compensation is not an indicator of the company’s performance and that the arms race towards excessively high executive compensation is not a winnable race. At the point when money becomes just a way of keeping score, compensation is probably too high.
Earlier in 2007, Michael Kinsley presciently in Time about,
a development in the larger economy. For most people, the point of money is that you can buy things with it. But at the top, where people already can buy whatever they want, the purpose of money is keeping score: making sure that you don't slip down in the Forbes 400 list.So, putting someone who believes that he must always make more money in order to keep "winning" in charge of a large health care system does not seem to be a recipe for better patient care or more access, but rather for ever-increasing executive compensation while making money becomes the overwhelming priority for the organization, completely eclipsing such quaint concepts as quality of care, reasonable costs, or adequate access.
Recent history has not shown that for-profit hospitals deliver cheaper, better, or more accessible care than not-for-profit institutions. While their presence has influenced not-for-profit hospitals to behave more like for-profit institutions, costs have risen inexorably while quality and access decline.
Moreover, for-profit hospitals run by private equity (as opposed to publicly traded corporations) would likely to be even more opaque than they were when they were not-for-profit. Increasing opacity of health care would likely worsen, not improve our current problems.
Deals that turn not-for-profit hospital systems into privately held for-profit systems ought to be scrutinized ith extreme skepticism. The questions raised above about the currently proposed deals ought to be addressed, In addition, I would suggest that all such deals should be conditioned on a requirement that the taken-over hospitals, and their parent private equity companies have to disclose at least as much as both public for-profit health care corporations and not-for-profit health care organizations are required to disclose, e.g., their ownership, the make-up of their boards of directors, the compensation, in detail, of their most highly paid officers, employees, and board members, all conflicts of interest affecting their leaders, etc. By the way, maybe such disclosure should be required of all health care organizations above some reasonable minimum size. If private equity companies are unwilling to make such disclosures, maybe they should not be allowed to run health care organizations.
Insulin Controls Your Fat
I'd like to point out a nice post by Peter over at hyperlipid (keep in mind when you read it he has a sarcastic style). He dug up a published in 1998 in the Journal of Clinical Endocrinology & Metabolism. In the study, they put 24 overweight subjects on a low-calorie diet composed almost entirely of meal replacement shakes and "nutrition bars". Half of the participants got the drug diazoxide, which reduces the secretion of insulin by the pancreas. The other half took a placebo.
The bottom line is that the diazoxide-treated group lost much more weight over time than the placebo group, and they continued to lose after the placebo group's weight had stabilized at around 8 weeks. Yes, these poor people drank meal replacement shakes and ate nutrition bars for 9 weeks.
This result makes a lot of sense. Insulin is the hormone that keeps your fat cells from releasing fat. It's also the hormone that tells them to grab fat and sugar out of the blood and store it. Overweight people tend to have elevated insulin. Low blood insulin is a signal to fat cells to release their contents into the bloodstream to be burned by other tissues. This is one of the reasons why I emphasize keeping insulin low. If you need some motivation Here's how to normalize insulin without taking a toxic drug:
- Avoid grains (especially wheat and its derivatives), and keep carbohydrate intake low for weight loss.
- Avoid all sugar in any form except occasional fruit.
- Exercise.
- Intermittent fasting. A 24-hour fast once a week is a good way to start.
Effects on the Heart and Brain
I'm revisiting the topic of the omega-6/omega-3 balance and total polyunsaturated fat (PUFA) intake because of some interesting studies I've gotten a hold of lately . Two of the studies are in pigs, which I feel are a decent model organism for studying the effect of diet on health as it relates to humans. Pigs are omnivorous (although more slanted toward plant foods), have a similar digestive system to humans (although sturdier), are of similar size and fat composition to humans, and have been eating grains for about the same amount of time as humans.
In the on the omega-6/omega-3 balance, I came to the conclusion that a roughly balanced but relatively low intake of omega-6 and omega-3 fats is consistent with the diets of healthy non-industrial cultures. There were a few cultures that had a fairly high long-chain omega-3 intake from seafood (10% of calories), but none ate much omega-6.
explores the effect of omega-6 and omega-3 fats on heart function. Dr. Sheila Innis and her group fed young male pigs three different diets:
- An unbalanced, low PUFA diet. Pig chow with 1.2% linoleic acid (LA; the main omega-6 plant fat) and 0.06% alpha linolenic acid (ALA; the main omega-3 plant fat).
- A balanced, low PUFA diet. Pig chow with 1.4% LA and 1.2% ALA.
- An unbalanced, but better-than-average, "modern diet". Pig chow with 11.6% LA and 1.2% ALA.
The most striking finding of all was the difference in lipid peroxidation between groups. Lipid peroxidation is a measure of oxidative damage to cellular fats. In the balanced diet hearts, peroxidation was half the level found in the first group, and one-third the level found in the third group! This shows that omega-3 fats exert a powerful anti-oxidant effect that can be more than counteracted by excessive omega-6. Nitrosative stress, another type of damage, tracked with n-6 intake regardless of n-3, with the third group almost tripling the first two. I think this result is highly relevant to the long-term development of cardiac problems, and perhaps cardiovascular disease in general.
with the same lead author Sanjoy Ghosh, rats fed a diet enriched in omega-6 from sunflower oil showed an increase in nitrosative damage, damage to mitochondrial DNA, and a decrease in maximum cardiac work capacity (i.e., their hearts were weaker). This is consistent with the previous study and shows that the mammalian heart does not like too much omega-6! The amount of sunflower oil these rats were eating (20% food by weight) is not far off from the amount of industrial oil the average American eats.
A third paper by Dr. Sheila Innis' group studied the effect of the omega-6 : omega-3 balance on the brain fat composition of pigs, and the development of neurons in vitro (in a culture dish). There were four diets, the first three similar to those in the first study:
- Deficient. 1.2% LA and 0.05% ALA.
- Contemporary. 10.7% LA and 1.1% ALA.
- Evolutionary. 1.2% LA and 1.1% ALA.
- Supplemented. The contemporary diet plus 0.3% AA and 0.3% DHA.
The researchers then cultured neurons and showed that they require DHA to develop properly in culture, and that long-chain omega-6 fats are a poor substitute. Overall, the paper shows that the modern diet causes a major fatty acid imbalance in the brain, which is expected to lead to developmental problems and probably others as well. This can be partially corrected by supplementing with fish oil.
Together, these studies are a small glimpse of the countless effects we are having on every organ system, by eating fats that are unfamiliar to our pre-industrial bodies. In the next post, I'll put this information into the context of the modern human diet.
Too busy for your hair?
Three healthy hair habits you need to maintain even when you're swamped
We all go through times when we are so busy, we're lucky if we even get a decent shower in, never mind our hair. The last thing you want is to become so engulfed in your work that you begin to backslide on your hair maintenance. You know what happens if we neglect to give our hair some TLC for even a short period of time, we end up having to make up for the neglect with months of deep conditioning, trimming, and babying just to get back to where we were.
If you want to avoid neglecting your hair when you have little time, just remember these three tips:
1. Nightly Care- I don't care how late you stayed up getting your work done, you still need to commit to spending just a few minutes every night adding a moisturizing product to your hair. Something special happens during the night when your hair gets some time to absorb moisturizer under a silk or satin scarf. By the time morning comes and you are ready to run out of the door, you need'nt have to worry about what condition your hair will be in when you remove the scarf. This habit is a life saver for both you and your hair when you are running short of time.
2. Fabulous Hair Accessories-The very last thing you want to do when you are short on time is try to style your hair. Running a comb through your hair when you are in a hurry is not cool. That's when we end up with broken hairs at our feet. Avoid this action all together by stocking up on fabulous hair clips, pins, headbands and other hair accessories. When your hair is adorned in a fabulous accent, you automatically reduce the amount of combing you have to do. Accessories give a hint of glamour when we are sporting our protective styles. When we know our hair style looks fabulous, we aren't constantly trying to manipulate it. The less we manipulate, the more our hair thrives.
3. A Solid Hair Routine-Most of our hair routines consist of many intricate steps involving various healthy hair potions in order to get our hair just right. The problem with that is we can't always rely on our 20 step hair routine when we have little time. What we need to do instead is to create a basic hair routine that works just as well. The basic routine should include your favorite shampoo, moisturizing, and/or deep conditioner. Don't skimp on beneficial steps such as a pre-poo if it has a positive impact on the health of your hair.
The most important part of the solid hair routine is your styling method. If your hair only looks right when you roller set, then you must make sure that you roller set. You do not want to experience undesirable results only to go back and have to re-wash and style your hair all over again. Worse yet, you do not want to cause more damage by air drying if your hair reacts adversely to this stylig method. When you look for ways to shorten your routine, remember that your goal is to still achieve very similar results.
Now is the time to plan for those occasions when we can't provide as much time to our hair as we would like. Take a look at your routine and figure out the most beneficial steps and products. The ones that contribute the best results. Those are the key actions that you want to keep and improve upon. They are going to be life savers when you have little time.
Take a few minutes and mentally go over your hair routine. Decide which steps can you omit if you had to and which steps absolutely have to happen. By doing this now, you are saving both your time and your hair in the future.
-Here's to the health of your hair.
Full-fat Dairy for Cardiovascular Health
I just saw a paper in the AJCN titled It's a prospective study with a 15-year follow-up period. Here's a quote from the abstract:
There was no consistent and significant association between total dairy intake and total or cause-specific mortality. However, compared with those with the lowest intake of full-fat dairy, participants with the highest intake (median intake 339 g/day) had reduced death due to CVD (HR: 0.31; 95% confidence interval (CI): 0.12–0.79; P for trend = 0.04) after adjustment for calcium intake and other confounders. Intakes of low-fat dairy, specific dairy foods, calcium and vitamin D showed no consistent associations.People who ate the most full-fat dairy had a 69% lower risk of cardiovascular death than those who ate the least. Otherwise stated, people who mostly avoided dairy or consumed low-fat dairy had more than three times the risk of dying of coronary heart disease or stroke than people who ate the most full-fat diary.
Contrary to popular belief, full-fat dairy, including milk, butter and cheese, has never been convincingly linked to cardiovascular disease. In fact, it has rather consistently been linked to a lower risk, What has been linked to cardiovascular disease is milk fat's replacement, high vitamin K2 intake was linked to a lower risk of fatal heart attack, aortic calcification and all-cause mortality. Most of the K2 came from full-fat cheese. In my opinion, artisanal cheese and butter made from pasture-fed milk are the ultimate dairy foods.
From a 2005 on milk and cardiovascular disease in the EJCN:
In total, 10 studies were identified. Their results show a high degree of consistency in the reported risk for heart disease and stroke, all but one study suggesting a relative risk of less than one in subjects with the highest intakes of milk.The fat is where the vitamins A, K2, E and D are. The fat is where the medium-chain triglycerides, and omega-3 fatty acids are. The fat is where the conjugated linoleic acid is. So the next time someone admonishes you to reduce your dairy fat intake, what are you going to tell them??
...the studies, taken together, suggest that milk drinking may be associated with a small but worthwhile reduction in heart disease and stroke risk.
...All the cohort studies in the present review had, however, been set up at times when reduced-fat milks were unavailable, or scarce.
Insiders Hijacking Established Institutions for their Personal Benefit
As we learn more about the causes of the global financial melt-down, aka great recession, the lessons appear more applicable to health care. My latest example comes from last week's Wall Street Journal. There appeared an article by a Professor from the Faculty of Management of McGill University (Montreal, Canada) on executive compensation that has important lessons for health care (Mintzberg H. No more executive bonuses. Wall Street Journal, Nov 30, 2009. )
Prof Mintzberg's first major premise was that current executive compensation at major corporations resembles a rigged casino:
Although these executives like to think of themselves as leaders, when it comes to their pay practices, many of them haven't been demonstrating leadership at all. Instead they've been acting like gamblers—except that the games they play are hopelessly rigged in their favor.
First, they play with other people's money—the stockholders', not to mention the livelihoods of their employees and the sustainability of their institutions.
Second, they collect not when they win so much as when it appears that they are winning—because their company's stock price has gone up and their bonuses have kicked in.
Third, they also collect when they lose—it's called a 'golden parachute.'
Fourth, some even collect just for drawing cards—for example, receiving a special bonus when they have signed a merger, before anyone can know if it will work out. Most mergers don't.
And fifth, on top of all this, there are chief executives who collect merely for not leaving the table. This little trick is called a 'retention bonus' —being paid for staying in the game!
Prof Mintzberg points out that while there is no some recognition that the compensation system needs to be fixed, most proposals would simply tinker with the notion of pay for performance. However, Prof Mintzberg believes that such tinkering is hopeless, because the whole system is based on false assumptions. These are
"• A company's health is represented by its financial measures alone—even better, by just the price of its stock."
However,
Companies are a lot more complicated than that. Their health is significantly represented by what accountants call goodwill, which in its basic sense means a company's intrinsic value beyond its tangible assets: the quality of its brands, its overall reputation in the marketplace, the depth of its culture, the commitment of its people, and so on.
So the elements of true performance are multiple, and extremely hard to measure.
The consequences of making simple financial measures the only metric of performance are severe:
This flawed assumption, though, does far more damage than simply distorting CEO compensation. All too often, financial measures are a convenient substitute used by disconnected executives who don't know what else to do—including how to manage more deeply.
Or worse, such measures encourage abuse from impatient CEOs, who can have a field day cashing in that goodwill by cutting back on maintenance and customer service, 'downsizing' experienced employees while others are left to 'burn out,' trashing valued brands, and so on. Quickly the measured costs are reduced while slowly the institution deteriorates.
"• Performance measures, whether short or long term, represent the true strength of the company."
Prof Mintzer suggested that this has lead to an attempt to subsitute long-term rather than short-term financial measures. However, no one knows how long "long-term" should be.
" • The CEO, with a few other senior executives, is primarily responsible for the company's performance."
This one is especially pernicious
What if the CEO was lucky enough to have been in the right place at the right time? When it comes to a company's current performance, history matters, culture matters, markets matter, even weather can matter. How many chief executives have succeeded simply by maneuvering themselves into favorable situations and then hanging on while taking credit for all the success? In something as complex as the contemporary large corporation, how can success over three or even 10 years possibly be attributed to a single individual? Where is teamwork and all that talk about people being 'our most important asset?'So Prof Mintzberg observed, "if you do pay bonuses, you get the wrong person in ... [the CEO] chair."
More important, should any company even try to attribute success to one person? A robust enterprise is not a collection of 'human resources'; it's a community of human beings. All kinds of people are responsible for its performance. Focusing on a few—indeed, only one, who may have parachuted into the most senior post from the outside—just discourages everyone else in the company. Sometimes, there is the impression that a forceful chief executive has turned around a troubled company. But how sure can we be that such a turnaround will be long-lasting? After all, so many of these supposed corporate resurrections eventually go sour.
Thus,
Executive bonuses provide the perfect tool to screen candidates for the CEO job. Anyone who insists on them should be dismissed out of hand, because he or she has demonstrated an absence of the leadership attitude required for a sustainable enterprise.
In summation, "All this compensation madness is not about markets or talents or incentives, but rather about insiders hijacking established institutions for their personal benefit."
I submit that Prof Mintzberg's essay is as applicable to health care organizations, not only public for-profit health care corporations, but also many of the not-for-profit organizations that have sought to become more businesslike, as it is to any large corporations.
We have discussed numerous examples of ill-informed, self-interested, conflicted and corrupt leaders of health care organizations, most of whom became rich despite, or perhaps because of these attributes.
We have seen examples of many of what Prof Mintzberg lists as examples of outcomes of the bonus culture:
- Short-term results twisted and hyped to enhance the reputation of a "visionary" CEO. (For example, see the cautionary tale of the Allegheny Health Education and Research Foundation.
I would underline one particular point. The perverse incentives generated by the current bonus culture in business have lead to practices antithetical to the long-term prosperity of corporations, including cutting the quality and quantity of the product to cut costs, and firing or over-working employees, including the most experienced and sophisticated ones (outside of the leaders' inner circles). This would be bad for any kind of organization, but in health care can lead to distress, disease, disability, and death.
I again submit that to truly reform health care, we need to reform the current business culture of health care. One primary element of that reformation is refocusing leadership on the health care mission. For not-for-profit health care organizations, the mission must take precedence over making more money. On the other hand, for-profit health care corporations that put short-term revenues (and bonuses paid to top leaders) before the quality of their products and hence their long-term reputations may find themselves, like some US automobile companies, without markets, without profits, and bankrupt.
Steam Deep Conditioning Video
I didn't expect it but I got quite a few comments from my steam pre-poo video. In that video, I parted the hair section by section while in front of my facial steamer. A couple people mentioned that it looked rather labor intensive. While I do agree that doing it section by section does take a lot of time and effort, it also has it's benefits.
Well now it's time to reveal how I used the same facial steamer, along with my hooded dryer, and converted it into a replica of an honest to goodness hair steamer.
You guys might remember another post from the good 'ole days when I tried, desperately to create my own version of a steamer with my caruso kit and a plastic bin. Well those days are no longer because I've now graduated from thıs to this:
The Over-Selling of Seroquel
The anonymous blogger on the Clinical Psychology and Psychiatry blog has been hard at work on the story of how research on Seroquel (quetiapine, by AstraZeneca) was manipulated and oversold. His latest effort is Once again, a major theme is how a "key opinion leader," that is, a prominent medical academic lavishly paid as a consultant or speaker, became overly enthusiastic about his employer's product. Unforunately, academic medicine is now rife with well-paid key opinion leaders. I suspect many may have cause in the future to feel sheepish about their former enthusiasms. Meanwhile, beware marketers in academics' clothing.
The Health Care Bubble: Parallels with the Global Financial Meltdown
The global financial melt-down, or great recession, or whatever it will be called was a big surprise in September, 2008, to those of us not immersed in finance. A year later there is an opportunity to at least better understand the events leading up to it. I have managed to read two focused books on aspects of the melt-down,
Reading the recent history of the meltdown makes me uncomfortably aware of parallels between these events and the current dysfunction of the health care system. In his discussion of the run-up to the crash, Mr Gasparino emphasized a number of issues which I will catalog along with their health care parallels.
Prices Always Go Up
The prices in question were those of real-estate, and the notion that they would always go up helped to fuel would an explosion of mortgage loans made to people who had little chance of fully repaying them. When housing prices reached an unsustainable level and started to fall, the melt-down began.
- It is a cliche that overall health care costs in the US have been going up much faster than inflation for as long as most of us can remember (at least since the 1970s), creating the expectation that they always will go up.
Products were Over-Rated by the Apparent Experts
Mortgages made to people who were unlikely to be able to pay them back were sold by irresponsible originators, and then packaged into financial derivatives by finance firms. Many of these derivatives were rated "AAA" by trusted rating firms, even though they contained multiple individually risky mortages. The rating firms boasted of expertise, and used complex mathematical models supposedly based on evidence to make their ratings.
- In health care, we have come to trust expert professionals' assessments of products (like drugs and devices) and services based on their expertise and clinical research evidence.
Evidence Used to Rate Products was Suspect
The mathematical models used to predict risk were based on limited data and assumptions. In particular, they did not account for the possibility that real-estate prices might go down, or that particular circumstances might cause multiple home-owners to default on their mortgages at the same time. The increasing level of defaults, signaling that the derivatives based on the mortgages might be riskier and less valuable than previously thought, caused the melt-down to accelerate.
The Experts were Conflicted
The rating agencies were paid by the finance firms which sold the derivatives. Ratings agencies that did not deliver sufficiently good ratings were likely to lose business. "By 2005 triple-A ratings were being handed out like candy: underwriters could nearly demand they wanted on a deal and did."
Deceptive Marketing
Per The Sellout, "On Wall Street, complexity isn't something to be avoided - it allows smooth-talking salesmen to obscure simple concepts like risk and losses."
Politicians Pushed Access without Regard to Consequences
US politicians from both parties pushed ever more accessible mortgages for the laudable goal of making better housing available to the less advantaged, but seemed unconcerned about how they would eventually pay back the loans.
- The driving motivation for most current health care reforms efforts in the US seems to be to provide "access," now redefined as some sort of health insurance, without much attention to the reasons health care has become so inaccessible in the first place.
Major Organizations Lead by the Clueless
The Sellout provided some notable vignettes, including those about Jimmy Cayne, the CEO of Bear Stearns, who did not understand the complex derivatives his firm bought and sold, or the level of risk the firm was assuming; Stan O'Neal, the CEO of Merrill Lynch, whose tenure was "one of the strangest, most volatile, and ultimately most disastrous that Wall Street had ever seen;" and Charles Prince, the CEO of Citigroup, who apparently was a good lawyer, but had "little experience running a business," much less one as complex as Citigroup.
Overpaid, Isolated, Arrogant, Imperial CEOs
The Sellout provided more notable vignettes. Jimmy Cayne (see above), was at one point worth more than US $1 billion. He spent more and more time playing bridge, and less managing his company. Stan O'Neal (see above), would often vanish to play golf. The leadership of Richard Fuld, the CEO of Lehman Brothers, "was more like that of a cult leader than even that of an imperial CEO."
- We have repeatedly discussed how large health care organizations' leaders may be overpaid (some making nearly as much as the leaders of some financial firms before the collapse), arrogant some aspiring to be members of the. One striking example was the former CEO of UnitedHealth, Dr William McGuire, who was once worth more than US $1 billion before it became apparent that some of his fortune was based on..
Sycophantic Cronies as "Stewards"
The Sellout discussed how members of the boards of directors of financial firms were mostly chosen by the CEOs they were supposed to supervise. For example, Jimmy Cayne, who had "a firm grip over his board of directors," noting "my board is my board."
- We have often discussed poor CEOs they are supposed to supervise. We also have noted how health care organizations' are often lead by the same Masters of the Universe who brought us the global financial collapse. For example, Cornell's Weill Medical School was named after former Sanford Weill, who constructed the giant conglomerate Citegroup, but did not figure out how to make its pieces fit together, and was forced "to step down as CEO as the research scandal [investigation] initiated by [former New York state Attorney General] Spitzer snared its highest-profile target, Weill himself." (from The Sellout, p. 187.)
Suppression of Dissent
The Sellout noted how increasingly arrogant leaders of financial firms ignored advice of more conservative or risk-adverse employees. Dissenters were often afraid to speak out, and some were fired. For example, at Bear Stearns, Jimmy Cayne increasingly marginalized "Ace" Greenberg, who was wary of excess risk. At Lehman Brothers, the cult of personality that surrounded Fuld suppressed dissent and debate.
Ineffective, or Captured Regulators
From the 1980s onward, deregulation of the financial industry advanced. The Sellout discussed how the Federal Reserve, lead by Allan Greenspan, enabled if not cheer-lead for the bubble. The Securities and Exchange Commission (SEC) was often ineffectual at best.
Summary
We have discussed the impetus to make physicians give up their ostensibly to increase competition , and to then ostensibly to reduce costs. Since the 1980s, health care has increasingly been dominated by large organizations run as businesses by business managers. It should therefore be no surprise that the ethos of health care management has come to resemble the ethos of business management in general. Thus, maybe the parallels between some of the issues related to the global financial meltdown and the issues related to current health care dysfunction should not be surprising.
A few other bloggers and business writers have referred to a health care bubble in the last few years.
So I make a fearless assertion and prediction. Health care dysfunction has lead to a health care bubble, which is likely to burst soon with considerable adverse consequences. Perhaps a controlled deflation of the bubble would be possible, but would require more courage and clear thinking than most of our political and health care leaders have exhibited so far. We have repeatedly noted how current efforts to reform health care have ignored most of the issues discussed above and documented repeatedly on Health Care Renewal. If one of the currently proposed versions of health care reform becomes law, it may postpone for a while the popping of the bubble. However, the longer the bubble grows, the nastier the bursting of it.
Do not say we did not warn you.
Traditional Preparation Methods Improve Grains' Nutritive Value
Soaking or Germinating Grains
The most basic method of preparing grains is prolonged soaking in water, followed by cooking. This combination reduces the level of water-soluble and heat-sensitive toxins and anti-nutrients such as tannins, saponins, digestive enzyme inhibitors and lectins, as well as flatulence factors. It also partially degrades phytic acid, which is a potent inhibitor of mineral absorption, an inhibitor of the digestive enzyme trypsin and anof dental health... This improves the digestibility and nutritional value of grains as well as legumes.
I prefer to soak all grains and legumes for at least 12 hours in a warm location, preferably 24. This includes foods that most people don't soak, such as lentils. Soaking does not reduce phytic acid at all in grains that have been heat-treated, such as oats and kasha (technically not a grain), because they no longer contain the phytic acid-degrading enzyme phytase. Cooking without soaking first also does not have much effect on phytic acid.
The next level of grain preparation is germination. After soaking, rinse the grains twice per day for an additional day or two. This activates the grains' sprouting program and further increases their digestibility and vitamin content. When combined with cooking, it reduces phytic acid, although modestly. Therefore, most of the minerals in sprouted whole grains will continue to be inaccessible. Many raw sprouted grains and legumes are edible, but I wouldn't use them as a staple food because they retain most of their phytic acid as well as some heat-sensitive anti-nutrients
Grinding and Fermenting Grains
Many cultures around the world have independently discovered fermentation as a way to greatly improve the digestibility and nutritive value of grains Typically, grains are soaked, ground, and allowed to sour ferment for times ranging from 12 hours to several days. In some cases, a portion of the bran is removed before or after grinding.
In addition to the reduction in toxins and anti-nutrients afforded by soaking and cooking, grinding and fermentation goes much further. Grinding greatly increases the surface area of the grains and breaks up their cellular structure, releasing enzymes which are important for the transformation to come. Under the right conditions, which are easy to achieve, lactic acid bacteria rapidly acidify the batter. These bacteria are naturally present on grains, but adding a starter makes the process more efficient and reliable.
Due to some quirk of nature, grain phytase is maximally active at a pH of between 4.5 and 5.5, which is mildly acidic. This is why the Weston Price foundation recommends soaking grains in an acidic medium before cooking. The combination of grinding and sour fermentation causes grains to efficiently degrade their own phytic acid (as long as they haven't been heat treated first), making minerals much more available for absorption . This transforms whole grains from a poor source of minerals into a good source.
The degree of phytic acid degradation depends on the starting amount of phytase in the grain. Corn, rice, oats and millet don't contain much phytase activity, so they require either a longer fermentation time, or the addition of high-phytase grains to the batter Whole raw buckwheat, wheat, and particularly rye contain a large amount of phytase although I feel wheat is problematic for other reasons.
As fermentation proceeds, bacteria secrete enzymes that begin digesting the protein, starch and other substances in the batter. Fermentation reduces lectin levels substantially, which are reduced further by cooking Lectins are toxins that can interfere with digestion and may be involved in autoimmune disease, an idea championed by Dr. Loren Cordain. Grain lectins are generally heat-sensitive, but one notable exception is the nasty lectin wheat germ agglutinin (WGA). As its name suggests, WGA is found in wheat germ, and thus is mostly absent in white flour. WGA may have been another reason why DART participants who increased their wheat fiber intake had significantly more heart attacks than those who didn't. I don't know if fermentation degrades WGA.
One of the problems with grains is their poor protein quality. Besides containing a fairly low concentration of protein to begin with, they also don't contain a good balance of essential amino acids. This prevents their efficient use by the body, unless a separate source of certain amino acids is eaten along with them. The main limiting amino acid in grains is lysine. Legumes are rich in lysine, which is why cultures around the world pair them with grains. Bacterial fermentation produces lysine, often increasing its concentration by many fold and making grains nearly a "complete protein", i.e. one that contains the ideal balance of essential amino acids as do animal proteins (scroll down to see graph). Not very many plant foods can make that claim. Fermentation also increases the concentration of the amino acid methionine and certain vitamins.
Another problem with grain protein is it's poorly digested relative to animal protein. This means that a portion of it escapes digestion, leading to a lower nutritive value and a higher risk of allergy due to undigested protein hanging around in the digestive tract. Fermentation followed by cooking increases the digestibility of grain protein, bringing it nearly to the same level as meat...This may relate to the destruction of protease inhibitors (trypsin inhibitors, phytic acid) and the partial pre-digestion of grain proteins by bacteria.
Once you delve into the research on traditional grain preparation methods, you begin to see why grain-eating cultures throughout the world have favored certain techniques. Proper grain processing transforms them from toxic to nutritious, from health-degrading to health-giving. Modern industrial grain processing has largely eschewed these time-honored techniques, replacing them with low-extraction milling, extrusion and quick-rise yeast strains.
Many people will not be willing to go through the trouble of grinding and fermentation to prepare grains. I can sympathize, although if you have the right tools, once you establish a routine it really isn't that much work. It just requires a bit of organization. In fact, it can even be downright convenient. I often keep a bowl of fermented dosa or buckwheat batter in the fridge, ready to make a tasty "pancake" at a moment's notice. In the next post, I'll describe a few recipes from different parts of the world.
Putting a New Schein to the FDA?
When the national discussion seems preoccupied with the bonuses at AIG, the nomination of a new leader of the US Food and Drug Administration did not seem to get the attention it may have deserved. Last week, the president nominated Dr Margaret Hamburg to this position.
President Obama has decided to nominate former New York City Health Commissioner Margaret Hamburg to head the Food and Drug Administration, turning to a onetime Clinton administration official to help right the beleaguered regulatory agency, a source briefed on the choice said Wednesday.
Hamburg, 53, a physician who has worked extensively on bioterrorism issues, is a senior scientist at the Nuclear Threat Initiative, a Washington-based foundation focused on threats from nuclear, biological and chemical weapons.
Though less experienced as a regulator, Hamburg has extensive government experience. She served as health commissioner in New York for six years in the 1990s before becoming assistant secretary for planning and evaluation at the Department of Health and Human Services in 1997.
Tucked away at the end of the LA Times story, and not emphasized in other news articles, was a salient fact:
She sits on the board of medical supply distributor Henry Schein Inc., but would have to surrender the position if confirmed by the Senate.
Many now believe the FDA is in crisis, having failed to protect the people from unduly hazardous drugs and devices, and becoming too cozy with drug and device companies, which it may not regard, instead of the population as a whole, as the agencie's clients. Would Dr Hamburg's current position with Henry Schein Inc, however, jeopardize her ability to restore peoples' trust that the agency will put their interests, rather than those of health care corporations first?
is a large distributor of health care supplies, including drugs and devices. For an example of its very extensive catalog, Henry Schein makes its profits by selling the products that the FDA regulates, particularly drugs and devices. In her role as director of Henry Schein, Dr Hamburg had a legal responsibility to enhance the finances and profits of the company and its stockholders. As we have many times previously, a corporate director has a legal obligation to advance the profits and financial fortunes of the corporation he or she serves. As Robert AG Monks put it, corporate directors are supposed to "demonstrate unyielding loyalty to the company's shareholders" [Per Monks RAG, Minow N. 3rd edition. Malden, MA: Blackwell Publishing, 2004. P.200.]
As compensation for that loyalty, corporate directors are usually exceedingly well-paid for the nominal hours they spend in their meetings.So, according to the company's Dr Hamburg owned the equivalent of 63,472 shares of stock (current value, at the price of $37.32,, $ 2,368,775.04). Her total compensation in 2007 for her position as director was $249,151.)
Given that Dr Hamburg has spent over five years living with the obligation for unyielding loyalty to the interests of Henry Schein, and has become what many people would consider rich in the process, how easy will it be for her to turn to becoming a strict regulator of the products her former company used to sell? Time will tell. But this is the to a major health care post charged with improving the health of all citizens that has gone to someone currently obligated to protect the interests of corporations that now profiting from today's health care milieu. Let us see if this will lead to the change we need in health care.
Going Green for the health of your hair
There's lots of talk nowadays about going green. Well I'm here to talk about how we could be friendly to our hair by going green. Specifically, green superfoods and how they can take our health, and our hair to the next level.
I ceased from eating red meat and chicken about a year and a half ago. As I started researching the nutritional impacts to my decision, I stumbled upon a wonderful world of green supplements that I had never before heard of. These superfoods came in the form of blue-green algae. The more I researched the health benefits the more excited I got about the overall possible improvement to my hair. I even found this fantastic video on youtube that went into detail about the nourishing qualities of the green foods.
This food product has been called the world's healthiest food. I was attracted by the fact that spirulina, pound for pound, contains more protein that meat. It even contains high amount of valuable B vitamins one does not normally find in plant foods.
Lets talk about some of the benefits:
*Spirulina contains 10 times the concentration of beta carotene of carrots.
*Spirulina is the highest protein food without the negative effects of cholesterol.
*Spirulina contains essential fatty acids and amino acids.
*Spirulina contains phytonutrients for optimal health.
Spirulina's close relative is chlorella. Chlorella contains all of the wonderful nutritional properties of spirulina along with an added property that helps to detoxify the body. I can usually find Spirulina in powder form but for some reason, I usually tend to find Chlorella in tablets. I keep both the spirulina powder and chlorella tablets around. The powder for when I have time to make delicious smoothies in the morning. The pills for when I have to rush out the door.
Sometime last year I was able to cultivate the habit of drinking a green smoothie every morning. The smoothie was a combination of:
1 Banana
2 Vanilla Soy Milk
3 Spirulina
4 Powdered fiber
It was a fairly simple and truly delicious drink. The spirulina will make everything turn green but don't be fooled, you will not likely taste it. The only time I can remember actually tasting the stuff was when I got adventurous and mixed the powder with plain water. That was before I knew how easily I could mask the taste with just a banana and some soy milk.
At one point in time I was faithfully making my morning smoothie daily. My wavy new growth was proof that my hair follicles were being nourished by the superfood. The new hair was unlike anything that every grew out of my head before. It made stretching a snap. I fell off the daily smoothie bandwagon when my mixer malfunctioned. But I know that now is the time to get back to my routine! Since going without a blender for so long I have found alternative ways to enjoy my spirulina powder.
*I mix with my Yoplait yogurt
*I add to my Bolthouse farm juices.
Next I will try mixing into plain fruit juices to see how it goes. These alternative ways of consuming will keep me from making excuses when I don't feel like peeling a banana. I can no longer make excuses for not consuming this incredible product every single day.
So join me, won't you, in helping to make our world a better place. A better place by going green and creating a head of healthy hair. The planet will thank you.
The Malpractices of the Multitudes: the HIT Mission Hostile User Experience, Part 8
More on the origin of this post's title, penned in 1836, below.
This post is part 8, and the finale, of a series on the stunningly poor human engineering of production healthcare IT from major vendors, in use today at major medical centers. These devices provide a decidedly mission hostile user experience, yet with an almost religious fervor are being touted as cybernetic miracles to cure healthcare's ills.
My college is a member of the consortium, consisting of schools of information science and technology (notably, not "information technology and science").
The iSchools are interested in the relationship between information, people and technology. This is characterized by a commitment to learning and understanding the role of information in human endeavors. The iSchools take it as given that expertise in all forms of information is required for progress in science, business, education, and culture. This expertise must include understanding of the uses and users of information, as well as information technologies and their applications.
Note the "as well as." Note the primary focus, and that which is secondary. This philosophy parallels that of Medical Informatics well.
This probably sounds like Martian to many in the healthcare and perhaps the broader business IT sector.
One of my colleagues on reviewing this HIT series had this to say:
It's really nice to hear that for once IT professionals have been able to successfully repeat the development lifecycle for healthcare information systems:
- Fail to understand the problem ->
- create a fragmentary and inaccurate requirements definition ->
- design an ambiguous, ignorant and risk-laden user interface ->
- pull all the misguided notions together with baling wire and call it a design->
- translate the "design" into an executable form, adding and subtracting design elements at random ->
- observe the first output from the system and declare it ready for the healthcare professionals. fini
Did I miss anything?
I believe he captured the essense of today's HIT vendor market well.
Here are examples of screen displays of vital patient information, displays that force clinicians to go on wild goose chases and seem designed by true neophytes to the field of information presentation and user interaction design. This is not to single out any one vendor. Many vendor products have deficiencies.
See this display of something as simple (one would think) as blood pressures:
(click to enlarge)Note the following:
- Diastolic blood pressures in the left column;
- Systolic blood pressures in the roight column;
- An adventure to match them by date;
- No column headers at top.
Which value goes with which? How much energy does it use up to scroll around and connect the two?
This display is so poorly conceived, one wonders why it was included at all in a production system.
There's more. Let's troll for data, shall we?
See the blood oxygen saturation level, circled?
(click to enlarge)What percentage oxygen was this patient receiving?
It's not there! Where is it?
Scroll down ...
(click to enlarge)... and down ...
(click to enlarge)Our answer, at last! Circled. Of course, the corresponding pulse oximetry is now off the screen.
How much attention would it have taken to present the two together?
How much coding would it have taken with today's computers, that execute billions of instructions per second, to dynamically condense the presentation of information, eliminating the absolutely empty cells between the two values?
Similar isses are noted for other biomedically coupled values, such as coumadin dose and blood thinning value (INR).
Screw matching those up, and as my mentor Victor P. Satinsky, MD might have said, your patient's dead.
Speaking about information sparsity, how's this display?
(click to enlarge)The EHR disperses and fragments vital patient information. How, exactly, is this is supposed to make clinicians more efficient and less error prone?
I am only presenting the easiest to present problems, easiest that is in a static medium such as a blog.
If presented dynamically, we find with some EHR's, for example, that it takes 50 or so mouse clicks across various screens and drop down lists and drop boxes to enter 5 common diagnoses.
It takes selecting from multiple hierarchical lists and buttons across four different screens, multiple times repetitively, to find out how well a patient is eating.
Here is simple advice from J Gen Intern Med 2009; 24(1):21-26.
It is imperative that usability principles are embedded in CPOE design to avoid
• overly complex screens
• poor grouping of like terms
• an inflexible human-computer interface
• mis-use of clinician time
Do the HIT vendors actually read such advice?
I wonder.
Medical Informatics reminds me of dentistry in its early days. B.T. Longbothom, author of the second dentistry book published in the U.S. ("A Treatise on Dentistry", 1802), gave an excellent description in his preface of problems at the time. His observations apply to Medical Informatics in our present age:
The word "dentist" has been so infamously abused by ignorant pretenders, and is in general so indifferently understood, that I cannot forbear giving what I conceive to be its original meaning: viz, the profession of one who undertakes and is capable not only of cleaning, extracting, replacing by transplantation and making artificial teeth, but can also from his knowledge of dentistry, preserve those that remain in good condition, prevent in a very great degree, those that are loose, or those that are in a decayed state, from being further injured, and can guard against the several diseases, to which the teeth, gums and mouth are liable, a knowledge none but those regularly instructed, and who have had a long, and extensive practice, can possibly attain, but which is absolutely necessary, to complete the character of a Surgeon Dentist.
Hardly anyone spoke out.
More than thirty years later, untrained practitioners were as prevalent as ever. One of the leading dentists of the time, Shearjashub Spooner, in his "Guide to Sound Teeth, or, A Popular Treatise on the Teeth" (1836) warned the public of a phenomenon I believe now applies to Medical Informatics and healthcare IT:
One thing is certain, this profession must either rise or sink. If means are not taken to suppress and discountenance the malpractices of the multitude of incompetent persons, who are pressing into it, merely for the sake of its emoluments, it must sink, - for the few competent and well educated men, who are now upholding it, will abandon a disreputable profession, in a country of enterprise like ours, and turn their attention to some other calling more congenial to the feelings of honorable and enlightened men.
I understand that point of view.
And with that, I end this series.
Polyunsaturated Fat Intake: What About Humans?
Now we know how to raise a healthy pig or rat: balance omega-6 linoleic acid (LA) and omega-3 alpha-linolenic acid (LNA) and keep both relatively low. LA and LNA are the most basic (and shortest) forms of omega-6 and omega-3 fats. They are the only fats the body can't make on its own. They're found in plant foods, and animal foods to a lesser extent. Animals convert them to longer-chain fats like arachidonic acid (AA; omega-6), EPA (omega-3) and DHA (omega-3). These long-chain, animal PUFA are involved in a dizzying array of cellular processes. They participate directly as well as being further elongated to form a large class of very influential signaling molecules.
Since Viti Levu, one of the islands of this group, is one of the larger islands of the Pacific Ocean, I had hoped to find on it a district far enough from the sea to make it necessary for the natives to have lived entirely on land foods. Accordingly, with the assistance of the government officials and by using a recently opened government road I was able to get well into the interior of the island by motor vehicle, and from this point to proceed farther inland on foot with two guides. I was not able, however, to get beyond the piles of sea shells which had been carried into the interior. My guide told me that it had always been essential, as it is today, for the people of the interior to obtain some food from the sea, and that even during the times of most bitter warfare between the inland or hill tribes and the coast tribes, those of the interior would bring down during the night choice plant foods from the mountain areas and place them in caches and return the following night and obtain the sea foods that had been placed in those depositories by the shore tribes. The individuals who carried these foods were never molested, not even during active warfare. He told me further that they require food from the sea at least every three months, even to this day. This was a matter of keen interest, and at the same time disappointment since one of the purposes of the expedition to the South Seas was to find, if possible, plants or fruits which together, without the use of animal products, were capable of providing all of the requirements of the body for growth and for maintenance of good health and a high state of physical efficiency.
I believe the most critical element is reducing omega-6 LA by eliminating industrial vegetable oils (soybean, corn, cottonseed, etc.) and the foods that contain them from the diet. Fats from pasture-raised ruminants (butter, beef, lamb etc.) and wild fish are naturally balanced. We no longer commonly eat the most concentrated land source of DHA, brain, so I think it's wise to eat seafood sometimes. According to the first study I cited, 1/4 teaspoon of fish oil (or cod liver oil) per day is enough to elevate plasma DHA quite significantly. This amount of omega-3 could be obtained by eating seafood weekly.
The Diet-Heart Hypothesis: Subdividing Lipoproteins
Two posts ago, we made the rounds of the commonly measured blood lipids (total cholesterol, LDL, HDL, triglycerides) and how they associate with cardiac risk. It's important to keep in mind that many things associate with cardiac risk, not just blood lipids. For example, men with low serum vitamin D are at a of heart attack than men with higher D levels. That alone is roughly equivalent to the predictive power of the blood lipids you get measured at the doctor's office. Coronary calcium scans (a measure of blood vessel calcification) also better than the most commonly measured blood lipids.
Lipoproteins Can be Subdivided into Several Subcategories
In the continual search for better measures of cardiac risk, researchers in the 1980s decided to break down lipoprotein particles into sub-categories. One of these researchers is Dr. Ronald M. Krauss. Krauss published extensively on the association between lipoprotein size and cardiac risk, eventually concluding
The plasma lipoprotein profile accompanying a preponderance of small, dense LDL particles (specifically LDL-III) is associated with up to a threefold increase in the susceptibility of developing [coronary artery disease]. This has been demonstrated in case-control studies of myocardial infarction and angiographically documented coronary disease.Krauss found that small, dense LDL (sdLDL) doesn't travel alone: it typically comes along with low HDL and high triglycerides*. He called this combination of factors "lipoprotein pattern B"; its opposite is "lipoprotein pattern A": large, buoyant LDL, high HDL and low triglycerides. Incidentally, low HDL and high triglycerides are hallmarks of the, the quintessential modern metabolic disorder.
Krauss and his colleagues went on to hypothesize that sdLDL promotes atherosclerosis because of its ability to penetrate the artery wall more easily than large LDL. He and others subsequently showed that sdLDL are also more prone to oxidation than large LDL
Diet Affects LDL Subcategories
The next step in Krauss's research was to see how diet affects lipoprotein patterns. In 1994, he published a comparing the effects of a low-fat (24%), high-carbohydrate (56%) diet to a "high-fat" (46%), "low-carbohydrate" (34%) diet on lipoprotein patterns. The high-fat diet also happened to be high in saturated fat-- 18% of calories. He found that
Out of the 87 men with pattern A on the high-fat diet, 36 converted to pattern B on the low-fat diet... Taken together, these results indicate that in the majority of men, the reduction in LDL cholesterol seen on a low-fat, high-carbohydrate diet is mainly because of a shift from larger, more cholesterol-enriched LDL to smaller, cholesterol-depleted LDL [sdLDL].In other words, in the majority of people, high-carbohydrate diets lower LDL cholesterol not by decreasing LDL particle count (which might be good), but by decreasing LDL size and increasing sdLDL (probably not good). This has been shown repeatedly, including with a However, in people who already exhibit pattern B, reducing fat does reduce LDL particle number. Keep in mind that the majority of carbohydrate in modern America comes from wheat and sugar.
Krauss then specifically explored the effect of saturated fat on LDL size. He re-analyzed the data from the study above, and found that:
In summary, the present study showed that changes in dietary saturated fat are associated with changes in LDL subclasses in healthy men. An increase in saturated fat, and in particular, myristic acid [as well as palmitic acid], was associated with increases in larger LDL particles (and decreases in smaller LDL particles). LDL particle diameter and peak flotation rate [density] were also positively associated with saturated fat, indicating shifts in LDL-particle distribution toward larger, cholesterol-enriched LDL.Participants who ate the most saturated fat had the largest LDL, and vice versa. Kudos to Dr. Krauss for publishing these provocative data. It's not an isolated finding. He in 1994 that:
Cross-sectional population analyses have suggested an association between reduced LDL particle size and relatively reduced dietary animal-fat intake, and increased consumption of carbohydrates.Diet Affects HDL Subcategories
Krauss also tested the effect of his dietary intervention on HDL. Several studies have found that the largest HDL particles, HDL2b, with HDL's protective effects (more HDL2b = fewer heart attacks). Compared to the diet high in total fat and saturated fat,
The results indicate that dietary changes suggested to be prudent for a large segment of the population will primarily affect [i.e., reduce] the concentrations of the most prominent antiatherogenic [anti-heart attack] HDL subpopulation.
Wrapping it Up
Contrary to the simplistic idea that saturated fat increases LDL and thus cardiac risk, total fat and saturated fat have a complex influence on blood lipids, the net effect of which is unclear, but is associated with a lower risk of heart attacks. These blood lipid changes persist for at least one year, so they may represent a long-term effect. It's important to remember that the primary sources of carbohydrate in the modern Western diet are wheat and sugar. Are the blood lipid patterns that associate with heart attack risk in Western countries partially acting as markers of wheat and sugar intake?
* This is why you may read that small, dense LDL is not an "independent predictor" of heart attack risk. Since it travels along with a particular pattern of HDL and triglycerides, in most studies it does not give information on cardiac risk beyond what you can get by measuring other lipoproteins.