Archive for the 'Public Health' category

Guest Post: The brightest and the most insightful people in the country?

Mar 08 2014 Published by under Academics, Careerism, NIH, NIH Careerism, Public Health

bluebirdhappinessThis is a guest appearance of the bluebird of Twitter happiness known as My T Chondria. I am almost positive the bird does some sort of science at some sort of US institution of scientific research. The bird is normally exhausted by typing messages 140 characters at a time so I was skeptical but....well, see for yourself.


MDs and PhDs are considered to be some of the brightest and the most insightful people in the country. Indeed, look no further than the nearest MD or PhD and ask them; they will attest at great length to their exceptional smarts and individual importance in maintaining the sun orbiting the Earth. Yet for all the combined education there remains a fundamental lack of appreciation of how intertwined the fate of these two professions are - ranking right up there on the irony scale with Pakistan threatening to nuke India (they are geographic neighbors, so that’s ironic, you see).

For anyone who has ever worked at a major academic medical center, we are told ad nausea how important we are in understanding human health. Yet we do so almost exclusively in parallel universes. Asked what its like to try to work with an MD, a PhD will often tell you MDs are ‘erratic, ill informed and totally lacking in any understanding of what goes into doing real research’. Conversely, asked what PhDs do, MDs will likely reply ‘they like to present very complex diagrams, write grants and develop models of disease and pathology that have little to do with any case I’ve ever seen.

I get to surf between these groups; my primary appointment in a clinical department affords me a perspective that is unique in that I am able to pass as either an MD or a PhD on any given day. I spend the majority of my time running a research lab but I can scream “House! Put down the scalpel you jackass! All you have to do is order a chest x-ray and look for pulmonary infiltrates to know it’s not sarcoidosis!” with the best of interns.

Figure 1. “It’s a fan!” “It's a spear!” The hilarity of people in white coats looking at their own little microcosm of an elephant and being unable to appreciate it is actually a bloated endangered species that could kill them all. And by bloated endangered species, I mean academic medicine*.  *Author note: Am I going to have to explain all my jokes?

Figure 1. “It’s a fan!” “It's a spear!” The hilarity of people in white coats looking at their own little microcosm of an elephant and being unable to appreciate it is actually a bloated endangered species that could kill them all. And by bloated endangered species, I mean academic medicine*.
*Author note: Am I going to have to explain all my jokes?

In drifting between these lands, I noticed the rifts earlier between ‘researchers and doctors’ which seemed vaguely amusing not so much now as first but as the business of academic medical is getting the shitte kicked out of it and PhDs think it has little to do with them.

In previous faculty meetings, I would watch tenure track PhDs glaze over as our beloved leader discussed the ‘blah, blah’ of clinical revenue streams.

Conversely, the MDs would eagerly reengage a new level of Candy Crush Saga as our chair commiserated with PhDs about pay lines and sequestration. (So clueless were the MDs about the recent plight of scientists that the esteemed journal JAMA even had to run an article in their online edition earlier in the year explaining sequestration to the primarily MD audience.)

At our most recent faculty meeting, there seemed to be a moment of real illumination between both groups that everyone in the medical center was screwed and better start making more widgets faster. Our Fearless Leader informed faculty that our hospital budget shortfall was progressing more quickly than we had anticipated even three months ago and vacations were canceled for faculty, more clinical hours were going to need to be booked and the bergermeister was coming to take all our toys (only two of these three have happened so far).

Figure 2. Predoctoral kitten downed by lack of understand of the health care industry on academic medicine.

Figure 2. Predoctoral kitten downed by lack of understand of the health care industry on academic medicine.

Later that day, I took to on Twitter to vent and look for pictures of kittens doing cute things (see Fig 2 as evidence of my hard work). Many of my Twitter followers are porn bots, but at least 2 or 3 are PhD-types and aghast that my medical center was being so aggressive. There were many sad emoji’s sent my way and a flutter of ‘how could they’ and ‘oh, your poor little university’ that made me wonder what planet everyone is on and if donuts were as delicious there as they were here (see Storify by @mrhansaker here).

EVERY medical center in the US is getting carpet bombed into financial oblivion by the economy, Medicare reimbursements and Obamacare. And yes, I assured my Tweeps, the amount of our gross national product that goes to health care is stoopidly high. But, a startling number of my PhD buddies were taken aback by the idea that those pesky ‘high health are cost’ they glaze over in faculty meeting or when listening to NPR is also covering their academic PhD arses.

So, for my PhD pals, whom I shall refer to as ‘People who are doctors only when they book hotel rooms’ (I’m kidding, I’m a kidder!), I wanted to run this down a bit further. If you have a medical center as part of your university, you have been riding clinician’s financial coat tails for a long friggin time. The indirect rate charged to granting organizations in no way covers operating costs for research. That takes an endowment or an additional revenue stream. Endowments usually come from long dead old rich doods. These endowments don't just sit in Scrooge McDucks cave. They get invested in things like the stock market. And the stock market got the shitte kicked out of not too long ago. Billions in endowment money were lost in the economic collapse - most Universities took 25-50% hits on their Scrooge McDuck funds. So, if you’re a PhD, you can take endowments out of the equation as what’s been filling in those pesky financial gaps between costs and expenses. No worries, you’re at a medical center so you have a revenue stream- your clinical enterprise. Sick people. America is ALWAYS good for some damn unhealthy and foolish folks who will make the worst choices possible and rack up a small fortune in insured and uninsured care.

Thank God for stoopid and unhealthy people, amirite?? This is even better because our Commander-in-Chief got an electoral mandate to insure everyone’s (ish) stoopid arse. More money for medical centers has got to be a win, yes? Not so much. Show me a medical center meeting its financial goals, hell even one that isn’t heading for a hundreds of millions of dollars of deficit for 2014, and I will show you a for profit medical center (read here: “not academic, so no jobs for you PhDs”).

The proverbial sky has been falling for research scientists for some time now as well documented by my kind host Drug Monkey and others with inferior blogs and better shoes. And indeed, MDs have been hounded into appreciating the genius that is the bench scientist. So valued are the basic researchers that they are sought after to heap more prestige on the medical center and an even better training environment which increases numbers of trainees, blah, blah.
Unlike clinicians, scientists have known the economic sky was falling for some time and have been zealously advocating the importance of science research bracing for impact. To the outside world, that looks a lot like holding your collective sphincters together as tightly as humanly possible and waiting for things to improve. Well-done people. Actually, you sort of sucked at advocating for yourselves as evidenced by the two of you who actually sent @nparmalee letters to hand deliver to your Congress Critters a few weeks ago, but I will need another bottle of wine for that.

The first warning to those PhD types in the 35+-age bracket would have been when Scamp-in-Chief Bill Clinton never quite delivered on his ‘peace dividend’. The one where all those pesky defense dollars would go to building a bigger, better, smarter American work force with futures in STEM (Dumber Bombs! Smarter People!). We would turn in our tanks and churn out better-educated versions of ourselves with outstanding oral hygiene to lead us forth into the new millennium free of disease and with cats with laser vision. Not only did we forget to provide sustainable growth mechanisms for STEM, we also neglected to maintain world peace and not screw the interns. Bill, you lovable rascal, at least you didn’t shoot anyone in the face. Just in the foot. Or both feet.

Metaphorically.

In the parallel world of MDs, who kindly request you simply refer to them as ‘real doctors’ for the rest of this diatribe, the pesky business of health care in academia has always been a house of cards. About 7% of MDs practice in the rare air that is academic medicine. This affords prestige, time for clinical research, collegiality, security and none of the business hassles of private practice, but about half the salary. Which, to be honest, is still a metric shitte ton of money especially if you do a bit of consulting. But now, there’s no research time, Medicaid is squeezing out every reimbursable dime and you are keeping the same hours as your hapless residents.

My take home from today friends is that the party seems to be winding down. Rather than recognizing that our fates are intertwined, MDs and PhDs frantically see more patients and write more grants and wonder when the sun will shine on us once again and society will appreciate our true worth. I have yet to see any evidence that for all the brain power and letters after peoples names, PhDs are even aware of that medicine money is research money. So you go put your blinders on and find that spear, and I’ll put mine on and grab this rope and no one will call it an elephant.

34 responses so far

FDA shuts down 23andMe

Nov 25 2013 Published by under Public Health

Wow!

The Food and Drug Administration has ordered DNA testing company 23andMe to stop marketing its over-the-counter genetic test, saying it’s being sold illegally to diagnose diseases, and with no proof it actually works.

I did not see this coming at all. Guess I was too focused on thinking about informed consent issues.

39 responses so far

Repost: Musty Must-Read: "Mrs. Winslow's Soothing Syrup"

I originally posted this Jan 09, 2008 on the old blog and reposted it 12/12/2008 with small improvements over the prior version. It has been one of my more popular posts when it comes to Google hits. You might want to check out a personal recipe for opiate based cough remedy as well.


The US Food and Drug Administration (FDA) began sending warning letters to sellers of so called "bio-identical hormone replacement therapy" today according to an AP report. Apparently the claims for alleviating menopausal symptoms are

not supported by medical evidence and are considered false and misleading.

Needless to say, these "compounded" products are being sold without FDA approval. It's all a conspiracy man! Dang FDA is a tool of BigPharma trying to keep cheap and effective remedies from the public. Noted tool of TheMan(BigPharmaDivision) Abel Pharmboy has a recent post in which he touches on "cosmeceutical" marketing of drugs and the FDA's authority to regulate cosmetics under

their regulatory authority is in part ordered by the Federal Food, Drug, and Cosmetic Act of 1938 (and subsequent legislation).

soothingsyrup.jpg
source
This reminds me of the glory days of the quack remedy / patent medicine era and today, from the mouldering archives, we take up a Case Report published by A. B. Hirsch, M.D. ["Mrs. Winslow's Soothing Syrup. American Medical Journal, 1884, 12(11):504-506] which is available from Google Books here. A footnote indicates that this Abstract was read before the Philadelphia County Medical Society on Sept 17, 1884. Ahh, Mrs. Winslow's . Used for over 60 years by mothers for their teething children.

Continue Reading »

One response so far

The Obama Administration's 2013 National Drug Control Strategy

Apr 24 2013 Published by under General Politics, Public Health

The ONDCP has been twittering up a storm about the release of the latest National Drug Control Strategy document [ PDF ].

The website touts five bullet points:

  • Prevent drug use before it ever begins through education
  • Expand access to treatment for Americans struggling with addiction
  • Reform our criminal justice system
  • Support Americans in recovery

Whether you think the Obama ONDCP has changed quickly enough for your liking or not, there has clearly been a change in the rhetoric compared with past...all the way back to the Reagan ONDCP. Rhetoric such as this....

While law enforcement will always play a vital role in protecting our communities from drug-related crime and violence, we simply cannot incarcerate our way out of the drug problem. Put simply, an enforcement-centric “war on drugs” approach to drug policy is counterproductive, inefficient, and costly. At the other extreme, drug legalization also runs counter to a public health and safety approach to drug policy. The more Americans use drugs, the higher the health, safety, productivity, and criminal justice costs we all have to bear.

...differs very clearly from the prior ONDCP approaches. Even McCaffrey, as conversant as he was with the science*, still leaned heavily toward the punitive side.

Naturally, I am best pleased that they have a section entitled "The Science":

Throughout much of the last century, scientists studying drug abuse labored in the shadows of powerful myths and misconceptions about the nature of addiction. When science began to study addictive behavior in the 1930s, people addicted to drugs were thought to be morally flawed and lacking in willpower. Those views shaped society's responses to drug abuse, treating it as a moral failing rather than a health problem, which led to an emphasis on punitive rather than preventative and therapeutic responses.

And I would say that we still labor under a great deal of resistance, even though the hard edges may have morphed. We hear people trying to parse "only psychological" addiction from "physiological" addiction...what is this if not more of the "moral failing" argument? We also have attempts to define some substances (and non-substance reinforcers) as being out of consideration for genuine addiction.....again, a similar discounting of the science related to addiction. If you grasp the fact that addictions are disruptions of reward pathways, and that there are a limited set of final-common-mechanisms for reward in the brain then it is no surprise that anything which trips the reward triggers has the potential to cause disruption.

Today, thanks to significant advances in neuroscience, our Nation's responses to drug abuse have begun to change. Groundbreaking discoveries about the brain have revolutionized our understanding of drug addiction, enabling us to respond more effectively to the problem.

Science demonstrates that addiction is a disease of the brain—a disease that can be prevented and treated, and from which people can recover.

Well yes...buuuuuut. Our ability to prevent and treat still has a long way to go. And this, I recognize fully, contributes to public misunderstanding. After all, if it is a disease, surely we must have very specific and mechanistically coherent treatments, right? We don't, for the most part, and so skepticism over the assertion of "a disease of the brain" will continue.

__
*He was the first Drug Czar I heard address a scientific audience. He was impressive. They guy that came after him during the Bush administration was...not.

3 responses so far

Pondering the Pitbulldenialista

Fascinating.

The dog botherers always insist the dog attacks are due to "bad owners". And that presumptively "good owners" will never have a dog that attacks or kills anyone.

We'll leave aside their denialism about their own doggy's noninjurious but threatening behavior and the inherent circularity of their argument for now.

The interesting point is what it takes to be a "good" owner. You have to train and "socialize" the dog. Control it. Keep it in the right circumstances. Train toddlers how to "approach it properly". Leash it. Lock the gate. Etc. never let down your vigilance for one little second.

What is all of this but a frank admission that these alleged domesticated animals are INHERENTLY dangerous to other citizens? If they weren't, the only problem would be "bad owners" who actively train the dog to aggress.

49 responses so far

R.I.P. C. Everett Koop

Feb 25 2013 Published by under Public Health

via Wikipedia

For those of us of a certain age, Dr. C. Everett Koop will always be the iconic Surgeon General of the United States of America.

For me, the reasons that he was also a great Surgeon General is summed up in these few lines in the ABC News item on Koop's passing.

Koop carried out a crusade to end smoking in the United States; his goal had been to do so by 2000. He said cigarettes were as addictive as heroin and cocaine. And he shocked his conservative supporters when he endorsed condoms and sex education to stop the spread of AIDS.

These were both very, very important things for the nation's top health official to do at the time. Especially when the President himself couldn't bear to say "AIDS" in public and many people still believed that smoking was just a 'habit', that low-tar and filtered cigarettes were safer and that the link to cancer had never been "scientifically proven" anyway.

RIP Dr. Koop

8 responses so far

Go Team!!!!!

Feb 03 2013 Published by under Neuroscience, Psychology, Public Health

I've decided I am rooting for neuronal survival during the NFL SuperBowl today.

Go #teamneuron!

5 responses so far

Antivaccaloon learns lesson the hard-ish way; luckily kid survives

Via the New Zealand Herald:

A boy who almost died of tetanus before Christmas is home and on the mend, but his parents are desperate for others to vaccinate their children after they did not.

Auckland couple Ian and Linda Williams thought they had made an informed decision against immunising their three children because of concerns over adverse reactions.

But they regretted their decision when middle child Alijah contracted the potentially fatal disease just before Christmas, and was put in an induced coma on life support at Starship hospital.

They immediately immunised their other children and wrote to Alijah's school to warn parents who had not vaccinated against the disease and others such as whooping cough.

"It was me that put my son in this situation," Mr Williams said.

Yes, yes it was. Don't let it be you who does the same, people. Vaccinate, vaccinate, vaccinate.

h/t: bengoldacre

5 responses so far

First Aid for Mental Health

Dec 15 2012 Published by under Psychology, Public Health

Almost by definition there is something wrong with the mental health of mass shooters like the Aurora cinema guy, the Sikh Temple shooter and the one who just killed 20 elementary school children, 6 staff members, his own mother and ultimately himself.

In parallel with the calls for better gun control in the US we experience calls for improved health care for the brain. But the failing is not the provision of care so much as it is the detection of mental health problems that might lead to mass shootings.

We will never get to a one to one prediction of who is about to become the next news cycle. But then, we don't know who will heal eventually from a given infection, who will recover from stroke without a given intervention...or who will get heart attack save for the cholesterol meds, statins and what not.

So we go with the odds.

And we detect problems with broad screening (annual checkups), acute responses (minor cardiac event perhaps)...and crowdsourcing.

If someone were bleeding in front of you, chances are decent that you would know whether to get a bandaid (even a 5 year old knows to add the antibiotic cream) or stick a finger on the vein while yelling for help. In a crowd? Someone would know CPR if a person stops breathing...in a pinch you'd have a go based only on what you remember from teevee shows.

What about when someone shows signs of a mental health problem? How does the crowd and pre-FirstResponse do with those situations?

I have only recently been made aware of Mental Health First Aid.

It intrigues me.

28 responses so far

Should NIMH be funding Me-Too drug development?

Hard on the heels of something I just learned about at a recent conference, the NIMH issued a Press Release for a new clinical trial they funded.

A drug that works through the same brain mechanism as the fast-acting antidepressant ketamine briefly improved treatment-resistant patients’ depression symptoms in minutes, with minimal untoward side effects, in a clinical trial conducted by the National Institutes of Health. The experimental agent, called AZD6765, acts through the brain’s glutamate chemical messenger system.

Interesting. The background is that prior studies* have shown that the dissociative anesthetic ketamine is capable of the rapid (within hours) amelioration of depressive symptoms. Yes, ketamine. The recreational drug known as Special K and the veterinary anesthetic they've used on your pet cat or dog. Same ketamine that is approved for human use in pediatric anesthesia, emergency medicine in some cases and for tricky clinical situations.

The same ketamine that has been widely used for decades in humans and nonhuman animals. It has established efficacy, mechanism of action and a huge therapeutic index. A big distance between effective doses and the dose that will kill you. Whether effect is recreational, medical or veterinary. Meaning it is safe.

So why are the studies (cited below*) of effect in depression so exciting? Because traditional drug therapy for depression takes weeks to have effect. Weeks of daily dosing. Selective Serotonin Reuptake Inhibitors (SSRIs) like Prozac are broadly familiar to most of my Readers, I would assume. Efficacy with these front-line meds takes up to three weeks to see effect on depressive symptoms. Trouble is, some cases of depression are acutely suicidal--they may just kill themselves before any SSRI has a chance to make them feel better. And hell, who wants to wait three weeks if another med could make you feel better by tomorrow? Prior to the ketamine work, the only other thing that seemed to have such a rapid effect was ECT. Yeah, ElectroConvulsive Therapy. Which has come a loooooong way from the One Flew Over the Cuckoo's Nest era....but still. A single ketamine dosing seems quite preferable.

So.....on to the me-too drug development! Woot!
Zarate CA Jr, Mathews D, Ibrahim L, Chaves JF, Marquardt C, Ukoh I, Jolkovsky L, Brutsche NE, Smith MA, Luckenbaugh DA. A Randomized Trial of a Low-Trapping Nonselective N-Methyl-D-Aspartate Channel Blocker in Major Depression. Biol Psychiatry. 2012 Nov 30. pii: S0006-3223(12)00941-9. doi: 10.1016/j.biopsych.2012.10.019. [Epub ahead of print][Publisher, PubMed]

This AZD6765 compound is, as you might deduce from the letters, property of AstraZeneca Pharmaceuticals and indeed one of the authors lists this as his affiliation. The rest of the folks are from the NIMH intramural program which, presumably, provided the majority of the funding for the study.

The conclusions appear to be that this novel compounds, with a similar mechanism of action as ketamine worked but less well. From the Presser:

About 32 percent of 22 treatment-resistant depressed patients infused with ASD6765 showed a clinically meaningful antidepressant response at 80 minutes after infusion that lasted for about half an hour – with residual antidepressant effects lasting two days for some. By contrast, 52 percent of patients receiving ketamine show a comparable response, with effects still detectable at seven days. So a single infusion of ketamine produces more robust and sustained improvement, but most patients continue to experience some symptoms with both drugs.

However, depression rating scores were significantly better among patients who received AZD6765 than in those who received placebos. The researchers deemed this noteworthy, since, on average, these patients had failed to improve in seven past antidepressant trials, and nearly half failed to respond to electroconvulsive therapy (ECT).

So this is good. Anything that shows promise as a rapid-alleviator of depression is good by my lights.

But why is NIMH spending taxpayer dollars to develop me-too drugs? Look, I recognize that drugs within a class of pharmacological mechanism, like the SSRIs, may be differentially effective for different patients. And it is a good thing if we have more options to tailor medication to the individual patient. ADHD is another situation where an array of monoamine transporter inhibitors, including methylphenidate and amphetamine, are used with success and failure. One drug works for one patient, another works for a different patient....and they might describe the other medication as even worse than not being treated. So...great.

But make no mistake. The central feature driving me-too drug development is profit. Drug companies decide they can take a big enough slice of the market away from the market-leader to make it worth their while. Perhaps they had development in parallel and had sunk enough cost in by the time their competitor gained FDA approval that there was no turning back. Whatever. Point being that they are in it for the money and not for some noble cause of serving that subset of patients that do not gain relief from their competitor's drug.

Over the past few years the side-chatter about the ketamine effect on depression has frequently been a lament about the lack of financial motive for companies to push forward with ketamine. Push forward with specific clinical trials to gain on-label approval for the indication of depression. Push forward with marketing campaigns. Push forward with physician education and stroking like they do with their proprietary stuff.

The Zarate paper took a stab at claiming the reason for developing something else was an attempt to avoid the adverse effects of ketamine. The dissociative type effects can be unpleasant and recovery doesn't look fun. So there's some toehold there to claim one is motivated to find a "perfect" drug which somehow produces the therapeutic effect with nothing else. Color me skeptical, given what I know about existing NMDA channel blockers like ketamine (and PCP, did I mention that? Yeah, angel dust might work for depression....).

So I smell profit motive in this effort.

What I don't understand is why NIMH is involved with this. Why not just pursue the evidence body for ketamine?
___
*References pulled out of the paper
R.M. Berman, A. Cappiello, A. Anand, D.A. Oren, G.R. Heninger, D.S. Charney et al. Antidepressant effects of ketamine in depressed patients. Biol Psychiatry, 47 (2000), pp. 351–354

N. Diazgranados, L. Ibrahim, N.E. Brutsche, A. Newberg, P. Kronstein, S. Khalife et al. A randomized add-on trial of an N-methyl-D-aspartate antagonist in treatment-resistant bipolar depression. Arch Gen Psychiatry, 67 (2010), pp. 793–802

C.A. Zarate Jr, N.E. Brutsche, L. Ibrahim, J. Franco-Chaves, N. Diazgranados, A. Cravchik et al. Replication of ketamine’s antidepressant efficacy in bipolar depression: A randomized controlled add-on trial Biol Psychiatry, 71 (2012), pp. 939–946

G.W. Valentine, G.F. Mason, R. Gomez, M. Fasula, J. Watzl, B. Pittman et al. The antidepressant effect of ketamine is not associated with changes in occipital amino acid neurotransmitter content as measured by [(1)H]-MRS Psychiatry Res, 191 (2011), pp. 122–127

M. aan het Rot, K.A. Collins, J.W. Murrough, A.M. Perez, D.L. Reich, D.S. Charney et al. Safety and efficacy of repeated-dose intravenous ketamine for treatment-resistant depression Biol Psychiatry, 67 (2010), pp. 139–145

7 responses so far

Older posts »