the only universal truth about cancers is that the earlier they are caught, the better the response to treatment.
Except that this isn't even remotely true. That was a nice hypothesis a couple of decades ago, but it's turned out to be much more complicated than that. Some cancers can be treated very late in the game, some early, some it doesn't seem to make a difference when you do it. It's a very reasonable supposition, just happens not to be a correct one.
[citation needed]
I will respectfully disagree. Yes, I agree some cancers can be treated in later stages, but I did not say that they can't.
As you will see in almost every cancer, there is a precipitous decline in survival based on major staging (denoted by the roman numeral). There are a few *subtypes* in colorectal cancer that have variable survival (likely multifactorial due to changing definitions, evolving treatment protocols, and lower numbers of patients due to the subdivisions of the group), but I think you can see the trend. In fact, let's conduct a little experiment. Look me up when you get a diagnosis of cancer, we'll wait until you're stage IV until treatment is started. And we'll see what your outcome is. Granted the n will be 1, but methinks you will not be happy with _your_ outcome.
Now, here are my examples, please cite yours. I will warn you I do not accept data that can not be reproduced or is not peer-reviewed
Sorry, I am not. I have the usual general surgery training (which includes time on a surgical-oncology service), but I specialize in trauma, emergency general surgery, and surgical critical care. I do not routinely do cancer operations, any cancers that I operate on are incidental or have resulted in a surgical emergency like a perforated colon cancer.
Answer me this: why not routinely remove moles? Its always mystified me. If they are benign, then they should be safe to remove for cosmetic purposes, and if they are potentially dangerous, why not get rid of them ASAP?
Most "moles" are benign. The suspicious ones (ABCDEs) are removed and sent for pathology to detect if they are cancerous. It would not be possible to remove and pathologically screen all moles on every person.
Whether this new cure is a true breakthrough or not, it is really exciting to live in a time where things such as CURING CANCER are possible (even living on the verge of such a time is breathtaking).
Actually, most cancers are curable. I can cut out most tumors....the problem is getting to them early enough. Solid tumors are mostly responsive to surgery first, chemotherapy and, for some cancers, radiotherapy are best left to "mop up" residual cells be it tumor-in-situ or micrometastases or out metastatic disease, now there are a few exceptions - especially the "liquid tumors" or hematologic malignancies.
What I'd really like to see is better screening for cancers - the only universal truth about cancers is that the earlier they are caught, the better the response to treatment. Catch a cancerous growth early before is has spread locally and we can cut it out and you'll likely be cured. When it has a chance to invade locally and especially distally, I can't perform a simple operation to remove it - I have to take out more tissue and sometimes in different places or other organs...sometimes the tumor burden is so great that an operation won't make a difference. This is where chemo can also be used. But responses to chemo are almost universally poorer than surgery. And please bear in mind, most people use "cancer" like its a single entity. It is not. There are a multitude of cancerous transformations for each cell line in the body, each with its own peculiarities.
Don't get me wrong, any improvement in chemotherapy will increase survivor hood of cancer, but I doubt that this will do much to change the initial treatment of most cancers.
The actual situation is very complex and is actually somewhat rooted in the free market system....
Some of the factors involved:
1. anti-trust laws and specific legislation prevent hospitals and doctors for sharing price information (aka Sherman Anti Trust Act)
2. The government demands a discount from hospitals for services.
3. The insurance companies, not to be outdone by Uncle Sam, also demand discounts. (8th paragraph )
4. Different geographic locations have different pricing indexes.
5. Local competition, despite #1 above, can influence prices
6. Different patients have wildly varying medical histories and co-morbidities.
7. Most complex cases (esp surgery and other procedural based care) fall into a class of billing called the DRG (diagnostic related group), which is kind of a set rate for a package of care....so if I take out your gallbladder and you leave in 1 day or 3, the hospital gets paid the same (see side note below)
Taken all together, the hospital is basically free to charge what ever they want....not that they ever get it.
Most insurance companies pay a "regionally adjusted payment", and that's what gets paid....with a few exceptions. Those without insurance, usually get some kind of compassionate coverage from Medicaid (state funded, not Medicare). Those who do not are often eligible for charity care where part or all of the bill is reduced. So why not just bill the uninsured a lower upfront cost? Rule #2. Uncle Sammy wants his discount
The interesting side story....patients who have an exceptionally difficult problem can fall into a group called the outliers (imaginative name, but better I suppose than the untouchables....). These are pts who fall outside of the DRG....as such the hospital may submit a bill for outlier payment. This is typically $0.10 on the dollar of hospital billing. Well that sucks for the hospital....but a less-than-scrupulous Mega-Health-Care-Corp came up with the idea of inflating their outlier billing to be 10x what they had been billing.....the end result is $ for $ reimbursement. This was all well and good for them, for a couple of years....then Uncle Sammy caught on.....10 years later and they still haven't gotten rid of the shit smell after the government came down on them and beat the living shit out of them financially and punitively.
Why the hell would you spray them with a NSAID (aspirin/ibuprofen) analog that was withdrawn from the market because it had a slightly increased risk of mycardial infarction?
However, growth to visible cultures is composed of hundreds of generations, and if you had a more sensitive detector of bacterial reproduction, that didn't have to wait so many generations, you could reach colclusions[sic] a lot faster; limited primarily by the drug uptake rate.
Hmmm....me thinks you should look into your math...:-) (I'm being purely humorous at this point, not meant to be mean, but with real math)
doubling time is about 20 min in ideal circumstances so 100*20 is 2000 min or ~ 33.3 hrs
100 generations == 2^100 bacteria or 1,267,650,600,228,229,401,496,703,205,376
so total bio mass is about 13,343,690,528,718,204g or 13,343,690,528,718kg or 1.3e13kg
for reference, the earth weighs...5.9e24 kg, (moon is merely 7.3e22, the USS Iowa battleship is about 5.2e7kg, a supertanker is 1.1e10 kg)
For a gram of bacteria (that's a lot!) only takes about 40 generations under ideal circumstances....now I'm ignoring lag and standing phases and focusing on the log phase just to give you an idea of the order of magnitude.
They claim they can detect bacterial metabolism directly. So for bactericides, at least, they don't even have to wait one generation to detect results.
Well, there's still the lag for them to grow to culture, again its the in vivo milieu that needs to be discarded.
I suspect that bacteria could be classified crudely using some variant of flow cytometry, and then you could test antibiotics against each group.
Looks like its been done. Didn't read too far in, I suspect it is not ost effective tho.
The real usefulness of a technique like this (as I understand from the sepsis researchers that I've interacted with), is improved antibiotic stewardship -- preventing overuse of antibiotics and reducing the time the patient need be treated.
Please see my line about "De-escalated" - that is antibiotic stewardship in action.
These rapid assays can provide a better and more timely means to monitor a patient's response to treatment.
Again, where can this be applied in a "noisy" real world scenario? The researcher took an already cultured (i.e. purified) sample to prove the concept. I am trying illustrate the complexity of translating this into a real world application.
The talk about early diagnosis and saving lives is simply a lot more sexy and easier to sell than antibiotic stewardship.
They are two sides of the same coin....the bug I treat today with the tightest adequate spectrum of coverage is the bug I do not have to treat with the big guns later, or worse, have the big guns fail.....The situation for my patients really descends into the realm of "life sucks" when we're having the discussion "if we try this antibiotic I can treat his/her infection, but we're going to trash his/her {kidneys | lung | liver} in the process."
The grandstanding about this particular application aside, though, the technique itself is interesting.
No doubt that this is interesting, I again question where this is going to be useful....The best I can see is using it in place of the traditional sensitivity step - replacing the Kirby-Bauer test...but this is going to save hours. I guess that's going to be the "big saving"; still every hour I gain is something. Hopefully they can make this test cost-effective so we can actually persuade the bean-counters that it'll be worth it.
Granted, but in my experience, common and uncommon are anything but....
Also PCR and ELISA are much more expensive and time consuming processes than plating or "brothing", and you also have to have a reasonable clue as to the organism that you expect to encounter (see below) - If I knew the bug before hand, I'd treat for it. Those in my position often get surprised by the organism that finally grows. I once had a case of endocarditis in a cardiac transplant patient, the culture came back with an unusual organism....googl-ing that organism yielded 4 hits (granted not the most scientific process) - sorry can't recall the bug, it was that unusual.
But also please reference my statement about amplification of the dominant organism above the ambient noise.
Sorry, just looked down and saw the reply by the.original.drg, basically the same argument, but with some personal experience thrown in
That's nice that a new technique is developed to measure/observe bacteria, but what's with all that bullshit about rushed bacterial infection?
PR idiots.
As a clinical (critical care, if you care to know) physician, I too am a bit puzzled by the description.
Patients in septic shock are very sick and the prescription of antibiotics is a delicate subject....antibiotics need to be started within a few hours of diagnosis, and getting it wrong (prescribing an antibiotic to which the bacteria is resistant) and the patient has a 50% increase in mortality. To this end we use the broadest spectrum antibiotics available, and most hospitals develop an "Antibiogram " specific for their institution and their pt population. These antibiotics are so powerful, it is rare, but not unheard of, for organisms to be resistant to them.
The process goes like this:
Pt is admitted to an ICU
Cultures of all likely sources (urine, lung, blood, CSF, abscess fluid) are obtained
Antibiotics are started (sometimes before the cultures are drawn, but ideally after), as well as other therapies
Over the next few days the antibiotics are "De-escalated" as dictated by the cultures (see below)
Hopefully the pt recovers and their care is down-graded and ultimately discharged
The cultures are sent to the lab after being draw and in a process that (time-wise) parallels the above:
The sample is extracted from the specimen container and are plated on a growth medium or placed in a broth
They are allowed to grow for (around) 24 hours
The plates are examined to determine if anything actually grew (may take up to 3 days for blood)
If something grew, two processes happen:
The culture is sent through a variety of tests (gram-stain, etc) to determine the species of bacteria which will dictate the next step.
The specimen is then re-suspended in a culture medium and plated and allowed to grow in the presence of antibiotics thus yielding that particular organisms antibiogram
A you can see, there really isn't anywhere to rush the process. And I would be very interested to see how they can speed this up with their technology....the who purpose of the plating is to amplify the bacteria from the milieu of the body fluids and to find the dominant organism growing.
In addition, some cultures are already "contaminated" with body flora (e.g. upper respiratory and stool) and the purpose of the culture is to amplify pathological bacteria from the benign-normal flora.
Active alcoholism is a contraindication to transplant, however, damage due to alcohol related diseases is not:
Except from UpToDate (requires subscription)UpToDate.com
INTRODUCTION — After initial reluctance to transplant patients with alcoholic liver disease, it is now clear that transplantation offers an excellent survival advantage in appropriately selected patients, equal to that for other disease indications. The original reluctance stemmed from the perception that the disease was self-inflicted and from the possible presence of alcohol-mediated damage to sites outside the liver [1,2]. There was also concern that compliance with postoperative recommendations would be suboptimal and that recidivism would lead to graft failure. Opposing opinions and accumulated data have addressed these reservations [3]. Liver transplantation appears to be cost-effective for alcoholic liver disease, albeit possibly less so than for transplantation for some other indications such as primary biliary cirrhosis and primary sclerosing cholangitis [2,4-6].
snip
Alcohol abstinence and psychosocial factors — Sobriety and adequate social support are essential. No absolute interval of sobriety is required because some patients who are otherwise suitable candidates will not survive a six-month period.
However, a period of six months of sobriety is used widely for predicting recidivism and also allows for hepatic recovery from ongoing alcohol-related injury [31], but accurately determining which patients are abstinent can be difficult. One study that included 40 patients with alcoholic liver disease who were admitted for an assessment for liver transplant found that 38 percent of patients had urine tests that were positive for alcohol (20 percent) and/or illicit drugs (30 percent) [32]. However, only 3 percent of the patients admitted to using alcohol.
Cancers would generally disqualify you
Not entirely. You can have HCC (hepatocellular concinoma) and get a transplant:
INTRODUCTION — Hepatocellular carcinoma (HCC) is an aggressive tumor that often occurs in the setting of chronic liver disease and cirrhosis. (See "Epidemiology and etiologic associations of hepatocellular carcinoma".)
The only potentially curative treatment options are resection and liver transplantation Among patients who are not candidates for liver resection, some who have cirrhosis and HCC are candidates for potentially curative liver transplantation. Unfortunately, the majority of patients are not eligible for either resection or transplantation because of tumor extent, underlying liver dysfunction, and lack of donor organs.
(extra link mine)
The liver makes a good candidate because it is a "nice" organ to transplant. It is very tolerant of ABO incompatibility. It also has a decent survival outside of the body, IIRC, it is exceeded only by the kidney for durability outside of the body.
My concern is that this "liver-in-a-box" makes bile. Bear with here.....
RBCs (red blood cells) are primarily broken down in the spleen, not the liver. The hemoglobin is then broken down in macrophages (which do exist in the liver, but typically aren't involved in this part) into bilirubin which is transported to the liver by binding with albumin. Once in the liver, it is conjugated (chemically linked) to a sugar to increase its solubility, it is then excreted into the bile (which gives the bile the golden brown coloring). If there is no spleen in this circuit, what's breaking down the RBCs(now granted the liver can assume some of this function in asplenic patients, but I'm not sure it can take over this quickly)? This sounds like a fundamental problem with their system....guess if they can solve that they can keep a liver on the shelf for a week or more.
Could just imaging the Monty Python skit coming out of that!
antibiotic treatments used as placebos for vial infections
I'm sorry but a medical professional should flat out know better.
As a physician, I agree.
The problem is that we are now subject to an "objective" review, where the MBA CEO's of hospitals and health care systems have to measure and quantify everything. The problem is this is not a normal customer-seller relationship....this is more like going to the lawyer for advice (Gawd, did I just compare physicians to lawyers????), you are seeking "expert advice" and when it may not be what you want or expect, a rift develops. The physician (rarely) denies something because they are being a jerk, they are (usually) doing it in the patient's best interest. However, with the need to maximize your PG scores, people are acquiescing. Yes, I know this is not a new problem and pre-dates the PG score, but this is a perfect example of "market forces" in medicine, and why people who think medicine is a business like manufacturing cars are dead wrong....it IS a business, but unlike just about any other out there.
Despite not agreeing totally with the start of this thread, there is _some_ validity to what was said:
From Wikipedia (not my favorite source, mind you)
Principles of screening
World Health Organization guidelines were published in 1968, but are still applicable today.[2]
The condition should be an important health problem.
There should be a treatment for the condition.
Facilities for diagnosis and treatment should be available.
There should be a latent stage of the disease.
There should be a test or examination for the condition.
etc
A good screening test is one that provides a definitive answer. You DEFINITELY have AIDS / rabies / smallpox, for example. Whether you can treat/cure AIDS/rabies/smallpox? Well, that's something else entirely.
Actually, you are wrong here. There are very few tests in medicine that are "absolute answers". Every test has an error rate associated with it. We typically look at sensitivity (the chances of actually detecting the disease) and specificity (the chance of the positive test being the disease in question). This leads to the concepts of false-positives(you don't have the disease, but the test says you do) and false-negatives(you have the disease but we missed it). Going further down the statistical highway, when we include the incidence of the disease in the population and the probability that an individual has a disease...that yields positive or negative predictive values (the chances that a positive (or negative) test is indicative of existence (or absence) of disease in that person.
Let me be brief, and state no test is 100% sensitive nor 100% specific, and while you may approach 100% with PPV or NPV, the other cannot, therefore, be 100%.
As such the original article is very wrong in their claims:
says their new technology can diagnose Alzheimer's disease up to six years before symptoms appear with 100 percent accurac
The program analyzes patients' eye movements and time spent looking at familiar and new images and then generates a score. Kaplan said 100 percent of subjects who scored below 50 percent on the test have gone to receive an Alzheimer's diagnosis within six years, while none of those who scored above 67 have developed Alzheimer's.
I'm sorry, what is their prediction when the patient scores a 55?
But if you can't screen to provide a diagnosis, then you can't isolate symptoms, spot OTHER symptoms which may be masked by similar diseases that someone DOESN'T have (and only a screen will tell you that), or work out how to manage the condition, even if you can't treat it. Management might refer to, for example, being told not to share your blood with AIDS, or getting benefits and home-help for Alzheimer's, or even just "don't do this particular exercise / take this particular drug".
Er....I'm not sure _what_ you are trying to say here. But let me clarify: screening does not by definition provide a diagnosis....it mere raises the level of concern. Take the (very poorly chosen) example of breast cancer....mammography (which is starting to fallout of favor for screening) screening alerts the physician to the potential for a cancer. After mammography, typically we attempt to obtain a tissue diagnosis (biopsy) to "prove" a cancer. But even then, errors can still be made.
As a physician, I both read and compose medical records, obviously. This is the closest response to what actually goes on with a chart.
The medical chart is, ideally, an impartial, objective view of the pt's medical condition. It includes, in the most granular form:
1. a subjective portion - this is the problem as described by the patient, and guided by the physician. It reflects (hopefully) in the patient's own words what they are experiencing.
2. an objective portion - this is what we see and can describe from the physical exam. It may also include lab studies, radiographs, ultrasounds, outside testing....basically anything we can measure and quantify directly.
3. The assessment - what we think is going on.
4. the plan - what we want to do about it.
Sometimes, things can be clouded because physicians are human too...I more than once have read, and occasionally written, something like: "Mr XYZ is a 51 year old, disagreeable gentleman who is in chronic renal failure who is having trouble "controlling his potassium levels". He has be counselled in the past by myself and several other physicians to control his potassium intake; however, he refuses to do so, stating "I will eat what the hell I want to, and not you nor anyone else is going to tell me otherwise" "
Now, is this wrong? No - but the patient is going to take offense to this hard, clinical look at himself. I would not want him to see this,even though there is nothing wrong, simply because it is going to breakdown what (little) physician-patient relations we have. So why would I write it? Because it is the most concise and descriptive depiction of what is going on with this patient. In my work, I need to be very cold and calculating in how I approach a medical problem.....I have to temper that with the fact that I am dealing with another person and they will not understand how I need to look at them. The chart reveals one side of this coin, my speaking to the patient reveals the other. If this patient were allowed to edit this, well, why the hell did I see him?
Now, take this to the realm of psychiatry...and I think you can extrapolate unto the joys and wonders of trying to accurately document medical conditions.
"I'm not going to do test X because the lab I own doesn't sell that service, but I'll send him for an extra MRI because I've got a boat payment to make"
To respond directly to this ludicrous statement: This is patently against the law
Price gouging...
Private hospital in tiny town: $18,000 for 36 hours in a womens health room with a straight saline drip, half of that bill was for the saline drip (billed as "IV therapy", it had no meds in it and was only there so they had a line open if needed)
Closest hospital equipped to deal with a 7 week preemie: $17,000 for 10 days stay total. Lifeflight, 3 days high risk pregnancy observation and blood pressure treatment, c-section, 7 days of recovery, and emergency hemorrhage treatment 2 days after the c-section
Even couple hour ER trips on the weekends where they just tell us "Sorry you're in blinding pain but I don't feel like doing anything, have some tylenol" result in multiple $5,000-10,000 bills from the hospital, doctor, nurses, oncall surgeon/anesthesia/radiology who wasn't even there and did noting.
I'm sorry, but [citation needed] here. I work in the health industry. A helicopter flight alone to a close hospital is on the order of $10,000. One figure quoted to me was that it costs $1,000 to wheel the bird out of the hanger (granted, likely a mark-up). ICU care is on the order of $3,000-5,000 a day minimum, without major intervention. A c-section is going to be on the order of $10,000-30,000 itself. The OR is billed on the order of $30-100 per minute. Blood is a couple hundred (~$500) per/unit. This doesn't even include the cost of medications or ancillary services.
Your bill for a high risk pregnancy/premie treatment is more likely billed at $170,000, and in reality could reach $250,000. What you saw was probably a negotiated price from your health insurance, or mark-down from medicaid
I will agree that your community hospital bill was way out of line, but the upgrade in care, especially at a teaching hospital is going to be much higher.
Also a 7 week premie is non-viable. That is considered a spontaneous abortion. You probably meant to say a 32-week premie, which while serious, is a very survivable stage with modern care. (Premies are classified by length of gestation, not by the time remaining.) And FWIW, the current cut off (e.g. documentation of survival) is at about 25 weeks, it improves at 26 weeks where the mortality (chance of death) is about 50%
As an aside, I threw out those figures off the top of my head, and decided to verify and add the citations....I was pretty damn close (off on the ICU by about $1,000/day, but I was still in the ballpark). I'm either: that cynical or I've been at this too long....
I'd love to address your problem, but this would quickly balloon into a dissertation on the topic (and I'm not even a pain specialist). I can not go into detail here other than to say, yes pain treatment in this country is a problem. There are many issues driving this problem. Government control is a big factor, the fear of doing further harm, the failure to address underlying problems, misunderstanding, mistrust, and yes, even those who are abusing the system for their own personal gain (we call them addicts) themselves.
My best advice is to establish a good relationship with a qualified pain specialist and avoid moving around. I know that sounds like overly optimistic or naive advice, but really, your constant moving is the root of the problem here. The biggest reason it is likely to be interpreted as addictive behavior is: that's what addicts do. I realize your wife may not be an addict, but when the behavior fits the profile, people will be suspicious.
Yes, I very much have confidence in my knowledge and abilities. I am akin to a sub-specialist and as such I tend to be referred a subset of patients. As a "sub-specialist", I have the luxury to focus intensely on a small subset of diseases that I know very well. The range of diseases I treat is smaller than an internist (or GP or family practitioner, etc), and, in addition, especially for me, my diagnoses are dependent on a physical exam, targeted questioning, targeted lab work and imaging. For me, the computer would be much less useful than the internist who referred the patient to me...that physician requires a much larger, but much less deep, knowledge base, and it is he or she who would likely, benefit from the "peripheral brain" as we call such systems. (recall, I do acknowledge that there may be benefits to this system in certain circumstances, this is one)
There are also disease processes that are, for lack of a better term, "ill-defined". I will cite celiac disease, multiple sclerosis, and fibromyalgia, but there are a ton of others. These diseases are best treated by specialists who see a higher volume of these patients. In these cases, as in mine, the "experts" will likely beat the machine, while the "generalists" may benefit from the "peripheral brain". My guess is that your internist missed this diagnosis, but had you been referred to a GI specialist, the outcome may have been different (I'm only supposing, I do not know you or your case).
This also brings up the topic (and I am not singling you out) that dealing with _individuals_ can be tough. There can be a lot of "noise" in the interview and history. Facts that the layman think are relevant are very often not...and during long interviews (especially ones that ramble) tend to cause even the best physicians to tune out and we can sometimes miss critical "nuggets" of fact that are buried in the [emotional] discharge that we get. I will submit that I suspect the computer is most likely picking through "predigested" factoids and that if a patient were to fully unload their emotional load* the system would do one of two things 1) it would fail to elucidate the diagnosis or 2) would end up interrogating ~245 diagnostic pathways that would eliminate the usefulness of this system**. This tied into the previous paragraph about "ill-defined" diseases being tougher to diagnose.
To delve further, a diagnosis can also be lead astray by the importance that patients ascribe to their symptoms. I will illustrate: an 80-year old who lost her husband to a heart-attack (we call it a myocardial infarction or MI) 1 year ago may be so preoccupied by the fear that she too will die of an MI that she ignores the abdominal pain (say it's pancreatitis from a gallstone) and focuses more on the referred pain to her chest. Guess what....everyone (machine included) goes down the wrong path. You can imagine more complex scenarios where the disease is right in front of you, but you can't see it because of the human factor. It takes a skilled clinician to drill down to the facts and find the diagnosis (or him or her subtly noticing that the woman is clutching her belly instead of her chest).
As for your reaction to caffeine, I have never seen that. I doubt that may have, and that little has been written about that***....so I seriously doubt that Watson or this system would help your case as the probability of this being the case is low.
In a broader sense, I will submit that the computer can not infer what is does not "know". A human physician with reasoning can "think outside the box" and form a hypothesis and test it....do you think these systems are capable of this? Yeah....I don't think so, either.
Now, you want to know how I really earn my money? I do it by being critical of the medical literature. It may come a shock to some (but frequent readers of slashdot should not be), but not all articles are of the same caliber or worth. Some are outright fraudulent. My task is to be critical of the literature and to carefully
As an attending physician, I have several issues with this article.
A) the slashdot title is a little sensationalistic....never did TFA mention diagnosis without a physician in the loop.
B) by what standards was the final diagnosis discovered (i.e. the gold standard)? Another physician? Another program? Was the trial blinded?
C) this article mentions only one disease process - depression, I fail to accept, blindly, that their results can be extrapolated - that is the crux of medical versus scientific research....see D. Not all diagnoses are obtained by just talking with a patient, in fact short of a psychiatric diagnosis, most require a physical exam....and a competent one. Suppose someone is obviously malingering and complaining about abdominal pain....this system would not pick up on malingering and would likely recommend an operation....a totally wrong diagnosis.
D) this is a retrospective study...in medicine, this is not adequate proof of effectiveness.....you need to perform a prospective trial, preferably with randomization and blinding to adequately prove your hypothesis for treatment. Actually, upon re-reading TFA...it was _simulations_ that were performed. This is hardly world class evidence.
E) cost savings were mentioned, but not long term outcomes....who cares if I saved 75% in the cost of treatment if the patient didn't get better in the end. (yes, short term were noted, but anyone who's ever been on long term therapy knows that the short term does not dictate the long term outcome.
F) In life threatening situations - those that require the most expedient decisions, often with less than complete information, this system would be useless because the patient would die in the time it takes you to input the facts.
G) not all situations are cut and dry. I am often consulted to make decisions about patients that are not addressed in any book. In fact, there may be only 1 or 2 journal articles about the problem, and often there are none. Making a decision treatment in the absence of an established precedent is not going to be one of this systems strengths...."Oh, I'm sorry, I can't help you....I just got the blue-screen of death from the program that was supposed to diagnose you!"
H) would this program tolerate patient autonomy? What happens when the patient refuses some or all of the initial treatment plan?
So, while I point out flaws, it is not to say that this is totally without merit....I am merely pointing out the obvious short coming of this article. In certain fields this could be very advantageous.
I will tell you that in my field, this computer program borders on useless. There is very little doubt about what my diagnosis is, and when I am in doubt, my best evidence is collected by doing something. And computers are really a long way away from matching my skill set. A lot of my diagnosis is made by touching the patient during the physical exam. That exam can completely revamp my decision that started based on the history. And, since I am the one performing procedures, I also would not have a machine dictate the exact method that I use - I am the one performing the operation, I do it the way that I know will result in a safe and effective outcome. In my case, I just don't really don't know what this system would provide to me for patients.
Such a long time, did they already have pen and paper?
I can't remember, so much has changed.
Hmmmm....Actually went to medical school > 8 years ago....let me detail somethings that most may not know about it....
1st year for a "traditional" medical school, fall semester is usually biochem and anatomy....both usually involve a lot of diagrams and less note taking.
Your prof may or may not have handouts....ours used slides and were just transitioning to powerpoint....no joke...but think about it...not much of that information has changed over the years....esp for anatomy. Biochem, they add on for a (very) few new disease processed, and recently added the HMGCoA pathway.
Spring is usually histology and physiology....again histo is a lot of drawing of cells. Physio is less so, but more flow chart like diagrams. Micro...some note taking some diagrams....Neuro science...._lots_ of diagrams....
2nd year....hardly anyone goes to class....our second year class room was ~1/3 the size of the first year....so small that the entire 2nd year class could not fit into the lecture hall at the same time. I am neither joking nor exaggerating. Fall is pharm...good for notetaking...as is path....spring is a continuation of path and intro clinical medicine....again both are ok for note-taking.
The problem here is also that most schools still have a note-service....this is where someone is responsible for taping the lectures and distributing them out for people to review and type out the notes....the original crowd-sourcing. This is usually why most realize that going to class is rarely helpful.
3rd year....clinicals...ha - forget about note taking....you're on the move constantly, and scribbling furiously on a scrap of paper, and mostly reading out of a pocket sized book when you have those rare moments of down time....that or you're sleeping. The few lectures you have, you'll be too busy eating, or catching up on sleep. No...not kidding here either.
4th year....you pick easy electives, finish your core classes.....the fall you're off interviewing for residency, you hardly ever take notes..."'cause you know it all" already. You're just killing time til you match and then killing more time til you graduate.
Intern year.....you realize you know squat -- just like 3rd year of med school, but now you actually have responsibility! You never get a chance to sit through a lecture cause you're damn pager is going off...during rounds the orders are barked out so quickly, you'll only be able to jot 1/2 of it down on any available scrap of paper....you'll devise your own system of how to handle this....and I assure you....it will not be electronically.
2nd year....you actually find that you did learn something the previous year (must have been via diffusion)....but now you're the one barking orders, or you have a much better idea of what's coming so you rarely have to write much down.
Just my $0.02....YMMV
Source: Spent the last 9 years as a resident/fellow and the 4 years prior to that as a med student....and saw everyone else doing the _same_exact_thing_.
Well....let's see from your study, n=1 and the outcome was 100%. The p value? Probably about 1.
What you cite is "anecdotal evidence" and what works for you, may not work for anyone else...and in fact, you probably ended up removing a number of food sources that contribute to heartburn such as caffeine.
The reason your physicians don't see to care is that they can't generalize the information....so they would be remiss to pass this information on.
Someone could set up a project to research this... but that takes time and money...so who would pay for the study? The corn growers? The makers of proton-pump inhibitors? Neither one cares, and would actually discourage such a study as it would hurt their bottom-line...so the federal government might fund it...but then there are those lovely folk known as lobbyists...I'm sure they would love to push for funding for said research....
Guess I'd have to say, it's just not a hot-button issue.
And for the record, I'm a physician. (But certainly not a primary care physician).
---
From WebMD: (http://www.webmd.com/heartburn-gerd/guide/understanding-heartburn-basics)
What Causes It?
The basic cause of heartburn is an underactive lower esophageal sphincter, or LES, that doesn't tighten as it should. Two excesses often contribute to this problem: too much food in the stomach (overeating) or too much pressure on the stomach (frequently from obesity or pregnancy). Certain foods commonly relax the LES, including tomatoes, citrus fruits, garlic, onions, chocolate, coffee, alcohol, caffeinated products, and peppermint. Dishes high in fats and oils (animal or vegetable) often lead to heartburn, as do certain medications. Stress increases acid production and can cause heartburn. And smoking, which relaxes the LES and stimulates stomach acid, is a major contributor.
Slashdot Mirror
Home birth is quite safe in all but high-risk cases, and we know which ones those are.
Several Ob-Gyns I know are fond of noting:
You can't expect 21st century outcomes with 18th century ambiance.
Caveat Emptor.
Had the same thought. His name is Garrett Lisi
I heard tell that the Russians were in talks with him.....
the only universal truth about cancers is that the earlier they are caught, the better the response to treatment.
Except that this isn't even remotely true. That was a nice hypothesis a couple of decades ago, but it's turned out to be much more complicated than that. Some cancers can be treated very late in the game, some early, some it doesn't seem to make a difference when you do it. It's a very reasonable supposition, just happens not to be a correct one.
[citation needed]
I will respectfully disagree. Yes, I agree some cancers can be treated in later stages, but I did not say that they can't. As you will see in almost every cancer, there is a precipitous decline in survival based on major staging (denoted by the roman numeral). There are a few *subtypes* in colorectal cancer that have variable survival (likely multifactorial due to changing definitions, evolving treatment protocols, and lower numbers of patients due to the subdivisions of the group), but I think you can see the trend. In fact, let's conduct a little experiment. Look me up when you get a diagnosis of cancer, we'll wait until you're stage IV until treatment is started. And we'll see what your outcome is. Granted the n will be 1, but methinks you will not be happy with _your_ outcome. Now, here are my examples, please cite yours. I will warn you I do not accept data that can not be reproduced or is not peer-reviewed
Breast:
Stage 5-year Survival Rate
0 xxxxxxxxxxxxxx 93%
I xxxxxxxxxxxxxx 88%
IIA xxxxxxxxxxxxx 81%
IIB xxxxxxxxxxxxx 74%
IIIA xxxxxxxxxxxxx 67%
IIIB xxxxxxxxxxxxx 41%
IIIC xxxxxxxxxxxxx 49%
IV xxxxxxxxxxxxxx 15%
Colon:
Stage 5-year Observed Survival Rate
I xxxxxxxxxxxxxxxxxx 74%
IIA xxxxxxxxxxxxxxxxx 67%
IIB xxxxxxxxxxxxxxxxx 59%
IIC xxxxxxxxxxxxxxxxx 37%
IIIA xxxxxxxxxxxxxxxxx 73%
IIIB xxxxxxxxxxxxxxxxx 46%
IIIC xxxxxxxxxxxxxxxxx 28%
IV xxxxxxxxxxxxxxxxx 6%
Rectal:
Stage 5-year Observed Survival Rate
I xxxxxxxxxxxxxxxxxx 74%
IIA xxxxxxxxxxxxxxxxx 65%
IIB xxxxxxxxxxxxxxxxx 52%
IIC xxxxxxxxxxxxxxxxx 32%
IIIA xxxxxxxxxxxxxxxxx 74%
IIIB xxxxxxxxxxxxxxxxx 45%
IIIC xxxxxxxxxxxxxxxxx 33%
IV xxxxxxxxxxxxxxxxxx 6%
Non-small cell lung cancer:
Stage 5-year Survival Rate
IA xxxxxxxxxxxxxxxxx 49%
IB xxxxxxxxxxxxxxxxxx 45%
IIA xxxxxxxxxxxxxxxxx 30%
IIB xxxxxxxxxxxxxxxxx 31%
IIIA xxxxxxxxxxxxxxxxx 14%
IIIB xxxxxxxxxxxxxxxxx 5%
IV xxxxxxxxxxxxxxxxx 1%
Small cell lung cancer:
Stage 5-year Relative Survival Rate
I xxxxxxxxxxxxxxxxxx 31%
II xxxxxxxxxxxxxxxxx 19%
III xxxxxxxxxxxxxxxxxx 8%
IV xxxxxxxxxxxxxxxxx 2%
Similar statistics exist for: bladder cancer, cervial cancer, endomertrial cance
Sorry, I am not. I have the usual general surgery training (which includes time on a surgical-oncology service), but I specialize in trauma, emergency general surgery, and surgical critical care. I do not routinely do cancer operations, any cancers that I operate on are incidental or have resulted in a surgical emergency like a perforated colon cancer.
Answer me this: why not routinely remove moles? Its always mystified me. If they are benign, then they should be safe to remove for cosmetic purposes, and if they are potentially dangerous, why not get rid of them ASAP?
Most "moles" are benign. The suspicious ones (ABCDEs) are removed and sent for pathology to detect if they are cancerous. It would not be possible to remove and pathologically screen all moles on every person.
Whether this new cure is a true breakthrough or not, it is really exciting to live in a time where things such as CURING CANCER are possible (even living on the verge of such a time is breathtaking).
Actually, most cancers are curable. I can cut out most tumors....the problem is getting to them early enough. Solid tumors are mostly responsive to surgery first, chemotherapy and, for some cancers, radiotherapy are best left to "mop up" residual cells be it tumor-in-situ or micrometastases or out metastatic disease, now there are a few exceptions - especially the "liquid tumors" or hematologic malignancies.
What I'd really like to see is better screening for cancers - the only universal truth about cancers is that the earlier they are caught, the better the response to treatment. Catch a cancerous growth early before is has spread locally and we can cut it out and you'll likely be cured. When it has a chance to invade locally and especially distally, I can't perform a simple operation to remove it - I have to take out more tissue and sometimes in different places or other organs...sometimes the tumor burden is so great that an operation won't make a difference. This is where chemo can also be used. But responses to chemo are almost universally poorer than surgery. And please bear in mind, most people use "cancer" like its a single entity. It is not. There are a multitude of cancerous transformations for each cell line in the body, each with its own peculiarities.
Don't get me wrong, any improvement in chemotherapy will increase survivor hood of cancer, but I doubt that this will do much to change the initial treatment of most cancers.
Some of the factors involved:
1. anti-trust laws and specific legislation prevent hospitals and doctors for sharing price information (aka Sherman Anti Trust Act)
2. The government demands a discount from hospitals for services.
3. The insurance companies, not to be outdone by Uncle Sam, also demand discounts. (8th paragraph )
4. Different geographic locations have different pricing indexes.
5. Local competition, despite #1 above, can influence prices
6. Different patients have wildly varying medical histories and co-morbidities.
7. Most complex cases (esp surgery and other procedural based care) fall into a class of billing called the DRG (diagnostic related group), which is kind of a set rate for a package of care....so if I take out your gallbladder and you leave in 1 day or 3, the hospital gets paid the same (see side note below)
Taken all together, the hospital is basically free to charge what ever they want....not that they ever get it.
Most insurance companies pay a "regionally adjusted payment", and that's what gets paid....with a few exceptions. Those without insurance, usually get some kind of compassionate coverage from Medicaid (state funded, not Medicare). Those who do not are often eligible for charity care where part or all of the bill is reduced. So why not just bill the uninsured a lower upfront cost? Rule #2. Uncle Sammy wants his discount
The interesting side story....patients who have an exceptionally difficult problem can fall into a group called the outliers (imaginative name, but better I suppose than the untouchables....). These are pts who fall outside of the DRG....as such the hospital may submit a bill for outlier payment. This is typically $0.10 on the dollar of hospital billing. Well that sucks for the hospital....but a less-than-scrupulous Mega-Health-Care-Corp came up with the idea of inflating their outlier billing to be 10x what they had been billing.....the end result is $ for $ reimbursement. This was all well and good for them, for a couple of years....then Uncle Sammy caught on.....10 years later and they still haven't gotten rid of the shit smell after the government came down on them and beat the living shit out of them financially and punitively.
DR;PW (did not read;pay walled)
If you want it gone, spray it with FOOF
However, growth to visible cultures is composed of hundreds of generations, and if you had a more sensitive detector of bacterial reproduction, that didn't have to wait so many generations, you could reach colclusions[sic] a lot faster; limited primarily by the drug uptake rate.
Hmmm....me thinks you should look into your math...:-) (I'm being purely humorous at this point, not meant to be mean, but with real math)
doubling time is about 20 min in ideal circumstances so 100*20 is 2000 min or ~ 33.3 hrs
100 generations == 2^100 bacteria or 1,267,650,600,228,229,401,496,703,205,376
each bacteria weights about 9.5^-13g
so total bio mass is about 13,343,690,528,718,204g or 13,343,690,528,718kg or 1.3e13kg
for reference, the earth weighs...5.9e24 kg, (moon is merely 7.3e22, the USS Iowa battleship is about 5.2e7kg, a supertanker is 1.1e10 kg)
For a gram of bacteria (that's a lot!) only takes about 40 generations under ideal circumstances....now I'm ignoring lag and standing phases and focusing on the log phase just to give you an idea of the order of magnitude.
They claim they can detect bacterial metabolism directly. So for bactericides, at least, they don't even have to wait one generation to detect results.
Well, there's still the lag for them to grow to culture, again its the in vivo milieu that needs to be discarded.
I suspect that bacteria could be classified crudely using some variant of flow cytometry, and then you could test antibiotics against each group.
Looks like its been done. Didn't read too far in, I suspect it is not ost effective tho.
The real usefulness of a technique like this (as I understand from the sepsis researchers that I've interacted with), is improved antibiotic stewardship -- preventing overuse of antibiotics and reducing the time the patient need be treated.
Please see my line about "De-escalated" - that is antibiotic stewardship in action.
These rapid assays can provide a better and more timely means to monitor a patient's response to treatment.
Again, where can this be applied in a "noisy" real world scenario? The researcher took an already cultured (i.e. purified) sample to prove the concept. I am trying illustrate the complexity of translating this into a real world application.
The talk about early diagnosis and saving lives is simply a lot more sexy and easier to sell than antibiotic stewardship.
They are two sides of the same coin....the bug I treat today with the tightest adequate spectrum of coverage is the bug I do not have to treat with the big guns later, or worse, have the big guns fail.....The situation for my patients really descends into the realm of "life sucks" when we're having the discussion "if we try this antibiotic I can treat his/her infection, but we're going to trash his/her {kidneys | lung | liver} in the process."
The grandstanding about this particular application aside, though, the technique itself is interesting.
No doubt that this is interesting, I again question where this is going to be useful....The best I can see is using it in place of the traditional sensitivity step - replacing the Kirby-Bauer test...but this is going to save hours. I guess that's going to be the "big saving"; still every hour I gain is something. Hopefully they can make this test cost-effective so we can actually persuade the bean-counters that it'll be worth it.
Also PCR and ELISA are much more expensive and time consuming processes than plating or "brothing", and you also have to have a reasonable clue as to the organism that you expect to encounter (see below) - If I knew the bug before hand, I'd treat for it. Those in my position often get surprised by the organism that finally grows. I once had a case of endocarditis in a cardiac transplant patient, the culture came back with an unusual organism....googl-ing that organism yielded 4 hits (granted not the most scientific process) - sorry can't recall the bug, it was that unusual.
But also please reference my statement about amplification of the dominant organism above the ambient noise.
Sorry, just looked down and saw the reply by the.original.drg, basically the same argument, but with some personal experience thrown in
That's nice that a new technique is developed to measure/observe bacteria, but what's with all that bullshit about rushed bacterial infection?
PR idiots.
As a clinical (critical care, if you care to know) physician, I too am a bit puzzled by the description.
Patients in septic shock are very sick and the prescription of antibiotics is a delicate subject....antibiotics need to be started within a few hours of diagnosis, and getting it wrong (prescribing an antibiotic to which the bacteria is resistant) and the patient has a 50% increase in mortality. To this end we use the broadest spectrum antibiotics available, and most hospitals develop an "Antibiogram " specific for their institution and their pt population. These antibiotics are so powerful, it is rare, but not unheard of, for organisms to be resistant to them.
The process goes like this:
Pt is admitted to an ICU
Cultures of all likely sources (urine, lung, blood, CSF, abscess fluid) are obtained
Antibiotics are started (sometimes before the cultures are drawn, but ideally after), as well as other therapies
Over the next few days the antibiotics are "De-escalated" as dictated by the cultures (see below)
Hopefully the pt recovers and their care is down-graded and ultimately discharged
The cultures are sent to the lab after being draw and in a process that (time-wise) parallels the above:
The sample is extracted from the specimen container and are plated on a growth medium or placed in a broth
They are allowed to grow for (around) 24 hours
The plates are examined to determine if anything actually grew (may take up to 3 days for blood)
If something grew, two processes happen:
The culture is sent through a variety of tests (gram-stain, etc) to determine the species of bacteria which will dictate the next step.
The specimen is then re-suspended in a culture medium and plated and allowed to grow in the presence of antibiotics thus yielding that particular organisms antibiogram
A you can see, there really isn't anywhere to rush the process. And I would be very interested to see how they can speed this up with their technology....the who purpose of the plating is to amplify the bacteria from the milieu of the body fluids and to find the dominant organism growing.
In addition, some cultures are already "contaminated" with body flora (e.g. upper respiratory and stool) and the purpose of the culture is to amplify pathological bacteria from the benign-normal flora.
Longer video that gives a better front to back description
Active alcoholism is a contraindication to transplant, however, damage due to alcohol related diseases is not:
Except from UpToDate (requires subscription)UpToDate.com
INTRODUCTION — After initial reluctance to transplant patients with alcoholic liver disease, it is now clear that transplantation offers an excellent survival advantage in appropriately selected patients, equal to that for other disease indications. The original reluctance stemmed from the perception that the disease was self-inflicted and from the possible presence of alcohol-mediated damage to sites outside the liver [1,2]. There was also concern that compliance with postoperative recommendations would be suboptimal and that recidivism would lead to graft failure. Opposing opinions and accumulated data have addressed these reservations [3]. Liver transplantation appears to be cost-effective for alcoholic liver disease, albeit possibly less so than for transplantation for some other indications such as primary biliary cirrhosis and primary sclerosing cholangitis [2,4-6].
snip
Alcohol abstinence and psychosocial factors — Sobriety and adequate social support are essential. No absolute interval of sobriety is required because some patients who are otherwise suitable candidates will not survive a six-month period. However, a period of six months of sobriety is used widely for predicting recidivism and also allows for hepatic recovery from ongoing alcohol-related injury [31], but accurately determining which patients are abstinent can be difficult. One study that included 40 patients with alcoholic liver disease who were admitted for an assessment for liver transplant found that 38 percent of patients had urine tests that were positive for alcohol (20 percent) and/or illicit drugs (30 percent) [32]. However, only 3 percent of the patients admitted to using alcohol.
Cancers would generally disqualify you
Not entirely. You can have HCC (hepatocellular concinoma) and get a transplant:
Also from UpToDate
INTRODUCTION — Hepatocellular carcinoma (HCC) is an aggressive tumor that often occurs in the setting of chronic liver disease and cirrhosis. (See "Epidemiology and etiologic associations of hepatocellular carcinoma".)
The only potentially curative treatment options are resection and liver transplantation Among patients who are not candidates for liver resection, some who have cirrhosis and HCC are candidates for potentially curative liver transplantation. Unfortunately, the majority of patients are not eligible for either resection or transplantation because of tumor extent, underlying liver dysfunction, and lack of donor organs.
(extra link mine)
The liver makes a good candidate because it is a "nice" organ to transplant. It is very tolerant of ABO incompatibility. It also has a decent survival outside of the body, IIRC, it is exceeded only by the kidney for durability outside of the body.
My concern is that this "liver-in-a-box" makes bile. Bear with here.....
RBCs (red blood cells) are primarily broken down in the spleen, not the liver. The hemoglobin is then broken down in macrophages (which do exist in the liver, but typically aren't involved in this part) into bilirubin which is transported to the liver by binding with albumin. Once in the liver, it is conjugated (chemically linked) to a sugar to increase its solubility, it is then excreted into the bile (which gives the bile the golden brown coloring). If there is no spleen in this circuit, what's breaking down the RBCs(now granted the liver can assume some of this function in asplenic patients, but I'm not sure it can take over this quickly)? This sounds like a fundamental problem with their system....guess if they can solve that they can keep a liver on the shelf for a week or more.
Could just imaging the Monty Python skit coming out of that!
As a physician, I agree.
The problem is that we are now subject to an "objective" review, where the MBA CEO's of hospitals and health care systems have to measure and quantify everything. The problem is this is not a normal customer-seller relationship....this is more like going to the lawyer for advice (Gawd, did I just compare physicians to lawyers????), you are seeking "expert advice" and when it may not be what you want or expect, a rift develops. The physician (rarely) denies something because they are being a jerk, they are (usually) doing it in the patient's best interest. However, with the need to maximize your PG scores, people are acquiescing. Yes, I know this is not a new problem and pre-dates the PG score, but this is a perfect example of "market forces" in medicine, and why people who think medicine is a business like manufacturing cars are dead wrong....it IS a business, but unlike just about any other out there.
Don't be stupid.
Despite not agreeing totally with the start of this thread, there is _some_ validity to what was said: From Wikipedia (not my favorite source, mind you)
A good screening test is one that provides a definitive answer. You DEFINITELY have AIDS / rabies / smallpox, for example. Whether you can treat/cure AIDS/rabies/smallpox? Well, that's something else entirely.
Actually, you are wrong here. There are very few tests in medicine that are "absolute answers". Every test has an error rate associated with it. We typically look at sensitivity (the chances of actually detecting the disease) and specificity (the chance of the positive test being the disease in question). This leads to the concepts of false-positives(you don't have the disease, but the test says you do) and false-negatives(you have the disease but we missed it). Going further down the statistical highway, when we include the incidence of the disease in the population and the probability that an individual has a disease...that yields positive or negative predictive values (the chances that a positive (or negative) test is indicative of existence (or absence) of disease in that person.
Let me be brief, and state no test is 100% sensitive nor 100% specific, and while you may approach 100% with PPV or NPV, the other cannot, therefore, be 100%.
As such the original article is very wrong in their claims:
says their new technology can diagnose Alzheimer's disease up to six years before symptoms appear with 100 percent accurac
The program analyzes patients' eye movements and time spent looking at familiar and new images and then generates a score. Kaplan said 100 percent of subjects who scored below 50 percent on the test have gone to receive an Alzheimer's diagnosis within six years, while none of those who scored above 67 have developed Alzheimer's.
I'm sorry, what is their prediction when the patient scores a 55?
But if you can't screen to provide a diagnosis, then you can't isolate symptoms, spot OTHER symptoms which may be masked by similar diseases that someone DOESN'T have (and only a screen will tell you that), or work out how to manage the condition, even if you can't treat it. Management might refer to, for example, being told not to share your blood with AIDS, or getting benefits and home-help for Alzheimer's, or even just "don't do this particular exercise / take this particular drug".
Er....I'm not sure _what_ you are trying to say here. But let me clarify: screening does not by definition provide a diagnosis....it mere raises the level of concern. Take the (very poorly chosen) example of breast cancer....mammography (which is starting to fall out of favor for screening) screening alerts the physician to the potential for a cancer. After mammography, typically we attempt to obtain a tissue diagnosis (biopsy) to "prove" a cancer. But even then, errors can still be made.
A good screening test has the following:
The medical chart is, ideally, an impartial, objective view of the pt's medical condition. It includes, in the most granular form:
1. a subjective portion - this is the problem as described by the patient, and guided by the physician. It reflects (hopefully) in the patient's own words what they are experiencing.
2. an objective portion - this is what we see and can describe from the physical exam. It may also include lab studies, radiographs, ultrasounds, outside testing....basically anything we can measure and quantify directly.
3. The assessment - what we think is going on.
4. the plan - what we want to do about it.
Sometimes, things can be clouded because physicians are human too...I more than once have read, and occasionally written, something like: "Mr XYZ is a 51 year old, disagreeable gentleman who is in chronic renal failure who is having trouble "controlling his potassium levels". He has be counselled in the past by myself and several other physicians to control his potassium intake; however, he refuses to do so, stating "I will eat what the hell I want to, and not you nor anyone else is going to tell me otherwise" "
Now, is this wrong? No - but the patient is going to take offense to this hard, clinical look at himself. I would not want him to see this,even though there is nothing wrong, simply because it is going to breakdown what (little) physician-patient relations we have. So why would I write it? Because it is the most concise and descriptive depiction of what is going on with this patient. In my work, I need to be very cold and calculating in how I approach a medical problem.....I have to temper that with the fact that I am dealing with another person and they will not understand how I need to look at them. The chart reveals one side of this coin, my speaking to the patient reveals the other. If this patient were allowed to edit this, well, why the hell did I see him?
Now, take this to the realm of psychiatry...and I think you can extrapolate unto the joys and wonders of trying to accurately document medical conditions.
"I'm not going to do test X because the lab I own doesn't sell that service, but I'll send him for an extra MRI because I've got a boat payment to make"
To respond directly to this ludicrous statement: This is patently against the law
Price gouging... Private hospital in tiny town: $18,000 for 36 hours in a womens health room with a straight saline drip, half of that bill was for the saline drip (billed as "IV therapy", it had no meds in it and was only there so they had a line open if needed) Closest hospital equipped to deal with a 7 week preemie: $17,000 for 10 days stay total. Lifeflight, 3 days high risk pregnancy observation and blood pressure treatment, c-section, 7 days of recovery, and emergency hemorrhage treatment 2 days after the c-section
Even couple hour ER trips on the weekends where they just tell us "Sorry you're in blinding pain but I don't feel like doing anything, have some tylenol" result in multiple $5,000-10,000 bills from the hospital, doctor, nurses, oncall surgeon/anesthesia/radiology who wasn't even there and did noting.
I'm sorry, but [citation needed] here. I work in the health industry. A helicopter flight alone to a close hospital is on the order of $10,000. One figure quoted to me was that it costs $1,000 to wheel the bird out of the hanger (granted, likely a mark-up). ICU care is on the order of $3,000-5,000 a day minimum, without major intervention. A c-section is going to be on the order of $10,000-30,000 itself. The OR is billed on the order of $30-100 per minute. Blood is a couple hundred (~$500) per/unit. This doesn't even include the cost of medications or ancillary services.
Your bill for a high risk pregnancy/premie treatment is more likely billed at $170,000, and in reality could reach $250,000. What you saw was probably a negotiated price from your health insurance, or mark-down from medicaid
I will agree that your community hospital bill was way out of line, but the upgrade in care, especially at a teaching hospital is going to be much higher.
Also a 7 week premie is non-viable. That is considered a spontaneous abortion. You probably meant to say a 32-week premie, which while serious, is a very survivable stage with modern care. (Premies are classified by length of gestation, not by the time remaining.) And FWIW, the current cut off (e.g. documentation of survival) is at about 25 weeks, it improves at 26 weeks where the mortality (chance of death) is about 50%
As an aside, I threw out those figures off the top of my head, and decided to verify and add the citations....I was pretty damn close (off on the ICU by about $1,000/day, but I was still in the ballpark). I'm either: that cynical or I've been at this too long....
I'd love to address your problem, but this would quickly balloon into a dissertation on the topic (and I'm not even a pain specialist). I can not go into detail here other than to say, yes pain treatment in this country is a problem. There are many issues driving this problem. Government control is a big factor, the fear of doing further harm, the failure to address underlying problems, misunderstanding, mistrust, and yes, even those who are abusing the system for their own personal gain (we call them addicts) themselves.
My best advice is to establish a good relationship with a qualified pain specialist and avoid moving around. I know that sounds like overly optimistic or naive advice, but really, your constant moving is the root of the problem here. The biggest reason it is likely to be interpreted as addictive behavior is: that's what addicts do. I realize your wife may not be an addict, but when the behavior fits the profile, people will be suspicious.
There are also disease processes that are, for lack of a better term, "ill-defined". I will cite celiac disease, multiple sclerosis, and fibromyalgia, but there are a ton of others. These diseases are best treated by specialists who see a higher volume of these patients. In these cases, as in mine, the "experts" will likely beat the machine, while the "generalists" may benefit from the "peripheral brain". My guess is that your internist missed this diagnosis, but had you been referred to a GI specialist, the outcome may have been different (I'm only supposing, I do not know you or your case).
This also brings up the topic (and I am not singling you out) that dealing with _individuals_ can be tough. There can be a lot of "noise" in the interview and history. Facts that the layman think are relevant are very often not...and during long interviews (especially ones that ramble) tend to cause even the best physicians to tune out and we can sometimes miss critical "nuggets" of fact that are buried in the [emotional] discharge that we get. I will submit that I suspect the computer is most likely picking through "predigested" factoids and that if a patient were to fully unload their emotional load* the system would do one of two things 1) it would fail to elucidate the diagnosis or 2) would end up interrogating ~245 diagnostic pathways that would eliminate the usefulness of this system**. This tied into the previous paragraph about "ill-defined" diseases being tougher to diagnose.
To delve further, a diagnosis can also be lead astray by the importance that patients ascribe to their symptoms. I will illustrate: an 80-year old who lost her husband to a heart-attack (we call it a myocardial infarction or MI) 1 year ago may be so preoccupied by the fear that she too will die of an MI that she ignores the abdominal pain (say it's pancreatitis from a gallstone) and focuses more on the referred pain to her chest. Guess what....everyone (machine included) goes down the wrong path. You can imagine more complex scenarios where the disease is right in front of you, but you can't see it because of the human factor. It takes a skilled clinician to drill down to the facts and find the diagnosis (or him or her subtly noticing that the woman is clutching her belly instead of her chest).
As for your reaction to caffeine, I have never seen that. I doubt that may have, and that little has been written about that***....so I seriously doubt that Watson or this system would help your case as the probability of this being the case is low.
In a broader sense, I will submit that the computer can not infer what is does not "know". A human physician with reasoning can "think outside the box" and form a hypothesis and test it....do you think these systems are capable of this? Yeah....I don't think so, either.
Now, you want to know how I really earn my money? I do it by being critical of the medical literature. It may come a shock to some (but frequent readers of slashdot should not be), but not all articles are of the same caliber or worth. Some are outright fraudulent. My task is to be critical of the literature and to carefully
A) the slashdot title is a little sensationalistic....never did TFA mention diagnosis without a physician in the loop.
B) by what standards was the final diagnosis discovered (i.e. the gold standard)? Another physician? Another program? Was the trial blinded?
C) this article mentions only one disease process - depression, I fail to accept, blindly, that their results can be extrapolated - that is the crux of medical versus scientific research....see D. Not all diagnoses are obtained by just talking with a patient, in fact short of a psychiatric diagnosis, most require a physical exam....and a competent one. Suppose someone is obviously malingering and complaining about abdominal pain....this system would not pick up on malingering and would likely recommend an operation....a totally wrong diagnosis.
D) this is a retrospective study...in medicine, this is not adequate proof of effectiveness.....you need to perform a prospective trial, preferably with randomization and blinding to adequately prove your hypothesis for treatment. Actually, upon re-reading TFA...it was _simulations_ that were performed. This is hardly world class evidence.
E) cost savings were mentioned, but not long term outcomes....who cares if I saved 75% in the cost of treatment if the patient didn't get better in the end. (yes, short term were noted, but anyone who's ever been on long term therapy knows that the short term does not dictate the long term outcome.
F) In life threatening situations - those that require the most expedient decisions, often with less than complete information, this system would be useless because the patient would die in the time it takes you to input the facts.
G) not all situations are cut and dry. I am often consulted to make decisions about patients that are not addressed in any book. In fact, there may be only 1 or 2 journal articles about the problem, and often there are none. Making a decision treatment in the absence of an established precedent is not going to be one of this systems strengths...."Oh, I'm sorry, I can't help you....I just got the blue-screen of death from the program that was supposed to diagnose you!"
H) would this program tolerate patient autonomy? What happens when the patient refuses some or all of the initial treatment plan?
So, while I point out flaws, it is not to say that this is totally without merit....I am merely pointing out the obvious short coming of this article. In certain fields this could be very advantageous.
I will tell you that in my field, this computer program borders on useless. There is very little doubt about what my diagnosis is, and when I am in doubt, my best evidence is collected by doing something. And computers are really a long way away from matching my skill set. A lot of my diagnosis is made by touching the patient during the physical exam. That exam can completely revamp my decision that started based on the history. And, since I am the one performing procedures, I also would not have a machine dictate the exact method that I use - I am the one performing the operation, I do it the way that I know will result in a safe and effective outcome. In my case, I just don't really don't know what this system would provide to me for patients.
But could we make backups? Oh, wait, never mind.
A guy with a PCR machine could make a few billion copies in a few hours....RIAA would have a fit.
But on the other hand....
Just hope a retrovirus doesn't get into your library....
Such a long time, did they already have pen and paper? I can't remember, so much has changed.
Hmmmm....Actually went to medical school > 8 years ago....let me detail somethings that most may not know about it....
1st year for a "traditional" medical school, fall semester is usually biochem and anatomy....both usually involve a lot of diagrams and less note taking. Your prof may or may not have handouts....ours used slides and were just transitioning to powerpoint....no joke...but think about it...not much of that information has changed over the years....esp for anatomy. Biochem, they add on for a (very) few new disease processed, and recently added the HMGCoA pathway.
Spring is usually histology and physiology....again histo is a lot of drawing of cells. Physio is less so, but more flow chart like diagrams. Micro...some note taking some diagrams....Neuro science...._lots_ of diagrams....
2nd year....hardly anyone goes to class....our second year class room was ~1/3 the size of the first year....so small that the entire 2nd year class could not fit into the lecture hall at the same time. I am neither joking nor exaggerating. Fall is pharm...good for notetaking...as is path....spring is a continuation of path and intro clinical medicine....again both are ok for note-taking.
The problem here is also that most schools still have a note-service....this is where someone is responsible for taping the lectures and distributing them out for people to review and type out the notes....the original crowd-sourcing. This is usually why most realize that going to class is rarely helpful.
3rd year....clinicals...ha - forget about note taking....you're on the move constantly, and scribbling furiously on a scrap of paper, and mostly reading out of a pocket sized book when you have those rare moments of down time....that or you're sleeping. The few lectures you have, you'll be too busy eating, or catching up on sleep. No...not kidding here either.
4th year....you pick easy electives, finish your core classes.....the fall you're off interviewing for residency, you hardly ever take notes..."'cause you know it all" already. You're just killing time til you match and then killing more time til you graduate.
Intern year.....you realize you know squat -- just like 3rd year of med school, but now you actually have responsibility! You never get a chance to sit through a lecture cause you're damn pager is going off...during rounds the orders are barked out so quickly, you'll only be able to jot 1/2 of it down on any available scrap of paper....you'll devise your own system of how to handle this....and I assure you....it will not be electronically.
2nd year....you actually find that you did learn something the previous year (must have been via diffusion)....but now you're the one barking orders, or you have a much better idea of what's coming so you rarely have to write much down.
Just my $0.02....YMMV
Source: Spent the last 9 years as a resident/fellow and the 4 years prior to that as a med student....and saw everyone else doing the _same_exact_thing_.
What you cite is "anecdotal evidence" and what works for you, may not work for anyone else...and in fact, you probably ended up removing a number of food sources that contribute to heartburn such as caffeine.
The reason your physicians don't see to care is that they can't generalize the information....so they would be remiss to pass this information on.
Someone could set up a project to research this... but that takes time and money...so who would pay for the study? The corn growers? The makers of proton-pump inhibitors? Neither one cares, and would actually discourage such a study as it would hurt their bottom-line...so the federal government might fund it...but then there are those lovely folk known as lobbyists...I'm sure they would love to push for funding for said research....
Guess I'd have to say, it's just not a hot-button issue.
And for the record, I'm a physician. (But certainly not a primary care physician).
--- From WebMD: (http://www.webmd.com/heartburn-gerd/guide/understanding-heartburn-basics)
What Causes It?
The basic cause of heartburn is an underactive lower esophageal sphincter, or LES, that doesn't tighten as it should. Two excesses often contribute to this problem: too much food in the stomach (overeating) or too much pressure on the stomach (frequently from obesity or pregnancy). Certain foods commonly relax the LES, including tomatoes, citrus fruits, garlic, onions, chocolate, coffee, alcohol, caffeinated products, and peppermint. Dishes high in fats and oils (animal or vegetable) often lead to heartburn, as do certain medications. Stress increases acid production and can cause heartburn. And smoking, which relaxes the LES and stimulates stomach acid, is a major contributor.