Category Archives: General Health

Global Disease Burden

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In 1991, the World Bank and the World Health Organization launched the Global Burden of Disease Study.  A recent article reviews the key findings (NEJM 2013; 369: 448-57).

The goals of the study are to compare the burden of one disease with others; as such, it is “necessary to consider the age at death and life expectancy of persons affected by each disease and to take account of the degree of disability (eg. discomfort, pain, or functional limitations.”  A comprehensive measure of disability, disability-adjusted life-years or DALYs, was used for comparisons.

The study examined 291 types of diseases and injuries as well as 67 risk factors in 187 countries, looking at the years 1990, 2005, and 2010.

Findings:

  • In 2010, there were 2482 million DALYs which is a decrease of 0.6% from 1990.  On the basis of population growth, DALYs would have increased by 37.9% without improvements in disease burden.
  • Major causes of death in 2010: Ischemic heart disease-far ahead #1 (21.1% of deaths, 7850 thousand DALYs), Stroke (6.5% of deaths, 2574 thousand DALYs), Lung/airway cancer (6.1% of deaths, 3033 thousand DALYs), Alzheimer’s (5.9% of deaths, 2022 thousand DALYs), COPD (5.8% of deaths, 3659 thousand DALYs).
  • Global DALYs in 2010 (top ten -starting with #1): Ischemic heart disease, Lower respiratory tract infections, stroke, diarrhea, HIV-AIDs, Malaria, Low Back pain, Preterm birth complications, COPD, and road-traffic injury.
  • Top risk factors (starting with #1): High blood pressure, tobacco smoking (including 2nd-hand smoke), household air pollution, diet low in fruit, alcohol use, high body-mass index, high fasting plasma glucose level, childhood underweight, exposure to outside pollution, physical inactivity, diet high in sodium

Since 1990, there has been a shift.  “In general, communicable, maternal, neonatal, and nutritional conditions decreased in absolute terms.”  The main exceptions were HIV and malaria. Noncommunicable diseases, especially diabetes, have been increasing in terms of percentage and absolute numbers.

Another important change has been a relative increase in disability compared with premature death.  In addition, of the “top 25 causes of years lived with disability, only COPD, diabetes, road-traffic injury, ischemic heart disease, and diarrhea are also among the tope 25 causes of years of life lost.”  “What ails most persons is not necessarily what kills them.”

Bottom-line: While collecting this type of data has many potential limitations, the broad picture it provides should help inform policymakers with priorities for research and intervention.  This data also allows the US to benchmark its efforts compared to other countries.  For example, according to the authors, currently the US has the best global performance with respect to stroke and the worst with respect to lung cancer and Alzheimer’s disease; however, “data and analyses are lacking to elucidate the drivers of these changes in relative performance.”

Fewer Intern Hours & No Change in Patient Safety

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Excerpt from Gastroenterology & Endoscopy News (Shorter Workweeks for Interns Do Not Promote Patient Safety) :

A policy to shorten the workweek for interns in the United States has failed to improve their quality of life and has possibly put patients at greater risk for medical errors, a new study has found (Sen S et al. JAMA Intern Med 2013;173:657-662).

The 2011 policy change, recommended by the Accreditation Council for Graduate Medical Education, capped at 16 continuous hours the longest shift a first-year resident could work in the hope that doing so would ease the strain on physician trainees.

But although the new rules have shortened the typical intern’s workweek from 67 to 64.3 hours, they haven’t encouraged residents to sleep more, helped them to avoid depression or increased their overall sense of well-being, the study found…The study was based on email surveys of 2,323 residents …entered training in 2009, 2010 and 2011, after the rule change.

“Given that increased sleep was a key [mechanism] through which the new duty-hour restrictions were intended to improve the health of residents, the lack of such an effect in the postimplementation cohort in our study is a cause for concern,” wrote the authors, led by Srijan Sen, MD, PhD, a psychiatrist at the University of Michigan in Ann Arbor. “Designing work schedules that account for circadian phase and explicitly training residents on practices to increase sleep time and improve sleep quality may be necessary.”

Linking diet, genes, and gut microbes to…heart disease

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A recent editorial (NEJM 2013; 368: 1647-49) helps explain the link between diet, genes, and gut microbes.  This editorial places in context a study, NEJM 2013; 368: 1575-84).  “The investigators found than dietary choline is metabolized by gut microbes to trimethylamine (TMA), which in turn is absorbed into the host bloodstream and metabolized in the liver to trimethylamine-N-oxide (TMAO).”  TMAO is thought to promote atherogenesis.

The study involved two phases.  In the first, using mass spectrometry, before and after suppression of gut microbes with antibiotics, they showed that a phosphatidylcholine challenge increased all choline metabolites; however, antibiotic use suppressed the formation of TMAO.

In the second phase, they looked at fasting plasma TMAO in relation to cardiovascular events in more than 4000 participants who underwent elective coronary angiography.  They identified an “independent, dose-dependent relationship between TMAO and the risk of a cardiovascular event.”

TMAO levels depend on the interaction between gut microbial production of TMAO which is affected by diet and by host genetic factors. The genetic factors are related to flavin-containing monooxygenases (FMO1 and FMO3); these enzymes oxidize TMA to TMAO are vary significantly in mice (and probably humans). With regard to diet, by limiting choline-rich foods (see links below regarding choline-rich foods) or by using probiotics, this may limit TMAO production and lower the risk of heart disease.

While these observations are intriguing, the mechanisms of TMAO in causing atherosclerosis and its primary function are unknown and much more information is needed to truly make these findings useful.  It is possible that TMAO is simply a biomarker of other factors.

One aside, the editorial states that our gut microbes contain “at least 100 times as many genes as our own genome.”

Take-home message: TMAO is a new potentially modifiable risk factor for atherosclerotic disease.

Related blog links:

Other related links:

Seeing is Believing

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As noted in a recent blog (Food Marketing Detectable on Functional MRI | gutsandgrowth), functional MRI is being studied for a number of applications.  Now, more data has emerged that a “pain signature” can be identified with this technology (NEJM 2014; 368: 1388-97).

Using a series of experiments, the authors enrolled 114 healthy participants and ultimately identified an imaging signature that was associated with heat-induced pain and increased nonlinearly with increasing stimulus intensity.  The first part of the study involved a machine-learning analyses after inducing physical pain by applying heat to the forearm of the participants.  The sensitivity and specificity were 94% or more in discriminating painful heat from nonpainful warmth, pain anticipation, and pain recall.  In the fourth part of the study, the authors showed that the signature response was reduced when an opiod analgesic (remifentanil) was administered.

Because this study enrolled otherwise healthy patients, the results cannot be extrapolated to other populations.  Nevertheless, it is likely that other painful conditions will have unique functional MRI signatures.

Pain is not easy to ascertain and obtaining functional MRIs is not likely to have a role in the near future as a clinical tool.  The concept of identifying a measurable pain biomarker though has been strengthened by this study.

Related blog entry:

Pain changes brain | gutsandgrowth

Why Social Media is Important for Doctors

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The following link is to a NY Times article and below are a few excerpts:

http://well.blogs.nytimes.com/2013/03/21/doctors-and-their-online-reputation/?smid=tw-nytimeshealth&seid=auto

 “While most doctors have come to terms with the fact that their patients routinely go online for information about what ails them, they remain uneasy about a more recent trend: the Internet is quickly becoming the resource of choice for patients to connect with, learn more about and even rate their doctors. And while many have used Facebook, Twitter, LinkedIn or online medical community sites like Sermo to engage with friends and colleagues, few have communicated with patients as, well, doctors. Most abstain for one simple reason: they aren’t sure how to be a doctor online.”
The link discusses a new book by Kevin Pho (KevinMD) and Susan Gay.  “In“Establishing, Managing and Protecting Your Online Reputation: A Social Media Guide for Physicians and Medical Practices,” “Dr. Pho and Ms. Gay offer highly organized key points, useful statistics and exuberant testimonials from doctors who have successfully leapt over the digital divide. There is plenty of practical advice, too, on topics ranging from what to post and when to engage, confer or rebuff, to how to decide what might be unethical or T.M.I. (Answer: ‘Can you say it aloud in a full hospital elevator?”)The book is an excellent and helpful resource. But what elevates it beyond the category of valuable how-to manual is the passionate call to arms that resonates from all those well-enumerated directions and clearly labeled diagrams. Like it or not, the authors warn, the Internet has profoundly changed the patient-doctor relationship, and doctors must embrace its effects on patient care — or risk losing their own influence.'”The article also notes that on the internet many individuals without any scientific background may have equal footing with recognized experts.  Another subject broached in this article is the issue of ranking physicians.”The biggest risk of social media in health care,” they conclude, “is not using it at all.”
Related website resources:

The Difficulty with Drug Development

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Recent statistics from the pharmaceutical industry provide information about why it costs so much (1.2 billion dollars) to develop new medications.

  • Average time for experimental drug to go from lab to patients: 10-15 years
  • Only 5 in 5,000 compounds that enter preclinical testing make it to human testing
  • Only one of those five is approved for use in humans
  • Of approved drugs, only one in five makes more than the costs of development
  • FDA applications typically run more than 100,000 pages

Source: PhRMA Report 2012: Medicines in Development for Cancer

“I want a new drug …
One that don’t cost too much…
I want a new drug
One that does what it should
One that won’t make me feel too bad
One that won’t make me feel too good”

–Huey Lewis and the News: “I want a new drug”

Public Health Casualties: Collateral Damage in the War on Terror

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This week there is a fascinating editorial that I almost skipped because the title didn’t grab my attention: “Ensuring Public Health Neutrality” (NEJM 2013; 368: 1073-1075).

This commentary provides background by recollecting Red Cross relief flights to Biafra being shot down by the Nigerian government. “In the minds of some people, ..these attacks were justified by another clear violation of humanitarian neutrality: on at least one occasion, a plane painted with the Red Cross insignia was actually carrying weapons.”

Fast-forward to January 6, 2013.  12 deans of U.S. schools of public health sent a letter to President Obama protesting the conduct of a sham vaccination campaign as part of the hunt for Osama bin Laden.  Apparently, the CIA hired a Pakistani surgeon to go house to house vaccinating children but also drawing back a little blood in the syringe in order to analyze the DNA.  This ploy was not effective in the bin Laden compound as the surgeon’s team was kicked out.

So what are the consequences?

  • Pakistan has expelled foreign staff of the international aid agency Save the Children (Sept 2012)
  • Eight polio vaccination workers were killed (Dec 2012)
  • U.N. has suspended its polio-eradication efforts in Pakistan.  Pakistan is one of three countries where polio has not been eradicated (Nigeria and Afghanistan are the other two).
  • This undermines vaccination in Pakistan where 150,000 children die of vaccine-preventable illness each year.

Using physicians in this manner violates the Hippocratic Oath: “Whatever house I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice.”

The authors note that “although some U.S. policymakers consider immediate national security concerns a higher priority than long-term global health efforts, the CIA’s false vaccination campaign in Pakistan may cause collateral damage with profound long-term implications for national security.  If every aid worker..is suspected of being a spy, the children..of the world will no longer have protection against our greatest killers.”

Public health neutrality –a different twist to think about while you are watching “Zero Dark Thirty.”

Related links:

New FDA warning for azithromycin (Zithromax)

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“The FDA is warning that a widely used antibiotic from Pfizer can cause rare but deadly heart rhythms in some patients. The agency is adding new warnings to the label of Zithromax, which is used to treat bronchitis, pneumonia and other infections.

Doctors should consider prescribing other antibiotics to patients at risk of heart problems, including those with irregular heartbeats or low levels of potassium or magnesium in their blood. Zithromax is popular because it often can be taken for fewer days than other antibiotics. The warning may prompt doctors to choose other options, though the new label notes that other antibiotics have similar effects on the heart.”

Read more here: http://www.thenewstribune.com/2013/03/13/2511288/fda-issues-warning-about-zithromax.html#storylink=cpy

Also from previous FDA statement:
[05-17-2012] “The U.S. Food and Drug Administration (FDA) is
aware of the study published in the New England Journal of Medicine,
on May 17, 20121, that compared the risks of cardiovascular death in patients treated with azithromycin (Zithromax), amoxicillin, ciprofloxacin (Cipro), levofloxacin (Levaquin), and no antibacterial drug.  The study reported a small increase in cardiovascular
deaths, and in the risk of death from any cause, in persons treated with a 5-day
course of azithromycin (Zithromax) compared to persons treated with amoxicillin,
ciprofloxacin, or no drug. The risks of cardiovascular death associated with
levofloxacin treatment were similar to those associated with azithromycin
treatment.”  Thus, levofloxacin also was associated with an increased risk.
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Build the information medical highway and expect more traffic

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A recent article indicates that increased patient access to online records was associated with increased in-person and telephone contacts (JAMA 2012; 308: 2012-19).

Background (from study introduction): The Institute of Medicine’s report on “Crossing the Quality Chasm” indicated that electronic patient-physician messaging was a promising technology to improve quality and efficiency.  Furthermore, previous studies have suggested that 25-70% of all visits to physicians do not require face-to-face appointments.

Design: To explore this topic further, the authors performed a retrospective cohort study on the use of health care services between 2005-2010 at Kaiser Permanente in Colorado.  This study examined patients ≥18 years old and looked at health care utilization before and after initiation of MyHealthManager (MHM). Users of MHM were compared with nonusers.  And, both groups (users and nonusers) were examined with regard to their health care utilization before and after MHM rollout. The first 30 days before and after activation of MHM were excluded from analysis to minimize the effect of increased utilization at the initiation of MHM.

Results:

  • By June 2009, patient use of MHM had increased to 53.8%.  In total, 87,206 MHM patients were identified and 71,663 nonusers were identified for study participation. 
  • MHM users were slightly older and more likely to be female.
  • After initiation of MHM, the rate of office visits increased by 0.7 per member per year (p<0.001) and the number of telephone encounters increased by 0.3 per member per year (p<0.001).  
  • The authors breakdown this data based on age, absence of chronic disease, presence of specific diseases (diabetes, coronary artery disease, congestive heart failure).  In all of these scenarios, MHM users had increased visits after initiation of MHM.  Nonusers generally had the same or less visits at the same time.
  • Figure 2 shows that MHM and nonusers had identical health care utilization beforehand.  Afterwards, the MHM users maintained a parallel line of increased usage that was fairly consistent for a year after rollout.

Why did this happen?  The authors note that the result was contrary to their expectations.  They speculate that individuals may have increased their in-person use after developing additional concerns following their review of information online and that individuals may sign up who are already more likely to use services.  Online access, in these individuals, may facilitate access to more frequent visits.

I think this article points to a more pervasive miscalculation of the effect of information technology and health care utilization.  While electronic health records (EHRs) can help organize and communicate vast amounts of information, the proposition that they will ultimately reduce health care costs/utilization or improve efficiency is looking dubious.  In my opinion, the best we can hope for is that EHRs, when used optimally, will improve the quality of the care.  It is equally possible, however, that EHRs could result in more legible but less accurate information due to well-recognized issues like copy-forwarding with inadequate editing.

Related blog posts:

Global Justice and Vaccine Policy

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I definitely was piqued by the editorial titled “Global Justice and the Proposed Ban on Thimerosal-Containing Vaccines.” (Pediatrics 2013; 131: 154-156) I wondered how vaccine policy could affect global justice.

In high-income countries, vaccines have shifted increasingly to preservative-free single-dose vials.  Whereas in poorer countries, vaccines have continued to rely on multidose vials which frequently contain thimerosal as a preservative.  The move away from thimerosal which contains ethyl mercury “was a precautionary move in response to theoretical concerns, now known to be unfounded.”

Currently, a multinational environmental treaty is close to finalization and this treaty aims to restrict human and environmental exposure to mercury.  The World Health Organization and the broader public health community have recommended that thimerosal be exempt from the treaty to avoid disruption in the global vaccine supply.  However, some nongovernmental groups have objected to the use of thimerosal in poorer countries when it has been phased out in wealthier countries.

Why Thimerosal Should be Exempt from this Ban:

  • No credible scientific evidence of any risk to human health from thimerosal
  • Vaccines with thimerosal are used in >120 countries to immunize ~84 million children every year.  It is estimated that these vaccines save 1.4 million children every year.
  • Potential vaccines affected include hepatitis B, tetanus, and diptheria-tetanus-pertutsis
  • “Although there are other preservatives…, none are yet viable alternatives to thimerosal”

The individuals and organizations who have opposed thimerosal come from wealthier countries and would not suffer the consequences of a potential ban.  “Where’s the justice in that?”

Related references:

  • Pediatrics 2013; 131: 149-151. Public health experts recommend the ongoing use of thimerosal as a preservative.
  • Pediatrics 2013; 131: 152-153.  Provides context for previous AAP joint statement on thimerosal in 1999.

Related blog entry:

Vaccine successes and ambitions | gutsandgrowth