Transcript Oprafication of Medicine

News You Can Use
AAOM
December 2013 Online Journal
DL Harshfield MD MS
Director of Integrative Imaging
College of Integrative Medicine- coimed.org
Little Rock, Arkansas
Cognition and Vision
New Cholesterol Guidelines Abandon
LDL Targets
More Than a Billion People Taking Statins?:
Potential Implications of the New
Cardiovascular Guidelines
The American College of Cardiology/American Heart
Association (ACC/AHA) guidelines on assessment of
cardiovascular risk1 and on treatment of blood cholesterol,
which included recommendations for primary prevention with
statins,2 came under intense criticism immediately with their
release. Main concerns focused on flawed methods
(problems with the risk calculation),3 ethics (conflicts of
interest),4 and inferences (too many people offered
treatment).
With potentially more than 1 billion people caught in the statin
dilemma, there should be hundreds of thousands of
interested participants for such trials.
With expanded target populations and more affordable generic
prices, the cumulative global sales of statins may approach
$1 trillion by 2020. Lipitor sales alone exceeded $120 billion
between 1996 and 2011.
More Than a Billion People Taking Statins?:
Potential Implications of the New
Cardiovascular Guidelines
New recommendations on hypertension management in older people released.
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The New York Times (12/19, A23, Kolata, Subscription Publication) reports that “new guidelines suggest that
people over 60 can have a higher blood pressure than previously recommended before starting treatment to
lower it.” The guidelines committee, “composed of 17 academics, was tasked with updating guidelines last reexamined a decade ago.” The recommendations were “published online on Wednesday in The Journal of the
American Medical Association.”
The AP (12/19) reports that “the panel completed its work earlier this year, around the same time that the
National Heart, Lung and Blood Institute announced that it was getting out of the guidelines business and
turning the job over to the American Heart Association and American College of Cardiology.”
The Wall Street Journal (12/19, A2, Winslow, Subscription Publication) points out that neither the
American College of Cardiology nor the American Heart Association vetted the document, nor did the NHLBI.
The Los Angeles Times (12/19, Kaplan) “Science Times” blog reports that “rather than aim for a target
blood pressure of 140/90 mm Hg, the target will be relaxed slightly to 150/90 mm Hg, according to” the “new
guidelines.” The guidelines’ authors “emphasized that they were not changing the definition of high blood
pressure.” Instead, “they are recognizing that data from randomized clinical trials do not show that using drugs
to nudge down systolic blood pressure from 150 to 140 provides any health benefit.”
Bloomberg News (12/19, Cortez) reports that individuals aged “60 and older were focused on in the
guidelines because they ‘are a unique population and we are concerned about the number of medications that
may be required,’ said Paul James, the lead author of the article.”
According to the Boston Globe (12/19, Kotz), “a number of cardiologists...complained that the new
guideline was not issued by any major medical group or government entity.”
Harlan Krumholz, MD, discusses the guidelines in the New York Times (12/19) “Well” blog. Also covering
the story are CNN (12/19, Willingham), MedPage Today (12/19, Neale), and HealthDay (12/19, Thompson).
Population Medicine
ESC/ESH Blood Pressure Guidelines
• Currently we have European Society of
Cardiology/European Society of Hypertension
guidelines stating that blood pressure should be
less than 140 mm/Hg for all.
• Now, if you go through the guidelines it talks about
how those over 80 years...are exempt, but why do
we have to have this "for-all" approach?
• That is just not working, it's not right; it's basically
the structure of guidelines that doesn't respect the
individuality of what's unique about us biologically,
physiologically, and anatomically -- our
environment, everything.
Probiotics and the Brain, Cinnamon and
Diabetes Meds
Population Medicine
Demand for Specialists Will Outpace Primary
Care by 2025
• The demand for adult primary care
services will grow by 14% in the next 12
years, according to a study published
online November 4 in Health Affairs.
• However, with an aging population and
expanded medical coverage, demand will
grow even more markedly for specialized
services.
http://content.healthaffairs.org/content/32/11/2013.abstract
Population Medicine
To estimate future demand, the investigators took into
account numerous factors, including:
• In just 12 years, the US population will have increased by
9.5%, and the population aged 65 years and older will
grow by 45%, according to US Census Bureau
projections.
• The population with Parkinson's disease is projected to
increase by 68% between 2010 and 2030.
• By 2025, the elderly population with Alzheimer's
disease is expected to increase 40%, according to the
Alzheimer's Association.
• The National Cancer Institute projects 18.1 million more
cancer survivors by 2020 (up 30% from 2010).
• The proportion of elderly Americans with chronic disease
rose from 86.9% in 1998 to 92.2% in 2008.
http://content.healthaffairs.org/content/32/11/2013.abstract
Population Medicine
Oprafication of Medicine
• Another part of the story that seems to have had a
big impact in the United States is the Oprah effect
of creating monsters.
• There are 3 physicians that she brought to the
forefront:
1. Mehmet Oz,
2. Andrew Weil, and
3. Deepak Chopra.
• And it seems like all 3 of them had a big
amplification of their impact -- if not even the
beginning of their stardom -- with Oprah.
Population Medicine
Oprafication of Medicine
What Oz and Chopra and Weil all have in common
is this notion of medicine as a guru, sort of,
"Listen to me."
And medicine is not that. Science is viewed by
some as distant, technological, and cold.
If you remember the TV show Star Trek, but there
was the doctor on that show -- Bones McCoy. He
would take this scanning device, and he would
scan up and down, look on that device, and that
was the diagnosis. It was immutable. It was
clear. There wasn't any question about it, and
that is just not medicine.
What people like Oprah, and like Oz, Chopra, and
Weil, do is imbue their medicine with a kind of
spirituality.
It becomes a matter of them and their personality
rather than the data, which is always a little
dangerous.
Population Medicine
People will say you can't trust science because, for
example, one study will show one thing, and then
that study will be shown to be incorrect.
But that that is good: That means that science is selfcorrecting.
We can take a textbook and throw it over our shoulder
without a backward glance as we get more and
more information, but to some people that
mutability and fluidity is viewed as disconcerting.
They want something that is surer, and these people
provide that in their books. You look at Andrew
Weil's books. He tells you how to be a friend, he
tells you how to make low-fat salad dressing, he
tells you how to live your life -- and that is
attractive.
Population Medicine
Alternative Medicine and Celebrities
Siddhartha Mukherjee is a Rhodes Scholar wrote a
wonderful book on cancer, The Emperor of All
Maladies . He trained at Cambridge and then
Harvard. He has an expertise and experience in
cancer. He wrote a Pulitzer Prize-winning book that
really explained cancer for the general public.
And yet he is not the person the media go to when
they are trying to explain cancer; it is Suzanne
Somers. And who is she? She was Chrissy on
Three's Company. She was the promoter of the
ThighMaster. That is what recommends her to the
population as an expert in cancer, but it has always
been true. I don't see that changing.
Population Medicine
• The paper in the New England Journal of Medicine
on a big Italian study that showed that fish oil didn't
do anything for preventing heart disease.
/viewarticle/803823
• And there were recent studies that showed that at
least the antioxidant part of omega-3 fatty acids
actually could increase your risk for such things as
cancer.
/viewarticle/808139
Population Medicine
'Our' Brains on Coffee
• The New York Times, June 6, 2013: "This
Is Your Brain on Coffee" -- why drinking 3
cups a day may be good for us.
• Well, does that take into account that at
least 20% of people carry an allele where
the metabolism of caffeine is markedly
reduced, and that risk allele has indeed
been linked to a higher risk of heart
attack?
• Why should there be a recommendation
now that all of us should be drinking 3
cups of coffee a day?
Population Medicine
Salt Guidelines
• Then in May of this year there was a big Institute of
Medicine report regarding what should be the salt
guidelines.
• And this got all sorts of organizations rankled -- the
American Heart Association [for instance] -- about
what should be the salt recommendations for
everyone.
• This is crazy stuff, because we know that there are
some people who are remarkably salt-sensitive and
will have a blood-pressure response to a salt load,
and then there are many others who are what
essentially appears to be salt-resistant, as they can
have as much salt in their diet as possible and it's
not going to have an effect on their blood pressure.
Population Medicine
The Confusion Over Vitamin D
There is a lot of confusion about what should be a
population level of vitamin D that is good for people.
Suddenly we are all vitamin D deficient, and the level has
changed and now the normal range has been revised so
that everybody seems to be vitamin D deficient.
Certainly, vitamin D is of value for the child who is
exclusively breastfed. The mother doesn't get outside
very much. The child doesn't get outside very much.
Absolutely, vitamin D is of value there.
Otherwise, regarding bone thinning -- the use of vitamin D
plus calcium – the data just aren't clear and are certainly
not compelling,
10 years from now we are going to look back and ask,
"What is this vitamin D craze?" and be past it.
Population Medicine
The antiaging industry
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$6 billion-a-year industry
The notion that we can in some ways turn
back the clock has been something that
has been attractive to us ever since the
days of Ponce de Leon.
• We are always looking for the fountain of
youth, and we do live longer than we used
to, but the reason that we live longer
than we used to has everything to do
with the way that we live and nothing to
do with the way that we age.
Population Medicine
The antiaging industry
• We have had vaccines.
• We exercise more.
• We are more careful about our diet, about
eating more fruits and vegetables.
• We try to avoid stress.
• All of that has contributed to our living
longer, and this entire antiaging industry
has really contributed nothing to why
we live longer.
Population Medicine
Dietary Supplement industry
$34 billion-a-year industry.
54,000 dietary supplements on the market.
The problem with the industry is that it is unregulated.
The Cartel of vitamin supplement companies came
together in Santa Barbara and put out a big
campaign with Mel Gibson [featured in
commercials].
Senator Orrin Hatch (R, Utah) [and his role in the
Dietary Supplement Health and Education Act of
1994 (DSHEA).
The politics and the background that has prevented
the US Food and Drug Administration (FDA) from
having oversight of this enormous area of health
and medicine.
Population Medicine
Dietary Supplement industry
a lot of people making a lot of money,
including big pharmaceutical
companies. Pfizer bought Alacer
recently, which is probably the biggest
maker of megavitamins in the United
States.
Hoffmann-La Roche has been a player in
the megavitamin and supplement game
since the 1930s.
Population Medicine
Dangerous Side Effects of Little
Consequence
Now there are more than 20 studies to show
that if you take large quantities of vitamin
A or vitamin E or beta-carotene, which is a
vitamin A precursor, you actually increase
your risk for cancer and increase your risk
for heart disease.
Population Medicine
Meditation and the Placebo Response
The placebo response and the physiology of
the placebo response is physiologically
based.
We need a word that is different from
"placebo," because when people hear that
word, they think it is dismissive -- that it is
just all in their heads.
Population Medicine
Theranos Wellness Centers
Rebooting of laboratory medicine, and if there ever
was a portion of medicine that probably needed
creative destruction, this was it
Wellness centers are next to the pharmacy inside of
these retail locations. There is a tremendous
amount of knowledge in the pharmacist, and so we
have trained and certified phlebotomists or other
appropriately state-certified personnel.
But we are also leveraging the expertise of the
pharmacist in being able to provide a care
framework for the patients who come in to do their
tests.
And that is something that we think is a wonderful
application of the talent that exists in these
pharmacies with respect to being able to have that
level of oversight and care.
Population Medicine
Theranos Wellness Centers
We can take a tiny sample and do not need dedicated
tubes of blood for each type of test that we run.
We can, on a given ‘painless’ finger stick sample,
automatically run to other assay methodologies that
traditionally would require a separate draw, which
means that if something is out of range, we can, on
the same sample, run tests that a physician would
like to have ordered to better figure out why it's out
of range.
For example, in the morning a patient could come to a
wellness center and we could draw a sample. The
physician could say on their requisition that if this is
out of range, automatically run this other test.
And that afternoon, when the physician sees the
patient, they have all of that information
Population Medicine
23andMe
• At this time, we have suspended our health-related
genetic tests to comply with the U.S. Food and Drug
Administration’s directive to discontinue new consumer
access during our regulatory review process.
• Current 23andMe customers who received health-related
results prior to November 22, 2013 will continue to have
access to that information. However, no new healthrelated updates will be provided to your account.
• Customers who purchased kits before November 22, 2013
will still receive health-related results.
• We are continuing to provide you with both ancestryrelated genetic tests and raw genetic data, without
23andMe’s interpretation.
Population Medicine
The Out-of-Hospital Experience
• The structural icons of medicine are undergoing
reassessment. What do we do with hospitals
and clinics in a digital medicine world.
• We should start delivering healthcare "farther
and farther" from the hospital setting and "even
out of doctors' offices.“
• Over 70% of patients would prefer a virtual
rather than a physical office visit.
• A large Intel poll of 12,000 consumers found that
most believe that hospitals as we know them
today will be "obsolete in the near future."
Population Medicine
Tracking the Human Body
The FDA approval of smartphone ECGs and
digitized pills heralded the beginning of many
more novel digital ways that we will be tracking
patients in the future. A watch that passively and
continuously captures blood pressure from
every heartbeat is just around the corner.
We don't even know what "normal" blood pressure
is when it can be assessed 24/7, throughout the
night, and during any time of stress, and this is
representative of what the era of wireless sensor
tracking will bring.
Detecting objects as
small as protein
molecules using
multispectral
imaging
“Raman scattering provides
information on the ways
molecules vibrate, which is
equivalent to taking their
fingerprint. It’s a bit like a bar
code,” said Martel. “Raman
signals are specific for each
molecule and thus useful in
identifying these molecules.”
A nanoprobe, consisting of a dye
encapsulated in a carbon nanotube
(credit: Universite de Montreal)
New Insights into the Dementia
Epidemic
• Described in the early 1980s as “The
Silent Epidemic,” dementia in the elderly
will soon become a clarion call for public
health experts worldwide.
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The Sunshine Act
A provision of the Affordable Care Act (ACA) seeks to expose
financial dealing between industry and physicians and
discourage conflicts of interest for the latter.
The world will always be governed by selfinterest: we should not try to stop this: we
should try and make the self-interest of
cads a little more coincident with that of
decent people.
--Samuel Butler
Will disruptive
innovations cure
health care?
Harvard Business School, Boston, USA.
It's no secret that health care delivery is convoluted, expensive, and
often deeply dissatisfying to consumers. But what is less obvious is
that a way out of this crisis exists. Simpler alternatives to expensive
care are already here--everything from $5 eyeglasses that people can
use to correct their own vision to angioplasty instead of open-heart
surgery.
Just as the PC replaced the mainframe and the telephone replaced the
telegraph operator, disruptive innovations are changing the landscape
of health care. Nurse practitioners, general practitioners, and even
patients can do things in less-expensive, decentralized settings that
could once be performed only by expensive specialists in centralized,
inconvenient locations. But established institutions--teaching
hospitals, medical schools, insurance companies, and managed care
facilities--are fighting these innovations tooth and nail. Instead of
embracing change, they're turning the thumbscrews on their old
processes--laying off workers, delaying payments, merging, and
adding layers of overhead workers. Not only is this at the root of
consumer dissatisfaction with the present system, it sows the seeds
of its own destruction.
The history of disruptive innovations tells us that incumbent
institutions will be replaced with ones whose business models are
appropriate to the new technologies and markets. Instead of working
to preserve the existing systems, regulators, physicians, and
pharmaceutical companies need to ask how they can enable more
disruptive innovations to emerge. If the natural process of disruption
is allowed to proceed, the result will be higher quality, lower cost,
more convenient health care for everyone.