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Comment Re:Better model? (Score 1) 245 245

We have one incident where a pilot crashed a plane, which doesn't seem to equate to the entire aviation safety system being irretrievably broken. We had people knowing that pilot was depressed, but I'm not aware of him repeatedly telling people he was going to do something terrible nd take the lives of innocents one day soon.

We also have evidence that enacting checklists in hospitals (a la the Checklist Manifesto) didn't actually change much in practice, at least as currently implemented, so what works for aviation safety may not be directly analogous to what works in hospital safety, which is a rather different question in any event as to how to provide safe, cost-effective care. (One could safely perform a lot of pointless knee and heart surgery, for example, with low complication rates, that didn't provide any significant benefit in the first place.)

I think the idea of paying physicians for quality rather than quantity is a good one. There are plenty of honest physicians who don't game the current system (and in the realm of primary care it's not easy - your pediatrician can't schedule too many extra checkups for profit) but there are others who convince themselves that offering patients what they want, even if it's expensive and the evidence isn't great is giving the customer what they want.

Developing accurate measures of quality and utility and risk adjustment is not going to be easy, and the pathway is littered with mistakes. Us primary care physicians were tasked up until the last couple of years to keep our diabetics in tight control, until we just recently figured out that probably did more harm than good for most people. That's science for you: the questions tend to stay the same, but the answers keep changing. We may be bumbling forward, but it does seem to be (generally) forward.

Comment Re:Why? (Score 3, Interesting) 166 166

As noted above, MUMPS (in the guise of Intersystems' Caché) is the database underlying both the VA's Vista and Epic Systems' Epic, which are probably the two leading large-scale EMR vendors on the planet. My 5 state hospital system uses the latter, having upgraded from a system that just handled part of one state and ran on top of Oracle and would regularly slow to a crawl. I don't know how much of Intersystem's marketing-speak to believe, but for a gigantic disparate database of branching nodes of something on the order of a million patients and all their chart notes, telemetry data for those who have been hospitalized, lab results and links out to everything from fetal heart tracings to MRI's, the thing is fast and seems to be close to bullet-proof. MUMPS itself is scary (to me, anyway) with its global variables and odd syntax, and I have a few bones to pick about the interface, but the database layer is really remarkable.

Comment Re:Which vaccines? (Score 1) 616 616

I didn't (initially) wish to comment on forcing anyone to use a vaccine, only to your contention that HPV is neither contagious or deadly, when it's manifestly both. As to whether sexually transmitted infections don't represent imminent threats, HPV is about as contagious and dangerous as other viral diseases with latent courses, such as hepatitis B (transmitted through sex, vertical transmission from mother to newborn, and shared needles - but not by coughing at Disneyland), vaccination for which has long been required in every state I've worked in.

Other sexually transmitted viruses (like HIV) can reasonably be construed to present imminent threats in areas and among populations where they are endemic.

I suppose it's reasonable to argue we should make a list of which vaccines are required for school entry and which aren't. You mentioned flu vaccine above, for example, which has varying efficacy depending on antigenic drift of the virus from year to year, though even in bad years the vaccine seems to be effective at preventing invasive (deadly) disease in high risk populations, which include young children. Should we cross vaccines off the list if they are periodically less effective (but still effective) some years even though the disease is still deadly and manifestly contagious? Should we eliminate hep A because even though it's contagious it's just about never deadly? Or do we keep things simple and state we should vaccinate kids against diseases that are either manifestly contagious and onerous, deadly, or both?

I've periodically have patients dying of HPV-related cancers - not a lot, but it's out there. I suspect they would have appreciated universal vaccination had it been available for them before their first sexual contact and while they were getting routine childhood doctor visits, after which the utility of the vaccine goes down substantially.

Comment Re:Which vaccines? (Score 1) 616 616

HPV prevalence is about 70% in sexually active young people. HPV causes about 6100 deaths per year, and about 26900 cases of cancer per year in the US. Most deaths, however, occur in low-income countries - about">270,000 per year worldwide in 2012 for cervical cancer alone according to the World Health Organization.

So, I think it's reasonable to conclude HPV is indeed contagious, common and deadly. Also, in my experience (as a primary care physician), most people are enthusiastic about the idea of making Pap smears obsolete, which is a distinct possibility with widespread use of HPV vaccine.

Comment Re:I got a butt chewing for giving my daughter hon (Score 1) 243 243

We hold off on cow's milk until 1 year not so much because of allergic reactions but because it's associated with iron deficiency anemia. (And increased renal solute load.) From Agostoni C, et al, J Pediatr Gastroenterol Nutr. 2008;46(1):99: Cow's milk is a poor source of iron and should not be used as the main drink before 12 months, although small volumes may be added to complementary foods. Infant formula in most countries is supplemented with iron. Breast milk isn't exactly rich in iron, but harder for most babies to fall in love with and drink in unlimited amounts to the exclusions of everything else (a common happenstance) due to manufacturing limitations (which, granted, vary depending on the mom).

Comment Re:Not the real problem (Score 1) 1051 1051

Taking care of quite a few un-documented immigrants in my medical practice, I find that vaccination rates are typically pretty good, and parents are thoughtful enough to bring in their immunization cards (and their vaccine schedule is similar to ours, only we vaccinate for chickenpox and they vaccinate for tuberculosis). The Mexican immunization program in particular (at least according to the Houston Chronicle) does significantly better than the US one.

MONTERREY, MEXICO – If parents here are late getting their child inoculated, a public-health nurse will come to their home, pull down the youngster's pants and give the vaccination right there in the living room. If the parents are away at work, the nurse does not wait for them to come home and give permission. Shots are given anyway, and the paperwork is left with the baby sitter. It is a paternalistic approach almost impossible to imagine in the United States - where privacy rights and other freedoms are highly valued and immunizations are increasingly feared - but it has proved remarkably effective: Mexico has a 96 percent vaccination rate for children ages 1 to 4, compared with an immunization rate of 79 percent for 2-year-olds in the United States.

Comment Re:Redistribution (Score 1) 739 739

Among my commercially insured patients there's a mix of folks who are happier, angrier or ambivalent about changes in their coverage. For some folks things have gotten better (especially among the individually insured whose risk is now spread around) and for many worse, though worsening coverage with each passing year has been the rule.

Regrettably, the cost of insurance comes up frequently in my practice by necessity. Not just with figuring out which medicines an insurance company will reimburse for (down to needing to figure out if they prefer I prescribe capsules vs tablets of the sane medicine) but which procedures are reimbursable, which specialists they can see, how they get psychotherapy, if they can afford a followup visit with me, how their colonoscopy might get billed, or if their finances will be nuked to high heaven if they end up in the emergency department of hospital.

14 years ago in residency I did a rotation in Ireland and was amazed how much different practice was there (at least in rural County Clare) than what I'm used to in the US. Our copay here cost the same as the cost of their entire visit. The state paid for hospitalizations for everyone. Dr Gerry ran his entire practice on a 500 Euro piece of software with one nice lady in the front office and he got paid about the same as his US peers. He also had a nurse who handled much of the lady business. 16 year old girls were counseled on not imbibing more than two (imperial) pints a night.

Here, we need about 5 support people per primary physician to handle all the rules, paperwork, insurance reimbursement, claims and billing; and our computer system costs something on the order for $30,000 per doc per year all told. The Irish marveled at tales of how nuts our system is. Canadians (politely) make fun of it when we're at the same conferences. Seriously, WTF?

Comment Re:Redistribution (Score 5, Informative) 739 739

As a physician, the new system doesn't feel particularly more intrusive than what we had previously. What we do have is a lot of new patients who were previously uninsured. They don't seem angry about it; they seem happy (to a person, at least amongst the newly insured). And we can get to work preventing their modest problems from turning into gigantic, expensive once that got handled "for free" in the emergency department by spreading the cost of their uncompensated care around to everyone else.

Some of our previously insured patients seemed miffed because, just like before, medical care is expensive and the system is complicated. Some of them who used to blame the insurance companies now blame Obamacare.

Comment Re:rare or just not looked for? (Score 1) 75 75

I hope you'll (all) forgive me for furthering this part of the discussion, but in my line of work I continue to be mystified about how, say, sin brought about by mankind can result in two very nice, even very religiously adherent parents having a fetus who gets pretty severely bollixed (via isoalloimmunization as above, or the odd infection crossing the placenta, or a bit of chromosome scrambling) and dies before being born? (Or just about as bad, dies in their parents arms shortly after being born?)

My sincere apologies if you think I don't care about this question; it's one of several I care about very much and have great difficulty reconciling. The hospital chaplains' best explanations have amounted to, "Jesus said 'Suffer little children, and forbid them not, to come unto me., for such is the kingdom of heaven." Realizing that KJV usage has a different connotation for suffering, there's still a lot of suffering. I've never thought to say to one of these parents that this must be the result of sin. If you have a better explanation I could use to comfort the afflicted - afflicted, in this view, somehow by original sin which seems awfully distant - I'd love to hear it.

Comment Re:rare or just not looked for? (Score 5, Informative) 75 75

In the US, when you donate blood, you'll be tested for ABO/Rh, and some of the more "minor" blood antigens (minor insofar as they are less frequently implicated in transfusion reactions and pregnancy-related alloimmunization. Most pregnant women will get, in addition to ABO and Rh-D testing, tested with an antibody screen for sensitivity to antigens from other alleles on the Rh locus, Rh-C and Rh-E. The antibody screen also tests for anti-Kell (anti-K, typically the worst of the more minor antigens; we're taught "Kell kills"), anti-Duffy (Fy(a) and Fy(b)), and sometimes anti-Kidd antigens, and once in a while you'll see anti-P, anti MNS, and anti-Lewis, which typically cause little or no harm. (See this Medscape article for a few details.)

The deal is if you are (say) an Rh positive fetus in an Rh negative mom who was previously exposed to another fetus's D antigens (and D is often the culprit) you can get your blood cells nailed by mom's previously-formed anti-D antibodies. You get anemia, jaundice as well, and the potential various bad side effects therefrom (heart damage, brain damage, swelling all over[may not be safe for work]). Similar havoc ensues with anti-K. Preventive therapy with RhoGAM is available to prevent anti-D disease; it's a soup of anti-D antibodies that scavenge any fetal Rh-D positive blood cells that happen to find their way into mom's circulation. It's produced from pooled human blood plasma, though even most Jehovah's Witnesses (since a 1974 church opinion) and Jews (because there's an escape hatch in kashrut for saving human life) find it acceptable for treatment in order to prevent this fairly terrifying surprise G-d had in store for a few unlucky babies.

Comment Re:Interesting idea but likely horrific in practic (Score 1) 302 302

I think you're probably right in a lot of cases, but what I think this proposal is getting at is that right now we have a single contraceptive implant on the market that needs to be swapped out every 3 years. And, swapping it out means numbing up the area (which smarts), making a 1 cm incision with an 11 blade and fishing around with mosquito clamps to get the Nexplanon out which is often encapsulated with connective tissue and it doesn't want to come out, then injecting another one in. What if it could be turned on and off according to whether the woman wanted to have kids or was abstinent for awhile, so then we can avoid excess poking and prodding and hormones? If we could make that secure, would it be worth it? The cost of the Nexplanon in the US isn't much related to its materials (perhaps $5) as to the research costs and insurance and pharmaceutical company marble toilets with gold handles ($700). Couldn't an electronic Nexplanon with extended duration reasonably be cost effective if we can avoid the excess minor surgery, physician visits, and unintended babies?

Comment Re:Hmm (Score 2) 302 302

Strictly speaking, in the US, we're not paying people to have kids but paying for people who have already had kids to have baby food and clothing and medical care. Even in places where people don't get government support for their kids, they still have plenty of kids - as I think you may be alluding to in your second paragraph but I confess confusion about how reactionary undereducated dicks are particular to Pakastani folks and not, say, Kentuckians.

Government-supported access to contraception is likely highly cost effective - it makes not just intuitive sense, but studies seem to bear this out. Without all the bother of just letting teen moms and their homeless kids, you know, die in the streets and spread measles all around.

Comment Re:Mexico Vaccinates Better Than The US (Score 1) 387 387

In the Unicef document I referenced, the definition given is: "DPT3 - Percentage of infants that received three doses of diphtheria, pertussis (whooping cough) and tetanus vaccine," 99% for Mexico in 2012, and 95% for the US, respectively. The way I'm reading that the Government funding of vaccines is simply the percentage of those given that were funded by the government, like the Vaccines for Children Program in the US (which funds Medicaid and uninsured vaccines), but that 95% percent of the vaccines (say, in the US) were given by VFC - it's closer to 50%. In any event, the WHO numbers you cited are from the same source - it's just that from 2012 to 2013, Mexico went from 99 to 86% DTP3 coverage, and the US from 96 to 94%. The overall trend from 2000 is still 94-96% for the US, whereas Mexico was 97-99% until 2013. I don't know what happened in 2013; I practice family medicine in the Pacific Northwest, in a clinic that serves a large immigrant population, and have gotten a fair amount of practice scrutinizing foreign pediatric immunization cards. I think you may have misread the data source explanations in the Unicef document. I can tell you that, in general, in my experience, my Mexican families think vaccines are a good way to protect their kids. My upper class white families tend to have considerably more skepticism.

Comment Re:Mexico Vaccinates Better Than The US (Score 1) 387 387

You might look into the epidemiology of tuberculosis - where the US vaccination rate (of BCG vaccine for TB) is about 0, and it's on the standard schedule of vaccinations in Mexico. There's no particularly good vaccine for TB, but it's the US that has the whooping cough epidemic, not Mexico. See

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