Archive | September 2012

The challenge of rational medicine’s journey from patient- to pathogen-specific

Recently, the New England Journal of Medicine (NEJM) released their 200th anniversary article titled, “Therapeutic Evolution and the Challenge of Rational Medicine,” by Greene et al. [1].  This article gives us a walkthrough of how medicine has evolved in the past 200 years: specifically, from patient-centered in approximately the first century and a half, to pathogen-centered in the last fifty or so years. Traditionally, western doctors had an in-depth knowledge of herbs — and a wide range of (often bizarre) treatments, ranging from the application of the “Devil’s dung” plant to the practice of bloodletting, i.e. “breathing a vein,” to assist in the curing of a disease. While some of these treatments are arguably questionable, specifically the well-versed knowledge of traditional western doctors focused more on the human perspective, and, as a result, may have been a vital ingredient to the overall well-being of the patient. This component appears lost today — where our healers are efficaciously oriented toward targeting a specific pathogen, with very specific aims. This compartmentalization of focus (generating doctors with specific knowledge about specific subjects) leaves patients with any other possible ailments or concerns to hang in the dark. While the light of the brilliant doctor who shines in his specific field of focus may isolate and treat the primary cause of a disease, the flashlight he is shining with on the patient may just as well blind the patient to any other factors just as important that could improve general well-being. The flashlight will of course cast shadows of its own. As the article in NEJM subtly points out, there can be no medicine without both therapeutic enthusiasm and therapeutic skepticism, and skepticism has flourished in the rationale of science ever since the chilling specter emerged from medicines such as thalidomide, Diethylstilbestrol, Vioxx, and Avandia [ibid]. These drugs were developed for specific purposes, i.e. to prevent morning tiredness, to act as an antidiabetic, etc., and while the focus of developing these drugs may have been done through well intention, the outcomes clearly revealed something menacing lurking in the shadows.

“As the locus of disease has narrowed from the afflicted person to the molecular mechanism, and the target of magic bullets has followed suit, physicians have faced regular reminders of the limits of the reductionist approach.” [1]

As we have been endlessly discovering smaller and smaller particles; and smaller and smaller actions that lead to larger reactions, one might wonder if this approach is the best to solely focus on. What may be an additional approach more fitting for our new century?  The Shanghai Center for Systems Biomedicine has released an interesting article titled, “Toward new drugs for the human and non-human cells in people,” by Zhao et al. [2]. This explores the realization that the human body is only sparsely comprised of actual “human” cells. There is in fact a multitude of lifeforms that live within us and work in synergy with our body. For example, our metabolism is aided by lifeforms such as veillonella, bifidobacteria, and lactobacilli. Zhao et al. explain that humans are “superorganisms” due to the fact that we are 10% human cells and 90% microbes (primarily in the intestines).

“‘Super'” in that sense means ‘above and beyond.’ Scientists thus are viewing people as vast ecosystems in which human, bacterial, fungal and other cells interact with each another.” [2]

Therefore, when microbes significantly affect our genetic actions and reactions through gene regulation; i.e. on and off switching, this directly affects our immune response — and thus affects how diseases or disorders manifest. Due to this complexity, scientists realize how the reductionist approach can certainly fail — as all individuals will have a different response to treatment. We are complex beings and thus require complex interventions, and that certainly does not mean we should delve further to find even smaller particles or specialize ourselves even more. We should, on the contrary, seek a more holistic approach. For example, our own nutrition, diets, medications, mental state and physical activity (or lack thereof) completely affect the manifestation of our microbe populations within our bodies — and thus completely affect which genes are expressed and which are not. There is nature just as much as there is nurture.  The so called “functional metagenomics” proposed by Zhao et al. [2] for developing new medicines that affect our microbes (and I say “our” for simplicity, because these organisms work together with us) are showing promise through traditional Chinese medicine  (TCM) — an archaic yet thriving art of medicine that continues to prosper and grow in popularity even among the general scientific community as time passes. In the case of gene-environment reactions, most chronic conditions are involved. Here, Zhao et al. claim the gut microbiome is vital and TCM is tailored to target both the host as well as the synergistic microbes — thus being a holistic medicine, as treatments are not specifically tailored such as the conventional drug approach, which targets in an isolated fashion typical receptors within the “druggable genome.”

It appears that for the next age — moving on from an efficacious, isolated approach in primary care — we are not going back to a patient-centered approach which began in traditional western rational science, but rather a “super organismic” track that attempts to integrate as many human and non-human factors as possible.

References

1. Jeremy A. Greene, M.D., Ph.D., David S. Jones, M.D., Ph.D., and Scott H. Podolsky. M.D. Therapeutic Evolution and the Challenge of Rational Medicine. N Engl J Med 2012; 367:1077-1082. September 20, 2012. DOI: 10.1056/NEJMp1113570

2. Zhao L, Nicholson JK, Lu A, Wang Z, Tang H, Holmes E, Shen J, Zhang X, Li JV,  Lindon JC. Targeting the human genome-microbiome axis for drug discovery: inspirations from global systems biology and traditional Chinese medicine. J Proteome Res. 2012 Jul 6;11(7):3509-19. Epub 2012 Jun 5.

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23 and 1/2 hours

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There seems to be one single, simple best thing to keep our lives healthy and to prevent especially non-communicable diseases: a small, but regular dose of physical activity. This is especially relevant for elderly people as they often suffer from multi-morbidity, but could potentially stay more healthy by changing their lifestyles just a little bit.

Wouldn’t it be easy to put eating and sleeping in 23 and 1/2 hours and keep 30 minutes for physical activit? It doesn’t even have to be on a daily basis, but e.g. going for a 30 minutes walk three times a week has already proven to reduce the risk for arthritis by 47%, for dementia by 50% and for diabetes by 58%.

So how about prescribing physical activity? If doctors did that for their patients – do you think it would have an impact on people’s health?

Check out this video by Michael Evans and Mercury Films Inc. http://www.youtube.com/watch?v=aUaInS6HIGo. It has also been posted by the Swedish Professional Association for Physical Activity. http://www.yfa.se/

Also check out Michael Evans’ blog: http://www.myfavouritemedicine.com/23-and-a-half-hours/

Council of Labor Affairs in Taiwan is Piloting A Programme That Will Provide The Elderly Accessibility To Foreign Caregivers on An Hourly Basis

Taiwan, like other places in Asia, is experiencing rapid ageing. According to some estimates, by 2025, the population of those over 65 years-of-age will be 20 percent, up from 8 percent in 2008. With a population just over 25 million, this represents a huge increase in a relatively short period of time–a problem further exacerbated with population trends such as increased women in the work-place, increased people living alone –being separated from the elderly, and decreased fertility.

Adequate manpower continues to represent a challenge, in part due to Taiwan’s strict laws on foreign immigration and caregiving but also due to the aforementioned trends, such as low fertility rates. Taiwan typically provides good care to veterans and old people, but little community support is available. Little government support is also provided to those who wish to age at home.

Despite this, most elderly Taiwanese prefer to age at home and, many of them, prefer to stay at home rather than go out and partake in community services. Given this fact, recently, Taiwan is undertaking a series of building projects aimed at building age-friendly environment to keep elderly energetic and age successfully at home.

However the issue still remains–with informal caregiving structures on the decline from more women participating in the work force and more elderly ageing at home, who will be able to care for the elderly as they choose to age at home?

Starting 2013, the Council of Labor Affairs will test out a pilot programme that will allow foreign workers to work part-time by the hour.

Citizens over the age of 80 who score 60 or less on the Bartel Index will be eligible to apply for part-time foreign caregiving services. Currently, due to immigration laws, only the elderly who suffer from 1-10 severe mental or physical disabilities and score lower than 35 on the Bartel Index/require around-the-clock care are eligible to employ a foreign caregiver.

Typically these caregivers are hired full-time and the employer is responsible for providing food and accommodation. With the new pilot, the arrangement will be quite different: rather than making employers responsible for housing and accommodation, part-time foreign workers will be employed by NGOs who will take responsibility for their well-being and care.

While there will be no limits on how many hours foreign caregivers can be hired for, their employment needs to be in-line with Taiwan’s Labor Standards Act. All agreements between caregivers and non-profit organisations are to be covered in a contract, stipulating what is expected on the part of both the employee and the employer.

Reimbursement issues are still to be defined at a later time between two parties: local governments and the non-profit organisations (the prospective employers).

Receiving full-time local home-based caregiving care, is available for those elderly at a much higher income bracket. However, there are also government-supported long-term care services available to the elderly, particularly for the veterans, the poor, and those with disabilities. If the elderly is a veteran, the veteran affairs commission provides homes and long-term care services. The Council for Agriculture provides some assistance for aged farmers. For poor elderly with mild-disabilities, the Ministry of Interior provides long-term care support such as step-down care facilities, home services, dementia day care and care in a community setting, and the Bureau of Nursing and Health provides long-term care services, such as nursing home care and home nursing/home care rehabilitation to the poor and disabled.

The new pilot programme then has the potential to cater to a new market of elderly–to allow elderly who are slightly more affluent but still low to middle, middle class, who may not be in need of full-time caregiving support and who wish to age at home–the ability to receive long-term care services from a foreign caregiver who may not be as costly as a local one and only for when needed. It still remains to be seen how this programme will be operationalised and will ensure that local caregivers are adequately provided for. Also, whether or not foreign caregivers will accept the contractual terms and be willing to be part-time caregivers in Taiwan.

Source: http://focustaiwan.tw/ShowNews/WebNews_Detail.aspx?Type=aSOC&ID=201209090012

Physical Fitness and Chronic Disease Prevention

In the most upcoming issue of the Archives of Internal Medicine (Sept 24, 2012), there is an article by Dr. Benjamin L. Willis and colleagues called “Midlife Fitness and the Development of Chronic Conditions in Later Life”.  Their findings lend more support to the idea that being more active helps prevent chronic conditions.

It was an impressive article in that they made use of a large cohort of subjects–18,670 total– that took a physical fitness test at one point in time in middle age (average age 49 years old).  They then looked at how many chronic diseases, through Medicare data, these people developed and when.  They found that people who were most active, compared to the least active, were less likely to develop chronic diseases.  Furthermore, when they did develop a chronic disease, they developed them later in life.  This is support for what is referred to as compression of morbidity, which is the phenomenon that now that people live longer, much of the morbidity of disease is also being compressed into fewer years toward the end end of life, so that overall we live longer, less-sick lives.

Some of the specifics– They considered people’s physical fitness by a treadmill test and measured their fitness by “metabolic equivalents” (METs; a measure of intensity of activity).  They looked at 8 chronic diseases: ischemic heart disease, congestive heart failure, stroke, diabetes, chronic obstructive pulmonary disease, chronic kidney disease, Alzheimer’s, and cancer of the colon or lung.  They report that for each increase in MET, men had a 5% lower risk of developing a chronic disease and women had a 6% lower risk of developing a chronic disease.  And this was true when they looked at each of the diseases on their own, meaning more activity protected against all of these various conditions.  (For reference: sitting watching TV is ~1MET, walking is ~3 METs, and running ~7-8 METs.)

They say that exercise did not appear to extend lifespan, but those who died had fewer chronic conditions before they did.  And, of course, there were several potential problems with the study.  There were more men(~80%) then women, and this was overall a white, well-educated group– so this is not representative of our country as a whole.  They also cannot really say if people workout more and can attribute good health to that, if they workout more because they are fundamentally more healthy, or if they are healthier and workout for a third, but related, reason (like maybe good genes?).

Overall, this was an intriguing study and lends support the idea that activity is good for us and means we will live healthier lives, from middle age onward.  Not many of us will waste  much time arguing this– we would rather spend it being active!

More links:

The article: http://archinte.jamanetwork.com/article.aspx?articleid=1352789

Interview with the author, Dr. Benjamin Willis: http://archinte.jamanetwork.com/multimedia.aspx

Commentary in the same issue, “Thriving of the Fittest”: http://archinte.jamanetwork.com/article.aspx?articleid=1352790

NY Times article about the research: http://well.blogs.nytimes.com/2012/09/05/the-benefits-of-middle-age-fitness/

(Image: http://www.diabetesnaturalcure.info/diabetes-and-exercises/)

Developing eHealth Businesses for Aging Clients

My grandmother is in her 90′s and lives around 200 kilometers north of Manila, Philippines. She’s cared for by a live-in informal caregiver and my little heartache is that I don’t get to visit her often. I’m a doctor and the least I could do is monitor how she’s doing. Her physical therapist drops in once a week, but leaves no beside record of the physical therapy regimen administered to my grandma.

I’ve heard that some households install a CCTV camera in their grandmother’s room, and monitor granny online from London or wherever they work. Others make regular phone calls, or at least sends a SMS to the caregiver to ask for updates. Given the concern and high care we give our grandparents, telehealth services similar to the ones described above could allow for regular monitoring of their condition, which would provide loved ones with security and peace of mind.

Telehealth for the elderly, or telegeriatric services could be provided more widely if local governments would take the lead. It would be great, for instance, if my grandmother could be enrolled in an elderly care program in her town. Aside from being a viable health program, this is also a politically attractive project. The elderly account for around 7% of the population and are influential voters. The question is, how do we induce mayors to include telegeriatrics in their health programs?

Government staff do not readily adopt new technologies for their workflow unless sanctioned by their supervisors. Telehealth is already widely practiced, albeit informally. Doctors and nurses often get SMS and voice calls from family and friends asking them for health advice for little complaints that are too minor to warrant an actual visit to the clinic.

How do we shift from informal telegeriatrics to more programmatic and sanctioned telegeriatrics? Telehealth improves health services when it enhances the interaction between the patient and health care team in between face-to-face visits (Rupper et al 2008). Smith and Clay (2009) recommend that adequate funding be provided by government to jump-start the development of telegeriatric services, and it seems to be the case for the Philippines. Funding is a start, and we also need to figure out the financial details for such services.

First, we can shift informal telehealth to the formal sphere by getting the municipal physician to start officially monitoring three elderly patients using SMS or voice. It could be monitoring blood pressure, blood glucose, or insulin administration, but we should keep the first cellphone-mediated interactions simple and low risk.

After a few weeks, a time and motion study can be done of the first three patients. If it took say five minutes to check on each patient per day via cellphone, then we can multiply that by the number fifty patients with a similar type of hypertension in town, then do the math in terms of financing it as a next phase. The arithmetic on the budget is a rough estimate, but it should help the program managers start designing a program for implementing telegeriatrics on a larger scale.

Sources:

Anthony C Smith and Leonard C Gray, Med J Aust 2009; 190 (1): 15-19.
Randall Rupper et al, Federal Practitioner 2008: 21-25

U-health in Korea

Our teacher once accused us: “You’re incredible! What you guys don’t find on Wikipedia does not exist in your world – or what?”

Trying to find out more about “u-health”, I remembered that and it made me smile. U-health or u-health care cannot be found on Wikipedia (yet) and on the first sight it does not seem to be on many peoples’ minds in today’s world, but dig a little deeper!

U-health stands for ubiquitous health – omnipresent, universal, ever-present health. Sounds big! And there you go with your online-search… [Small note: I found so many interesting aspects that I don’t know where to start now – so let me just give you a basic idea with this blog post and let’s explore the topic further within the following ones.]

On the Congress on Nursing Informatics 2006 in Korea, u-health did cause lively discussions. The Korean Government had started a project on u-health services for the provision of health care services in the country’s rural areas using the advanced broadband infrastructure (NI 2006).

U-health care is a developing area of technology to monitor and improve a patient’s health status. It uses different environmental and patient sensors to gather data on almost any physiological characteristic to diagnose health problems (Brown et al. 2007). U-health should stand out through availability, transparency, seamlessness, awareness and trustworthiness – anytime and anywhere (Cha 2008).

Many industrialized countries are sitting on a demographic time bomb – facing problems in health care that are related to the growing number of elderly. Their limited resources in health need to be used more efficiently and effectively. So especially these societies could benefit from u-health care and its innovations to reach better diagnosis and treatment. It also has a lot of potential in improving hospital administration and patient management with reduction of medical errors, and in enhancing service quality, communication and collaboration. (Chang) However, at the same time, u-health care confronts ethical issues, e.g. when it comes to trust, privacy and liability, or in combining computer and information ethics with medical ethics (Brown 2007).

Hence, the bottom line is that yes, u-health is and will increasingly be on peoples’ minds (and it will probably soon appear on Wikipedia).

Societies as well as individuals will have to make difficult choices in the future.

1 Korea IT Times offers a variety of more interesting articles by Cha Joo-hak on the topic: http://www.koreaittimes.com/source/cha-joo-hak
2 Brown I and Adams A A 2007. The ethical challenges of ubiquitous healthcare. International Review of Information Ethics Vol. 8. www.i-r-i-e.net/inhalt/008/008_9.pdf
3 Cha J-H (2008). Defining the Perfect Ubiquitous Healthcare Information System. Korea IT Times. http://www.koreaittimes.com/story/56/defining-perfect-ubiquitous-healthcare-information-system
4 Cha J-H (2010)Who Shall Live Better? – Health Care and Socioeconomic Choice. Korea IT Times. http://www.koreaittimes.com/story/8559/who-shall-live-better-health-care-and-socioeconomic-choice
5 Chang B-C ().Ubiquitous-Healthcare Changed paradigm after introduction of EHR. Yonsei University. www.health-informatics.kk.usm.my/resources/2_Chang.pdf
6 NI 2006. The 9th International Congress on Nursing Informatics. Seoul, Korea June 2006. http://differance-engine.net/ni2006blog/?p=22

Sleep and Dementia

We all know how bad our thinking can be when we don’t get a good night’s sleep, but over time poor sleep may put us at higher risk of more profound cognitive problems, like dementia.

Recent studies presented at the Alzheimer’s conference this summer show that sleep disruptions of different kinds– like sleep apnea (abnormal periods of obstructed breathing or stopping breathing), decreased time sleeping, or waking up often– can lead to real cognitive deficits.

Dr. Kristine Yaffe, from Univ of California, San Francisco, directs a clinic that evaluates and treats patients with memory disorders.  Her research makes an important contribution because it looks at direct measures of sleep by observing people’s sleep quality and their subsequent development of cognitive problems 5 years later. Many other studies have looked at people’s self-report of how they sleep, which is notoriously inaccurate, and the concurrent presence of memory or cognitive problems.  Such an approach does not address the question of which came first, the cogntive problem or the sleep problem, but Dr. Yaffe’s work suggests that in some people sleep problems may come first.  Persons with disordered breathing (like sleep apnea) had more than 2 times the risk of dementia later on.

Let’s not all stay up even later worrying that by not getting good sleep we are imperiling our brains.  The lesson is yes, get good sleep (that’s an order)!  And for us that take care of patients, we should be asking them about their sleep and daytime functioning– daytime sleepiness can be an indicator that someone’s sleep at night is not adequate– and get them tested for sleeping problems.  Many sleep problems can be treated, and doing so may save precious brain function.

Other links:

NPR interview with Dr. Yaffe and news story: http://www.npr.org/player/v2/mediaPlayer.html?action=1&t=1&islist=false&id=159983037&m=160095742

Photo credit: http://www.pasunautre.com/2010/11/30/objet-dart-the-sleeping-muse-by-brancusi/