Technological Transformation

Technology has enabled bionics and artificial intelligence, each of which can have important applications in health care. As we continue to substitute body parts with machinery, however, we might wonder, “What makes us human?” This drawing interrogates the relationship between humanity and embodiment, specifically in neck and facial musculature and brain structures.

This image represents humankind’s union with technology. It shows the brain turning into a collection of integrated computer circuits and the neck muscles evolving into mechanization-ready cables, pumps, and wires. In artificial intelligence (AI), boundaries distinguishing life and technology are challenged. We wonder, “Is it possible for machines to think? Are our own brains just complex organizations of biological microchips?” Medical students are well positioned to appreciate how intimately technology is becoming part of human life. From wheelchairs and artificial limbs to new antibiotics and imaging, innovations are constantly growing in number and playing larger roles in our existence. If science unlocks the origins of thought, therapies for patients with neurocognitive or psychiatric problems could be enabled. Progress in AI will generate the need in medicine to explore ontological and ethical relationships among brains, minds, selves, and healing.

Elisabeth Miller – AMA Journal of Ethics – LINK

How Should Clinicians Engage With Online Health Information?

From the ‘AMA Journal of Ethics – Illuminating the Art of Medicine’

Many adults, physicians, and medical students search the internet for health information. Open access has many benefits, but the variable quality of internet health information—ranging from evidence based to false—raises ethical concerns. Using Wikipedia as a case study, this article argues that everyone engaging with internet health information has ethical responsibilities. Those hosting and writing for health websites should ensure that information is evidence based, accurate, up to date, and readable and be transparent about conflicts of interest. Health care professionals, including medical students, have both ethical responsibilities to help patients avoid false or misleading health information and practical opportunities to improve the quality of internet health information. All users of such information—professionals and patients alike—should develop critical appraisal skills and apply them to internet health information to distinguish the good from the junk.

The full article – LINK

Screening and General Health Checks in adults – the latest from Cochrane

Screening and prevention

‘Screening is a way of finding out if people are at higher risk of a health problem so that early treatment can be offered or information given to help them make informed decisions. Screening is a way of identifying apparently healthy people who may have an increased risk of a particular condition. The (NHS UK) offers a range of screening tests to different sections of the population.

The aim is to offer screening to the people who are most likely to benefit from it. For example, some screening tests are only offered to newborn babies, while others such as breast screening and abdominal aortic aneurysm screening are only offered to older people.’ [Ref NHS UK] This will give a very good understanding of what screening is and what are the screening tests that are recommended by the NHS-UK. This may be somewhat different from what the MoH recommends for Sri Lankan citizens. (I will try and get a link to the recommended screening programs by the Ministry). 

‘Very importantly, screening is not for people with symptoms. If you have any symptoms, go to your doctor.’

 

‘Prevention is better than cure’ makes intuitive sense. Yet there is evidence that some preventive activities are not effective, some are actually harmful. It has been said ‘all screening programs do some harm; some do good as well’. Screening of asymptomatic patients may lead to overdiagnosis, causing needless anxiety, appointments, tests, drugs and even operations, and may leave the patient less healthy as a consequence. Therefore, it is crucial that evidence clearly demonstrates that benefits outweigh those harms for each preventive activity. [Ref – RACGP Red book]

You can download the 9th ed Redbook

 

Screening test by the private sector

There are many screening tests offered by private sector laboratories and health care institutions. The UK government advice before you go for a test will be important and extremely helpful if you are planning to do so. “Private companies offer a wide range of health checks, from simple blood tests and physical examinations to full body scans and screening for serious conditions like aneurysms or heart failure. Some of the tests offered by private companies are not recommended by the UK NSC because it is not clear that the benefits outweigh the harms. If you’re thinking about paying for any of these checks, it’s worth asking the following questions first.’ Read the full instructions- LINK


LINK

General health checks for reducing illness and mortality

What is the aim of this review?

The aim of this Cochrane Review was to find out if general health checks reduce illness and deaths. This is an update of a previous Cochrane Review.

Key messages

Systematic offers of health checks are unlikely to be beneficial and may lead to unnecessary tests and treatments.

What was studied in the review?

General health checks involve multiple tests in a person who does not feel ill. The purpose is to find the disease early, prevent the disease from developing, or provide reassurance. Health checks are a common element of health care in some countries. Experience from screening programmes for individual diseases have shown that the benefits may be smaller than expected and the harms greater. We identified and analyzed all randomized trials that compared invitations for one or more health checks for the general public with no invitations. We analyzed the effect on illness and the risk of death, as well as other outcomes that reflect illness, for example, hospitalization and absence from work.

What are the main results of the review?

We found 17 randomized trials that had compared a group of adults offered general health checks to a group not offered health checks.

Fifteen trials reported results and included 251,891 participants. Eleven of these trials had studied the risk of death, and included 233,298 participants and assessed 21,535 deaths. This is an unusually large amount of data in healthcare research, which allowed us to draw our main conclusions with a high degree of certainty. Health checks have little or no effect on the risk of death from any cause (high‐certainty evidence), or on the risk of death from cancer (high‐certainty evidence), and probably have little or no effect on the risk of death from cardiovascular causes (moderate‐certainty evidence). Likewise, health checks have little or no effect on heart disease (high‐certainty evidence) and probably have little or no effect on stroke (moderate‐certainty evidence).

We propose that one reason for the apparent lack of effect may be that primary care physicians already identify and intervene when they suspect a patient to be at high risk of developing disease when they see them for other reasons. Also, those at high risk of developing disease may not attend general health checks when invited or may not follow suggested tests and treatments.

How up to date is the review?

The review authors searched for studies published up to 31 January 2018.

Authors’ conclusions

Implications for practice

Our results do not support the use of general health checks aimed at a general population. On the other hand, they do not imply either that physicians should stop clinically motivated testing and preventive activities, as such activities may be an important reason why an effect of general health checks has not been shown. Public healthcare initiatives to systematically offer general health checks and offers from private suppliers of general health checks are not supported by the best available evidence.

Implications for research

We see no reason to do more trials of general health checks, as it seems futile based on a large amount of available data and the fact that the results of previous trials have now been confirmed by a recent large trial. Further research in health checks should be limited to studying the effect of one component at a time and should include harmful effects. We also suggest that surrogate outcomes such as changes in risk factors are not used for assessing benefits since they do not capture harmful effects and since their relation to meaningful outcomes is usually in doubt. The required large randomized trials with long follow‐up are expensive but not nearly as expensive as the implementation of ineffective or harmful screening programmes. We suggest more focus on the effects of structural interventions to reduce disease, for example, higher taxes on tobacco and alcohol, or restricting corporate advertising for harmful products.

2019 – 03 – 17

Phishing – stealing legitimate user credentials

Phishing is a form of fraud in which an attacker masquerades as a reputable entity or person in email or other communication channels. The attacker uses phishing emails to distribute malicious links or attachments that can perform a variety of functions, including the extraction of login credentials or account information from victims. One common explanation for the term is that phishing is a homophone of fishing, and is so named because phishing scams use lures to catch unsuspecting victims, or fish. [LINK]

Phishing attacks typically rely on social networking techniques applied to email or other electronic communication methods, including direct messages sent over social networks, SMS text messages and other instant messaging modes.

Although many phishing emails are poorly written and clearly fake, cybercriminal groups increasingly use the same techniques professional marketers use to identify the most effective types of messages — the phishing hooks that get the highest open or click-through rate and the Facebook posts that generate the most likes. Phishing campaigns are often built around major events, holidays and anniversaries, or take advantage of breaking news stories, both true and fictitious.

phishing email Typically, a victim receives a message that appears to have been sent by a known contact or organization. The attack is carried out either through a malicious file attachment that contains phishing software, or through links connecting to malicious websites. In either case, the objective is to install malware on the user’s device or direct the victim to a malicious website set up to trick them into divulging personal and financial information, such as passwords, account IDs or credit card details.

 

 

Phishing defense begins with educating users to identify phishing messages, but there are other tactics that can cut down on successful attacks.

A gateway email filter can trap many mass-targeted phishing emails and reduce the number of phishing emails that reach users’ inboxes. Enterprise mail servers should make use of at least one email authentication standard to verify that inbound email is verified. These include the Sender Policy Framework (SPF) protocol, which can help reduce unsolicited email (spam); the DomainKeys Identified Mail (DKIM) protocol, which enables users to block all messages except for those that have been cryptographically signed; and the Domain-based Message Authentication, Reporting and Conformance (DMARC) protocol, which specifies that both SPF and DKIM be in use for inbound email, and which also provides a framework for using those protocols to block unsolicited email — including phishing email — more effectively.

Phishing attacks aimed at stealing legitimate user credentials have been used in the past 24 months to compromise 45% of UK organisations, 49% of France,  44% of the Netherlands. Ireland performed significantly better, with just 25% according research organisation. This information is from 2017 and the figures may be different now.

Adam Bradley from Sophos said criminals are adept at using social engineering to exploit human weakness, so while well-trained employees are an excellent deterrent, even the best user can slip up. Phishing is one of the most common routes of entry for cyber criminals. “As organisations grow, their risk of becoming a victim also increases as they become more lucrative targets and provide hackers with more potential points of failure.

Organisations should block malicious links, attachments and imposters before they reach users’ inboxes, said Bradley, and use the latest cyber security tools to stop ransomware and other advanced threats from running on devices even if a user clicks a malicious link or opens an infected attachment.

 

What we learned in 2018 in Health & Medicine according to the NYT

Developments in medicine and health that we’re still thinking about at year’s end. It’s not easy to say that any particular development in health or medicine was the most important in a given year [Ref – NYT]. But if we had to choose some highlights, we’d opt for these unforgettable events and findings.

 

 

 

From left, Douglas A. Warner III, Memorial Sloan Kettering’s board chairman; Dr. José Baselga, its former chief medical officer; and Dr. Craig B. Thompson, its chief executive, at its charity ball in New York last year. Credit Rebecca Smeyne for The New York Times

‘Dr. José Baselga, a towering figure in the cancer world, resigned from his post at Memorial Sloan Kettering Cancer Center in New York in September. An investigation by The Times and ProPublica had found that he failed to disclose millions of dollars in payments from health care companies in dozens of research articles. But Dr. Baselga wasn’t the only medical researcher who failed to make such disclosures, a problem that is aggravated by confusing advice from medical journals and a failure to adequately vet the contributors to their pages.’

  • Alcohol and heart health – We learned how public health research can be compromised by private interests.

In June, the National Institutes of Health shut down a study of the effects of moderate drinking on heart attacks and stroke, following an investigation by The Times. The researchers who proposed the study sought funding from beer and liquor companies, and suggested that the results would support a daily drink as a healthy choice. The N.I.H.’s director, Dr. Francis Collins, said the trial seemed to be “set up in a way that would maximize the chances of showing a positive effect of alcohol.”

  • Teenagers and e-cigarettes -We learned that vaping among young people is a growing national problem.

E-cigarettes may help some people quit smoking, but the soaring use of Juul and other vaping devices by teenagers has motivated the Food and Drug Administration to place new limits on the sales of e-cigarette flavors. Schools are grappling with students furtively vaping, as teenagers who may never have smoked a cigarette find themselves struggling to shake a new addiction to nicotine.

Dayton, Ohio, had one of the highest opioid overdose death rates in the nation. Now, it may be at the leading edge of a waning phase of the epidemic. While the data are preliminary, a variety of factors contributed to the reduction in deaths: Medicaid expansion paying for treatment; dwindling availability of one particular drug; greater use of naloxone, which can reverse overdoses; a large network of recovery support groups; and, law enforcement and public health workers improving their coordination.

People with hemophilia, the inability to form blood clots, spend their lives menaced by the prospect of uncontrolled bleeding into a muscle or joint, or even the brain. Experimental gene therapy treatments have rid a few patients — for now, at least — of the condition. It does not yet amount to a cure, and the treatment is imperfect. But some who received the treatments are finding themselves uneasily adjusting to a life with new freedoms.

  • Where a sore throat becomes a death sentence – We learned untreated strep throat leads to heart failure in poor countries.

In the United States and other rich countries, cheap antibiotics cure children with strep throat easily. But in poor countries, strep can result in rheumatic heart disease and a long, slow death sentence. In Rwanda, doctors from a group called Team Heart visit once a year to perform heart valve-replacement surgery for 16 people. But there are thousands more people who need the procedure in a country that has no heart surgeons.

In the winter of 2017-2018, 80,000 Americans died from the flu. It was the highest number in over a decade, and included 180 young children and teenagers. Some hospitals had to bring out their “surge tents” to treat the overflow of patients. While no flu vaccine is perfect at this time, the shots are particularly effective with children, and the secretary of health and human services, Alex M. Azar II, compared getting vaccinated with wearing your seatbelt. You already do that, don’t you?

Everywhere in the United States, hospitals are merging. Instead of creating savings that get passed on to consumers, an analysis found that in some regions, the opposite occurred. From 2010 through 2013, the price of an average hospital stay soared, with prices in most areas going up between 11 percent and 54 percent. What’s happening to the average cost of private hospital stay?

 

New Cholesterol Guidelines Personalize Risk and Add Treatments – JAMA 2019 Feb 6

In the new guidelines, statin treatment targets are back for both primary and secondary prevention. Patients whose 10-year risk of ASCVD is 20% or more should try to reduce LDL-C levels by at least 50%, the same goal as for people with clinical ASCVD. Those with more intermediate risk should aim for at least a 30% decrease.

The new update was met with considerably less controversy than the last incarnation, which deemphasized LDL-C treatment targets and introduced the AHA/ACC ASCVD risk calculator.

The updated guidelines and a companion AHA/ACC special report on risk assessment tools acknowledge that the calculator estimates risk for an average person in the US population and may overestimate—or underestimate—a given person’s chances of having an ASCVD event within 10 years.

Researchers presented at least 2 alternate calculators, including 1 using machine learningthat more accurately estimated risk in a specific cohort than did the ACC’s calculator. A recent report in JAMA Cardiology also found that using long-term cumulative systolic blood pressure instead of single blood pressure measurements could make the pooled cohort equations more accurate.

Another new feature of the guidelines is that clinicians are now encouraged to have a comprehensive risk discussion with patients before initiating statin therapy, which should include a consideration of potential adverse effects and drug interactions, costs, and patient preferences and values. “The guideline places importance on a process of shared decision-making,”

Greenland emphasized that no risk calculator is perfect: “Doctors have hunches about patients based on a variety of clinical factors, and what these calculators are intended to do is to make your hunch a little more accurate,” he said. For now, the guidelines reaffirm the use of the pooled cohort equations for the US population, and state that they should be used as a “starting point, not as the final arbiter, for decision-making in primary prevention of ASCVD.”

Meanwhile, a new AHA scientific statement released in December may help quell patient fears about statins. The report found that statin-related muscle aches and pains, the drugs’ most common adverse effects, occur in no more than 1% of patients. The statement concluded that statins have a low risk of adverse effects and that, for most people, their benefits outweigh the risks.

Screening for breast cancer in order to reduce the burden of breast cancer in Sri Lanka – the way forward – Is mammography an essential tool?

Screening for breast cancer in order to reduce the burden of breast cancer in Sri Lanka – the way forward – Is mammography an essential tool?

Yes, mammography is an essential tool for screening for breast cancer. To what extent mammography reduces the burden of breast cancer will depend on the context, country and the research. The NCCP guidelines published in 2014 gives a comprehensive detail in ‘Early Detection and Management of Breast Symptoms’. This is valid even today. [Ref]

Q1 Does mammography screening decrease the incidence or mortality rate from breast cancer?

N0, because mammography detects breast tumours in the asymptomatic phase. Therefore it does not have any effect on the incidence although it can detect cancers / tumours in the very early stages. Even the effect on mortality rates are minimal.  The evidence is given below.

(Pap-smears detect changes in the cervix even earlier than the asymptomatic stage – the pre-cancerous stage. This is why pap-smears decrease the incidence of cervical cancers.)

 

1992 Canadian National Breast Screening Study – Breast cancer detection and death rates among women aged 40 to 49 years. [Ref 1992]

Objectives were to evaluate the efficacy of the combination of annual screening with mammography, physical examination of the breasts and the teaching of breast self-examination in reducing the rate of death from breast cancer among women aged 40 to 49 years on entry.

Conclusions were that the study was internally valid, and there was no evidence of randomization bias. Screening with yearly mammography and physical examination of the breasts detected considerably more node-negative, small tumours than usual care, but it had no impact on the rate of death from breast cancer up to 7 years’ follow-up from entry.

2001 Screening for breast cancer with mammography – Cochrane Review [Ref 2001]

Objectives were to assess the effect of screening for breast cancer with mammography on mortality and morbidity.

Conclusions were that currently available reliable evidence does not show a survival benefit of mass screening for breast cancer (and the evidence is inconclusive for breast cancer mortality). Women, clinicians and policy makers should consider these findings carefully when they decide whether or not to attend or support screening program.

2002 Breast cancer mortality after 11 to 16 years follow-up. A randomized screening trial of mammography in women age 40 to 49 years. [Ref – 2002]

Objectives were to compare breast cancer mortality in 40- to 49-year-old women who received either 1) screening with annual mammography, breast physical examination, and instruction on breast self-examination on 4 or 5 occasions or 2) community care after a single breast physical examination and instruction on breast self-examination.

Conclusions. After 11 to 16 years of follow-up, four or five annual screenings with mammography, breast physical examination, and breast self-examination had not reduced breast cancer mortality compared with usual community care after a single breast physical examination and instruction on breast self-examination. The study data show that true effects of 20% or greater are unlikely.

 

2013 Screening for breast cancer with Mammography Cochrane Review [Ref – 2013]

Objective To assess the effect of screening for breast cancer with mammography on mortality and morbidity.

The eligible trials included 600,000 women in the analyses in the age range 39 to 74 years. Three trials with adequate randomisation did not show a statistically significant reduction in breast cancer mortality at 13 years (relative risk (RR) 0.90, 95% confidence interval (CI) 0.79 to 1.02); four trials with suboptimal randomisation showed a significant reduction in breast cancer mortality with an RR of 0.75 (95% CI 0.67 to 0.83). The RR for all seven trials combined was 0.81 (95% CI 0.74 to 0.87).

Conclusions If we assume that screening reduces breast cancer mortality by 15% and that overdiagnosis and overtreatment is at 30%, it means that for every 2000 women invited for screening throughout 10 years, one will avoid dying of breast cancer and 10 healthy women, who would not have been diagnosed if there had not been screening, will be treated unnecessarily. Furthermore, more than 200 women will experience important psychological distress including anxiety and uncertainty for years because of false positive findings. To help ensure that the women are fully informed before they decide whether or not to attend screening, we have written an evidence-based leaflet for lay people that is available in several languages.

2017 Effectiveness of and overdiagnosis from mammography screening in the Netherlands: population-based study [Ref – 2017]

Objective. To analyse stage specific incidence of breast cancer in the Netherlands where women have been invited to biennial mammography screening since 1989 (ages 50-69) and 1997 (ages 70-75), and to assess changes in breast cancer mortality and quantified overdiagnosis.

Conclusions. From 1989 to 2012, no significant decrease in the incidence of stage 2-4 breast cancers has been observed in women aged ≥50
Screening would be associated with 0 to 5% reductions in breast cancer mortality in women aged ≥50, whereas improved patient management would be associated with a 28% reduction.

In 2010-12 about one third of breast cancers among women invited to screening represented overdiagnosis.

2018 Mammography screening: A major issue in medicine. European Journal of Cancer [Ref – 2018]

  • After 20–30 years of mammography screening, the incidence rates of advanced and metastatic breast cancer have remained stable.
  • Breast cancer mortality rates have not decreased more rapidly in areas where mammography is in place since the late 1980s.
  • One third to one half of mammography-detected breast cancers would not have been clinical during lifetime (overdiagnosis).
  • Breast screening randomised trials have adopted distinctive methods that led to exaggerating the efficacy of screening.
  • The influence mammography screening may have on mortality decreases with the increasing efficiency of cancer therapies.
  • The comparison of the performance of different screening modalities – e.g. mammography, digital mammographyultrasonographymagnetic resonance imaging(MRI), three-dimensional tomosynthesis (TDT) – concentrates on detection rates, which is the ability of a technique to detect more cancers than other techniques. However, a greater detection rate tells little about the capacity to prevent interval and advanced cancers and could just reflect additional overdiagnosis. Studies based on the incidence of advanced cancers and on the evaluation of overdiagnosis should be conducted before marketing new breast-imaging technologies.

2014 Evidence-based de-implementation for contradicted, unproven, and aspiring healthcare practices. [Ref – 2014]

Abandoning ineffective medical practices and mitigating the risks of untested practices are important for improving patient health and containing healthcare costs. Historically, this process has relied on the evidence base, societal values, cultural tensions, and political sway, but not necessarily in that order. We propose a conceptual framework to guide and prioritize this process, shifting emphasis toward the principles of evidence-based medicine, acknowledging that evidence may still be misinterpreted or distorted by recalcitrant proponents of entrenched practices and other biases

 

Q2 Is Sri Lanka facing a breast cancer epidemic?  Probably YES. Epidemiologists will answer this correctly.  

Does mammography by early detection and treatment solve this problem – definitely NO

Then, what may be the solutions? – Prevention NOT necessarily early detection.

Can we prevent Breast Cancer?

A 2014 review of primary prevention of breast cancer [Ref]. ‘Despite recent calls to intensify the search for new risk factors for breast cancer, acting on information that we already have could prevent thousands of cases each year. This article reviews breast cancer primary prevention strategies that are applicable to all women, discusses the underutilization of chemoprevention in high-risk women, highlights the additional advances that could be made by including young women in prevention efforts, and comments on how the molecular heterogeneity of breast cancer affects prevention research and strategies.’

Factors that can be changed are called modifiable factors. [Ref – Australian Government]

  • Alcohol – drinking alcohol increases your risk for breast cancer. The more you drink, the greater the increase in risk. If you do drink alcohol, limit your alcohol intake to 1 standard drink a day.
  • Body weight – keeping to a healthy weight range reduces risk of breast cancer. Aim to keep to a healthy body weight that is within a Body Mass Index (BMI) range of 18.5 to 25 kg/m2, and have a waist circumference of below 80 cm (31.5 in).
  • Physical activity – active women of all ages are at reduced risk of breast cancer compared to women who do not exercise. Aim for at least 30 minutes of moderate-intensity physical activity every day. The more exercise you do, the bigger the benefits.
  • Menopausal hormone therapy – using menopausal hormone therapy (MHT) that contains both an oestrogen and a progestogen is associated with an increased risk of breast cancer, with the risk increasing the longer you take it. If you are taking MHT, review your needs regularly with your doctor.
  • Breastfeeding – breastfeeding can reduce risk of breast cancer – and the longer the duration of breastfeeding, the greater the benefits.

 

Q3 Considerable of cases can be missed through mammography alone. High quality mammography machines and ultrasound scans (especially in younger aged group) are needed for screening. 

Does high quality mammography machine by early detection solve this problem?  Again, NO

 

 

Age-adjusted breast cancer incidence in women aged 50 and over in the Netherlands, 1989 – 2012. From 1989 to 1996, biennial invitation to mammography of women aged 50-69 was implemented. In 1997 women aged 70-75 started to be invited for screening. Digital mammography replaced film-based mammography after 2006 [Ref – 2017].

 

Another recent assessment of Digital Breast Tomosynthesis with Hologic 3D Mammography Selenia Dimensions System for Use in Breast Cancer Screening in Norway, The Norwegian Institute of Public Health (NIPH) concluded that ‘There is too little evidence to conclude regarding the effects of the use of Hologic digital breast tomosynthesis in combination with digital mammography or synthesized digital mammography compared to digital mammography alone for the outcomes assessed in our report (recall rates, cancer detection rate, interval cancer rate, false positive and false negative rate, sensitivity, specificity, mortality and quality of life). Preparation of a full health technology assessment should be considered when sufficient evidence is available.’ [Ref]

 

Q4 Overdiagnosis of breast cancer through screening is high and will lead to lot of unwanted surgeries psychological trauma and lead to economic burden.

Do we have evidence for this? YES.

    

Q5 if there is evidence against mammography screening why is it been continued?

 ‘In January 2013, the Swiss Medical Board, an in­ dependent health technology assessment initiative under the auspices of the Conference of Health Ministers of the Swiss Cantons, the Swiss Medical Association, and the Swiss Acad­emy of Medical Sciences, was mandated to prepare a review of mammography screening. The two of us, a medical ethicist and a clinical epidemiologist, were mem­bers of the expert panel that ap­praised the evidence and its impli­cations. The other members were a clinical pharmacologist, an onco­logic surgeon, a nurse scientist, a lawyer, and a health economist. As we embarked on the project, we were aware of the controversies that have surrounded mammog­raphy screening for the past 10 to 15 years. When we reviewed the available evidence and contem­plated its implications in detail, however, we became increasingly concerned.’ Read the complete article [Ref]

More evidence from recent reviews

 

Coach, Don’t Just Teach

 

‘Both teaching and coaching are of course helping someone learn a particular skill or sharing a certain piece of knowledge. Teaching however, is primarily a one way interaction. A person that knows something shows you how to do something or tells you some piece of information that they know.

Coaching on the other had requires a cyclical, ongoing interaction. In order to coach someone, you need to first teach them something, then observe the student, and then provide feedback again. Unless all three of these interactions are taking place, it cannot be considered coaching.

The biggest difference is that, ultimately, teaching is about the teacher and coaching is about the student. The best teachers aren’t just teachers. They’re also coaches’. [Ref]

 

Percent in Highest Bracket in Patient Satisfaction Scores - Pre-Post Arm Differences for Hospitalists - Duke Coaching Communication Skills Study

Effective clinician-patient communication is essential for high-quality care and is linked to better patient adherence and greater satisfaction for both patients and clinicians. Direct one-on-one coaching has the potential to improve clinician-patient communication as well as clinician and patient satisfaction compared with other techniques commonly used. This was tested its effectiveness in a randomized controlled trial of 62 clinicians at Duke University School of Medicine.

In conclusion, the study found that the relatively low-intensity coaching intervention improved patient satisfaction and clinician communication. Clinicians found the coaching to be acceptable and helpful. Moving this work toward implementation requires a fully-powered trial that directly assesses patient satisfaction and other patient-centered outcomes and objectively assesses communication skills in a control group.

NEJM Catalyst January 2019LINK

Using AI to catch irregular heartbeats and to detect cervical cancer – NIH, USA

An arrhythmia is a problem with the rate or rhythm of the heartbeat. During an arrhythmia, the heart can beat too fast, too slowly, or with an irregular rhythm. When a heart beats too fast, the condition is called tachycardia. When a heart beats too slowly, the condition is called bradycardia. The most common test used to diagnose an arrhythmia is an electrocardiogram (EKG or ECG). [Ref]

“Thanks to advances in wearable health technologies, it’s now possible for people to monitor their heart rhythms at home for days, weeks, or even months via wireless electrocardiogram (EKG) patches. In fact, my Apple Watch makes it possible to record a real-time EKG whenever I want.” says Dr Francis Collins, Director of NIH, USA.

A powerful computer “studied” more than 90,000 EKG recordings, from which it “learned” to recognize patterns, form rules, and apply them accurately to future EKG readings. The computer became so “smart” that it could classify 10 different types of irregular heart rhythms, including atrial fibrillation (AFib). In fact, after just seven months of training, the computer-devised algorithm was as good—and in some cases even better than—cardiology experts at making the correct diagnostic call [Ref].  The findings suggest that artificial intelligence can be used to improve the accuracy and efficiency of EKG readings. In fact, Hannun reports that iRhythm Technologies, maker of the Zio patch, has already incorporated the algorithm into the interpretation now being used to analyze data from real patients. [Ref]

Nearly all cervical cancers are caused by the human papillomavirus (HPV). Cervical cancer screening—first with Pap smears and now also using HPV testing—have greatly reduced deaths from cervical cancer. But this cancer still claims the lives of more than 4,000 U.S. women each year, with higher frequency among women who are black or older [Ref]. Around the world, more than a quarter-million women die of this preventable disease, mostly in poor and remote areas [Ref].

In work described in the Journal of the National Cancer Institute [Ref], researchers used a high-performance computer to analyze thousands of cervical photographs, obtained more than 20 years ago from volunteers in a cancer screening study. The computer learned to recognize specific patterns associated with pre-cancerous and cancerous changes of the cervix, and that information was used to develop an algorithm for reliably detecting such changes in the collection of images. How they exactly did this – First, the researchers got the computer to create a convolutional neural network. That’s a fancy way of saying that they trained it to read images, filter out the millions of non-essential bytes, and retain the few hundred bytes in the photo that make it uniquely identifiable. They fed 1.28 million color images covering hundreds of common objects into the computer to create layers of processing ability that, like the human visual system, can distinguish objects and their qualities. The AI-generated algorithm outperformed human expert reviewers and all standard screening tests in detecting pre-cancerous changes. [Ref]

In fact, the researchers are already field testing their AI-inspired approach on smartphones in the United States and abroad. If all goes well, this low-cost, mobile approach could provide a valuable new tool to help reduce the burden of cervical cancer among underserved populations. The day that cervical cancer no longer steals the lives of hundreds of thousands of women a year worldwide will be a joyful moment for cancer researchers, as well as a major victory for women’s health.

Exercise: the miracle cure – Academy of Royal Medical Colleges, UK

‘The big four “proximate” causes of preventable ill-health are: smoking, poor nutrition, lack of physical activity and alcohol excess. Of these, the importance of regular exercise is the least well-known. Relatively low levels of increased activity can make a huge difference. All the evidence suggests small amounts of regular exercise (five times a week for 30 minutes each time for adults) brings dramatic benefits. The exercise should be moderate – enough to get a person slightly out of breath and/or sweaty, and with an increased heart rate. This report is a thorough review of that evidence.

Regular exercise can prevent dementia, type 2 diabetes, some cancers, depression, heart disease and other common serious conditions – reducing the risk of each by at least 30%. This is better than many drugs’ Academy of Medical Royal Colleges

 

Evidence of improvement in health for those with chronic conditions and scale of improvement

Condition Evidence for improvement, and scale of improvement with physical activity
Short term improvements Many papers report global improvements in health across a range of conditions. 17 “Physical activity helps to manage over 20 chronic conditions, including coronary heart disease, stroke, type 2 diabetes, cancer, obesity, mental health problems and musculoskeletal conditions”. 20
COPD Physical activity improves cardiorespiratory health. 21 Furthermore, in COPD, exercise training reduces dyspnoea symptoms and increases ability for exertion. 16
Heart disease and/ or Heart failure and/or Angina All studies show clear improvements in cardiovascular health with moderate exercise. 30 There are similar beneficial effects for sufferers of angina. 27 Overall, exercise reduces cardiac mortality by 31%. 16
Hypertension (high blood pressure) Hypertension is very common with 10% of adults in England having this diagnosis. 31 Hypertension is responsible for 50% of strokes and 50% of Ischaemic heart disease. 7,30 Most people with hypertension are on long-term medication. Randomised controlled trials show a clear lowering of blood pressure with aerobic training. 16 The scale of the reduction has been quantified: 31% of patients on average experience a drop of at least 10 mmHg with regular physical activity. 3
Cholesterol Across several studies, exercise led to a reduction in LDL by an average of 1 to 2mmol/l and an increase in “good” High Density Lipoprotein (HDL). 16