From what I can see, every medical blogger worth his salt has weighed in on the controversy involving the USPSTF and their new mammography guidelines. I have had a number of respectful disagreements with bloggers that I admire. Although we agree to disagree about the specific guidelines, I would like to use this blog post to detail another important aspect of the current controversy.
By now, we are all aware of the controversy which erupted when the USPSTF came out with new recommendations regarding mammography screening. The recommendations and the subsequent firestorm of criticism have been covered extensively in the media.
The panel (in my opinion) did a fantastic job in compiling and analyzing the very best research and evidence regarding mammography. This research has developed slowly and consistently in the academic literature. Anyone who is familiar with the statistics and recent scholarship in this area would not be surprised that there are ample questions regarding the utility of routine mammograms for women in their 40s without other risk factors.
The USPSTF concluded (similar to many other researchers) that the benefits of screening younger women have been overestimated and that the risks have been underestimated.
Writing in the Boston Globe, op-ed, Ellen Goodman said it best…
“They went on to recommend that women start having mammograms at 50 and then have them every other year instead of annually. But then they dropped these guidelines onto an unprepared public like leaflets from a helicopter of experts who didn’t understand the conditions on the ground.”
Indeed, those of us who think the recommendations from the USPSTF are evidence based, and reasonable have been fighting a battle which has been made harder by at least three factors:
- The main stream media looking for a “controversy” in the story that would capture ratings
- The knee-jerk response that this represents some type of health care rationing scheme by the Obama recommendation and that the administration wants “women to die”
- Legitimate fears of health care consumers which were exacerbated by the two aforementioned factors and the poor public relations utilized by the USPSTF in conveying this information.
In what may be described as the understatement of the decade, Dr. Diane Petetti stated that “We probably, in retrospect, could have been more clear.’’
Carnegie Mellon’s Baruch Fischhoff, an expert in risk communication describes the faults of the USPSTF as one of an external view in conflict with an internal view. He states that what the task force did was to “give an external view of what’s true at the population level.’’ In other words, they told the statistical story from up high, when what the general population was looking for was an internal view; “ does this mean for my life?”
A familiar case of gown being out of touch with town. With striking ramafications.
Gary Schwitzer of the Schwitzer health news blog has done a phenomenal job in documenting the deficiencies in mass media medical reporting. His observations are similar to what many of us who practice clinical or academic medcine would agree with.
I would strongly recommend that my readers refer to his blog for more information on this topic.
The poor communication by the USPSTF cannot be ignored by those of us who are concerned with propagating evidence based guidelines to improve patient care. If we are to move toward practices based on evidence and not anecdotes need to be prepared for the fact that the immediate response by some who have a vested interest in the status quo will be ridicule, questioning of motives and false allegations. Taken from this perspective, the controversy and vilification of the USPSTF represent a head-on assault at evidence based medicine.
The traditional medical scholarly publishing model is clearly in the process of being disrupted by more direct online communication. We are moving quickly into an age where the adoption of digital record-keeping along with accelerating quantities of outcomes based data from registries and EHRs will enable new models for medical research and analytics. If those of us who value evidence based medicine are content to have our side of the story conveyed on the editorial page of the NEJM we face the real possibility of being scooped and outflanked by bloggers and the twitterverse.
As recently commented on by Janice McCallum “Interpreting the results from the increasing number of empirical studies will take skill in statistics, public health and communication.” Perhaps it is unreasonable to think that public health scientists shoud also become public relations specialists, but the recent brouhaha over the USPSTF recommendations make it clear that this is a skill that will be in much demand.
We desperately need a new model for medical information communication that can translate and publish the most recent medical data into a form that can be easily digested by the general public.
We desperately need a new model for medical information communication that can translate and publish the most recent medical data into a form that can be easily digested by the general public.
This episode has highlighted the fact that the facts don’t speak for themselves. They need to be delivered by people who have not only facts, but context and who can frame the message as a story to a prepared public. Only then will the evidence become relevant and suitable for general dissemination.
Sent from Onyeije’s BlackBerry Storm
—–Original Message—–From: conyeije
Date: Sun, 29 Nov 2009 14:48:05 To: Chukwuma Onyeije
Subject: Father Son Weekend Project: Laser Show Lunchboxen… Found this project in volume 20 of Make Magazine. Metal lunchboxes are used to produce a laser light show. Each box is
constructed with old speakers and amps and connected to a laser. The
entire apparatus is then connected to an ipod for what will hopefully be a
fascinating display. All we need now is some assistance in assembling the
voltage regulator. Instructions are found here: http://makezine.com/20/lunchboxen Any assistance would be greatly appreciated.
Many people have asked me “What is Twitter?” and “What is it you talk about on Twitter?”. I still have difficulty in answering the first question, but at least I now have a pictorial answer for the second question, thanks to Chad Scira of tumblr.icodeforlove.com . File this under “Nerd Art”. LOL.
The original cloud can be found here. You can create your own TwitterCloud here.
words (ordered by most used)
Many people have asked me “What is Twitter?” and “What is it you talk about on Twitter?”. I still have difficulty in answering the first question, but at least I now have a pictorial answer for the second question, thanks to Chad Scira of tumblr.icodeforlove.com .
File this under Nerd Art. LOL.
Recently, I had the opportunity to listen to a presentation on Preeclampsia presented by Dr. Saul Weinreb of AskMyObGyn.com .
I am sharing a link to the audio from Twithear at the following link:
- Dr. Saul Weinreb on Preeclampsia part 1
- Dr. Saul Weinreb on Preeclampsia part 2
- Dr. Saul Weinreb on Preeclampsia part 3
- Dr. Saul Weinreb on Preeclampsia part 4
Dr. Weinreb’s site is highly informative, and I would recommend AskMyOBGYN.com to anyone with questions regarding pregnancy and gynecologic issues. Regular readers of my blog will also note that some of the articles at AskMyOBGYN.com are written by my friend Angela Davids, from www.KeepEmCookin.com.
I am also going to post a copy of this remix to my posterous blog and to preeclampsiaonline.net.
This blog post was also published on preeclampsiaonline.net by Chukwuma Onyeije, M.D.
At present, the cause of preeclampsia is unknown. However, it is clear that patients who have had preeclampsia are at risk for other cardiovascular conditions in later life. Recently published studies now show that in addition to these concerns; patients who have had preeclampsia are also at risk for hypothyroidism later in life.
This presentation reviews why this is an important consideration for the long term health of these patients.
The CDC recently provided information regarding the rates of obesity and diabetes in the United States by county.
The CDC map and accompanying article can be found here.
My first response was that rather than calling the Southeast the “Bible Belt” it should now be called the “Diabetes / Obesity Belt”
All jokes aside, the maps provided give yet another example of the massive public health problems that face our nation. For the record, at least one third of Americans are currently classified as obese
- Obesity is a major risk factor for type 2 diabetes, and it is estimated that more than 20 million Americans are currently diabetic,
- One out of three people with diabetes do not even realize that they have the disease.
The combination of diabetes and obesity has lead to the term “Diabesity” as a description of what many call an epidemic within the Ameican healthcare crisis. The usual suspects implicated in the diabesity epidemic include sedentary lifestyles, ubiquitous junk food, the supersizing of meal portions, and “emotional eating” are just a few.
From a public health standpoint I like the term diabesity because it makes us focus on not only esthetic aspects of obesity but rather the additional health concerns raised by the epidemic. Such a focus allows us to move from dealing with simply a largely preventable lifestyle related disease, namely obesity, and a huge and expensive health crisis, namely type 2 diabetes.
A few more sobering facts:
- Eighty per cent of type 2 diabetics are obese.
- Glucose metabolism are often seen with other forms of metabolic dysfunction involving lipids, uric acid, urinary albumin, clotting, inflammatory and fertility factors
- Additional mechanical complications such as arthritis, sleep apnea, stress incontinence, are also major health concern in this subset of the population.
Now, take another look at the map above. Why do you think that diabetes and obesity should be connected to geography? The CDC report suggests some answers, however, as clinicians and scientists I feel it is important that we look for underlying causes regarding why these conditions affect certain portions of the population more than others.
FURTHER READING: Diabesity: The Obesity-Diabetes Epidemic That Threatens America–And What We Must Do to Stop It
Originally posted by C. Onyeije, M.D. at PreeclampsiaOnline.net
- A recent study published in BMC Medical Geneticsreviews whether or not the levels of cell-free DNA are related to preeclampsia.
- DNA is nucleic acid that contains the genetic instructions used in the development and functioning of all known living organisms. DNA is normally found in an inner portion of the cell known as the nucleus. Recent studies have looked at the importance of so-called “Cell-free” DNA in various disease states. Cell-free DNA is DNA which can be detected in circulating blood. Numerous reports in the literature suggest that levels cell-free DNA in the blood may be a more certain tumors in the detection of early stages of cancer .
- Levels of cell-free DNA are also potentially an important marker for pregnancies at risk for premature birth
The current study looks at whether or not cell-free DNA levels in pregnant patients are related to:
- the clinical characteristics of preeclampsia
- the standard laboratory tests seen in patients with preeclampsia
- markers of inflammation,
- endothelial activation or injury (in other words injury to the inner
- layer of blood vessels often seen in preeclampsia)
- oxidative stress and
- cell-free fetal DNA levels.
How the study was performed?
Blood samples of 67 women with preeclampsia were compared to 70 pregnant women without preeclampsia. The analysis looked at levels of cell- free DNA as well as standard laboratory parameters tests obtained in pregnant patients.
The study concluded that levels of cell-free maternal and fetal DNA were higher in mothers with preeclampsia as shown below:
The quantity of cell-free DNA did not correlate to other lab findings in preeclampsia (with the exception of liver enzyme changes) and did not correlate to the clinical characteristics in the mothers (such as body mass index). The authors conclude that the increased levels of cell free DNA may be triggered by low-level liver damage seen in patients with preeclampsia.
- What does this mean for patients?Currently, there is not enough support for analyzing cell-free DNA in most patients with preeclampsia. However, we appear to be on the cusp of a number of technological breakthroughs involving DNA based diagnostic tests which will allow us to make much earlier diagnoses. In current day medicine, HELLP syndrome is the most severe form of preeclampsia. (HELLP stands for Hemolysis, Elevated Liver enxymes, and Low Platelets). In order for this diagnosis to be made, the patient’s preeclampsia must get to the point where the liver cells are severely damaged and leaking enzymes.
- The results of the current study provide hope that we may be close to a point where an analysis of cell-free DNA can give information about early liver damage in patients with preeclampsia before they get to the point of having HELLP syndrome.
- A full copy of the study can be found here: http://www.biomedcentral.com/content/pdf/1471-2350-10-120.pdf
- For further reading regarding the use of cutting edge diagnostic techniques I would recommend the following blog: http://thedecisiontree.com/blog/
- And the following books.
- The Decision Tree: Taking Control of Your Health in the New Era of Personalized Medicine
- The Future of Medicine: Megatrends in Health Care That Will Improve Your Quality of Life
- Genomic and Personalized Medicine, Two-Vol Set: V1-2
The following statistics regarding premature birth are sobering, to say the least.
- Currently the number of premature births in the United States is over 540,000 per year.
- The United States’ infant mortality rate exceeds that of China, New Zealand, Canada, Hong Kong, Israel, Japan, Australia, and Singapore.
- It’s estimated that simply by cutting the preterm birth rate in the US in half, to match Sweden’s, would save approximately 8,000 babies.
- Even though preemies in the US are more likely to survive than anywhere else, they are still more likely to die than full-term infants.
- Just under half of premature babies grow up with some form of neurological or developmental disorder.
- Premature infants can develop lifelong health issues such as cerebral palsy, blindness, hearing loss and learning disabilities.
- Despite the increase in medical advances in the US, the amount of premature births has increased 36% in the last 25 years.
- It is the group of “late preterm” births, which occur after 34-37 weeks of pregnancy, that are the fastest growing subgroup of premature births.
The increase in premature birth in the US is attributed to many causes. The smallest, most fragile babies are most common among poor women who lack prenatal health care and social support. As I have noted in other posts, Early inductions and cesareans are also to blame, according to experts. The complications of prematurity can be minimized by avoiding delivery before 39 weeks without a medical reason. Here are what I would consider the 10 most important things a pregnant woman can do to avoid a premature birth:
- Get proper prenatal care throughout your pregnancy.
- Don’t smoke, drink or take drugs while pregnant.
- Avoid violent or abusive situations.
- Lower stress levels. Only take on as much as you are capable of, avoid extremely stressful situations and practice stress-relief exercises as needed.
- Avoid early elective inductions and cesareans. These might be used in emergency situations for the better of mom and baby, but elective cesareans and inductions should not be undertaken before 39 weeks of pregnancy.
- Eat a well-balanced, nutritious diet, including fish or fish oil and folic acid.
- Exercise regularly.
- Avoid exposure to environmental toxins like car exhaust, pesticides and phthalates.
- Avoid working situations where you need to stand for long periods of time.
To learn more about premature labor, click here.
KeepEmCookin.com is another resource that I would strongly recommend for patients at risk for preterm labor
