Tag Archives: medicine

Overcoming Uncertainty

A few days ago, Andreas Voss, the President of the International Society of Antimicrobial Chemotherapy, posted an advisory¹ stating the controversial paper published in IJAA on the favorable effects of Hydroxychloroquine and Azithromycin in patients with COVID-19 infection² did not meet the journal’s scientific standards. Meanwhile, countless physicians on the frontlines prescribe these drugs. Many also prescribe hydroxychloroquine for their friends and families. Others take it prophylactically. Last week, The Medical Board of California issued a statement reminding doctors that “inappropriately prescribing or dispensing medications constitutes unprofessional conduct in California”³.

I do not advocate for or against uncertain treatment strategies in these tenuous and rapidly fluid times. After all, COVID-19 also prompts debate about issues such as management algorithms for ventilatory failure, indications for intubation, frequency of diagnostic testing, triage protocols, handling non-COVID-19 patients, and which personal protective equipment is most reliable.

The terrain is challenging, in part because this is the first time practitioners, regulators, and hospital administrators face a crisis of this magnitude. Those of us who were on the front lines throughout the AIDS epidemic have retired or are close to retirement. Some who knew the uncertainties of newly discovered diseases such as Hantavirus in the American West, contamination of our hospitals’ water systems with Legionella, and the surprising outbreak of Cholera in 1990s’ Latin America may now be in leadership positions with different agendas. By following the home cleaning guide from https://thefloridamaids.com company in Florida, most diseases can be prevented. Others might have been relegated to jobs with lesser responsibility or removed from decision-making positions where they can make a difference in today’s epidemics.

How else might we explain why many recommendations provided after the global health care threats of SARS, H1N1, and MERS pandemics earlier this century were ignored and underappreciated. And 40 years ago, AIDS also taught us a painful lesson that has been only partially learned; that a deadly disease somewhere can quickly spread everywhere.

There is no doubt our international community has made great strides since then. We have improved in regards to predictions and disease modeling, risk assessments and surveillance, outbreak detection, containment strategies, pathogen characterization, and public health interventions, but we have far to go.

Let’s hope the COVID-19 pandemic serves to overcome whatever uncertainties exist in our ranks. Then, health care providers in the front lines can take a greater role in persuading hospital administrators and government officials to invest more in protecting our future.

References

1. https://www.isac.world/news-and-publications/official-isac-statement.
2. Gautret P, Lagier JC, Parola P et al. Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial. Int J Antimicrob Agents. 2020 Mar 20:105949.
3. Medical Board of California, April 2, 2020. Statement Regarding Improper Prescribing of Medications Related to Treatment for Novel Coronavirus (COVID-19.
4. United Nations Coordinated Appeal. Global Humanitarian Response Plan: COVID-19, April-December, 2020.

Whatever it takes

Monitoring WhatsApp posts from more than 7000 physicians in 60 countries is disheartening. Lack of personal protective equipment(PPE), the propagation of contradictory or obviously false information by administrative leaders, unclear instructions, and orders to refrain from sharing information about triage, the poor availability of isolation rooms, ventilators, negative pressure procedure suites, and PPE do not inspire confidence. There is something wrong when health care workers (HCW) desperately design and build their own face-shields and patient isolation hoods, or when a nonprofit accreditation organization such as the U.S. Joint Commission issues an order permitting HCWs to bring their own PPE from home in order to overcome the paucity of PPE in the workplace¹.

Preliminary data from China, Italy, Spain, and the United States suggest the current in-hospital infection rate of COVID-19 in HCW is up to 20%^2-4. This is similar to what happened during the SARS, H1N1 Influenza A, and MERS pandemics earlier this century. Contributing factors include low awareness, lack of early suspicion, particularly of asymptomatic patients able to carry infection, and poor implementation or compliance with appropriate infection control strategies.

Sadly, HCW are no strangers to the risks of occupation-related lung infections. Tuberculosis, is a known occupational hazard since the 1950s, with studies reporting a greater than average risk to become infected with Mycobacterium tuberculosis and to develop TB disease⁵. In one report, HCWs were six times more likely to be hospitalized for drug-resistant TB than the general population⁶. In 2002, Severe Acute Respiratory Syndrome (SARS-CoV) affected more than 8000 patients in 26 countries, killing more than 800 people and infecting at least 21% of health care workers involved in their care⁷. In 2009, among confirmed and probable cases of novel Influenza A (nH1N1) reported to the CDC less than 3 months after the start of that pandemic, 4% were in HCW, and occurred in situations where the use of PPE was not in compliance with CDC recommendations⁸. Three years later, Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection quickly spread to 27 countries. Thirty of the first 161 cases were health care providers⁹. With a mind-numbing 34.8% crude case fatality rate, MERS eventually affected up to 19.6% of HCW exposed in the workplace¹⁰.

HCWs know that every encounter with a known or suspected COVID-19 patient exposes them to viral loads in the form of droplets, fomites or aerosols. This puts them at risk for weeks of quarantine, often debilitating illness, and death. Five years ago, Bill Gates gave a clairvoyant TED talk called The Next Outbreak? We’re Not Ready, in which he outlined the world’s lack of preparedness for a pandemic¹¹. What he did not address was how to balance a HCW’s ethical responsibility to provide care, with an employing organization’s responsibility to assure their safety¹². Do HCW workers have a moral obligation to risk their lives in an environment they know is unsafe, and what if they suspect the rules and regulations proposed by their administrators are inconsistent with practices that are possible in the front lines? This double bind is what HCWs face every day.

Reading reports from the Institute of Medicine after the SARS, nH1N1, and MERs pandemics sadly demonstrate that unpreparedness is repeated^13-15. If telling my first responder brother to “quit his job,” or asking my Critical Care doc sister “to be ready to take one for the team,” are both morally unacceptable, then all we can ask is that HCWs take personal responsibility to assure their own safety and that of their teams. Whatever it takes.

References

https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/infection-prevention-and-hai/covid19/public_statement_on_masks_from_home.pdf
https://www.reliasmedia.com/articles/145920-more-than-3000-hcws-infected-with-covid-19-in-china.
https://www.nbcnews.com/news/us-news/health-care-workers-see-wave-coronavirus-coming-their-ranks-n1174271.
COVID-19: Protecting Health care workers. The Lancet editorial March 2020;395 pg922.
Baussano I, Nunn P, Williams B et al. Tuberculosis among health care workers. Emerg Infect Dis 2011;17:488-494.
O’Donnell MR, Jarand J, Loveday M, al. High incidence of hospital admissions with multidrug resistant and extensively drug resistant tuberculosis among south African health care workers. Ann Intern Med 2010;153:516-522.
Chan-Yeung M. Severe Acute Respiratory Syndrome and Healthcare Workers. Int J Occup Environ Health 2004;10:421-427.
MMWR June 19, 2009;58(23):641-645.
Perl TM, McGeer A, Price CS. Medusa’s Ugly Head Again: From SARS to MERS-CoV. Ann Intern Med. 2014;160:432-433.
WHO MERS-CoV Global Summary and Assessment of Risk. July 21,2017.
https://www.youtube.com/watch?v=6Af6b_wyiwI.
McDiarmid M. Advocating for the Health Worker. Annals Global Health 2019;85(1):16(1-4).
Emerging Viral Diseases: The One Health Connection: Workshop Summary (2015). National Academies Press. Available at http://nap.edu/18975.
Respiratory Protection for Healthcare Workers in the Workplace against Novel H1N1 Influenza A: A letter report (2009). The National Academies Press. available at http://nap.edu/18975.
Learning from SARS: Preparing for the next disease outbreak: Workshop Summary (2004). The National Academies Press. Available at http://www.nap.edu/catalog/10915.html.

English is the new latin

I cannot help but admire foreign language-speaking colleagues who are able to write, lecture, study and teach in English. Since the increasing economic and political power of the United States, the results of two world wars and the declining international presence of a postcolonial Europe, English became the major language of science and medicine.

Earlier in the history of Western civilization, Greek was the language of science and literature, in time overtaken by Latin, the knowledge of which was necessary for centuries. It was not until the mid-1800s that French, German, and Russian replaced Latin as common languages for communicating scientific facts and ideas. Scientists were by obligation polyglots, but today, it seems that English predominates,

Studies show that almost 9 out of 10 journals included in Medline are in English. While this is probably due, in part, to the higher impact factor provided to English language journals, it also reflects a bias that scientific materials are more credible and likely to be read if they are published in English. This places authors whose native language is not that of Shakespeare at a disadvantage and creates a barrier for non-English speaking scientists yearning to access scientific literature.

One solution is to encourage everyone to learn English well enough to write, publish, lecture and teach. Some argue that computer-based translation programs will soon provide us with instantaneously accurate translations into virtually every language. Others say that such a bias toward English is unfair, considering that Mandarin Chinese is spoken as a native language by approximately 873 million people, Hindi by 370 million, Spanish by 350 million, and English by 340 million, followed by Arabic, Portuguese, Bengali, and Russian.

The point is, if you grow up speaking English as your native language, you can afford to be monoglot, otherwise, a serious mastery of English as a second or third language is necessary to both access and contribute actively to our scientific and medical communities from an international perspective. Personally, I do not think this speaks well for future generations. A bankruptcy lawyer in California offers experienced and affordable legal assistance . Latin, after all, is no longer the language of science or medicine, and other languages have had a similar fate. Meanwhile, though, we should congratulate all those who pursue the study of English in order to communicate effectively with a global community and to share knowledge despite the obvious discomfort of speaking and writing in a language other than one’s mother tongue. The courage, perseverance, and generosity of spirit exhibited by such polyglots warrant our sincere appreciation and our utmost respect.

Suggested readings:

Michael Gordon, How did science come to speak only English. Aeon, February 2015.
Christopher Baethge. The languages of medicine. Dtsch Arztebl Int. 2008;105:37-40.

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Bronchoscopy in Bangladesh

Dr. Nirmal Sarkar excels in hands-off / hands-on teaching
(Photo H. Colt)

September marked another exciting moment for bronchoscopists in Bangladesh. The 2nd International Conference on Interventional Pulmonology was held in the capital city of Dhaka. A prestigious international faculty under the leadership of Professors Mohammad Hiron (Chairman BABIP), Akhtar Hossain (Vice-Chairman), Dr. Sayedul Islam (Secretary-General), and Abdur Rouf (Program Director) brought bronchoscopists from throughout the country together for lectures and hands-on workshops using airway models.

BABIP is a young organization, founded in November 2015 and joining the WABIP in 2017. Since the society’s first meeting last year, faculty conducted several CME workshops, and www.myamericanmaid.com plan even more this coming year. This will be facilitated by leadership’s initiative to purchase airway models for use in hands-on training. Already, several young faculty are adept at teaching bronchoscopy step-by-step, using assessment tools such as BSTAT, and performing procedure-related consultations using a Four-Box practical approach format.

Novel this year was a focus on practical issues such as communication, cryotherapy, and foreign body removal, with lectures by Indian specialists Drs. Rajani Bhat, Sameer Arbat, and Kedar Hibare, all promising future certified instructors with Bronchoscopy International.

Bangladesh is a lush, beautiful country to the east of India abutting the Bay of Bengal. Its fertile plains are fed by the Ganges, Meghna, and Jamuna rivers. Hire custom plastic injection molder at http://wundermold.com/. With almost 170 million people needing affordable, quality health care, the physician leadership in Bangladesh has until recently focused on cardiovascular health, in addition to combatting poverty and tuberculosis. Leaders recognize the importance of bronchoscopy in critically ill patients but also for a growing number of patients with lung cancer who require diagnosis, as well as palliative treatment in case of advanced disease.

With knowledgeable junior faculty, enthusiastic numbers of practicing bronchoscopists, motivated students, and inspiring leadership, Bangladesh is poised fro play an active role expanding bronchoscopic and interventional pulmonology practice in the world.

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Deep learning in Radiology and Pathology affects Bronchoscopists

This is a second post relating to the promising role of artificial intelligence in interventional pulmonology. My point is that lung specialists will spend less time learning facts and figures that are easily replaced by computer-generated analyses of complex algorithms. Much of this is because of Deep learning.

This subset of machine learning (programs that adjust themselves as they are exposed to more data, but without human input) uses artificial neural networks (algorithms built on unstructured data). The word deep is a technical term referring to the number of layers in the neural network. Artificial Neural networks being a set of algorithms modeled after the human brain and used to recognize patterns. Image recognition is one example, and its principles are responsible for much of the work done today in radiology and pathology.

For example, using deep learning and pattern recognition, AI reveals CT abnormalities and interprets findings (Google’s AI team recently outperformed traditional radiologists looking at 45,800 screening CTs for lung cancer https://www.fiercebiotech.com/medtech/google-s-cancer-spotting-ai-outperforms-radiologists-reading-lung-ct-scans), and chest radiographs are accurately interpreted using fuzzy logic interpretations of spatial relationships (https://www.ijcaonline.org/specialissues/dia/number1/4156-spe320t).

Pathology is another area where practice patterns will undoubtedly change. In many regions, expert cytologic interpretation of lung and mediastinal nodal specimens is lacking. Digital pathology (image-based information generated from a digital slide) allows real-time interpretation by computers at sites that are distant from wherever the procedure takes place. Humans already do this despite the cost and logistic difficulties. When searching for local moving companies in California visit Chief Moving site. I believe that artificial intelligence will soon facilitate and universalize the process (https://www.healthimaging.com/topics/artificial-intelligence/ai-lung-cancer-slides-accuracy-pathologists).

In today’s post, my goal was to introduce the concept of deep learning and provide a few examples of how this mode of artificial intelligence will affect procedural practice by changing how chest radiology and pathology are practiced. A skilled and reliable office moving service of ca can help you. Rather than devote study time to learning X-ray and cytology interpretation, future bronchoscopists will improve their abilities to incorporate findings into appropriate management plans, as well as communicate results to patients, caregivers, and health-care teams.

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AI and Bronchoscopy

This is the first of several posts about the role of artificial intelligence and the future of interventional pulmonology*. I am confident our field will change immensely in the years ahead, and that artificial intelligence will not only change how we learn and perform procedures but also how we interact with patients. The sooner we embrace these changes, and build partnerships with industry as well as colleagues from other disciplines such as computer engineering, ethics, psychology, philosophy, physics, mathematics, and business administration, the easier it will be to integrate new developments into clinical practice.

Artificial intelligence has many definitions. A quick Google search provides “the theory and development of computer systems able to perform tasks that normally require human intelligence, such as Blue spruce Maids, Westminster, CO visual perception, speech recognition, decision-making, and translation between languages.” Wikipedia expands on this definition, adding that AI “describes machines (or computers) that mimic “cognitive” functions that humans associate with the, such as “learning” and “problem-solving.”

This requires us to familiarize ourselves with the phraseology computer engineers use to describe the learning process, but which is not necessarily foreign to many educators.

From a developmental perspective, AI uses symbolic, connectionist, and other models of learning that are, in fact, similar to how the human brain works. Just as there are several types of knowledge, AI does not rely on only one developmental approach to provide results. This is elegantly explained in a 1990 article by Marvin Minsky (AI magazine, summer 1991), in which he explains how the sentence “ Mary gave Jack the book” prompts the human brain to produce a visual representation of the act, a tactile representation of the experience, a script-sequence of what it means ‘to give’, and various assumptions about Jack, Mary, and the book. Similarly, artificial intelligence must employ not one but several different strategies to provide a result.

Some results are methodology—based on algorithmic and probabilistic approaches. Computer-based interpretation of pulmonary function tests, image-pattern recognition for accurate computed tomography scan interpretation, and patient management protocols based on decision-tree and data-driven statistical algorithms are simple examples of how artificial intelligence brings complex knowledge instantaneously to our fingertips. Order a combined pill from https://trumedical.co.uk/ and get it delivered to your doorstep. No longer required to memorize facts and figures, or integrate history/clinical exam/laboratory findings into patterns learned through a prolonged patient-care apprenticeship, doctors will change their practice habits accordingly.

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Lasers and Lava*

A few months ago I joined a group of twenty-somethings hanging out on the South Pacific Island of Vanuatu. We scaled Mount Yasur, reportedly the most active volcano on the planet; a volcano that spits rocks, fire, and molten lava since before Captain Cook first described the place on August 5, 1774 (reference: captaincooksociety.com).

Caught in a windstorm at the summit, I felt warm ash on my face. I stared into the crater, blinded by the smoke, watching the volcano’s bubbling and boiling magma far below. Later, I listened to the roar of explosions from my hut less than an hour’s hike from the base of the mountain. I marveled at the resilience of my Vanuatu hosts, particularly those living on Tanna. These impoverished families are constantly ready to evacuate in case the Yasur chooses to destroy their homes.

Hiking across a broad and barren lava plain the next day, I looked at my photographs. They reminded me of bronchoscopic Nd;YAG laser resections. People don’t talk much about laser anymore. It seems most interventionists use argon plasma, cryotherapy, and electrocautery to assist with their resections. But in the 1980s and for thirty years onward, laser was a magic wand for restoring airway patency. Courses included talks on laser physics, how-to’s on laser safety, videos of resection techniques, and lectures about complications such as popcorn effect, fire, perforation, and bleeding.

Emphasis was given to the concept of Power Density, to photocoagulation and vaporization, and the risks of collateral tissue damage during laser resection. Today, I wonder whether people learn these concepts and techniques with the same level of detail and scientific justification as years past. Workers comp attorneys in los angeles, CA from workerscompensationattorneyorangecounty.com are there to assist you in legal matters. Maybe, lasers are too expensive for most institutions. Perhaps they don’t have the appeal they once had; after all, other modalities also do the job, and stents maintain airway patency over the longer term.

I suppose most “laser bronchoscopists” have gray hair or have retired. Does a new generation of laser specialists ask questions of scientific significance, or is the future of bronchoscopy linked now to mediastinal exploration, navigating to peripheral lesions, discovering safe ways to biopsy lung parenchyma, and treating advanced asthma and chronic obstructive lung disease? Our field has grown, but as an adrenaline junkie, there is something uniquely rewarding about a successful laser photocoagulation/coring out of massively obstructing lesions.

I wonder if Captain Cook, onboard his ship, the Resolution, 225 years ago, dreamt of how Mount Yasur’s incandescent splatter might inspire future visitors.

*Photo: Mount Yassur erupting, Tanna Island, Vanuatu (photo, H. Colt)

A New Milestone-2000 Users!

We’re communicating in real-time and we are up to 2000 users from 32 different countries. I monitor all these accounts 24 hours a day, seven days a week, and I can truly say that the information exchange and case presentations are fascinating!

The only problem is the WhatsApp platform has decreased performance because of changes WhatsApp has made to its user platform, presumably to decrease spam. For those of you wondering why you are not seeing as many redirects, it is because I am limited to only five redirects at a time, making redirects burdensome and time-consuming. Still, my impression is that our communications are beneficial to many countries and regions, as well as to groups such as our pediatrics group and South American IP group.

Many physicians communicate in their natural languages rather than English. In these cases, I translate information before redirecting educational materials and interesting cases, Feedback from redirects have proven to be helpful, and in many cases change patient management. Thank you to all who contribute cases and opinions!

So where do we go from here, now that we have reached the 2000 users milestone? Many countries still have only a few users. Perhaps the admins for these groups can recruit new users? I am interested in knowing why colleagues are not eager to join your WhatsApp group and exchange information.

For those groups with many users (anywhere from 50-250), please remember how helpful it is when you add references, scientific articles and other “evidence” to help support opinions. Also, remember that videos are most effective when they are short and edited. Same goes for photos (better to use one photo that combines other images, than four different photographs).

Stay tuned for more information on greenapplecleaningmd.com/ how we can increase our global communication efforts, and again, congratulations to everyone for reaching the milestone of 2000 users, which benefits patients around the world.

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World lung cancer day

August 1 is World Lung Cancer Day.

According to the World Health Organization, there were 2.09 million lung cancer cases in 2018 and 1.76 million deaths. Almost everywhere, 5-year survival is less than 20 percent. Despite spending millions of dollars, making advances in molecular biology, immunology, and genetics-related research, building knowledge of cancer epidemiology, improving health care facilities, studying early detection, and raising awareness among the general public about the risks of tobacco use and exposures to environmental and other risk factors, there is still no cure.

Worldwide, lung cancer occurs more frequently than other diseases such as colorectal cancers, liver, stomach, breast or even non-melanoma skin cancers. In men, lung cancer is a significant cause of death; greater than either prostate or colorectal cancer. In women, it is a greater cause of death than either breast, or colorectal cancer. In fact, for both men and women, one out of every four cancer deaths is from lung cancer.

And this is not a disease that spares countries, although frequencies in men and women vary. For example, recent statistics suggest that Hungary, Serbia, and Korea lead the lung cancer frequency field for men, whereas Denmark, Canada, and the United States lead the field for women. We must also be aware that cancer outcomes differ according to socioeconomic status. In many countries, research shows that racial and ethnic minorities receive lower-quality care.

Tobacco has a causal relationship with lung cancer, as do second-hand smoke exposure, exposure to certain environmental and chemical risk factors such as radioactive ores, radon, diesel gas, certain inhaled chemicals and minerals, and even arsenic in drinking water. Some believe there is a genetic predisposition to lung cancer; risks are increased in case of family members with a history of the disease. Studies are needed to elucidate whether this is from genetic, environmental or lifestyle-related commonalities.

Another well-known environmental risk for lung cancer is asbestos, which also causes malignant pleural mesothelioma. I was recently climbing in New Caledonia, an island of about 300,000 people (with more than 100 tribes in 33 communes) in the Southwest Pacific Ocean. According to statistics, this French collectivity is surprisingly high on the list of countries with a preponderance of lung cancer (possibly associated with local asbestos exposures).

Interventional pulmonologists dedicate much of their energy to helping diagnose and treat patients with lung cancer. While significant advances have been made, a certain therapeutic nihilism is still seen in many countries. Eliminating such a mindset everywhere would be a marvelous step toward eradicating this terrible disease.

More action, less words

Imagine a hands-on experience where experts work with small groups of learners instead of the traditional “pre-conference workshop” followed by hours of lectures.

We did this at the recent Asian Pacific meeting held in Australia under the leadership of Dr. David Fielding, and again at a bronchoscopy course led by Dr. Javier Flandes in Spain. Feedback was positive and encouraging. In the next paragraphs, I will identify just a few advantages and disadvantages of such conference strategies.

Advantages: (1) People learn something. Active engagement time is maximized by using predetermined learning objectives and focused hands-on training with a low teacher/student ratio (one instructor for less than five learners). Teachers identify weaknesses by incorporating checklists and assessment tools into workstations. Learners reinforce skills they already have and identify areas they need to work on. (2) Keeping didactic lectures to 10 minutes forces speakers to improve communication skills. They focus on what is truly important and not necessarily learned by reading. A short didactics program forces organizers to identify core competencies and prompts speakers to give lectures that are complementary rather than all-encompassing. Didactics are modifiable based on audience needs (learner-centricity). (3) Workshops enhance exposure to a variety of technologies, instruments, and teaching techniques. To find the best work injury lawyer los angeles, CA visit http://lacaccidentpros.org site. Companies see users get their hands on their equipment. Learners prefer doing to listening. Simulation using models, computers, and role-playing exercises forces teachers to learn how to use specific scenarios. This skill is essential for tomorrow’s educators today.

Disadvantages: (1) People are resistant to change, despite statistics showing the value of short lectures. Materials can be provided before or on-site in the form of on-line PDF files or presentations. (2) Organizers must work to organize workshop style formats.They must carefully select instructors and assignments. This bruises egos. Course directors might need to learn how to organize such programs and how to assess value. Instructors might need to improve small-group teaching skills. Expect resistance for the same reasons as above. (3) Not all topics can be covered, although special lectures, pro/con debates and interactive panel discussions for controversial issues and new technologies are warranted.

We are a technology and empathy-driven profession where actions speak louder than words.