aladoc99

In general it's true that being on a ventilator for two weeks carries a high mortality, but that's largely due to being sick enough to require ventilation for that duration. Presumably without effective oxygenation or airway protection, these people would have died before the two week mark. COVID pneumonia presents a special case. Early on the thinking was that noninvasive ventilation with bipap etc would promote spread of the virus, so the recommendation was to proceed earlier to intubation. In retrospect this did appear to lead to higher mortality, likely related to ventilator associated pneumonia and sedation and paralytic drugs. So we've returned to a more ordinary stance where intubation is a last resort. So, intubation is bad, but for most circumstances, it beats a trip to the morgue.

I have to say, this sounds to me like trying to market an expert system for experienced woodworkers to choose the best chisel for a particular task based on the type of wood, size of the cut, etc. Practitioners have strong opinions regarding the implements they use; they use them in concert with other implements and modalities; and the small differences that may emerge from this kind of analysis are likely to be swallowed up by differences in copay or other things besides pure efficacy.

Impressive utility of the single-lead ECG recording, but I have to say that if I'm in charge, that patient's headed for bypass surgery, not stenting.

Drug reps in the US quit giving away pens and coffee mugs in the US in 2008, in accord with PhRMA rules (that's the drug manufacturers' association/lobby). They got to say it was improved ethics, but it was also a mutual disarmament agreement of sorts. "We'll stop giving out sticky pads if you will."

Headline is imprecise. The study is saying that higher doses of vit D do not strengthen bone more than lower doses, not that they don't strengthen bone at all, which is suggested by this headline.

He rejoined the pulse-bearing mass of humanity when he received a heart transplant in 2012.

My experience with such a system has been that it would quote ridiculously high prices for generic medications, so I'd simply tell patients their drug is on the $4 list at WalMart. An information source that's unreliable is worse than no information at all, since it poisons the well for competing systems.

Sorry for being obtuse. The point is that it doesn't take a physician to tell EVERY clinician calling with a patient for possible admission to send them to the ER. If the hospitalist is going to be liable for advice given on patients never seen, he can only err on the side of maximum treatment, since he hasn't had the benefit of seeing the patient and can't necessarily rely on the referring clinician's assessment.

Not a risk, a certainty. Until this ruling, not having a physician-patient relationship was an absolute safe harbor against professional liability. It was understood that the clinician seeing the patient had the ultimate responsibility. Now we can program Alexa to say "Send the patient to the ER" and save ourselves a great deal of time.

Whether or not Merck "did some fraudulent science," I'd need a better source than RFKJr to believe it. Preferably a scientific source. Here's some scientific sources on Gardasil, mostly after its introduction to the US market: https://scholar.google.com/scholar?q=safety+efficacy+quadriv...

It's worth pointing out that CT is extremely sensitive for calcium and hence bone, so that bones could be scanned at a lower Xray dose than soft tissue. 30 seconds of Googling showed a study where a whole body CT bone survey was carried out using 4.1 mSv, or about 200 chest xrays. If you're not looking for fine detail in the bones, an even lower dose might suffice.

One of the truisms of medicine is that ultimately every disease and every treatment has a 100% mortality, so we can never truly save a life. What we can do is promote the quality and quantity of life. In the US, the rule of thumb is that it's worth spending $50,000 to keep someone alive for a year, with that being the approximate cost of dialysis therapy. So, to save 10 years of life would be expected to be worth spending a half a million bucks. Which is all to say that an additional 10 years of reasonable quality of life is worth a lot, both to society and to most individuals. The other strain in your comment suggests that people who are presumably in some way responsible for their disease are less worthy of care. This opens up a giant slippery slope. Start with drug use, smoking, alcohol use, being overweight, eating meat, drinking coffee, working too many hours a week... Ultimately only celibate teetotalling vegans are worthy of medical care.

Any patient who tells me they've got to have my private number will be told that they've got to get a different doctor. It is vitally important for me to be able to disconnect from patients and their potentially bottomless well of need in order to maintain sanity.

I have to point out the obvious confounder here. The kids who get their tonsils and adenoids out are the ones with recurrent respiratory infections to begin with. Really the only way to control for this is to randomize kids to surgery or not and then follow for 20 years or more. This in contrast is an observational study, albeit with a very large number of subjects. They said they tried to control for confounding factors, but it's hard to see how effective that can be after the fact.

Although off-label marketing is inappropriate and possibly illegal, in this case I believe patients probably benefited from it.

Cost-effectiveness guidelines somewhat arbitrarily state that an expense of $50,000 per year of life is reasonable, since this is the estimated average annual cost of dialysis therapy. This gene therapy is sight-saving, but not lifesaving, so cost-effectiveness analysis must consider QALYs -- quality-adjusted life-years. How much is a year of blind life worth relative to a sighted year? There can be no definitive answer to this, but one guesstimate I found was 80%. Using this and the $850,000 total cost, one finds that the treatment would have to provide on average 85 sighted years to be considered cost-effective. Insurance companies could use this kind of analysis to restrict the treatment to infants.

digital signalling

'The simplest definition of a "mass casualty incident" is when you need more resources than you have.'

This definition is an example of the logical fallacy called begging the question. Nobody would deny that an incident that brings 250 gunshot victims to one center is a "mass casualty." The brilliance of Dr. Menes's approach is that he did not immediately assume insufficient resources. He didn't say this, but it appears to me that he proceeded under the thought that with careful planning and ingenuity, they might have just enough resources. This redefines triage from a rigid algorithm to something like "the optimal deployment of available resources to maximize the utility for as many as possible."

Not a surgeon or robot-user, but just by way of example, conventional wisdom in the medical world is that the best niche for robotically-assisted surgery is radical prostatectomy for prostate cancer. Conventional wisdom is that the robot permits better preservation of pelvic nerves, leading to lower rates of postoperative incontinence. If true, this is well worth a longer, more expensive procedure.

It seems as though people are getting the idea that this was a randomized trial, where people were assigned to receive units of blood from various types of donors. However, it was a retrospective case-control study, where records from everyday clinical practice were analyzed after the fact to look for patterns or, as in this case, try to answer questions. Did people who had received units of PRBCs from various types of donors fare any differently? I tend to view this kind of study as valuable for hypothesis generation, but not for solid conclusions, because it's impossible to control for every possible confounding factor. So the notion of ethics committees being concerned about patient's mortality doesn't apply here. All patients in the study have already either survived the study period or not. Same for safeguards, monitoring, and early termination.

Traditionally, cancer was considered "cured" when the patient survived 5 years without evidence of disease. We now know that quite a few cancers, including breast, have a significant rate of late recurrence, ie, after the five-year window. But it's still a very strong psychological milestone for the patient and a convenient and practical benchmark for the clinician.

Looking at the article in BMJ Open, I don't see that they controlled for obesity, either by BMI or any other measure. This is a huge confounder, making reflux symptoms worse and being an independent predictor of mortality. If I'm right, this is a huge oversight on their part.

It's important to recognize that capitation provides a powerful economic incentive to provide as little care as possible. Every pill, X-ray, MRI, or surgery comes straight out of the insurer's bottom line. You'd like to see an allergist/rheumatologist/orthopedic surgeon? How about the thirty-third of Nevember? Instead you can talk to a high-schooler in another country with a wellness script.

I think the 5% includes the administrative cost of the third-party administrators as well as HHS itself. The 95% is payments to hospitals, doctors, pharmacies, etc.

Not that the author of the linked piece will see this thread, but my experience has been that those patients who leave for personal reasons, as opposed to logistical reasons, e.g., changed insurance, moved away, etc. are usually not missed. My office staff will say, "We sent Ms. So-and-so's records over to Dr. Xyz" I'll say, "Gee, that's too bad." Almost invariably the reply comes back, "No, he can have her. She's impossible." (Of course, they're nice to me, but the office staff gets a more realistic picture.) So it tends to be that people who appreciate my style and personality hang around.

"the "spray bottle" tells us that the agent was targeting respiratory system, not dermal. "

I'm not sure this follows. If the cloth was impregnated with one of the binary components and the other was sprayed on the cloth, then VX would be synthesized right there in contact with the skin. I don't know that you could be sure a lethal dose would be inhaled in one or two seconds.

My guess is gas chromatography mass spectrometry, which yields a characteristic signature for many compounds.

Off the top of my head, stress reduction and meditation are part of the Dean Ornish program, which has some evidence for slowing atherosclerosis progression. Next question is, would causing a reduction in activity in the amygdala lead to reduced cardiovascular events?

Surgeons talk about a "look test" that refers to that certain something not captured by objective risk measures. A patient who doesn't look too bad on paper may look in person like they might not survive a haircut, let alone a valve replacement.

Every one of these proposed quality signals is prone to error. Publication history I would see as a negative quality signal. Less experience means more likely to be up-to-date on latest treatment techniques and algorithms. Reputation in the "Best Doctor" survey sense usually correlates with years in practice more than actual quality. The best indicator, in my experience, is to ask a nurse at that hospital who they would send a family member to for that specific problem. Even board certification does not hold great discriminatory power, in my experience. Analysis of these indicators would make for a worthwhile research project, but the more beneficial project would be to try to identify and disseminate those behaviors that form mechanisms of quality.