South Dakota is home to 3 of the 5 counties with the highest percent of cigarette smokers. We’ve written about one of those counties, Oglala Lakota County, severaltimes before as it has the lowest life expectancy of any county in the US (residents die at 67 on average), and median income is $30,347. Meanwhile, Utah is home to 6 of the 10 counties with the lowest percent of cigarette smokers. American Inequality has coveredseveral of these counties before. For example, Summit County has the highest life expectancy of any county in the US (residents die at 87 on average), and median income is 2.5x higher than in Oglala.
Cigarette smoking is 50% higher than in the following 12 states compared to the rest of the nation: Alabama, Arkansas, Indiana, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Tennessee and West Virginia. An average smoker in these 12 states goes through about 53 packs in one year, compared with an average of 29 packs in the rest of the US. Life expectancy is 3 years lower in these states compared to the national average.
In 1998, California became the first state to implement a smoke free law prohibiting smoking in all indoor areas of bars and restaurants, as well as in most indoor workplaces. As we can see from the map above, California now has one of the lowest percent of adults smoking in the country.
With the recent discovery that the CDC drafted — but never sent — a Health Alert in May 2021 about myocarditis after mRNA vaccination, I put together this timeline about vaccine myocarditis news and updates from government officials. I include a combination of documents from CDC and FDA, as well as what was covered in the mainstream media.
I think this timeline shows a pattern in which CDC & FDA failed to adequately investigate and inform the public about the risks of myocarditis early in the vaccine rollout. However, there was public acknowledgement by the CDC, as early as May 20, 2021, about a potential pattern of myocarditis after the 2nd dose of mRNA vaccines, particularly in young men.
On June 1, 2021, the CDC confirmed that they had identified a higher than expected signal of myocarditis for young men after mRNA vaccination, but that they still recommended Covid vaccination for everyone in this age group. Despite a lot more analysis and discussion of myocarditis after that, and a changing landscape with widespread natural immunity, the CDC & FDA position has changed very little since that time.
Looking a bit more closely you see why Grail’s test is actually useless, or dangerous, or both. Let’s start with the sensitivity of the test. For a cancer screening test to work, it must find disease before it has caused symptoms — when it is in an early or premalignant stage. Say what you want about lung cancer screening, mammography, PSA, and colonoscopy (I’m talking to you Drs. M and P) but at least they look for, and succeed at finding, early stage/premalignant disease. Here is the sensitivity of the Galleri test by stage: stage 1, 16.8%; stage 2, 40.4%; stage 3, 77%; stage 4, 90.1%.
The test is nearly worthless at finding stage 1 disease, the stage we would like to find with screening. The type of disease that is usually cured with surgery alone.
How about specificity? Let’s consider a fictional, 64-year-old male patient who presents to his internist worried about pancreatic cancer. I pick pancreatic not only because it is a scary cancer: we can’t screen for it, our treatments stink, and it seems to kill half the people in NYT obituary section. I also chose it because it is the anecdotal disease in the WSJ article.
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Working through the math (prevalence 0.03%, sensitivity 61.9%, specificity 99.5%), this means our patient’s likelihood of having pancreatic cancer after a positive test is only 3.58%. For our patient, we have caused anxiety and the need for an MRI. You almost hope to find pancreatic cancer at this point to be able to say, “Well, it was all worth it.” If the MRI or ERCP is negative, the patient will live with fear and constant monitoring. (You will have to wait until next week to consider with me the impact of this test if we were to deploy it widely).
If the evaluation is positive, and you have managed to diagnose asymptomatic, pancreatic cancer, the likelihood of survival is probably, at best, 50%.
Let’s end this week with two thoughts. First the data for the Galleri test is not good, yet. The test characteristics are certainly not those we would like to see for a screening test. Even more importantly, good test characteristics are just the start. To know that a test is worthwhile, you would like to know that it does more good than harm. This has not even been tested. The WSJ article scoffs at the idea that we would want this data.5
Even more, the health professionals who administer methadone — and another commonly used treatment drug called buprenorphine — say the medications enable people to find new jobs, to regain custody of their children and to more easily recover from the mind-altering effects of opioids.
Lugo is just one of the tens of thousands of people who benefitted from a methadone treatment program in Connecticut in recent years, but state officials want to see that number increase even more to combat the state’s ongoing epidemic.
A special advisory committee, set up to manage roughly $600 million in opioid settlement funds for Connecticut, published a report earlier this year that laid out several key strategies for curtailing opioid overdoes in the state, and it argued that increasing the accessibility and use of methadone and buprenorphine would be the most effective approach to stemming the mounting death toll.
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Sharfstein, who also cowrote a book titled “The Opioid Epidemic: What Everyone Needs to Know,” said treatment programs that incorporate methadone and buprenorphine meet both of those principles.
The effectiveness of medication-assisted treatment, Sharfstein said, has been reviewed by the American Medical Association, the American Psychiatric Association and the National Academies of Sciences, Engineering, and Medicine.
And research has suggested that the use of methadone and buprenorphine in treating opioid use disorders can substantially reduce people’s chances of fatally overdosing — some studies suggest by up to 50%.
“For a disease that is killing many Americans, that is a significant reduction in mortality that you can get with appropriate treatment that includes medications,” Sharfstein said. “And that I think is just an incredibly important point to keep in mind as officials are thinking about expanding access to treatment.”
Many black women report feeling silenced or ignored by healthcare providers during their pregnancy journey.
“It is 2023 almost 2024, and in this time, we should not be dying in birth. Period. You may be the medical professional, and you may have great textbook knowledge and you may have many degrees, but nobody is in my body but me, and nobody can tell me that this pain that I’m feeling is not there,” King said.
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This month New York Governor Kathy Hochul called the issue a crisis and a disgrace. Hochul announced more than $4 million in funding for regional perinatal centers and said doula services will now be covered for all Medicaid enrollees beginning January first.
In a statement, Governor Hochul said, “as the first mom and grandma to serve as Governor of New York, I’m committed to doing everything in my power to tackle the disturbing rise in infant mortality.”
Esther is hopeful the attacks on this issue from all fronts will lead to better outcomes for women and babies in the future.
Despite the surging older population, there are fewer geriatricians now (just over 7,400) than in 2000 (10,270), he noted in a recent piece in JAMA. (In those two decades, the population 65 and older expanded by more than 60%.) Research suggests each geriatrician should care for no more than 700 patients; the current ratio of providers to older patients is 1 to 10,000.
What’s more, medical schools aren’t required to teach students about geriatrics, and fewer than half mandate any geriatrics-specific skills training or clinical experience. And the pipeline of doctors who complete a one-year fellowship required for specialization in geriatrics is narrow. Of 411 geriatric fellowship positions available in 2022-23, 30% went unfilled.
The implications are stark: Geriatricians will be unable to meet soaring demand for their services as the aged U.S. population swells for decades to come. There are just too few of them. “Sadly, our health system and its workforce are wholly unprepared to deal with an imminent surge of multimorbidity, functional impairment, dementia and frailty,” Gurwitz warned in his JAMA piece.
This is far from a new concern. Fifteen years ago, a report from the National Academies of Sciences, Engineering, and Medicine concluded: “Unless action is taken immediately, the health care workforce will lack the capacity (in both size and ability) to meet the needs of older patients in the future.” According to the American Geriatrics Society, 30,000 geriatricians will be needed by 2030 to care for frail, medically complex seniors.
More than two dozen attorneys general are urging Food and Drug Administration officials to take urgent action to address disparities in how well pulse oximeters, the fingertip devices used to monitor a person’s oxygen levels, work on people with darker skin.
In a Nov. 1 letter, the AGs noted that it had been a year since the FDA convened a public meeting of experts, who called for clearer labeling and more rigorous testing of the devices, and that no action had been taken.
“We, the undersigned Attorneys General, write to encourage the FDA to act with urgency to address the inaccuracy of pulse oximetry when used on people with darker toned skin,” said the letter, written by California Attorney General Rob Bonta and signed by 24 other attorneys general.
Pulse oximeters’ overestimation of oxygen levels in patients with darker skin has, in a slew of recent research studies, been linked to poorer outcomes for many patients because of delayed diagnosis, delayed hospital admissions, and delayed access to treatment, including for severe Covid-19 infections. Higher amounts of pigments called melanin in darker skin interfere with the ability of light-based sensors in pulse oximeters to detect oxygen levels in blood.
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The delay has frustrated health care workers who use pulse oximeters and have studied them and followed the progress toward creating new devices that work better. “I just get mad that these things are not on the market,” Theodore J. Iwashyna, an ICU physician at Johns Hopkins, told STAT. “Just last week in my ICU, I had a patient whose pulse oximeter was reading 100% at the same time that his arterial blood gas showed that his oxygen levels were dangerously low. I need these things to work, and work in all my patients.”
It’s not the orgy of pink that reminds me of breast cancer. It’s the Nobel Prize in Physiology or Medicine. I have a rooting interest, and so far I’ve been disappointed. I want the prize to go to UCLA cancer researcher Dennis Slamon, who in recent years has been on the Great Mentioner’s short list (an improvement since I started paying attention a decade or so ago).
Slamon’s work did two things: Beginning with HER2+ breast cancer, it demonstrated that cancers could be identified by specific genetic variants, rather than merely where they occur in the body. Then it showed that those variations could be targeted and treated with specific antibodies. The first practical result was the drug Herceptin, which treats the roughly 25 percent of breast cancer patients with an especially aggressive form.
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The usual sources were still not interested in paying for research. But in 1989, Slamon was treating Hollywood honcho Brandon Tartikoff, best known for his stint as president of NBC, for Hodgkin’s lymphoma. Tartikoff’s wife Lilly was grateful for the care and asked Slamon what she might do to help him. He told her about the idea of finding a drug to treat HER2+ breast cancer. Soon thereafter, in a classic Hollywood moment, she ran into Ronald O. Perelman, who owned Revlon, at Wolfgang Puck’s original Spago restaurant. She gave him the pitch: You own Revlon. Revlon sells to women. Women get breast cancer. You and Revlon should support this research. He agreed to let his representative meet with Slamon.
At the meeting, Slamon was accompanied by his colleague John Glaspy, who is a notably blunt-spoken person. Even if they got government funding, Glaspy warned, it would take several years and by then “we’ll have a Rose Bowl full of dead women” from breast cancer. The pitch worked.
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In 1998, the drug was approved for treatment of Stage 4 HER2+ breast cancer and in 2006 it was approved for treating early stage cancers. A year later, it saved my life.
Author(s): Virginia Postrel
Publication Date: 9 Oct 2023
Publication Site: Virginia Postrel’s newsletter at Substack
Her pleas for help were shrugged off, she said, and she was repeatedly sent home from the hospital. Doctors and nurses told her she was suffering from normal contractions, she said, even as her abdominal pain worsened and she began to vomit bile. Angelica said she wasn’t taken seriously until a searing pain rocketed throughout her body and her baby’s heart rate plummeted.
Rushed into the operating room for an emergency cesarean section, months before her due date, she nearly died of an undiagnosed case of sepsis.
Even more disheartening: Angelica worked at the University of Alabama at Birmingham, the university affiliated with the hospital that treated her.
Her experience is a reflection of the medical racism, bias and inattentive care that Black Americans endure. Black women have the highest maternal mortality rate in the United States — 69.9 per 100,000 live births for 2021, almost three times the rate for white women, according to the Centers for Disease Control and Prevention.
Black babies are more likely to die, and also far more likely to be born prematurely, setting the stage for health issues that could follow them through their lives.
The SOA Research Institute’s Mortality and Longevity Strategic Research Program is pleased to make available a research report that quantifies differences in mortality and disease prevalence by health status. Additionally, period life tables by health status, sex, and age are available in Appendix D.
Author(s):
Natalia S. Gavrilova, Ph.D. Leonid A. Gavrilov, Ph.D.
Improving diagnosis in health care is a moral, professional and public health imperative, according to the U.S. National Academy of Medicine. However, little is known about the full scope of harms related to medical misdiagnosis — current estimates range widely. Using novel methods, a team from the Johns Hopkins Armstrong Institute Center for Diagnostic Excellence and partners from the Risk Management Foundation of the Harvard Medical Institutions sought to derive what is believed to be the first rigorous national estimate of permanent disability and death from diagnostic error.
The original research article was published July 17 by BMJ Quality & Safety. Results of the new analysis of national data found that across all clinical settings, including hospital and clinic-based care, an estimated 795,000 Americans die or are permanently disabled by diagnostic error each year, confirming the pressing nature of the public health problem.
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To identify their findings, researchers multiplied national measures of disease incidence by the disease-specific proportion of patients with that illness who experience errors or harms. Researchers repeated this method for the 15 diseases causing the most harms, then extrapolated to the grand total across all dangerous diseases. To assess the accuracy of the final estimates, the study’s authors ran the analyses under different sets of assumptions to measure the impact of methodological choices and then tested the validity of findings by comparing them with independent data sources and expert review. The resulting national estimate of 371,000 deaths and 424,000 permanent disabilities reflects serious harms widely across care settings, and it matches data produced from multiple prior studies that focused on diagnostic errors in ambulatory clinics and emergency departments and during inpatient care.
Vascular events, infections and cancers, dubbed the Big Three, account for 75% of the serious harms. The study found that 15 diseases account for 50.7% of the total serious harms. Five conditions causing the most frequent serious harms account for 38.7% of total serious harms: stroke, sepsis, pneumonia, venous thromboembolism and lung cancer. The overall average error rate across diseases was estimated at 11.1%, but the rate ranges widely from 1.5% for heart attack to 62% for spinal abscess. The top cause of serious harm from misdiagnosis was stroke, which was found to be missed in 17.5% of cases.
Specialty Utilization Specialty utilization by a total of 1802 patients evaluated at the Comprehensive COVID Center (CCC) during the first 21 months in a total of 2361 initial visits in 12 specialty clinics. The mean number of specialty clinics visited by CCC patients was 1.3 (range 1-6) and multiple clinic consultations accounted for 405 visits.
Excerpt:
Background
Persistent multi-organ symptoms after COVID-19 have been termed “long COVID” or “post-acute sequelae of SARS-CoV-2 infection” (PASC). The complexity of these clinical manifestations posed challenges early in the pandemic as different ambulatory models formed out of necessity to manage the influx of patients. Little is known about the characteristics and outcomes of patients seeking care at multidisciplinary post-COVID centers.
Methods
We performed a retrospective cohort study of patients evaluated at our multidisciplinary Comprehensive COVID-19 Center (CCC) in Chicago, IL, between May 2020 and February 2022. We analyzed specialty clinic utilization and clinical test results according to severity of acute COVID-19.
Results
We evaluated 1802 patients a median of 8 months from acute COVID-19 onset, including 350 post-hospitalization and 1452 non-hospitalized patients. Patients were seen in 2361 initial visits in 12 specialty clinics, with 1151 (48.8%) in neurology, 591 (25%) in pulmonology, and 284 (12%) in cardiology. Among patients tested, 742/878(85%) reported decreased quality of life, 284/553(51%) had cognitive impairment, 195/434(44.9%) had alteration of lung function, 249/299(83.3%) had abnormal CT chest scans, and 14/116(12.1%) had elevated heart rate on rhythm monitoring. Frequency of cognitive impairment and pulmonary dysfunction was associated with severity of acute COVID-19. Non-hospitalized patients with positive SARS-CoV-2 testing had similar findings than those with negative or no test results.
Conclusions
The CCC experience shows common utilization of multiple specialists by long COVID patients, who harbor frequent neurologic, pulmonary, and cardiologic abnormalities. Differences in post-hospitalization and non-hospitalized groups suggest distinct pathogenic mechanisms of long COVID in these populations.
Keywords: Long COVID, Post-Acute Sequelae of SARS-CoV-2 Infection, PASC, Multidisciplinary Care, Health Service Delivery
Author(s): Joseph Bailey, M.D.,a,⁎ Bianca Lavelle, M.D.,b Janet Miller, B.S.,a Millenia Jimenez, B.S.,c Patrick H. Lim, M.S.,c Zachary S. Orban, B.S.,c Jeffrey R. Clark, B.A.,c Ria Tomar, B.S.,a Amy Ludwig, M.D.,a Sareen T. Ali, B.S.,c Grace K. Lank, B.S.,c Allison Zielinski, M.D.,d Ruben Mylvaganam, M.D.,a Ravi Kalhan, M.D.,a Malek El Muayed, M.D.,e R. Kannan Mutharasan, M.D.,d Eric M. Liotta, M.D. M.S.,c Jacob I Sznajder, M.D.,a Charles Davidson, M.D.,d Igor J. Koralnik, M.D.,c,1 and Marc A. Sala, M.D.a,1, for the Northwestern Medicine Comprehensive COVID Center Investigators
