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Post-Luigi, the "Extremist" Threat is You
If you’re wondering why this sounds so different from the hysteria that’s played out in the media, intelligence reports like the NYPD one we published above are a big part of the reason why. Not only do these reports stoke fear and inflate threats, but the furtive way in which they’re circulated shields them from public scrutiny. The deal the media makes with their law enforcement sources not to publish documents in full results in big, splashy headlines and pull quotes focusing on the most sensational passages but devoid of any context. The victims of these distorted narratives aren’t just ordinary people, but corporations as well, many of which enjoy privileged access (just like the media) to these government intelligence reports.
The NYPD’s intelligence bureau is just one node in a web of around 70 state-level “fusion centers” surging these kind of threat reports to companies. Presumably the companies just think they’re being responsible by signing up for the reports. In reality they’re being subtly indoctrinated into the national security state’s way of seeing things. When this apparatus of fusion centers emerged in the wake of 9/11, the warnings pertained to al Qaeda. But as the global war on terror draws down, the supposed bad guy is increasingly the American people, on both the “far-right” and “far-left” (who decides what counts as “far”?), from MAGA to anti-corporate “extremists” online.
The High Price of Fertility: Tracking the Global Trade of Human Eggs
By the time the 27 eggs reach their destination, they will have generated revenue for doctors, agents, airlines, lawyers, counselors, couriers, insurers and drug companies. Karen is paid $35,000.
Your Lab Tests - by Eric Topol - Ground Truths
You can see in the graph below that inter-individual vacation is far greater than intra-individual variation for each of the CBC metrics, and that long-term (15-year+) variation is similar to short-term at the individual level. On that note, these same researchers had previously shown that even after an acute event such as infection, trauma, or marked inflammation, the CBC setpoint values for that individual return to baseline. There are examples when that isn’t necessarily the case, as seen with the increase in hemoglobin and hematocrit in women after menopause (as presented in the Supplementary material) but overall the stability of the CBC metrics in any given individual over decades is notable. That was also shown to be th case across age, sex, race and ethnicity.
How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them — ProPublica
The vague wording made van Terheyden suspect that Dr. Cheryl Dopke, the medical director who signed it, had not taken much care with his case.
Van Terheyden was right to be suspicious. His claim was just one of roughly 60,000 that Dopke denied in a single month last year, according to internal Cigna records reviewed by ProPublica and The Capitol Forum.
The rejection of van Terheyden’s claim was typical for Cigna, one of the country’s largest insurers. The company has built a system that allows its doctors to instantly reject a claim on medical grounds without opening the patient file, leaving people with unexpected bills, according to corporate documents and interviews with former Cigna officials. Over a period of two months last year, Cigna doctors denied over 300,000 requests for payments using this method, spending an average of 1.2 seconds on each case, the documents show. The company has reported it covers or administers health care plans for 18 million people.
Insurers Are Dictating Care and We're Sick, Sick, Sick of It! | MedPage Today
A final tactic is step therapy
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, or the practice of requiring patients to attempt less expensive treatments first, even if a clinician believes another option may offer a better outcome. This summer, government officials in New York negotiated a $1 million settlement with UnitedHealthcare for allegedly failing to cover
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all federally approved birth control without restriction. The company allegedly denied a patient coverage
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for a certain progestin-only oral contraception pill, forcing the patient to try alternative treatments, despite the fact that progestin-only contraceptives can be a good option
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for patients with certain health conditions.
A Montana Hospital Let Dr. Thomas Weiner Continue Practicing Despite Concerns — ProPublica
The hospital fired Weiner on Nov. 17, 2020. Johnson, the CEO, convened a meeting with the cancer staff, telling them Warwick’s death was “the tip of the iceberg.” He barred attendees from recording the meeting, court documents show, and the hospital’s chief nurse paced the room, instructing employees to put their phones away. All of Weiner’s patients should seek second opinions, Johnson said.
Johnson also told the staff, “Don’t be surprised if black suits show up.” Weiner’s nurses understood this to mean that federal law enforcement or the Department of Health and Human Services would be investigating. “He explained it to be suits — there were going to be suits coming into the office and asking for things,” according to the testimony of nurse Andrea Thies, who, despite Johnson’s orders, took notes during the meeting.
What Happens When US Hospitals Binge on Nurse Practitioners - Bloomberg
In a 2022 article published on the Kaufman Hall website, Bates praised the practices of industry-leading Emory Critical Care Center at Emory University Hospital in Atlanta. The critical care center employs 200 advanced practice providers and 88 physicians. Not only is that the inverse of the typical staffing, but the supervising physicians don’t roam the wards. They’re sitting in a “centralized system-wide e-command center,” Bates wrote.
Vishal Bakshi, a physician assistant who serves as Emory’s chief advanced practice provider, says the organization has “embraced the idea of having an efficient system of health-care delivery with the APP at the forefront and the physician acting as the manager of the flow,” he says. “There are many ways to do medicine. We are going to do it with APPs as the backbone of the ICU.”
Large Language Model Influence on Diagnostic Reasoning: A Randomized Clinical Trial | Clinical Decision Support | JAMA Network Open | JAMA Network
The clinical case vignettes were curated and summarized by human clinicians, a pragmatic and common approach to isolate the diagnostic reasoning process, but this does not capture competence in many other areas important to clinical reasoning, including patient interviewing and data collection.
Large Language Model Influence on Diagnostic Reasoning: A Randomized Clinical Trial | Clinical Decision Support | JAMA Network Open | JAMA Network
An unexpected secondary result was that the LLM alone performed significantly better than both groups of humans, similar to a recent study with different LLM technology.31 This may be explained by the sensitivity of LLM output to prompt formulation.32 There are numerous frameworks for prompting LLMs and an emerging consensus on prompting strategies, many of which focus on providing details on the task, context, and instructions; our prompt was iteratively developed using these frameworks. Training clinicians in best prompting practices may improve physician performance with LLMs. Alternatively, organizations could invest in predefined prompting for diagnostic decision support integrated into clinical workflows and documentation, enabling synergy between the tools and clinicians. Prior studies on AI systems show disparate effects depending on the component of the diagnostic process they are used in.33,34 Given the conversational nature of chatbots, changes in how the LLM interacts with humans, for example by specifically pointing out features that do not fit the differential diagnosis, might improve diagnostic and reflective performance.35,36 More generally, we see opportunity with deliberate consideration and redesign of medical education and practice frameworks that adapt to disruptive emerging technologies and enable the best use of computer and human resources to deliver optimal medical care.
Large Language Model Influence on Diagnostic Reasoning: A Randomized Clinical Trial | Clinical Decision Support | JAMA Network Open | JAMA Network
In the 3 runs of the LLM alone, the median score per case was 92% (IQR, 82%-97%). Comparing LLM alone with the control group found an absolute score difference of 16 percentage points (95% CI, 2-30 percentage points; P = .03) favoring the LLM alone.
The Trouble With Upcoding Extends Far Beyond Ethics | MedPage Today
This practice seemed harmless enough. However, I later learned that upcoding is responsible for $12-25 billion in overpayments
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to Medicare Advantage insurers each year, enough to provide free vision and hearing care to every senior over age 65. I was involved in a practice that, at best, was billing in a way that increased our income a bit and, at worst, was defrauding taxpayers and contributing corporate profits to both insurers and healthcare companies. This was a moral dilemma that was quite different than those I studied in my medical school medical ethics class.
I now live in Charlottesville, Virginia, the headquarters of University of Virginia (UVA) Health. It recently came to light that administrators at UVA Health received a letter
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about a year ago from 128 employed physicians, alleging that the leadership pressured them to engage in fraudulent billing practices and created a toxic work environment that endangered patients. Subsequent reporting
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quoted physicians who were fearful of fines or even prosecution for complying with practices that they felt were unethical.
The Horrors of Hepatitis Research | Carl Elliott | The New York Review of Books
The names of physicians once celebrated for ethically questionable research are finally being removed from medical school buildings, awards, and lectureships. In 2008 the University of Pittsburgh discontinued a lecture series named for John Cutler, one of the principal researchers in the Tuskegee syphilis study from 1932 to 1972 and the Guatemala syphilis study of the mid-1940s. Ten years later it removed the name of Thomas Parran, another Tuskegee researcher, from a building in its School of Public Health. In 2021 the University of Pennsylvania took similar measures with Albert Kligman, the dermatologist responsible for decades of barbarous experiments at Holmesburg Prison in Philadelphia, renaming the Kligman Professorship and phasing out a lectureship named after him. A movement is now underway at the University of Cincinnati to honor those who died in the Pentagon-funded radiation experiments conducted there in the 1960s and early 1970s by Eugene Saenger, a radiologist honored by the university with the Daniel Drake Medal, the College of Medicine’s highest honor.
Of all the infamous research scandals that emerged in the 1960s and 1970s, however, none is more contested than the one over the Willowbrook hepatitis study. Between 1956 and 1972 a team of researchers from New York University led (beginning in 1958) by Saul Krugman deliberately infected institutionalized, mentally disabled children at the Willowbrook State School on Staten Island with the hepatitis virus. Along with the Tuskegee syphilis study and the 1963 cancer study at the Jewish Chronic Disease Hospital in Brooklyn, Willowbrook is part of what the historian Susan Reverby calls the bioethics “holy trinity” of research horror stories. Yet Krugman was widely celebrated among his peers. The year the study ended, he was elected president of the American Pediatric Society. Later he was honored with some of medicine’s most prestigious prizes, including the Robert Koch Gold Medal (1978), the John Howland Award (1981), and the Mary Woodard Lasker Public Service Award (1983). Even today Krugman has defenders. The Oxford Textbook of Clinical Research Ethics argues that misguided criticism of the Willowbrook study has “cast a restrictive ethical pall” over pediatric research.
Leaked Training Shows How Doctors in New York’s Biggest Hospital System Are Using AI
But the presentation and materials viewed by 404 Media include leadership saying AI Hub can be used for "clinical or clinical adjacent" tasks, as well as answering questions about hospital policies and billing, writing job descriptions and editing writing, and summarizing electronic medical record excerpts and inputting patients’ personally identifying and protected health information. The demonstration also showed potential capabilities that included “detect pancreas cancer,” and “parse HL7,” a health data standard used to share electronic health records.
Is there a difference between Jay Varma for tecovirimat and Ashish Jha for Paxlovid?
Ashish Jha used a media campaign to push paxlovid, just as SigaTech wanted Varma to do. Ashish exploited the lay press, and was part of an administration that spent over 10 billion dollars on the drug— without randomized data it helps Americans who had already had covid, had vaccines or against prevailing strains, i.e. most of us.
Ashish Jha is just like Jay Varma— a public health figure pushing a corporate product based on propaganda and not science. If anything Jha’s advocacy of Paxlovid is worse than Varma’s advocacy of tecovirimat for 4 reasons
Monkeypox is rarer than covid, which makes randomized trials harder.
Monkeypox is mostly isolated to Africa, while COVID was widespread (easier to run trials)
Tecovirimat is often given to sicker pts than outpatient paxlovid (less dire)
Tecovirimat spending will be less than 10 billion.
Jay Varma admits that SigaTech wanted him to create a media narrative around tecovirimat to approve and sell it, even while randomized trials were ongoing and evidence unclear. Ashish Jha actually did create a media narrative around a costly pill with horrific drug-drug interactions to millions of Americans when the best data showed it would not help them. He did so because his boss spent billions on the drug, and had political advantage to push it, even if it were nothing better than placebo, in order to reassure his supporters who were still afraid of covid because they created exaggerated fear in young people.
An overdose of second opinions
To me we live in a bizarre world. Doctors take hundreds of thousands of dollars from pharmaceutical companies and then recommend those costly, toxic drugs to patients for uses that lack good randomized data. The same doctors help the companies design the trials that repeatedly fail to run the right comparisons— which help ensure that their unproven recommendations remain unfalsifiable (you can’t say they are wrong, just that there is no proof they are right). The hospitals make money from autotransplant, and refuse to heed evidence saying it has no survival benefit (DETERMINATION). The doctors make money from second opinions, and don’t care if they confuse the patient while indulging their fantasy of being the best doctor. The system is fundamentally broken. It won’t be reformed from within. Only external pressure can crack it.
The first step you can do: is search your oncologist for drug company payments on open-payments and be skeptical when they take money from Abbvie and recommend venetoclax maintainence.
An overdose of second opinions
The patient printed out information on all these regimens and sought guidance. Each ‘expert’ was adamant. What should she do?
The answer was, of course, every ‘expert’ was making shit up. There was no right answer. Among all these options, we only have a few large randomized studies to provide lamplight in the darkness.
Acetazolamide for OSA and Central Sleep Apnea: A Comprehensive Systematic Review and Meta-Analysis - PubMed
Overall, acetazolamide vs control lowered the AHI by -0.7 effect sizes (95% CI, -0.83 to -0.58; I2 = 0%; moderate QoE) that corresponded to a reduction of 37.7% (95% CI, -44.7 to -31.3) or 13.8/h (95% CI, -16.3 to -11.4; AHIControl = 36.5/h). The AHI reduction was similar in OSA vs CSA, but significantly greater with higher doses (at least up to 500 mg/d). Furthermore, acetazolamide improved oxygen saturation nadir by +4.4% (95% CI, 2.3 to 6.5; I2 = 63%; no evidence of effect modification; very low QoE) and several secondary outcomes that included sleep quality measures and BP (mostly low QoE).
Kaiser Permanente brings new AI tool to help doctors focus on patients
“By reducing administrative tasks, we’re making it easier for our physicians to focus on patients and foster an environment where they can provide effective communication and transparency while meeting the individual needs of each patient who comes to them for care,” he said. “Creating space for the patient and the physician connection is what inspired us to implement this technology. And we hope that those connections and improved efficiencies will help with the sustainability of the practice of medicine for many doctors.”
The ChatGPT chatbot powered by GPT-4 scored better than the panelists on measures of diagnostic and treatment accuracy when it analyzed 20 real-life cases and considered 20 possible patient questions, reported Andy S. Huang, MD, of the Icahn School of Medicine at Mount Sinai in New York City, and colleagues in JAMA Ophthalmology
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.
Physical interventions to interrupt or reduce the spread of respiratory viruses - Jefferson, T - 2023 | Cochrane Library
The pooled results of RCTs did not show a clear reduction in respiratory viral infection with the use of medical/surgical masks. There were no clear differences between the use of medical/surgical masks compared with N95/P2 respirators in healthcare workers when used in routine care to reduce respiratory viral infection.
Opinion | The Mask Mandates Did Nothing. Will Any Lessons Be Learned? - The New York Times
But when it comes to the population-level benefits of masking, the verdict is in: Mask mandates were a bust. Those skeptics who were furiously mocked as cranks and occasionally censored as “misinformers” for opposing mandates were right. The mainstream experts and pundits who supported mandates were wrong. In a better world, it would behoove the latter group to acknowledge their error, along with its considerable physical, psychological, pedagogical and political costs.
Hospital Bills Inflated by Surgeons Double Booking - Bloomberg
The University of Southern California’s hospital system is accused of billing for thousands of cases - costing taxpayers “hundreds of millions of dollars” - where the teaching physician left residents unattended to perform even spine and brain surgeries. When one doctor confronted a department head about an “embarrassingly high” rate of surgical injuries at one of its facilities, the administrator responded, according to the lawsuit:
“Well, that’s where the residents go to practice on the poor folks.”
Doctors watching pharma TV ads in ‘blue jeans moments’ often search to find out more, Roku survey says – Endpoints News
More than two-thirds (67%) of physicians said they researched a product after seeing a pharma ad while watching TV.
Is Doctor Pay Too High? NIH Pulls Plug on Misinfo Research; FDA and EPA Butt Heads | MedPage Today
Previous NIH Director Francis Collins, MD, PhD, publicly proposed the project idea in 2021, saying, "We basically have seen the accurate medical information overtaken, all too often, by the inaccurate conspiracies and false information on social media," and "I do think we need to understand better how -- in the current climate -- people make decisions."
America’s Love Affair with Adderall | The Free Press
Each maintained their childhood prescriptions throughout high school and college, and into their professional lives. Each had a wake-up call that prompted them to get off the drug. For Sloan Tate, it was realizing she lacked the emotional capacity to mourn when her grandmother died. Alex Cosec, a 32-year-old guitar player, real estate photographer, and fitness coach from Minneapolis, told me he decided to join Narcotics Anonymous after his ex-girlfriend called the cops on him when he took too much Adderall, among other substances, and began throwing things in their apartment.
“I’m the Adderall addict,” Cat Marnell told me. She has a claim to the title. At one point she was taking 120 milligrams of Adderall a day (60 milligrams is a high prescription dose). She wrote a book about it. She’s been in rehab for Adderall five times. Marnell was prescribed Adderall at 19 after being on Ritalin for most of her life. Adderall was different for Marnell. “Adderall was much more of a narcotic experience, and so at age 19 that was very appealing to me to be flying high from it. And that very swiftly turned into sleepless nights, dependency, obsession, a celebration of it. I was absolutely in love with Adderall,” she told me.
America’s Love Affair with Adderall | The Free Press
Many TikTok videos list ways to get an Adderall prescription online and how to self-diagnose ADHD (three symptoms cited by the CDC include being “easily distracted,” acting as if “driven by a motor,” and having “trouble organizing tasks and activities”). Studies have found that watching TikTok increases self-diagnosis for ADHD. The hashtag #ADHD has 14 billion views, and #ADHDdiagnosis has 46.1 million views.
Last year the company Cerebral, which provides online therapy and medication, was the third largest advertiser on TikTok after Amazon and HBO. After filling out a questionnaire, followed by a 30-minute video call with a “licensed prescriber,” Cerebral can provide an ADHD diagnosis and prescription for medication.
