Moving On to New Website

Thanks for following my blog which since 2007 has provided a home for my thoughts and musings about the challenges for doctors and patients to get the right care each time. This blog was the starting point for my first book – Stay Healthy, Live Longer, Spend Wisely – Making Intelligent Choices in America’s Healthcare System.

I hope you continue to enjoy much of the terrific content here as well as follow me to my new home which features the latest commentary and insight at Davis Liu, MD as well as my newest book – The Thrifty Patient – Vital Insider Tips For Saving Money and Staying Healthy.

Of course you can still follow me on Twitter @davisliumd


Davis Liu, MD

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“Tag Busters” an infection prevention and antimicrobial stewardship collaborative opportunity is no longer accepting registrations.

We appreciate the interest that many communities have had in participating in the online collaborative. Due to the popularity of this opportunity, we would like to announce that the collaborative has reached capacity and is no longer accepting registrations. At this time we will not be maintaining a waitlist. 

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AIDC: Future of Electronic Health Records

Key Blocker in usage of EHR’s
Clinicians are always under
pressure, in any given visit be it as a part of an outpatient clinic visit or a
bed side round. They are expected to make eye contact, listen empathetically,
process nonverbal cues, keep lab tests, allergies, and medication lists in
mind, and formulate differential diagnoses. The same clinician is also required
to document clinical notes granularly enough to support clinical coding and
enter data in a structured way to comply with data quality and regulatory
With widespread usage of EHR’s it
has become common to see clinicians and other allied professionals staying
after hours to do just data entry into EHR’s to comply with mandated data
entry. This is reducing physicians and other providers into data entry clerks
and is detracting them from being productive to provide quality care. This
ended up making data entry as the largest potential obstacle to the effective
use of EHR within clinical settings. Physicians at Yale and the University of
California recently argued that EHRs are becoming detrimental to the care of
patients as physicians spend twice as much time in front of a computer compared
to face time with a patient.
However there are other multiple
studies which proved that real time entry of patient data will make the current
data available to clinicians and help them target the right patients to provide
care. But real time entry of data adds additional burden to the clinicians
taking their valuable and critical time away from providing care to patients
and often leading to missing and erroneous data impacting patient outcomes and
creating administrative overheads.
Currently there are some tools
and work arounds within clinical settings to lessen the burden of data entry.
Intuitive User Interface: Clinicians have been complaining about quality
of the interface they were forced to use since the inception of EHR’s. The user
interfaces were often found to be not intuitive and required countless keystrokes
and they found it difficult to align their work process with what was needed to
be entered into the EHR.  Even today the
best of the EHR’s in the market have sloppy user interfaces, but vendors are
making effort to create user interfaces by designing based on human behaviour principles
and by working, observing and consulting with end users.  The intuitive user interfaces need to be accompanied
by proper education, training and support to aid in easier use of EHR by users.
EHRs with intuitive user
interfaces aggregate information pertinent to the problem at hand and are
designed using data visualization techniques for optimal display. But intuitive
user interfaces has its own limitations in terms of space on screen,
expectations of varied users and affordability and human senses.
Digital Dictation: To reduce clinician’s workload related to data
entry in EHR’s lot of organisations use digital dictation tools with voice-to-text
capability to speed up data entry. EHR providers are increasingly incorporating
and integrating voice-recognition software into their products to allow clinicians
to directly narrate into the system. There is an overhead of narrated notes
need to be reviewed for accuracy and then approved, but clinicians are found approving
their entries without reviewing them. This increases the risk of inaccurate
data and mistakes. The art of converting narrative into structured data and
incorporating semantic workflow to support the narrative is quite complex.
Natural Language Processing: Natural language processing (NLP) is increasingly
considered as a viable technical solution for improving clinical outcomes and
simplifying data entry. NLP deciphers doctors’ notes and other
unstructured information generated during patient visit into structured,
standardized formats. However NLP suffers from the similar issues as digital
dictation and text is often ungrammatical, consists of “bullet point” telegraphic
phrases with no semantic context.
Internet of Things (IoT) is a concept
that basically connects any device with an on and off switch to the Internet.
IoT’s offer Automatic identification and data capture (AIDC) technologies, AIDC
refers to the process of automatically identifying and collecting information about
patients and logging this information in an application such as EHR.  AIDC refers to a range of different types of
data capture devices such as barcodes, biometrics, RFID (Radio Frequency
Identification), magnetic stripes, smart cards, OCR (Optical Character Recognition)
and sensors.
What AIDC can do for EHR’s is
briefly discussed below.
Digitising Written Notes:
Many clinicians are still more comfortable working with paper and asking them
to enter data electronically can lead to resistance against an EHR
implementation. Automated document and data capture technology can be leveraged
to enable doctors to continue to utilize paper encounter forms with a new EHR
system. AIDC allows setting up bar codes (2-D or 3-D) automatically and assign
them to patient’s record by scanning and digitizing their back files and
integrating them with the EHR system to have a single view of an entire patient
history. OCR/ICR technology is typically incorporated in document and data
capture software applications that also have features like image processing for
improving the quality of scanned documents; forms recognition, to identify the
type of form being scanned; and forms processing, which enables the software to
identify and capture specific pieces of data.
Improving Efficiency: One
of the most important aspects of AIDC is to improve efficiency of an
organisation by assisting in equipment tracking, inventory management and patient
tracking. This is done using solutions involving RFID and mobile scanners which
will help organisation track assets, providing real-time information about
assets (drugs and consumables) ensuring hospitals have what they need, where they
need it, when they need it.
One of the good examples of improving
efficiency using AIDC technologies apart from the usual inventory management
and equipment tracking  is  bed management where bed occupancy sensors
provides an early warning by alerting that the user has left their bed and not
returned within a pre-set time period, indicating a possible fall. These sensors
can also be programmed to switch on lights, helping as digital signage devices.
Managing Patient Care: To provide better patient care, clinicians need access to medical
equipment and access clinical data which is increasingly being collected using
mobile devices and other wearable technologies. Mobile devices and wearable
sensors are a part of IoT solutions and they allow clinicians to gain
access to the information in real-time to improve patient experiences and
outcomes. The wearables and other wireless devices and sensors allow monitoring
patient temperature, Parkinson’s disease, post-surgery awakening, etc. These
applications require asset tagging and patient tracking. The proliferation of
IoT devices allow data being automatically collected and fed into EHR systems
with vendors of IoT devices proving  interfaces to integrate them with EHR’s
thereby helping organizations gather more data and deliver better care.
How widespread is usage of AIDC?

Automatic identification &
data capture (AIDC) technology in healthcare has greatly promoted the
error-free data collection and improved patient safety. It is helping reduce
medication errors and related healthcare expenditure. Growing focus on patient
safety, technological revolution, and rising government legislations on the use
of barcode & RFID technology are further expected to boost the growth of
the global healthcare automatic identification & data capture (AIDC)
Automatic Identification & Data
capture (AIDC) market within healthcare industry is mainly segmented into
clinical and non-clinical applications. The non-clinical application segment
holds the largest share, owing to the higher adoption of barcode & RFID
technology in the non-clinical applications such as supply chain management and
medical staff & asset tracking, though the clinical application segment is
also growing fast. Global Healthcare Automatic Identification & Data
Capture (AIDC) Market is expected to reach USD 3,122.7 million by 2022
supported by a CAGR of 15.4% during the forecast period of 2017 to 2022.
The Wythenshawe Hospital used a
traditional paper-based process to manually enter patient information into
patient records. This process is known to be less reliable than automated entry
and can cause major health concerns for patients as a result of the opportunity
for human error. For the medical facility, error that leads to the injury or
even death of a patient opens the door for major legal complications. The
Wythenshawe Hospital staff also found the process to be time-consuming, as
doctors and nurses had to take time away from patients to enter data, recall
patient records or refill prescriptions manually.
Wythenshawe Hospital decided to
implement a system based on bar codes and bar code scanning devices to support
staff in scanning codes on patient records. By automating this activity, the
staff is able to automatically retrieve a patient’s Electronic Medical Record
Six trusts which include
Salisbury NHS Foundation Trust, Plymouth Hospital NHS Trust and Leeds Teaching
Hospital have been selected as a part of Scan4Safety project which used
barcoding to better identify and match patients, products and locations.  Across the six demonstrator sites, early signs
of benefits are extremely encouraging, with over £700,000 of savings
already being identified:
Stock reduction/one off stock holiday –
Reduction in wastage/obsolescence –
Non-clinical pay efficiencies – £46,000
Based on these initial findings, it is estimated that for a typical NHS
Hospital trust, the benefits could be:
Time release to patient care – equivalent
to 16 band 5 nurses per trusts, that’s 2,400 band 5 nurses across the NHS.
A reduction of inventory averaging £1.5
million per trust, £216 million across the NHS.
Ongoing operational efficiencies of £2.4
million per trust annually, that’s £365 million across the NHS.
What are the challenges with AIDC?
AIDC devices and technologies interfaces with
EHR are not ‘plug-and-play’. The devices will need some kind of interface to be
installed that will translate the measurement data from the device into a
format that the EHR database can understand and use
AIDC devices provide high volume of data which is
required to be captured and processed at high speed
Unlike manual data capture the data coming from
AIDC devices need to be categorised into wanted and unwanted data categories
ISO/IEC standards such 16022 Data Matrix and 18004
QR Code
ISO/IEC 29161 Unique Identification for IoT
ISO 17367 Supply chain applications of RFID –
Product tagging
ISO/IEC WD 30101 Sensor Network and its
Interfaces for Smart Grid System
GS1 Global Specifications,
HIBC Health Industry Bar Code,

Source link

Should you eat only low fat or no fat dairy products? The answer may surprise you.

This advice plus other advice to limit
saturated fats rapidly led to a massive shift in America to use of low and no
fat dairy products from whole fat diary. Unfortunately, for whatever reasons,
today America has an epidemic of obesity, overweight, metabolic syndrome, diabetes
and perhaps now an increasing incidence of cardiovascular disease.   

Was the dairy advice correct or not? A recent perspective
article in the J of the American Medical Association asked experts and suggests
that the answer is simply not clear. 

One observation is that Americans use
cheese primarily to create pizzas, cheeseburgers and junk foods, while
Europeans use cheese as cheese itself.

What is known about the health benefits or non-benefits is
based on observational studies which amount to associations rather than clear
cause and effect as would be found in a randomized trial where some group gets full
fat diary and the other does not. Still, observational studies at least give directions
for consideration. 

In the PURE study of 136,000+ individuals 35-70 years of
age, a higher intake of dairy fat was actually associated with lower risk of
cardiovascular events and mortality. “Whole fat dairy seemed to be more
protective than nonfat or low-fat dairy”

Another approach is to look at biomarkers, in this case by
examining the blood content of three specific fatty acids are primary derived
from dairy products. It turned out that when 16 such studies were pooled with
63,00 participants, those with higher levels of the three fatty acids were less
likely to develop diabetes during the time of the trial. 

What about weight gain? It turns out there is no clear-cut
evidence that full fat dairy is more likely to lead to weight gain than low fat
or no fat diary consumption. An expert quoted in the article noted that there
is no strong data to show that full fat diary leads to more weight, more cardiovascular
disease or more metabolic syndrome. Rather observational studies suggest just
the opposite. 

Another expert interviewed suggested that the key is not to worry
about any one ingredient in the diet but what is most important is the overall dietary
pattern. This makes good sense to me.

Rubin, R, Whole-fat or nonfat dairy? the debate continues, J Amer Med Assoc,
2018; 320:2514-2516

Some 40 years ago, the Dept of Agriculture recommended a
switch to no or low-fat milk and dairy products as part of the effort to reduce
the consumption of saturated fats.

For the Years of Investigation to Come: a Guide to Resources for Challenging Health Care Corruption

The Enduring Problem of Health Care Corruption

Now arrives the years of investigation.  Here in the US, a new majority in the US House of Representatives promises multi-pronged investigations of, among other topics, the corruption that now seems pervasive at the highest reaches of the US government, corruption that has badly affected efforts to truly reform US health care (look here).  Meanwhile, similar investigations are likely to get underway in various US states.  We can only hope that this flurry of activity will end up with some positive steps to reduce US health care corruption, an enduring problem about which we often write.

As we wrote in August, 2017, Transparency International (TI) defines corruption as

Abuse of entrusted power for private gain

In 2006, TI published a report
on health care corruption, which asserted that corruption is widespread
throughout the world, serious, and causes severe harm to patients and

the scale of corruption is vast in both rich and poor countries.


Corruption might mean the difference between life and death for
those in need of urgent care. It is invariably the poor in society who
are affected most by corruption because they often cannot afford bribes
or private health care. But corruption in the richest parts of the world
also has its costs.

The report got little attention.  Health care corruption
has been nearly a taboo topic in the US, anechoic, presumably because its discussion would offend the people it makes rich and powerful. As suggested by the recent Transparency International report on corruption in the pharmaceutical industry,

However, strong control over key processes combined with huge resources
and big profits to be made make the pharmaceutical industry particularly
vulnerable to corruption. Pharmaceutical companies have the
opportunity to use their influence and resources to exploit weak
governance structures and divert policy and institutions away from
public health
objectives and towards their own profit maximising interests.

Presumably the leaders of other kinds of corrupt organizations can do the same. 

When health care corruption
is discussed in English speaking developed countries, it is almost
always in terms of a problem that affects some other places, mainly 
presumably benighted less developed
countries.  At best, the corruption in developed countries that gets
discussed is at low levels. 
In the US, frequent examples are the “pill mills”  and various cheating
government and private insurance programs by practitioners and
patients.  Lately these have gotten even more attention as they are
decried as a cause of the narcotics (opioids) crisis (e.g., look here).  In contrast, the US government has been less inclined to address the
activities of the leaders of the pharmaceutical companies who have
pushed legal narcotics (e.g., see this post). 

However, Health Care Renewal has stressed “grand corruption,” or the
corruption of health care leaders.  We have noted the continuing impunity of top health care corporate managers.  Health care corporations have allegedly used kickbacks and fraud to enhance their revenue, but at best such corporations have been able to make legal settlements
that result in fines that small relative to their  multi-billion
revenues without admitting guilt.  Almost never are top corporate
managers subject to any negative consequences.

We have been posting about this for years at Health Care Renewal, while seeing little progress on this issue.

Things only seem to be getting worse given the increasing evidence that the Trump administration is corrupt at the highest levels.   In January, 2018, we first raised the question about how health care corruption could be pursued under a corrupt regime.  We noted sources that
summarized Trump’s. the Trump family’s, and the Trump administration’s
corruption..  These included a website, entitled “Tracking Trump’s Conflicts of Interest” published by the Sunlight Foundation, and two articles published in the Washington Monthly in January, 2018. “Commander-in-Thief,” categorized Mr Trump’s conflicted and corrupt behavior.  A Year in Trump Corruption,” was a catalog of the most salient cases in these categories in 2017.

In July, 2018, we addressed the Trump regime’s corruption again  By then, more summaries of Trump et al corruption had appeared.   In April, 2018, New York Magazine published “501 Days in Swampland,” a time-line of  starting just after the 2016 presidential election. In June, 2018, ProPublica reviewed
questionable spending amounting to $16.1 million since the beginning of
Trump’s candidacy for president at Trump properties by the US
government, and by Trump’s campaign, and by state and local governments. Meanwhile, Public Citizen released a report on money spent at Trump’s hospitality properties.  Meanwhile, the voluminous Tracking Corruption and Conflicts of Interest in the Trump Administration summary appearing in the Global Anti-Corruption Blog has grown and grown. 

 So the driver of US health care corruption may now be the executive branch of government and its relationship with the Trump family and cronies, trumping even the influence of health care corporate corruption.  

However, in our work we have been heartened to find some useful resources (although unfortunately none specifically targeted at health care corruption in the US).  To inspire others to join the fight against health care corruption and related ills, I take this opportunity to post an idiosyncratic list of some of the most helpful resources I have found (including one very new one).  In alphabetical order:

Basel Institute on Governance

Located in Basel, Switzerland,

an independent not-for-profit competence centre working around the world
with the public and private sectors to counter corruption and other
financial crimes and to improve the quality of governance.

The Institute does not have a specific health care focus, but focuses on broad issues with applicability to health care: asset recovery, public governance, corporate governance and compliance, collective action, and public finance management.

Curbing Corruption

This is a new website staffed by anti-corruption experts mainly based in the UK, meant

to appeal widely to people who want to take action to reduce corruption
within their sector of society, and/or within their organisation. This
includes Members of Parliament, the private sector, civil society
organisations, professional associations, the media and the judiciary.

However, their main focus now are politicians and public officials.

The website includes sector specific resources, including a very extensive review document on the health sector.

Global Anti-Corruption Blog

A multi-author US based blog

devoted to promoting analysis and discussion of the problem of
corruption around the world. This blog is intended to provide a forum
for exchanging information and ideas across disciplinary and
professional boundaries, and to foster rigorous, vigorous, and
constructive debate about corruption’s causes, consequences, and
potential remedies.

It includes an extensive list of international anti-corruption resources (much bigger than this idiosyncratic list), but which tellingly has no organization specifically focused on health care, and no organization specifically focused on US corruption.

Transparency International

Perhaps the best known international anti-corruption NGO (non-governmental organization), based in Berlin, Germany.  It proclaims 

From villages in rural India to the corridors of power in
Brussels, Transparency International gives voice to the victims and
witnesses of corruption. We work together with governments, businesses
and citizens to stop the abuse of power, bribery and secret deals.

a global movement with one vision, we want a world free of corruption.
Through chapters in more than 100 countries and an international
secretariat in Berlin, we are leading the fight against corruption to
turn this vision into reality.

Its website is extensive.  It hosts more or less biannual International Anti-Corruption Conferences.  It provides many resources, including a well known annual international survey of corruption perceptions.  It has chapters in multiple countries (although, tellingly, its US chapter was dis-accredited in 2017, look here).

The TI UK chapter has a specific health care initiative focusing on the pharmaceutical industry.

U4 Anti-Corruption Resource Centre

Located in Bergen, Norway,

 U4 is a permanent centre at the Chr. Michelsen Institute
(CMI) in Norway. CMI is a non-profit, multi-disciplinary research
institute with social scientists specialising in development studies.

Its introductory statement

At U4, we work to reduce the harmful impact of corruption on society. We
share research and evidence to help international development actors
get sustainable results.

U4 provides publications and resources for various sectors, including health care.


Corruption in health care is a daunting problem, but 2018 showed us in the US that when people get upset enough about problems, things happen (albeit, not always great things).  So we urge all concerned about health care corruption to make things happen.  The resources above may help them do so.

We Must Stop Torturing Elderly Patients with Unnecessary Medical Procedures

Until this afternoon I was going to post a more policy-oriented
article, but I received a call indicating my father-in-law, who is 95 years
old, is now in a rehabilitation facility after a fall which did not result in any
broken bones. This event resulted in a cardiac surgeon installing a cardiac device
in his heart to keep it pumping rhythmically regardless of the patient’s
wishes. Mel was not in distress and at age 95 merely had a low heart rate,
because he is approaching the end of his life. At this point he is forgetful
and in the early stages of dementia. This invasive medical intervention was not
solicited by the family and was encouraged only by the medical providers.
Pacemakers are forced on elderly patients all of the time in
the United States. It often provides no improvement in quality of life and in
fact, contributes to the patient living longer to suffer through dementia,
incapacity to perform activities of daily living, and to lose other aspects of a
good life. I am anguished that my father-in-law has been subjected to this
treatment because it will only prolong his suffering and not improve his life.
His mother, Rosemary, died at age 93, active up until the end, so why deny Mel
this graceful exit.
 Further, there isn’t
a single clinician who would submit to this procedure at that age, so why are
they imposing it on their elderly patients?
To further understand how aberrations in the U.S. healthcare
system encourage overuse, sales of extremely expensive medical devices, and dehumanization
of healthcare, I encourage you to read Katy Butler’s Knocking on Heaven’s Door,
The Path Way to a Better Way of Death, which was published in 2013. It is her
personal story of how the cardiac pacemaker kept her 93-year-old father alive
through dementia and other misery. Here is a link to my review of her book in
the New York Journal of Books:
Cardiac surgeons are the top earners for physicians and
there are tremendous financial incentives to install pacemakers and other cardiac
devices on increasing numbers of patients, regardless of viability and efficacy.
Mel, with his private insurance can afford to pay whatever the procedures will
cost and this is like the “whale” in the healthcare system, the patient whom is
so lucrative he will provide financing for a whole host of things in the healthcare
system. Doctors in the U.S. don’t make any money for telling a patient to go
home and enjoy the last days of their life. They are paid to provide
intervention regardless of systemic costs and not to think holistically.
In 2013, my guidebook to the U.S. healthcare system devoted
a chapter to creating a good death and I encourage you to read that, so that
you may have more control over the last days of your life than Mel has. Here is
a link to that book, which is still selling in eBook and hardcover versions:
As for me, I hope my son will send me out on raft and set my
bones on fire in a true Viking send off in spiritual reverence for the veracity
with which I have lived my life.
And this is the healthpolicymaven signing off encouraging
you to draft medical powers of attorney and don’t leave it up to your children
to make these care decisions, appoint a professional clinical advocate.  A sound living will requires more than
designating treatments which you will eschew, you need to have a medical
advocate who understands the U.S. healthcare system.  And please don’t sign blanket releases when
you enter medical facilities, be clear on that for which you consent and that
for which you do not.
Roberta E. Winter an independent health policy analyst and
writer has continuously published this column since 2007. All opinions
expressed here are her own and not subject to any corporate or institutional

2018 Top 10 Posts from Healthcare Marketing Matters

It’s that time of the year where a; the Top 10 lists come
out.  So, being a crowd follower (not),
here are the Top 10 posts for 2018 from Healthcare Marketing Matters top to
Thank you for reading and best wishes for success and
prosperity in 2019.
Increase the Power of Hospital Brand Marketing Using Your Triple Aim – Earned
Media, Public Relations & Social Media
2. Hospital Marketing Appears Random and Unconnected, Says
the Insured Healthcare Consumer
3. “Hey Alex, I Don’t Feel Well. Find A Physician Near Me.” Hospital
Marketer, Is Your Website Optimized for Voice Search?
4. Social Media Use for Hospitals, the Easy Guide to Message and
Channel Integration
8. Nine Essential Strategies for Engaging the Healthcare
Consumer & Patient 24/7, Because That is the World They Live In.
10. It’s Not Social Media Anymore. Social Has Become the New
Mainstream Media. Now what?
A note to my readers.
You may have noticed that haven’t been posting as frequently as before.
After 11 years of writing Healthcare Marketing Matters, the weekly research and
topic selection becomes a bit of a chore. While there has been much progress in
hospitals and marketing, it remains mired in a features approach looking at us and little content that fosters
true engagement with the patient and healthcare consumer.
The other reason is
Michael is a
healthcare business, marketing, communications strategist and thought-leader. 
As an internationally followed healthcare strategy blogger, his blog,
Healthcare Marketing Matters is read in  52 countries and listed on
100 Top Healthcare
Marketing Blogs, and Websites
at No. 3 on the list by Michael is a Life Fellow, American
College of Healthcare Executives, and a Professional Certified Marketer,
American Marketing Association. An expert
in healthcare marketing strategy, digital marketing & social media, Michael
is in the top 10 percent of social media experts nationwide and is considered
an established influencer. For inquiries regarding strategic consulting
engagements, call Michael at 815-351-0671. Opinions expressed are my own.

Health Care and Celiac Disease

disease is a serious genetic autoimmune disorder, according to the Celiac
Disease Foundation, where the ingestion of gluten leads to damage in the small
intestine.  It is estimated to affect 1 in 100 people worldwide.  Two
and one-half million Americans are undiagnosed and are at risk for long-term
health complications.
If you have celiac disease, eating gluten triggers an
immune response in your small intestine. Over time, this reaction damages your
small intestine’s lining and prevents absorption of some nutrients
(malabsorption). The intestinal damage often causes diarrhea, fatigue, weight
loss, bloating and anemia, and can lead to serious complications, according to
the Mayo Clinic.
In children, malabsorption can affect growth and
development, in addition to the symptoms seen in adults. There’s no cure for
celiac disease — but for most people, following a strict gluten-free diet can
help manage symptoms and promote intestinal healing.
people with celiac disease must avoid gluten — a protein found in foods
containing wheat, barley and rye — it can be challenging to get enough grains.
More information about this medical issue is located at this website:
disease cannot be “caught,” but rather the potential for celiac
disease is in the body from birth. Its onset is not confined to a
particular age range or gender, although more women are diagnosed than men,
according to the Celiac Support Association. It is not known exactly what
activates the disease, however three things are required for a person to
develop celiac disease:
genetic disposition:

being born with the necessary genes. The Human Leukocyte Antigen (HLA) genes
specifically linked to celiac disease are DR3, DQ2 and DQ8…and others.
external trigger:
environmental, emotional or physical event in one’s life. While triggering
factors are not fully understood, possibilities include, but are not limited to
adding solids to a baby’s diet, going through puberty, enduring a surgery or
pregnancy, experiencing a stressful situation, catching a virus, increasing
WBRO products in the diet, or developing a bacterial infection to which the
immune system responds inappropriately.
gluten and related prolamins.
, tissue
transglutaminase (TG2) also TG4 and TG6.
of proinflammatory cytokines
especially interferon (IFN-γ).
and young children who have celiac disease are more likely to have digestive
symptoms, such as abdominal pain, vomiting, diarrhea (even bloody diarrhea) and
constipation, and may fail to grow and gain weight. A child may also be
irritable, fretful, emotionally withdrawn, or excessively dependent. If the
child becomes malnourished, he or she may have a large tummy, thin thigh
muscles, and flat buttocks. Many children who have celiac disease are
overweight or obese.
may have digestive symptoms such as diarrhea and constipation. They may hit
puberty late and be short. Celiac disease might cause some hair loss (a
condition called alopecia areata) or dental problems.
are less likely to have digestive symptoms. Instead, they might have a general
feeling of poor health, including fatigue, bone or joint pain, irritability,
anxiety and depression, and missed menstrual periods in women. Some adults may
have digestive symptoms such as diarrhea or constipation.
(loss of calcium from the bones) and anemia are common in adults who have
celiac disease. A symptom of osteoporosis may be nighttime bone pain.
intolerance (a problem digesting milk products) is common in patients of all
ages who have celiac disease.
herpetiformis (an itchy, blistery skin problem) and canker sores in the mouth
are also common problems in people who have celiac disease.
disease can develop at any age after people start eating foods or medicines
that contain gluten. Left untreated, celiac disease can lead to additional
serious health problems, as reported by the Celiac Disease Foundation, such as
these healthcare issues:
deficiency anemia
onset osteoporosis or osteopenia
and miscarriage
and mineral deficiencies
and peripheral nervous system disorders, including ataxia, epileptic
seizures, dementia, migraine, neuropathy, myopathy and multifocal
bladder malfunction
to this advocacy website,
, t
here are more than 300 symptoms of celiac disease, and symptoms can be
different from person to person. If you have symptoms of celiac disease,
especially ones that last a long time, you should ask your doctor for a celiac
disease blood test. Left untreated, people with celiac disease are at-risk for
serious health consequences, like other autoimmune diseases, osteoporosis,
thyroid disease, and even certain cancers.
According to the National Institutes for Health, foods such as meat, fish, fruits,
vegetables, rice, and potatoes without additives or seasonings do not contain
gluten and are part of a well-balanced diet. You can eat gluten-free types of
bread, pasta, and other foods that are now easier to find in stores,
restaurants, and at special food companies. You also can eat potato, rice, soy,
amaranth, quinoa, buckwheat, or bean flour instead of wheat flour.
In the
past, doctors and dietitians advised against eating oats if you have celiac
disease. Evidence suggests that most people with the disease can safely eat
moderate amounts of oats, as long as they did not come in contact with wheat
gluten during processing. You should talk with your health care team about
whether to include oats in your diet.
shopping and eating out, remember to:
food labels —especially on canned, frozen, and processed foods—for ingredients
that contain gluten.
foods labelled “gluten-free;” by law, these foods must contain less than 20
parts per million, well below the threshold to cause problems in the great
majority of patients with celiac disease.
restaurant servers and chefs about how they prepare the food and what is in it
out whether a gluten-free menu is available.
a dinner or party host about gluten-free options before attending a social
labeled gluten-free tend to cost more than the same foods that have gluten. You
may find that naturally gluten-free foods are less expensive. With practice, looking
for gluten can become second nature. If you have just been diagnosed with
celiac disease, you and your family members may find support groups helpful as
you adjust to a new approach to eating. A significant amount of additional
support material is found at this website:
to Today,
could a normally harmless virus cause a sensitivity to
gluten? A new study has found that a certain type of virus could trigger a
person’s immune system to overreact to gluten, leading to celiac disease. The
findings, published this month in Science,
provide an explanation for why certain people develop celiac disease.
People with celiac disease had more antibodies to
reoviruses in their blood compared to healthy individuals. Furthermore, these
people with more antibodies were found to have more of the celiac disease
inflammation. Whether a person was infected with reoviruses at some point in
the past could explain why they develop celiac at a certain age or had worse
symptoms compared to others who were not infected. More information about this research is found here:

of your sensitivity to gluten, you should take preventive measures to ensure
you have all the answers about celiac disease. You may suffer from it and not
even know you have it. See your family doctor or a health care specialist if
you have questions or may be experiencing some of the symptoms. Celiac disease
has definite consequences to your health. Don’t take chances.

Ambergan Prime

Dear primary care doctor, Jeff Bezos is about to devour your lunch. All of it. And then he’ll eat the table, the plates, the napkins and the utensils too, so you’ll never have lunch ever again. Oh yeah, and they’ll also finally disrupt and fix health care once and for all, because enough is enough already. Mr. Bezos, it seems, got together with two of his innovator buddies, Warren Buffet from Berkshire Hathaway and Jamie Dimon from J.P. Morgan, and they are fixing up to serve us some freshly yummy and healthy concoction.
Let’s call it Ambergan for now.

This is big. This is huge. It comes from outside the sclerotic “industry”. And it’s all about technology. The founders are no doubt well versed in the latest disruption theories and Ambergan will be a classic Christensen stealth destroyer of existing markets. When the greatest investor that ever-lived combines forces with the greatest banker in recent memory and the premier markets slayer of all times, who happens to be the richest man on earth, all to bring good things to life (sorry GE), nothing but goodness will certainly ensue.

Everybody inside and outside the legacy health care industry is going to write volumes about this magnificent new venture in the coming days and months, so I will leave the big picture to my betters. But since our soon to be dead industry has been busy lately bloviating about the importance of good old fashioned, relationship based primary care, perhaps it would be useful to understand that Ambergan is likely to take the entire primary care thing off the table and stash it safely in the bottomless cash vaults of its founders. It’s not personal, dear doctor. It’s business. Ambergan will be your primary care platform and you may even like it.

I am not sure what Mr. Buffet is contributing to this venture, other than cash and the warm bodies of his employees to pilot the venture. As to Mr. Dimon, he could probably run a modern analytics-based, risk-assuming health management entity, a.k.a. insurance company, while blindfolded and with both hands tied behind his back, so he may be useful in the short term. Let’s face it though, the most interesting actor here is Mr. Bezos and his Amazon platform of everything. Whatever else happens, it is probably safe to assume that within the next ten to twenty years, most people will be getting much expanded primary care services directly, and almost exclusively, from Amazon.

Amazon is a transactional platform, where people buy and sell things that Amazon does not make, and often does not even stock. With its more recent forays into TV, movies and music, Amazon also has some experience selling, mostly subscription based, services to consumers. As strange as it may sound though, most Amazon profits come from a very different source. Amazon Web Services (AWS), a computing platform (cloud) service, mostly for businesses and governments is a modest part of Amazon revenues, but a huge contributor to its profits. This lay of the Amazon land practically begs for a little cross pollination, and health care may very well be the ideal vehicle for that.

Cloud services like AWS are essentially eliminating inhouse professionals and expertise in maintaining the basic infrastructure of computing, outsourcing it all to Amazon. Rings a bell? You can almost see the Amazon ads for its primary care services, telling hospitals that they should concentrate on their core business, which is cutting people open and stitching them back together, and leave routine care to Amazon’s primary care platform, expanding or shrinking just in time to match organization demands, with guaranteed uptimes of 99.99999%, and so forth. And you can almost see the direct to consumer ads too, can’t you? Sure you can. You know you can.

A few days ago, before the Ambergan announcement sent the health care markets into a tailspin, Amazon hired a top doctor from one of those trendy primary care corporations that like to misrepresent themselves as Direct Primary Care (DPC).  People speculated that Mr. Bezos, who previously invested in another failed DPC organization, may be ready to try his own hand at fake DPC for his own employees. Meh…  It didn’t sound right to me, because with or without Ambergan, the Amazon stars were already aligning towards a massive thrust into health care, from the bottom up, as any good disruptor usually does.

A few weeks ago, Amazon offered us an opportunity to invite Jeff Bezos into our bedroom. No, he won’t interfere with anything. You won’t even know he’s there. He’ll just sit quietly beside your bed and watch you sleep, until you ask for something, if you do, and if you don’t, that’s fine too. It’s called Echo Spot and other than being unusually cute, the camera/microphone device that looks a little like an old-fashioned alarm clock, is just another extension of the Alexa line of surveillance/service products that run your home and your life, which is precisely what an ideal primary care doctor is supposed to do, i.e. keep you healthy, where health is defined as  “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity”. 

You will subscribe to Ambergan Health. You will be monitored by Alexa in your home and maybe a future tiny Echo will let Alexa go outside with you. Perhaps they’ll throw Apple a crumb here to keep an eye on you when you leave your home, although it’s becoming increasingly unclear why you should. When you feel sick, you will summon a doctor on your Echo screen, and eventually he will appear preemptively before you get inconvenienced by any symptoms. You will be examined, diagnosed, treated and monitored in your home. And this should take care of most needs of most people most of the time. Not only is this a good start, but it’s a foundational step, and a perfect place to practice, because you can’t cater to complex needs if you have no idea how to care for simple needs.

Will there be room for marginal plays in drug pricing and maybe devices or exclusive contracting with delivery systems, as most experts (who drove health care into the ground) seem to think? Maybe, but negotiating lower prices for bulk purchasing is neither unique nor disruptive. It does sound like Ambergan will begin by deploying its services to its own employees, but make no mistake, this cannot be about creating yet another middling scheme for self-insured employers. If that’s all Ambergan is, there will be no innovation and no disruption. This must be about the entire health care market. This must be about doing to health care what Amazon did to retail. Amazon didn’t kill retail by restricting consumer choice to idiotic narrow networks of starving suppliers. That’s the Walmart model. Amazon decimated retail in precisely the opposite way. This is a business venture gunning for large market shares, and yes, I know it’s not seeking profits right now, but the entire Amazon retail bonanza started without profit and it remains mostly so to this day.

If you’re a primary care doctor, soon you will be able to have your own little storefront on Amazon, instead of or in addition to some strip mall or non-descript medical building. You will have to provide specifications for your services and cash will be king. Remember those new interstate licensing compacts? That will help here and so are the ever more relaxed telehealth rules and regulations. How about the recent rise in burned out doctors and cash practices? It’s almost like this was meant to be.

For the initial enterprise offering, substitute doctor farm for server farm and you get the AWS of medicine. For the end result, add another layer to the AWS, and substitute each doctor in the farm for say, detergent or movie, and you get the grand idea. Since everybody is shopping for substitutable services, this is the perfect insertion of the high-volume retail model into the high-profit AWS model.

Ambergan need not buy clinics, employ doctors or contract with systems, although it might start out that way. It just needs to get as many doctors as possible on the Amazon Health platform and have them compete, while people review and rate them into oblivion or success. The Amazon platform IS the network, and there will be terms, conditions, stars and promotions. There certainly are many legacy obstacles to overcome, and perhaps that is why Amazon couldn’t or wouldn’t go it alone. Throwing highly regulated markets wide open requires two strong lobbying arms, and a federal government willing to play fast and loose. The stars are indeed perfectly aligned for the first true disruption of our health care since 1965.

Some Tips on Acne Prevention

In many cases acne can be avoided. There are lots of ways to avoid acne. Ways to avoid acne include dietary changes, skin care and home treatments.

This article will have information that explores ways to avoid acne.

Ways to avoid acne #1: Use a cleansing diet to get rid of the impurities in your system.

Ways to avoid acne #2: Clean your skin everyday.

Ways to avoid acne #3: Use a benzoyl peroxide lotion to keep blemishes at bay.

Ways to avoid acne #4: Check your cosmetics, foods and other products to make sure you are not having a problem with allergies that can be mistaken for acne.

Ways to avoid acne #5: If you eat a high-fiber, low-fat diet you are less likely to have problems with acne.

Already kicked your bad diet and threw out aggravating cosmetics? And do you still have acne? Check out Acne Free in 3 Days, a natural how-to book on how to get rid of acne once and for all. — Editors

Ways to avoid acne #6: Some vitamins will decrease your chances of acne. Check with your doctor to see what she suggests.

Ways to avoid acne #7: Drink six to eight glasses of water a day. Water is important for the health of your skin.

Ways to avoid acne #8: Some people feel that cutting down on sugar, flour and caffeine is one of the ways to avoid acne.

Ways to avoid acne #9: If you have small blackheads or pimples do not pop them. This can lead to even more skin problems.

Ways to avoid acne #10: Don’t use greasy lotions and cosmetics as they contain oils that can promote acne.

Ways to avoid acne #11: Try not to take any medications that contain iodides or bromides.

The above information should help you find ways to avoid acne.