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Health care bots are only as good as the data and doctors they learn from

The number of tech companies pursuing health care seems to have reached an all-time high: Google, Amazon, Apple, and IBM’s Watson all want to change health care using artificial intelligence. IBM has even rebranded its health offering as “Watson Health — Cognitive Healthcare Solutions.” Although technologies from these giants show great promise, the question of whether effective health care AI already exists or whether it is still a dream remains.

As a physician, I believe that in order to understand what is artificially intelligent in health care, you have to first define what it means to be intelligent in health care. Consider the Turing test, a point when a machine becomes indistinguishable from a human.

Joshua Batson, a writer for Wired magazine, has mused whether there is an alternative measurement to the Turing test, one where the machine doesn’t just seem like a person, but an intelligent person. Think of it this way: If you were to ask a random person about symptoms you experience, they’d likely reply “I have no idea. You should ask your doctor.” A bot supplying that response would certainly be indistinguishable from a human — but we expect a little more than that.

The challenge of health care AI

Health is hard, and that makes AI in health care especially hard. Interpretation, empathy, and knowledge all have unique challenges in health care AI.

To date, interpretation is where much of the technology investment has gone. Whether for touchscreen or voice recognition, natural language processing (NLP) has seen enormous investment including Amazon’s Comprehend, IBM’s Natural Language Understanding, and Google Cloud Natural Language. But even though there are plenty of health-specific interpretation challenges, interpretation challenges are really no greater in this particular sector than in other domains.

Similarly, while empathy needs to be particularly appropriate for the emotionally charged field of health care, bots are equally challenged trying to strike just the right tone for retail customer service, legal services, or childcare advice.

That leaves knowledge. The knowledge needed to be a successful conversational bot is where health care diverges greatly from other fields. We can divide that knowledge into two major categories: What do you know about the individual? And what do you know about medicine in general that will be most useful their individual case?

If a person is a diabetic and has high cholesterol, for example, then we know from existing data that the risks of having a heart attack are higher for that person and that aggressive blood sugar and diet control are effective in significantly lowering that risk. That combines with a general knowledge of medicine which says that multiple randomized controlled trials have found diabetics with uncontrolled blood sugars and high cholesterol to be twice as likely as others to have a cardiac event.

What is good enough?

There are two approaches to creating an algorithm that delivers a customized message. Humans can create it based on their domain knowledge, or computers can derive the algorithm based on patterns observed in data — i.e., machine learning. With a perfect profile and perfect domain knowledge, humans or machines could create the perfect algorithm. Combined with good interpretation and empathy you would have the ideal, artificially intelligent conversation. In other words, you’d have created the perfect doctor.

The problem comes when the profile or domain knowledge is less than perfect (which it always is), and then trying to determine when it is “good enough.”

The answer to “When is that knowledge good enough?” really comes down to the strength of your profile knowledge and the strength of your domain knowledge. While you can make up a shortfall in one with the other, inevitably, you’re left with something very human: a judgment call on when the profile and domain knowledge is sufficient.

Lucky for us, rich and structured health data is more prevalent than ever before, but making that data actionable takes a lot of informatics and computationally intensive processes that few companies are prepared for. As a result, many companies have turned to deriving that information through pattern analysis or machine learning. And where you have key gaps in your knowledge — like environmental data — you can simply ask the patient.

Companies looking for new “conversational AI” are filling these gaps in health care, beyond Alexa and Siri. Conversational AI can take our health care experience from a traditional, episodic one to a more insightful, collaborative, and continuous one. For example, conversational AI can build out consumer profiles from native clinical and consumer data to answer difficult questions very quickly, like “Is this person on heart medication?” or “Does this person have any medications that could complicate their condition?”

Not until recently has the technology been able to touch this in-depth and profile on-the-fly. It’s become that perfect doctor, knowing not only everything about your health history, but knowing how all of that connects to combinations of characteristics. Now, organizations are beginning to use that profile knowledge to derive engagement points to better characterize some of the “softer” attributes of an individual, like self-esteem, literacy, or other factors that will dictate their level of engagement.

Think about all of the knowledge that medical professionals have derived from centuries of research. In 2016 alone, Research America estimated, the U.S. spent $171.8 billion on medical research. But how do we capture all of that knowledge, and how could we use it in conversational systems? This lack of standardization is why we’ve developed so many rules-based or expert systems over the years.

It’s also why there’s a lot of new investment in deriving domain knowledge from large data sets. Google’s DeepMind partnership with the U.K.’s National Health Service is a great example. By combining their rich data on diagnoses, outcomes, medications, test results, and other information, Google’s DeepMind can use AI to derive patterns that will help it predict an individual’s outcome. But do we have to wait upon large, prospective data analyses to derive medical knowledge, or can we start with what we know today?

Putting data points to work

Expert-defined vs. machine-defined knowledge will have to be balanced in the near term. We must start with the structured data that is available, then ask what we don’t know so that we can derive additional knowledge from observed patterns. Domain knowledge should start with expert consensus in order to derive additional knowledge from observed patterns.

Knowing one particular data point about an individual can make the biggest difference in being able to read their situation. That’s when you’ll start getting questions that may make no sense whatsoever, but will make all the sense in the world to the machine. Imagine a conversation like this:

BOT: I noticed you were in Charlotte last week. By any chance, did you happen to eat at Larry’s Restaurant on 5th Street?

USER: Uh, yes, I did actually.

BOT: Well, that could explain your stomach problems. There has been a Salmonella outbreak reported from that location. I’ve ordered Amoxicillin and it should be to you shortly. Make sure to take it for the full 10 days. The drug Cipro is normally the first line therapy, but it would potentially interact badly with your Glyburide. I’ll check back in daily to see how you’re doing.

But while we wait for the detection of patterns by machines, the knowledge that is already out there should not be overlooked, even if it takes a lot of informatics and computations. I’d like to think the perfect AI doctor is just around the corner. But my guess is that those who take a “good enough” approach today will be the ones who get there first. After all, for so many people who don’t have access to adequate care today, and for all that we’re spending on health care, we don’t yet have a health care system that is “good enough.”

Dr. Phil Marshall is the cofounder and chief product officer at Conversa Health, a conversation platform for the health care sector.

Article source: https://venturebeat.com/2018/06/22/health-care-bots-are-only-as-good-as-the-data-and-doctors-they-learn-from/

Your Good Health: Diabetic finds monitoring system too painful

Dear Dr. Roach: I am a 71-year-old woman who is Type 2 diabetic, but I find the glucose monitoring systems requiring blood samples so painful to use that I don’t test.

At present, I get along by taking a 500-mg metformin tablet three times a day and having bloodwork done about twice a year. My last fasting glucose test result (1/19/18) was 134 mg/dL, and my HbA1c was 6.9 per cent. Should I consider a continuous glucose monitor? I am overweight, so that is a factor I am working on.

C.P.

A continuous glucose monitor checks and electronically records many blood sugar readings, as often as every five minutes, which can sometimes be read by the user in real time or can be downloaded by the clinician at the end of two weeks (at which point, another unit is placed). The units themselves look like large buttons and contain a very thin needle with a sensor that measures the blood sugar.

CGM systems are used most often in people with Type 1 diabetes, but some patients with Type 2 may be candidates for the system, particularly those whose blood sugars are known or suspected to go too low.

I spoke with an expert at my institution, Esther Wei, a nurse practitioner and certified diabetes instructor, who would not recommend CGM for you, as it is unlikely that you would have low blood sugars being on metformin. Most insurances also require that their members be on both long-acting and short-acting insulin for them to cover CGM.

Your blood sugar levels are excellent, and your A1c levels are near the optimum advised in the most recent guidelines. Losing weight may improve several areas of health, but from the standpoint of diabetes, I wouldn’t increase your monitoring if it is so painful for you.

Dear Dr. Roach: During the past year or two, I have been using a daily sublingual vitamin B-12 supplement, sort of as witchcraft, to treat minor numbness in my feet, recognizing in the absence of signs, symptoms or laboratory evidence of deficiency that taking it has no science.

Today, I opened a fresh bottle of tablets and found that the tablet no longer dissolved under my tongue and actually was nondissolvable and hard (the previous tablet had been chalky and dissolvable). The small print on the new label said to swallow with food once daily, whereas the small print on the former bottle said to dissolve under the tongue three times daily. The dosage also had changed from 500 to 1,000.

L.D.B.

Even the most educated people may still benefit from the placebo response, which is the likely case for you, in absence of known B-12 deficiency. B-12 is safe and relatively inexpensive.

In people with known B-12 deficiency, sublingual (under the tongue) preparations and swallowed tablets were equally effective at returning blood B-12 levels to normal.

The study looked at vegans, who do not get B-12 in the diet, as well as people with pernicious anemia, who are unable to absorb B-12 efficiently due to an autoimmune disease that prevents the body from making a protein called intrinsic factor.

Intrinsic factor improves B-12 absorption greatly, but with enough B-12 (1,000 mcg once a day or 500 mcg three times a day are more than enough), the body can absorb as much B-12 as it needs. You can take either preparation.

Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu.

Article source: http://www.timescolonist.com/life/health/your-good-health-diabetic-finds-monitoring-system-too-painful-1.23345011

Your Good Health: Fatigue after prostate cancer issue of low testosterone

Dear Dr. Roach: Fifteen years ago, I had a successful brachytherapy treatment for prostate cancer. Subsequent annual PSA results indicate minimal levels. I am 82 years old and in otherwise excellent condition, and generally very active. However, in the past few years, I have had periods of considerable fatigue. My blood counts are within the normal range, but my testosterone is at a very low level. My family physician counsels against testosterone therapy because of the possibility of reigniting prostate cancer. This seems to be based on a long history of a causal relationship.

A senior fitness trainer at my squash club argues that quality of life is important, so I should try testosterone therapy and then watch my PSA levels carefully. He says this because there have been a number of more recent trials in which there seemed to be a changing view that there is no definite connection that testosterone therapy causes new cancer. He has several clients who have found renewed energy from testosterone therapy. I have reviewed endless articles on the topic, but find nothing definitive. This might be different for males who have not had a previous history of prostate cancer. What’s your opinion? The fatigue is troublesome, and I would like to try testosterone, but not at a real risk of setting myself back 15 years.

R.T.

I am glad your prostate cancer seems to be in remission. Brachytherapy is the use of implanted radiation “seeds” or “pellets” to destroy prostate cancer cells.

I can’t recommend a course of action that your own physician has counselled against, as he or she will have more information about you than I do.

The reason you aren’t finding any definitive articles is that there are no well-done scientific studies looking at people with a history of prostate cancer being treated with testosterone. There are some data, however. A 2013 review looked at seven studies with a total of about 200 men with a history of prostate cancer treated with testosterone. Only one had an increase in PSA level suggesting recurrence; most men were able to get normal testosterone levels, and most but not all had improvement in symptoms. Fatigue is a common symptom in men with low testosterone, but is not specific for low testosterone. Many conditions can be associated with fatigue.

My own practice, in consultation with the patient’s urologist, is to consider a trial of testosterone replacement in men who are thought to be cured of prostate cancer based on very low or nondetectable PSA levels, who have symptoms (and often physical exam findings) that are very consistent with low testosterone and who have a low level on laboratory testing. I agree that PSA levels (along with a history and physical exam) should be checked carefully.

Ultimately, it is a balance of risks. If the symptoms are bad enough to be worth a small risk of cancer recurrence, and for a patient who is able to weigh those risks himself and chooses to, I have cautiously prescribed testosterone.

Dear Dr. Roach: Can you give me your opinion on a pain-relief pill called “arthro?”

L.C.

I found several brands with similar names (“arthro” is from the Greek word for “joint”), all of which contained one or more supplements intended for joint health, especially glucosamine, chondroitin, methylsulfonylmethane, collagen and turmeric. These individually are marginally better than placebo, but placebo works surprisingly well, meaning that a lot of people will get relief with these products, which are generally safe. In combination, there might be more effectiveness, but also a larger (but still small) risk of side-effects.

Article source: http://www.timescolonist.com/life/health/your-good-health-fatigue-after-prostate-cancer-issue-of-low-testosterone-1.23346431

To Your Good Health: ED injections are not a first-line treatment

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Article source: https://www.roanoke.com/arts_and_entertainment/to_your_good_health/to-your-good-health-ed-injections-are-not-a-first/article_2c7ba803-7cbd-5510-932a-b3c5c42880f0.html

Atul Gawande, CEO?

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buildCdbUrl(e){var t=CDB_ENDPOINT;return t+=”?profileId=”+PROFILE_ID,t+=”av=”+String(ADAPTER_VERSION),t+=”cb=”+String(Math.floor(99999999999*Math.random())),e.integrationMode in INTEGRATION_MODES(t+=”im=”+INTEGRATION_MODES[e.integrationMode]),e.debug(t+=”debug=1″),e.noLog(t+=”nolog=1″),t}function buildCdbRequest(e,t){var n=void 0,r={publisher:{url:e.url},slots:t.map(function(e){n=e.params.networkIdvar t={impid:e.adUnitCode,transactionid:e.transactionId,auctionId:e.auctionId,sizes:e.sizes.map(function(e){return e[0]+”x”+e[1]})};return e.params.zoneId(t.zoneid=e.params.zoneId),e.params.publisherSubId(t.publishersubid=e.params.publisherSubId),e.params.nativeCallback(t.native=!0),t})};return n(r.publisher.networkid=n),r}function createNativeAd(e,t,n){return window.criteo_prebid_native_slots=window.criteo_prebid_native_slots||{},window.criteo_prebid_native_slots[e]={callback:n,payload:t},’

Article source: https://slate.com/business/2018/06/atul-gawande-as-health-care-ceo-a-good-idea.html

Your Good Health: Shingles vaccine recommended despite no …

Dear Dr. Roach: I am an 84-year-old female. Luckily for me, I have never been ill with chickenpox, measles or mumps. My family doctor thought that I should still get the shingles vaccine, even though a blood test proved that, indeed, I’d never had chickenpox. So I did. I read in the paper that there is a new shingles vaccine available and that everyone should get the new shot as a followup to the first. Do I really need to do that?

B.B.

I am getting many questions about the new Shingrix vaccine. It is recommended for adults over 50, with or without a history of chickenpox or shingles. It also is recommended for people who have already had the older shingles vaccine, Zostavax.

Shingrix is much more effective than Zostavax, and the side-effects are mostly local and do not last more than a day or two. Further, Zostavax’s effectiveness begins to wane after eight years or so, and Shingrix seems to have a much longer period of protection. Shingles at an older age is a very painful condition, and some people have pain that lasts for months or years.

Yours is a rare situation, in that you have laboratory evidence proving you have never had chickenpox. More than 99 per cent of adults have had chickenpox. Shingrix has not been tested in this situation, and the Centers for Disease Control and Prevention recommendations as of this writing would be for you to get the primary vaccine for chickenpox (two doses) and then get the zoster vaccine. You had the zoster vaccine (Zostavax), not the chickenpox vaccine (Varivax), which is not what would be recommended; however, it can count as the first of the two chickenpox vaccines. You need to wait a minimum of eight weeks before getting the Shingrix vaccine.

I suspect these recommendations may change in the future as we get more understanding of the effectiveness of the Shingrix vaccine.

Dear Dr. Roach: I just read your response to H.W.’s inquiry about “flesh eating” bacteria and am surprised that you indicated that surgical intervention is the primary treatment. I have read many articles about individuals being diagnosed with necrotizing fasciitis who then underwent massive tissue debridement that could have been delayed or avoided by first considering the possibility of an anaerobic gas bacillus type organism as the culprit.

I have seen firsthand the dramatic effect of hyperbaric oxygenation therapy has to turn these cases around, and I am dismayed that this type of treatment is not considered before drastic surgeries are performed. I think that a few treatments of hyperbaric oxygenation would not hurt and could be diagnostically valuable and perhaps therapeutic. It seems that there are many clinicians out there who don’t even know about HBO.

T.C.

Hyperbaric oxygen, the use of pure oxygen under pressure in a tank, has been used for serious infections such as gas gangrene and in necrotizing fasciitis. High concentrations of oxygen are toxic to these bacteria. Its use is limited to centres with the expensive equipment. Most studies have shown that it provides a significant benefit to early, aggressive surgical treatment. It is never used instead of surgical treatment, as the oxygen needs to get to the bacteria and won’t until surgery. It certainly can hurt if it delays definitive surgical treatment.

Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu.

Article source: http://www.timescolonist.com/life/health/your-good-health-shingles-vaccine-recommended-despite-no-history-of-chickenpox-1.23343012

Yoga biggest mass moment for good health and wellbeing, says PM Modi

DEHRADUN: Prime Minister Narendra Modi today said Yoga has become one of the biggest mass movements in the quest for good health and wellbeing as he lead an estimated 50,000 enthusiasts performing asanas during the 4th International Yoga day at the picturesque Forest Research Institute here.

He said from Dehradun to Dublin, from Shanghai to Chicago, from Jakarta to Johannesburg, Yoga is everywhere.

“The world has embraced Yoga and glimpses of this can be seen in the manner in which International Day of Yoga has been marked every year,” Modi said.

He said the way to lead a calm, creative and content life was Yoga.

“In Yoga, we have the perfect solution to the problems we face, either as individuals or in our society,” the Prime Minister said.

“Instead of dividing, Yoga unites. Instead of further animosity, Yoga assimilates. Instead of increasing suffering, Yoga heals,” he said.

Modi said Yoga presents a ray of hope for future of the world.

“Yoga is beautiful because it is ancient yet modern, it is constant yet evolving,” he said.

Article source: https://timesofindia.indiatimes.com/india/yoga-biggest-mass-moment-for-good-health-and-wellbeing-says-pm-modi/articleshow/64675181.cms

Your Good Health: Trimix injections for erectile dysfunction are risky

Dear Dr. Roach: Do Trimix injections work for erectile dysfunction, and are they safe?

M.B.

Erectile dysfunction is a common problem in men, especially as they get older. It may be a clue to serious disease of blood vessels, but also can represent low testosterone or other abnormal hormone levels, neurological issues or problems with relationships or mental health. Men who are overweight with ED often improve with weight loss. If no particular cause is identified, most men are treated with medications such as sildenafil (Viagra), which work by improving the blood flow to the penis.

However, these drugs are effective in only about 60 per cent of men who use them. For men who do not get a satisfactory result (and it is imperative to take the drugs correctly — for example, Viagra should be taken on an empty stomach one or two hours before planned sexual activity), then it is time to consider second-line treatments, such as vacuum pumps and medicines that men self-inject directly into the penis. Alprostadil is the only Food and Drug Administration-approved injection drug for ED, and it is successful 90 per cent of the time.

Trimix is a compounded mixture of alprostadil along with phentolamine and papaverine. I do not prescribe it because of the increased risk of infection with a compounded product, and because it is not clear to me that it is more effective than alprostadil alone. Some experts in male sexual problems do recommend it, although only in men who have not responded to alprostadil by itself. Any injection into the penis has the risk of causing a scar (plaque) in the penile tissue.

Dear Dr. Roach: I suffer from what seems to be vasovagal syncope. My family doctor is suggesting that I have a tilt table test. Could you elaborate on this kind of test? I have had stress tests and echocardiograms. I also have seen an electrophysiologist (in 2015) who was not inclined to recommend this test.

R.M.A.

Vasovagal syncope is the precise name for a common faint. It is a neurological reflex. That’s what “vasovagal” means — the vagus nerve controls heart rate, to a large extent, as well as the blood vessels themselves. The vagus nerve can slow down the heart and dilate blood vessels inappropriately due to neurological signals, causing blood pressure to go down, in response to many conditions, such as emotional stress, pain, fear, prolonged standing and heat exposure.

An experienced clinician usually can make the diagnosis of vasovagal syncope by a careful history and physical exam. Occasionally, there are times when the diagnosis is not clear, and the tilt table test is designed to evaluate that possibility.

A tilt table test is usually performed in an electrophysiology laboratory, so the fact that the electrophysiologist doesn’t recommend it carries weight with me. Your family doctor and cardiologist should make a combined decision about whether you need it.

Dear Dr. Roach: There is a recall of eggs near me due to salmonella. I always notify a friend online about recalls. But she says that as long as she washes her hands and her eggs, she doesn’t care about the recall. Why would they recall eggs if this was all a person had to do? What can I say to change her mind?

D.D.

Tell her that you can’t tell whether an egg has salmonella by looking at it, and that washing eggs can bring salmonella from the outside of the egg to the inside. Also, salmonella requires either high heat or low heat for a long time to be killed, which would make the egg unpalatable or inedible. Recalled eggs should not be eaten. It’s not worth the risk.

Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu.

Article source: http://www.timescolonist.com/life/health/your-good-health-trimix-injections-for-erectile-dysfunction-are-risky-1.23341051

Lower Saucon finances in good health

Lower Saucon finances in good health69 News

Lower Saucon finances in good health69 News

LOWER SAUCON TWP., Pa. – Council members in Lower Saucon Township were presented with a semi-annual financial report Wednesday night that detailed the state of the municipality’s finances for the 2018 year.

Finance Director Cathy Gorman said the township’s current financial standing is in “good shape” when aligned with what was budgeted for the year.

“We have received 69.9 percent of our budgeted revenues and have expended 39.43 (percent) of our general fund expenses. We are in good shape, budgetarily speaking,” she said.

Gorman added that the township is seeing earned income tax revenues above what was projected, which she said is a positive thing for the township.

“We’re seeing more than projected in our earned income tax, which is a good thing,” Gorman said.

The report doesn’t state the amount of revenue the township has received from earned income taxes, but does say that as the municipality’s population sees gains in income, projections will be adjusted accordingly.

The semi-annual report is designed to give council a mid-year update on the township’s finances, while also providing them with insight on factors to consider in the next year’s budget.

Looking ahead to the 2019 budget, Gorman told council that with contract negotiations coming up for non-uniform employees, the township will have to financially prepare for increased legal costs.

“We’ll be entering into contract negotiations for the non-uniform contract in 2018 and ‘19. I’ll be presenting to you estimates that we might need for additional legal fees,” she said.

Township applying for grants

The township will be applying for two grants that pertain to renovations and traffic, respectively.

The first approval was for a Northampton County Department of Community Economic Development grant that would help fund modification in Seidersville Hall. The grant would help fund renovations to bathrooms in the building, which serves as the township’s senior center, among other uses.

The second grant that the township will apply for is a PennDOT Automated Red Light Enforcement Program grant that would help the township pay for LED light replacements for six township traffic lights, as well as traffic detection security systems.

Article source: http://www.wfmz.com/news/lehigh-valley/lower-saucon-finances-in-good-health/756262510

To Your Good Health: ED injections are not a first-line treatment

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Article source: http://www.roanoke.com/life/columns_and_blogs/columns/to_your_good_health/to-your-good-health-ed-injections-are-not-a-first/article_2c7ba803-7cbd-5510-932a-b3c5c42880f0.html