Lab Soft News

Just Relax; Spousal Nagging Has a Beneficial Effect on Your Prostate Health

Men who live on their own are less likely than those living with a spouse or a partner to be screened for prostate cancer, even if they have a family history of the disease, a new study finds (see: Screenings: Partners and Prostate Cancer). Below are further details from the article:

The study did not venture an explanation for why men living with partners sought screening more often. But the lead author,....said it was possible that their partners encouraged them. The researchers drew on data from a long-term study of the residents of Olmsted County, Minn. Among other questions about their health, the residents were asked about their attitudes toward prostate cancer....Guidelines call for men with a family history of prostate cancer to be tested from age 45. But it was not until after 60 that they began being tested more often than men with no family history of the disease.

This article highlights the question gender relating to the utilization of healthcare services. It is widely understood that women make greater use of such services than men (see: (Gender, psychosocial factors and the use of medical services: a longitudinal analysis). Here a quote from only one article on this topic:

... female gender remained an independent predictor of higher utilization over the 22-year period studied, and psychosocial and health factors measured at the initial interview predicted service use even 19-22 years later. Controlling for factors identified as likely causes of gender-related differences in healthcare utilization, gender remains an important predictor of medical care use before and after removing sex-specific utilization.

It's not necessary to understand for the purposes of this note exactly why women utilize healthcare services more than men. However, it's quite clear that if one were to market the services of a clinical lab, the obvious strategy would be to focus on women who would likely be more responsive to such an appeal. Having said this, it also occurs to me that hospital labs and commercial reference labs view physicians as their primary customers and thus don't feel compelled to market to the general public, female or otherwise. They also don't do a good job in marketing to physicians. I addressed this topic in a previous note (see: Performance vs. Utility of Clinical Lab Tests: A Marketing Perspective) with the relevant excerpt below:

I have always held the opinion that the laboratory diagnostics industry, the clinical labs, and lab physicians do not market themselves and their services adequately to test-ordering physicians and to the general public.

The exception to this rule that clinical labs don't bother to market to the general public are the direct access testing (DAT) web sites including, recently, the personal genomic testing sites that are much in the news. I have posted a number of notes about DAT. My personal belief is that not marketing and emphasizing the value of in-vitro diagnostics to the general public has been a mistake and accounts, in part, for the general lack of appreciation and understanding of the contributions of lab medicine.

Continuing Differentiation of the Radiology Electronic Network Ecosystem

Ole Eichhorn has performed a very valuable service in his Daily Scan blog by publishing a long set of perceptive observations about the RSNA (Radiological Society of North America) conference in Chicago (Visiting RSNA). RSNA is one of the largest conferences in the world and attracts about 60,000 registrants annually. His blog note is a gem and I will return to it again because of the many valuable insights it contains. Below is only one of them -- short but powerful.

There were a number of “Nighthawk-like” companies, providing outsourced Radiology reading services. Either at night, or offshore, or with some kind of subspecialty. With Radiology being digital, it is clear that Radiology reading can be done remotely, and a whole ecosystem is forming around this. You can imagine the same thing happening in Pathology.

I have published multiple notes about the implications of the development of "nighthawk-like" outsourced radiology services. Here are four of them: Digital Pathology vs. Digital Radiology: A Broad Divide, NighHawk Radiology Services Enters Software Arena, On-Line Auctions for Radiologist Services Offered by Telerays, On-Line Radiology Auctions and the Explosive Growth of the Specialty). The importance of the rapid maturation of teleradiology into a viable business model can't be overstated. Here are some additional observations:

• Telemedicine has been struggling to find its true niche for three decades or more and is focused today mainly on providing services to underserved, incarcerated, and geographically remote populations. There is nothing wrong with this business model but it is destined to stay as a niche application. Teleradiology, on the other hand, has the potential to serve many if not all of the people in the U.S. (and most will not even know that it is happening). Put more bluntly, teleradiology is quickly becoming ubiquitous and Nighthawk demonstrated the practicality of radiology outsourcing.
• Although the word ecosystem is overworked, Ole is correct in applying it to the emergence of multiple "Nighthawk-like" teleradiology systems. These systems extend beyond mere physical radiology networks and involve both the technical Internet infrastructure as well as sophisticated workflow, reporting software, and collaboration by radiologists positioned around the world. In other words, this heralds a new way for the specialists to practice in the field.
• As Ole also points out, this teleradiology ecosystem has the potential to provide specialized radiologic interpretations to small remote hospitals on a scale never before imagined. I commented on this phenomenon in a previous note (see: On-Line Radiology Auctions and the Explosive Growth of the Specialty) in which I said that, for example, the services of a neuroradiologist are now accessible to patients in small rural hospitals or to multispecialty clinics. This has major quality implications for the U.S. population.
• Recall that this cascade of events has been precipitated by one company, Nighhawk Radiology, with the goal, as the name implies, of providing radiologic interpretive services to hospitals at night and on the weekends when the radiologists on the hospital staffs wanted some relief.

Teaching Lab Medicine to Medical Students & Residents: A Modern Approach

My guest blogger of last Friday, Dr. Tony Killeen, has come up with a practical and up-to-date solution for teaching lab medicine to medical students and pathology residents (see: Using Web 2.0 Tools to Teach a Lab Medicine Course at the University of Minnesota). His answer is to create web sites that accompany and complement a "classic" pathology course or a residency training program. Here's how Tony summarized his idea in his previous blog note:

Arguably the most exciting trend in higher education is the migration from content delivery in a classroom at a fixed time to web-based content delivery that is independent of the physical location of the instructor, the students and independent of time. An essential tool to facilitate this kind of new content delivery is course management software, which allows an instructor to build a course website that includes almost any kind of document: text, images, spreadsheets, databases, wikis, and of course, audiovisual content.

As Tony notes in this blog excerpt, a critical component of a course web site is a set of audiovisual presentations; let's call them electronic lectures presenting new and exciting knowledge about the field. If multiple course and residency training directors in pathology were to create such web sites with audiovisual materials, they could share such content across multiple medical schools and residency training programs, increasing the quality of teaching in all of them. As only one example of electronic grand rounds, Tony highly recommends the University of Washington's Laboratory Medicine Grand Rounds available at iTunesU. I have personally downloaded all of these lectures to my iPod and will listen to each of them.

Links to lab medicine blogs such as Lab Soft News embedded in these lab medicine and pathology teaching and training web sites will serve to enrich the formal didactic content and provide insights into breaking news in the field and outside opinions. Discussion forums for medical students and residents across course web sites can also bring student and resident ideas to bear on the material that is being taught.

GE Healthcare Cuts Jobs; Wisconsin to Bear Large Share of Losses

Wisconsin, a major focus of GE Healthcare operations, will be facing major job losses as the company responds to the failing economy (see: GE Healthcare plans job cuts as market weakens). Below is an excerpt from the article from a Milwaukee newspaper with boldface emphasis mine:

GE Healthcare plans job reductions in its global operations, including southeastern Wisconsin....GE Healthcare was based in Waukesha until 2004, when it moved its global headquarters to Britain. Nearly 3,000 workers are employed in Waukesha, where it retains the global headquarters of its diagnostic-imaging business and makes equipment for X-rays; magnetic resonance and molecular imaging; and computed tomography equipment known as CT scanners. Wauwatosa, meanwhile, is home to the global headquarters for GE Healthcare's clinical systems business unit with 1,100 employees....Company spokesman Brian McKaig emphasized that the layoffs are global. While they are not limited to southeastern Wisconsin, they will include the region, McKaig said....The company cited economic weakness in the medical equipment markets of the United States and parts of Western Europe. It added that government agencies and insurance companies have been clamping down on payments for hospital procedures. Mark Vachon, who runs the diagnostic imaging business in Waukesha, said he expects U.S. sales of big-ticket imaging equipment to decline by percentage points "in the mid-single digits" in 2009 from 2008.

Using Web 2.0 Tools to Teach a Lab Medicine Course at the University of Minnesota

Dr. Anthony KIlleen, a former colleague of mine at the University of Michigan and now an Associate Professor of Pathology at the University of Minnesota, emailed me about a web site that he had set up to support a lab medicine course that he was teaching. He was requesting permission for an RSS feed of this blog into the web site. I asked him if he would develop a blog note on this topic and he graciously accepted my offer. Boldface emphasis is mine.

Arguably the most exciting trend in higher education is the migration from content delivery in a classroom at a fixed time to web-based content delivery that is independent of the physical location of the instructor, the students and independent of time. An essential tool to facilitate this kind of new content delivery is course management software, which allows an instructor to build a course website that includes almost any kind of document: text, images, spreadsheets, databases, wikis, and of course, audiovisual content. Good course management software eliminates the need for an instructor to have to know anything about html, xml, css, Java, or most of the details of how a website is constructed or functions.

At the University of Minnesota where I teach Laboratory Medicine to second year medical students, I have been using a course management software program called Moodle. This is a popular, open-source product that the University of Minnesota uses to deliver content for hundreds of courses. Educational content for my course includes traditional written material with discussion forums and quizzes, and links to lectures delivered in a variety of formats including Adobe Presenter, MPEG4 movies for downloading to video-capable portable devices such as video iPods, iPhones etc., and MP3 for downloading just the audio content.

Moodle also enables RSS feeds from blogs, including Lab Soft News, to provide students with information about events and activities in this field and fresh content on an almost daily basis. The website thus ties together traditional learning material with contemporary content delivery formats and dynamic content that is updated as new blog entries are created at sources that can be entirely external to the course.  I have been very pleased with the ease of use of Moodle and the positive feedback from students. This is just one example of the application of the concept of Web 2.0, a synthesis of web tools that enhances communication and creativity, and is the direction in which higher education is moving.

::Update on 12/14/2008 @ 9:49 a.m.

Tony Killeen has generously provided us with the link to his clinical pathology course web site for your review.

Google Includes Magazines in Advanced Search

Because I seek both inspiration and content for Lab Soft News only on the web, I have been forced to become a bit of a web search connoisseur with my favorite search engine being Google. I was therefore interested to learn that Google Search now includes selected magazines (see: Google updates search index with old magazines). Below is an excerpt from the story with boldface emphasis mine:

Google has added a magazine rack to its Internet search engine. As part of its quest to corral more content published on paper, Google... has made digital copies of more than 1 million articles from magazines that hit the newsstands decades ago. For now, the old magazine articles can be found only through Google's search service for finding digital copies of books. But the Mountain View, Calif.-based company plans to eventually include magazine articles in its general search results. Users who want to restrict the scope of their inquiries to magazines can choose that option through the book search's "advanced" function....The list of old magazines already available through Google include past issues of New York Magazine, Popular Mechanics, Popular Science and Ebony. Google has been trying to reel in more content from non-Internet sources for the past four years. The crusade began with agreements to copy books sitting on the shelves of several major libraries — an ambitious project that triggered a copyright battle with publishers and authors that was finally settled in October. Besides books and magazine articles, Google also provides a digital gateway to the archives of several newspapers and millions of old photos from Life magazine.

I, for one, was not very knowledgeable about the process for specifically searching the content of books and now magazines that have been indexed by Google. As noted in the excerpt above, all that you need to do is navigate to the Advanced Search page of Google. At the bottom of this page, you are offered the option of clicking on categories such as the following: News Archive, Scholar, Book, and U.S. Government. The magazine search is included in the book search. If you click on Book, you have a choice of the following categories: Fiction, Non-Fiction, and Random. History of Medicine, that may be relevant for some of the notes included here, is included in the Random Category. The Book page shows the the various covers of the books and magazines that have been indexed, a very useful feature.

As noted above, I only use web search tools to research topics for this blog, as a matter of expediency and personal choice. As a result of this expanded search access to print materials, I will attempt to provide a wider perspective of clinical lab issues when appropriate and relevant. We are very fortunate that our digital universe keeps expanding in this way.

Generation Health: A Genetic Testing Management Company

We are evolving from the specialty of medical genetics, with its emphasis on the identification of a specific genetic abnormalities such as Down Syndrome (Trisomy 21), to medical genomics. This latter approach to genetic disease has been defined in a Mayo Clinic publication in the following way:

The application of basic knowledge of the human genome to questions that influence human health. Medical genomics promises a fundamental change in the practice of medicine by: identifying new genes with disease relevance; providing better characterization of subcategories of disease; providing better identification of risk factors; and creating the potential for individualized drug therapies.

Medical genomics is designed to address diseases relating to the entire genome as opposed to medical genetics that had a much more limited horizon and did not address broad areas such as disease risk factors and individualized targeted drug therapies. For me, one of the ironies of medical genomics, as it is now evolving, is that consumers are being exposed to it through consumer-oriented web sites such as 23andMe before the field has sufficiently matured within the formal medical establishment. To a certain extent, I think that this is partly the basis of some of the press buzz about 23andMe and also hostility on the part of physicians to personal genomics.

However, there is now some evidence that sophisticated services relating to genetic testing and medical genomics are beginning to be offered. Generation Health is a case in point. Copied from the company home page, here is a summary of its mission:

Generation Health is a health management company that specializes in helping employers and other health care payors manage medical costs and improve their employees' and members' health by assuring optimal utilization of genetic testing. Just as pharmacy benefit managers (PBMs) arose in the 1980's to help health care payors better manage their pharmacy expenditures, Generation Health recognizes the need for a genetic testing benefit manager to be a trusted third party that can help payors manage this increasingly complex field. Clients will realize value in several ways:

• Establishing a framework and rationale for covering and excluding specific genetic tests, based upon clinical validity and utility.
• Prior authorization of all covered tests for eligible employees based upon sound medical criteria.
• Negotiating discounted testing prices and quality/service standards with a contracted network of genetic testing labs.
• Identifying patients, through analysis of medical and prescription claims, who may benefit from genetic testing, and then facilitating their testing.

So Generation Health appears to be one of the first companies to take a stake in the management of genetic testing and, therefore, inevitably, in the management of genomic diseases. In my view, there will be a great need for such services in the long run. It will enjoy a first-mover advantage. The key question is whether the market is ready at this point for such services. There is no question that genetic testing is, and will continue to be, both complex and unnerving for patients and payors. Both of these groups will need all the knowledge and help that they can get.

Seeking the Correct Definition for a "Lifestyle Disease"

I must admit at the start of this note that I thought I understood the definition of lifestyle diseases -- in my mind, the term referred to diseases caused by some action, or lack of action, on the part of an individual that caused a disease to develop. Examples of the former, an action taken, would be lung cancer caused by smoking or hepatic cirrhosis caused by excessive ethanol intake. It turns out that I was wrong in my use of the term. The causes of lifestyle diseases are based on the general behavior of populations rather than individuals. Here is the definition from the Wikipedia:

Lifestyle diseases (also called diseases of longevity or diseases of civilization) are diseases that appear to increase in frequency as countries become more industrialized and people live longer. They include Alzheimer's disease, atherosclerosis, asthma, cancer, chronic liver disease or cirrhosis, Chronic Obstructive Pulmonary Disease, Type 2 diabetes, heart disease, nephritis or chronic renal failure, osteoporosis, acne, stroke, depression and obesity.

The reason I was thinking about this topic was that a recent article had caught my attention (see: Molecular imaging that will bring about a revolution in diagnosis and drug discovery). Its categorization of cancer, dementia, and diabetes as lifestyle diseases makes perfect sense now that I understand the correct definition for lifestyle disease (boldface emphasis mine):

Molecular imaging is essential for a better understanding of life, because phenomena in living beings result from interactions between molecules. Masaaki Suzuki, of the Molecular Probe and Drug Design Laboratory, says, “Molecular imaging is the ultimate goal of life science.” Molecular imaging is expected to help in the detection of lifestyle-related diseases, such as cancer, dementia, and diabetes, at an early stage, as well as in developing good new drugs with the fewest side-effects far more quickly. 

Taking the example of cancer as a lifestyle disease, I do understand the idea that a longer life free of, say, infectious diseases, may increase the risk of developing cancer for an individual. Hence the notion that lifestyle diseases being synonymous with diseases of longevity. I also understand that living in an industrialized nation could increase one's exposure to pollutants or food additives that might be carcinogenic. However, I also suspect that some individuals are genetically predisposed to developing malignant neoplasms, partly as a result of having a less efficient or effective DNA repair mechanism, allowing more rogue cells to develop and proliferate. Here's an interesting little article on cancer immunology that includes a reference to the cancer immunosurveillance theory.

Predisposition to Disease and Pre-Disease on the Health Continuum

In previous post, I provided a diagram distinguishing what I called the Wellness Domain from what I called the Overt Disease Domain (see: Wellness, Preventive Medicine, and the Classic Disease Model). I followed up on this note with another one (see: Genomic Testing, Pre-Symptomatic Disease, and Health Insurance) in which I made the following statement:

...[G]enomic medicine is identifying people with a predisposition to disease and the Early Health Model is identifying people with early forms of disease as manifested by biomarker abnormalities. For the present, such "healthcare consumers" (not patients) are best categorized as being "well" because we are uncertain how many of them will go on to develop overt symptomatic disease. Also implicit in this statement is that we also don't know which of these patients with early forms of disease and a predisposition to disease to treat.

To restate this previous thought, I placed those individuals with a either a predisposition to disease or pre-disease (pre-symptomatic, pre-clinical disease but with abnormal biomarkers suggesting some degree of pathophysiology) into the wellness domain and contrasted them with "sick" patients who have clinically manifest acute or chronic illnesses. This approach got me more interested in the continuum of health from perfect wellness to a pre-disposition to disease to pre-disease to overt acute and finally chronic disease. In order to better understand and further explore this health continuum, I developed another diagram that is presented below. In a previous note, I also made reference to Siemens' references to the continuum of health in a previous posted note  (see: Siemens as the "First Full Service Diagnostic Company").

In this new diagram, I have arranged wellness, predisposition to disease, pre-disease, and overt  disease on a horizontal axis. As you can see, there are both genetic and non-genetic factors that predispose an individual to the development of a disease. I define a pre-disease as the diagnosis of a disease by lab testing or perhaps molecular imaging but without any overt signs and symptoms of it. Note in this diagram that I indicate that the need for treatment or therapy, marked by the "Rx" symbol, is questioned at this time for both patients with a predisposition to disease and also a diagnosed pre-disease.

Currently, one of the most interesting questions associated with the early disease model is whether it is appropriate to treat patients with pre-diseases. If they are deemed treatable and as we come to better understand the nature of pre-disease, a second question is what drugs to treat them with. As soon as we work out this question, we will then be faced with the new question of how and when to treat patients with a predisposition to disease, genetic or otherwise.

Brochure for Lab InfoTech Summit 2009 Now Available

The brochure for the upcoming Lab InfoTech Summit 2009 to be held on March 16-18, 2009, at the Venetian Resort Hotel in Las Vegas is now available. A PDF version of the brochure can be viewed here. Copies will shortly be mailed to pathologists, lab professionals, and industry representatives around the country. The conference web site will be ready to accept on-line conference registrations in about a week. Meanwhile, you can grab a first look at the lecture and workshop topics and participating faculty. A total of 33 exhibitors have agreed to participate thus far with several more anticipated prior to the start date. This is the largest exhibition of its kind in the country. If you are considering the purchase or upgrade of your LIS, AP-LIS, lab middleware, lab portal software, or digital pathology imaging equipment, this is the conference for you. The upcoming event marks the 27th consecutive year of continuing medical education for the Lab InfoTech Summit.