NEJM Highlights March 2016: Getting value for money in healthcare, Zika bad news, linking the microbiome to the metabolic syndrome

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Could Uber happen to healthcare?

A Perspective article that points out that the success of Uber is rooted in the flaws of an industry where customer convenience and value for money took the backseat to the interest of a set of service providers highly protected by regulation. Sounds familiar?  Obviously, the regulatory moats of healthcare are much wider and deeper, but in a curious mix of warning (watch out!) and encouragement (this will be good for you if you embrace it!) the authors argue that the medical profession should not consider themselves immune from the disruption that has affected the taxi industry. Missing from this lens though is the tremendous impact of Uber in surfacing information to all the participants – clarity of when a ride will pick up, what route it will take, when it will arrive, and at what cost. Which leads us to a second Perspective, on the various biases that systematically push physicians (and patients) to believe that interventions have more impact than they do in reality, leading to over-utilization.  The authors illustrate this with two pithy heuristics: “before you conclude that a treatment was effective look for other explanations” and “if you see evidence of success, look for evidence of failure”.  Imagine, a service that would really surface the expected and actual value of healthcare interventions – now that would be disruptive… Uber’s Message for Health Care (subscriber access); The Science of Choosing Wisely — Overcoming the Therapeutic Illusion (free access);

 

Confirmed beyond reasonable doubt: Zika causes microcephaly

A pair of brief reports describing two pregnancies where the mothers contracted Zika late in the first term of pregnancy. Subsequent ultrasounds showed major abnormalities in brain development and led to abortions. In both cases, fetal autopsies showed a high degree of localization of Zika virus to the brain (through RT-PCR and electron microscopy) with accompanying devastation of cortical and subcortical structures. Zika Virus Associated with Microcephaly; Zika Virus Infection with Prolonged Maternal Viremia and Fetal Brain Abnormalities; Zika Virus (free access)

 

Manipulating the endocrine system through the microbiome

A Clinical Implications of Basic Research article describes a set of experiments in which the transplantation of gut microbiota from cold-exposed mice induces the replication of the cold-exposed phenotype in warm-exposed mice (i.e. they become lean) because the “cold-derived” microbiota appears to drive remodeling of the structure of the gut and of the fatty tissues.  The term metabolic syndrome was coined quite a while ago to describe constellation of symptoms including obesity and diabetes, but it has suffered for decades from a lack of unifying perspective.  It feels like this is finally coming together with two missing pieces of the puzzle taking their place in the overall picture: (1) the surprisingly rich physiology of fat (notably the discovery of beige fat, and the realization that brown fat does exist in humans), (2) the fact that the gut microbiome does not just passively reflect what we eat, but rather has a driving impact on the whole of human metabolism. A paradigm shift may be in the works. Burning Fat by Bugging the System; (subscriber access)

 

The New England Journal of Medicine is a premier weekly medical journal covering many topics of interest to the health sector. In this monthly series we offer a brief overview of highlights that might be of interest to our clients and others.