Injuries remain the most common cause of death among children and adolescents, with motor vehicles crashes the leading cause of death until 2017. Beginning in 2017, however, firearms surpassed motor vehicle injuries as the leading cause of death from injury.

The linked article notes this occurred because of fewer deaths from motor vehicle injuries and increasing firearm-related deaths. To an extent, then, the "leading cause" depends on how you slice and dice the data, but the trend line of firearm deaths is pointed upward. We have a lots of research in the US that goes into motor vehicle safety, but it's been hard to get any such federal support for firearm safety since the latter is politically toxic for a significant part of our elected representatives. Instead, in many places, we've made it easier to carry concealed weapons without a permit, protected the firearms industry from lawsuits, and we seem incapable of even having a discussion of national firearms policy beyond thoughts and prayers after each mass shooting.

We do have a pretty good idea of vaccine-induced vs natural immunity: the former is a bit more than 5 times more effective.

That may vary between variants, though we have reason to believe that vaccine-induced immunity may be more durable among variants since SARS-CoV2 spike proteins may vary less than other surface proteins of the viral capsid. Anecdotally, as a clinician, all my dead patients were unvaccinated, as are all of my patients who were hospitalized. They've survived but have ongoing symptoms (brain fog, unsteadiness, fatigue, shortness of breath, ongoing diarrhea, and at least one person seems to have brain damage).

I have yet to have a vaccinated patient with severe consequences, and while there is probably selection bias there (maybe vaccinated patients don't get out as much or wear better masks), it's easy to worry more about my stubbornly unvaccinated patients who think their immune systems are "strong" and anything natural must be more effective because it comes from nature.

I don't work for Epic; I work for a hospital that is a customer. When we need something, we'll typically try to build it ourselves. Some things we plead for Epic for build for us if it isn't doable using their software. I think there's typically no charge for that beyond routine maintenance. We will sometimes also write our own browser-based apps that can grab data out of the EMR.

I don't speak for my employer, but I've never seen Epic try to sell us new features.

For all the grief we're in with distrust of government and evidence, polarization and dehumanization of people who think differently from us... I'm glad to hear of scientists sobbing with joy upon learning the effectiveness of a vaccine. Especially one that could get humanity out of its current SARS-Cov-2 rut. I think it would do all of us good to spread this news far and wide: scientific knowledge is far more likely to illuminate the world than crankiness and conspiracy theories.

From the pages you cited:

Cigarette smoking is the leading preventable cause of death in the United States. The prevalence of obesity in the United States was 42.4% (as of 2017-2018), up from 30.5% in 1999-2000, which can lead to heart disease, stroke, diabetes, and cancer (which happen to include the 2 top leading causes of death in the US) The number of gun deaths (a phenomenon that hits red states particularly) is likely a leading factor in the increase in rates of suicide.

Infectious diseases are important too (and the CDC spends plenty of effort on them), but I'm not sure why (in normal times) you'd prioritize non-infectious diseases over the problems that typically kill people in the highest numbers. Infectious disease outbreaks are always going to surprise us; they are novel by definition, and life is full of surprises. (Insert disclaimer here about the extent to which viruses are alive.)

In the area I'm working in (as a physician), as well as with people I know in New York City, testing is no longer constrained by test kit availability but by personal protective equipment needed by the people collecting the test. Recommended testing is a combination nasopharyngeal and oropharyngeal swab: we stick a long, thin wire Q-tip in through nose back about 4 inches, and then another one way back in your throat. We stopped nasopharyngeal washes (instead of swabs) in our area because this commonly resulted in patients gagging, coughing and aerosolizing a floating cloud of whatever they were infected with; this is less common with nasopharyngeal swabs but still a problem.

We're no longer switching masks between patients but trying to reuse them as much as possible, because there aren't enough masks to go around. That will risk infecting both health care personnel, and probably to some extent patients. If you live in the Seattle area and have a sewing machine, my healthcare organization (for whom I do not speak in an official capacity) would love you to volunteer to make masks; we'l send you materials.

To the grandparent who claimed that... > The CDC is just a bloated bureaucracy, like most government organizations in a count[r]y our size, and didn't get off its ass fast enough. They certainly weren't > destroying evidence or quarantining people in secret facilities or anything like that.

I wonder what you mean by "bloated." The CDC was on this pandemic from the moment it appeared to be problematic, admittedly botched the initial tests results, and now has to spend a fair amount of time correcting the ongoing stream of misstatements of fact by the president who has been planning to cut its budget. In my personal experience, people don't work at the CDC for the prospect of an easy government job. They tend to be dedicated clinicians and scientists who are interested in how to get the most bang for the buck, life-saving-wise, and happily travel to infected regions of the country and world to help keep you safe from a variety of horrible diseases. As an example of how CDC medical officers take advantage of government largess, enjoy these job postings where for 25-50% of a typical low-end physician salary you can work for up to two years in places like Angola and Bangladesh.

Sorry: I get a bit chapped when people with no likely first-hand knowledge slag my personal favorite heroic government bureaucracy.

I'd be interested in knowing about these other devices - how widely available are they, and how good are they at detecting A fib? A fib is not particularly straightforward to detect - lots of things cause irregular heartbeat that are not atrial fibrillation (premature atrial of ventricular contractions, sinus arrhythmia - neither of which are immediately worrisome - being probably the most common). I'm a physician, and if I'm trying to figure out if someone has atrial fibrillation I pretty much resort to an EKG —and even that won't always catch it, so sometimes we end up sending people home with portable monitors that record for weeks or a month at a time. Medical grade event monitors and loop recorders don't seem to be available to end users; the portable EKG monitors on Amazon look clunky and dicey. (I guess if I had to have dicey, I'd try to skip the clunky.)

Yes, Democrats have a well-known negative stance about Rh-positive babies. Including A+, B+, AB+, and of course O+(?)

Oooh-kay. For those of you not familiar with basic newborn hematology, if a mom has Rh-negative blood (relatively rare compared at 15% to Rh-positive blood) and the baby has Rh-positive blood, and during pregnancy the mom's blood gets exposed to babies (can happen in car accidents and other placental problems resulting in fetal-maternal hemorrhage - the fetus's blood ends up in mom's circulation) the mom will start to make antibodies against the babies Rh antigens (more specifically, Rh-D antigens - there's more than one - Rhesus is a whole group; the D antigen is the troublesome one). This is one of the reasons couples contemplating marriage used to get blood tests in the United States, before the introduction of the medicine folks like James Harrison made possible.

In the United States, anti-D is typically referred to by its brand name, RhoGAM. It has antibodies to Rh-D - just a small amount, though. You inject this into a mom, her immune system detects them, and then if it sees actual anti-D from the fetus her immune system doesn't freak out and attack the fetal blood cells. Now and then we run into patients who do not like vaccines, which RhoGAM more or less is. The first baby is fine. The second baby to be exposed will often die (NSFW: pictures). In babies who don't die from hemolytic disease of the newborn (where their blood cells are destroyed, by maternal antibodies, among other problems) they can suffer brain damage. Treatment involves exchange transfusion and, in less severe cases, phototherapy, where we shine 460 nm light on them for a few days—hopefully not knocking too many DNA off the strand in the process.

Alternatively, you can take your chances with red raspberry and nettle tea, according to this person who claims to uphold evidence-based wellness, though she doesn't actually cite any evidence.

RhoGAM is made from pooled human plasma, like the gentleman cited in the article. He just happened to have a substantial amount of the antibodies, likely the result of blood transfusion exposure.

Imbruvica is priced at about US$12,000-13,000 for a month's supply (typically dosed as 420 mg daily for leukemias and related diseases, taken as 140 mg cap x 3 at a time once daily until either it or the disease kills you). If you RTFA, you'll find that's $133 a pill. They're going to introduce 3 new tablet sizes —280 mg, 420 mg, and 560 mg, and charge US$400 for each of them, no matter how many mg are in it. Once that's done, they'll make the old 140 mg capsule unavailable.

So some physicians did a trial last year that found 140 mg a day actually works as well as 420 mg for certain cancers. This, however, would cut into profits by 66%, so instead you can get a new 140 mg tablet for $400 instead of the old 140 mg capsule for $133. See, the pharmaceutical companies do understand math: you pay for treatment of the disease, not for the amount of medicine, and if it turns out you can be treated for a disease for a third of the price, they can just raise the price.

Or I suppose you could split the new 420 mg tablet into 3 pieces (carefully!) and pay the same price as before, or quarter the new 560's and get a modest discount. Cancer patients love gambling with a pill splitter for their $12k/month meds! As the drug company puts it, this is "a new innovation to provide patients with a convenient one pill, once-a-day dosing regimen and improved packaging, with the intent to improve adherence to this important therapy.”

So, that's believable - they are increasing the price of the old capsule by discontinuing it and replacing it with one that costs 3 times as much to "improve adherence." It's accurate to say they are correcting a pricing anomaly, I suppose, except it's one that didn't exist until research proved you didn't necessarily need as much of this medicine. You pay for your survival, not the drug.

Most drugs have a bunch of patents, including ones for the active ingredient, the delivery mechanism, the coating, etc. The patents will have staggered expiration dates, which can maximize the time a drug remains on patent. Albuterol inhalers, for example, which used to be generic until they were reformulated to be ozone safe, has 4 US patents for one particular formulation (ProAir). That helps keep this 40 year old drug at $57-$70 an inhaler. Somehow, back when it was generic, it was $4 an inhaler. Albuterol was supposed to be going generic again any minute now for the past 2-3 years, but it's still hung up in court —all for a drug that probably ought to be over-the-counter. IMHO.

Do you have any citations for this? Given the antigenic shift in the viral protein coat of influenza viruses, I'm not aware of evidence that past infections prevent future infection. It looks like there is evidence that natural immunity prevents infection from that same strain, but it doesn't look like there's evidence it provides you with much infection to inevitably drifting isotypes.

Doctors (these days largely through their large, single or multi-speciality practices) in the US negotiate charges with each individual insurance carrier, each in a race to be bigger in order to exact more negotiating power. Or, more precisely, groups and hospitals come up with a "charge master" list of prices which is really just the start of negotiating tactics:

• Medical group: We charge $590 for a checkup.
• Insurance company: If you want access to the patients in our Sapphire Plus Horizons Extra plans, we'll pay you $80 for a checkup.
• Medical group: Your patients will have to drive 20 miles out of their way to see other providers, then, because we won't take anything less than $120

Except in very rural areas, it's not a monopoly in most places in the US — it's more of wrestling giants, with the uninsured getting screwed since they get stuck with the $590 "list price" that is really just supposed to start off the negotiation.

The AMA isn't a trade union (they don't negotiate pay and benefits for physicians, and only 25% of US physicians are members). The AMA contracts with the feds to develop a list of the relative values of chargeable medical procedures (which then get modified by insurance companies, who decided actual remuneration.

The AMA does come up with a code of ethics, but ensuring US physicians meet acceptable standards of competency is up to your state or territorial medical board, which are all quasi-governmental entities.

I enjoyed your comment about the "health insurance pigeon hole." I mean I get everyone hates health insurance, but what about the car insurance pigeon hole, and the fire insurance pigeon hole? The fundamental idea of insurance — spreading out risk — seems like a good one, and all insurance markets are regulated. It's a fascinating question if health insurance needs to be more regulated, or less, or simply standardized like they do in most other industrialized companies so it can be understood by mere mortals.

I agree with most of the foregoing. I am a primary care physician, and when people ask me for the prices of things —even when I'm able to spend 20 minutes downloading their formulary from some terrible website and then figure out the math of their deductible and out of pocket maximums I typically get it wrong. Every individual plan from every distinct insurance provider is structured differently, and the negotiated prices for the different billable procedures I do are considered (as I understand it) trade secrets of the insurance providers between them and each group of health care providers.

The only way of getting a menu of prices like they have posted at the Jiffy Lube is to go to a place that foregoes insurance and lets you pay cash. My group actually has a "price estimating hotline" staffed by a nice group of people who spend all day trying to tell you what your co-pay might be for a given service, but that's only good for figuring what you're in for, and not useful for comparison shopping.

This isn't a conspiracy of physicians to keep prices obscure: we really don't know. It's a side effect of the complex (expensive, inhumane) insurance system in the United States. (The same one that my Canadian colleagues love to roll their eyes at when we go to the same conferences, wondering why we put up with it.)

There's plenty of medical and insurance regulation in this country (resulting in me needing to fill out 8 page forms to get people 3 unpaid days off work for a cold, or a 20 item form to get diabetic test strips for diabetic patients). It would be nice to see more harmonized regulations, though, that didn't assume private enterprise was the perfect cure for all market problems. Health care isn't the same as oil changes and automobile repair. I'm among those who think the Affordable Care Act represented the hopeful breezes for a better future, and that its Swiss-styled system was not the unmitigated disaster my right wing friends claimed it to be.

I think this is a good point: a good primary care clinician should provide a good gatekeeping service for referrals. We should refer you only when it's likely to help, and to a competent specialist. I do think some PCP's refer more than they should because they feel pressed for time and/or think that it's simply easier to send the patient for a specialist to give a more detailed opinion. That opinion can be blinkered, though.

In my mind, competency for specialists includes knowing not just the full range of treatments, but spending time with many patients telling them they should do nothing —no fancy procedures or medications. It's not universal, but there are many specialists out there who are willing to risk making patients unhappy by not waving their magic wand, and who are willing to spend the time (and liability) to do so despite it being to their own economic disadvantage. I'm looking forward to changes in the US health care system that will encourage this, instead of encouraging simply doing as many billable procedures as possible.