Subject: News from Dr. Kevin Fickenscher
From: "Dr. Kevin Fickenscher" <[email-masked]>
To: <[email-masked]>
Date: Tue, 22 Dec 2015 10:29:41 -0500 (EST)

The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=00189E6-v_2JAa_mxU_AqOQjOJKUqIhczlUobRq9z4hxpYmuYSavnTsqAAzyyS33vRF8oxiRXGtEiIZSgfl3RGyDgR9ZaoFac1AHd8G8hP8kFkVLmAUvUPgk_j_6BJ9oaKRCB972oPk5n8frugHAIsZFmGrD8fEnhHMdORIdswMzk4lrE49u4u4nQ==&c=plhmGMfs4BKFNcCyeFht-oHVzlfyZT0HUg_-j7-HQ9Nj4i2DEtEgmg==&ch=GR8SAlx4sMpsSISb3jM5nVWIoevWLCLeEgFTDWypSYhn5CqWo4iMTg==]
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Fickenscher Files, Vol. 3, Issue 39
Kevin M. Fickenscher [http://r20.rs6.net/tn.jsp?f=00189E6-v_2JAa_mxU_AqOQjOJKUqIhczlUobRq9z4hxpYmuYSavnTsqCvSyU6_U3MG--tE1vNGYSwr860QQchf5ta1ot4FyGLQ6LVD21SYaIv7uN5JqY4r5M7lD7d9obbBHjdRas4I3p7OKJ5XLJQXyjoKa_cNA5_2U6xaF3CbwqQq8J7Dqlsr4KAf1ra_v8SP7IQPuacNblv8gpLHR_VhuJPOXX4q6RoGB2eszhY0AE1FDQfryRkzdPoscGOm42omjnhm3p1ioAg=&c=plhmGMfs4BKFNcCyeFht-oHVzlfyZT0HUg_-j7-HQ9Nj4i2DEtEgmg==&ch=GR8SAlx4sMpsSISb3jM5nVWIoevWLCLeEgFTDWypSYhn5CqWo4iMTg==],
MD, CPE, FACPE, FAAFP
@MDKev

A compilation of information, thoughts, and perspectives on the issues of the day
related to healthcare, technology, and beyond - including the latest culinary explorations.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Quote(s) Of The Week
Thoughts we should listen to...
My wish is that you can live in peace, regardless of your ethnic group, your culture,
your religion and your social background
Pope Francis in comments at a refugee camp Bangui airport in Uganda on 2015-1201

"He is a bright and talented person without any doubt. He is the absolute leader
 of the presidential race...He is an outstanding and talented personality without
any doubts,"
Vladimir Putin, President of Russia, in comments to journalists on the candidacy
 of Donald Trump for President of the United States

"It is always a great honor to be so nicely complimented by a man so highly respected
within his own country and beyond,"

Donald Trump, in response to Putin's positive comments on the Trump candidacy.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Consulo Indicium
Information for your Consideration...
Perhaps It's A Bad Idea - Eighteen months ago, the Missouri Legislature passed a
 law [http://r20.rs6.net/tn.jsp?f=00189E6-v_2JAa_mxU_AqOQjOJKUqIhczlUobRq9z4hxpYmuYSavnTsqMBm-YOQ-L9RLBT3vMYgznV7m1JBgeZr4n75m1eH_L5pgTm5wo9jyRorH371Q91zmO6E-qUH6GvBn_xbxI9iks9xXhi0dyQx2BF5YEvhnVlupm16eG_v_7qVBnWm-rCVE46toPerZnbdcgwcpGXln8LqLc0fNjJwsjDJwAko7QfsqUYbfr57nGYESXKBDy_Q7sQSXzf4splc2u_nGPOLA_1faSgFVXZieXjNQ_qPlECiOFKpaRySXRLPWnvywdHZqgSk5GEio8W7CP3TSxHikpp3haUpAcM37ek_jIbKaD6uXtltpwUJNTu6FAw9kFk3HUb1ksYOcFaJvhYHm6c1qGffAcUMfPcT2eldMQZk8KjGMCZpTAiRotkkKyTw2q1ks0aZm-X7PaT-Ug6RT_5O1o4_mKfxv9OzQYsqFhdkufXn06rcVm7lKTrQgAi4bFE129cVAibxFCjPjL94GYNPIf7cXv9ymGo7EnM0u8hSPcMb0oUygfX0VXPGhAi8aZS2ENBsuAtKYLrnvkWv8D0j8pZ33H_Sol0NIwfE6SsAcW6Qy5VrPvFPMu4Seex_oZiDpwEDGnTXnitSpxPOm2gzOauF6Bg8H6oFdA==&c=plhmGMfs4BKFNcCyeFht-oHVzlfyZT0HUg_-j7-HQ9Nj4i2DEtEgmg==&ch=GR8SAlx4sMpsSISb3jM5nVWIoevWLCLeEgFTDWypSYhn5CqWo4iMTg==]
with the intent of solving the shortage of physicians, primarily in the rural areas.
 The legislation allowed medical school graduates to start treating patients without
completing an internship nor a residency experience. Following this reversal of 
nearly a century in professional licensure, Arkansas and Kansas followed suit shortly
thereafter. However, according to recent reports "not a single new doctor" has applied
to establish a practice in any of the three states under the terms of the legislation
in those states. The end result is that in the case of Missouri, implementation 
of the program will likely be delayed until late 2016.  There is probably a reason
that not a single young, graduating physician has applied to practice under the 
legislation.  Perhaps it was a bad idea to begin with and, medical students understand
this better than the legislators.
The Death Toll Continues - As of November 30th there had been 334 days go by in 
2015 with 351 mass shootings.  The statistic was announced just following the Colorado
Springs Planned Parenthood shootings and does not include the San Bernardino shootings
or any others that might have occurred throughout the USA.  As a farm kid and a 
transplant from North Dakota, I understand - at least a little bit - the issue of
gun ownership.  However, I do not understand the notion that there should be no 
controls.
In checking out Wikipedia, the concept of freedom [http://r20.rs6.net/tn.jsp?f=00189E6-v_2JAa_mxU_AqOQjOJKUqIhczlUobRq9z4hxpYmuYSavnTsqMBm-YOQ-L9RlZa6DgAR0gvnJ08AgnPpSx9Lfstkzmr2XopiHIFgz7-5mm_vGeVXCBAqPHWiGajPlm0c9UU7lO9AejwSQKRwiD98bG_q4I_-SAVnSI0Vp3aTVZjPpcxlpIkOOJKHpSGYRgssnjlz2HvjqfAoKSOXIw==&c=plhmGMfs4BKFNcCyeFht-oHVzlfyZT0HUg_-j7-HQ9Nj4i2DEtEgmg==&ch=GR8SAlx4sMpsSISb3jM5nVWIoevWLCLeEgFTDWypSYhn5CqWo4iMTg==]
of movement [http://r20.rs6.net/tn.jsp?f=00189E6-v_2JAa_mxU_AqOQjOJKUqIhczlUobRq9z4hxpYmuYSavnTsqMBm-YOQ-L9RlZa6DgAR0gvnJ08AgnPpSx9Lfstkzmr2XopiHIFgz7-5mm_vGeVXCBAqPHWiGajPlm0c9UU7lO9AejwSQKRwiD98bG_q4I_-SAVnSI0Vp3aTVZjPpcxlpIkOOJKHpSGYRgssnjlz2HvjqfAoKSOXIw==&c=plhmGMfs4BKFNcCyeFht-oHVzlfyZT0HUg_-j7-HQ9Nj4i2DEtEgmg==&ch=GR8SAlx4sMpsSISb3jM5nVWIoevWLCLeEgFTDWypSYhn5CqWo4iMTg==]
under United States law [http://r20.rs6.net/tn.jsp?f=00189E6-v_2JAa_mxU_AqOQjOJKUqIhczlUobRq9z4hxpYmuYSavnTsqMBm-YOQ-L9RcfAuYf0AoML66rKVXirMDuMtIF_zbIcXoV6-1L9U7gb2SU6SznRY3K-7eMXr_BK7_9zT5RV9_SfGn8Toh6PnCPjjPZd36Gs_lV5ts54chT8NFuSbNR0lryvQGi-iDHcs9nHhpnvaFf0=&c=plhmGMfs4BKFNcCyeFht-oHVzlfyZT0HUg_-j7-HQ9Nj4i2DEtEgmg==&ch=GR8SAlx4sMpsSISb3jM5nVWIoevWLCLeEgFTDWypSYhn5CqWo4iMTg==]
is described, which is governed primarily by the Privileges and Immunities Clause
[http://r20.rs6.net/tn.jsp?f=00189E6-v_2JAa_mxU_AqOQjOJKUqIhczlUobRq9z4hxpYmuYSavnTsqMBm-YOQ-L9Rcxw5hXECfpt5MbbKEI1o8rTck4PdqIJFIekJS46iYMFLZVyRKOB6UMYyrurpjI8gWhF_lJq2yRst9qIHDntJD-D4Qmp6S6JNIFgC1VVb5wwtpL2RP5a4ZkAVK2v1SgYbySuYkCPFSQE-84u1726ov7tNahIe5A6h&c=plhmGMfs4BKFNcCyeFht-oHVzlfyZT0HUg_-j7-HQ9Nj4i2DEtEgmg==&ch=GR8SAlx4sMpsSISb3jM5nVWIoevWLCLeEgFTDWypSYhn5CqWo4iMTg==]
of the United States [http://r20.rs6.net/tn.jsp?f=00189E6-v_2JAa_mxU_AqOQjOJKUqIhczlUobRq9z4hxpYmuYSavnTsqMBm-YOQ-L9RGwGHxJxKfnD9x933HQvPPi5k_5JPVuNmnWpjDVdW4jhCVX5NTS9ePAzgI2r8NYfFX-r4NyiRoebIa-5_VKsk8qaZ4rVcFcF2Ujo6-UVw3yHPp1J-HV66RcF80K7Erw6Gc4gNDcw7orE=&c=plhmGMfs4BKFNcCyeFht-oHVzlfyZT0HUg_-j7-HQ9Nj4i2DEtEgmg==&ch=GR8SAlx4sMpsSISb3jM5nVWIoevWLCLeEgFTDWypSYhn5CqWo4iMTg==]
Constitution [http://r20.rs6.net/tn.jsp?f=00189E6-v_2JAa_mxU_AqOQjOJKUqIhczlUobRq9z4hxpYmuYSavnTsqMBm-YOQ-L9RvVfvFdqB1ljFDfFibxaBZLQ1pXMiuKMWmjCl1ygWRz3cWdlp-3FNav7vIoDmpo_vQ4YoMboFLBgtEVaXdA2AjtuVHrO9YmoQ1rEwofooictxCzV0y6PWfu0AsCyLvfd89vsv8mgCS1M=&c=plhmGMfs4BKFNcCyeFht-oHVzlfyZT0HUg_-j7-HQ9Nj4i2DEtEgmg==&ch=GR8SAlx4sMpsSISb3jM5nVWIoevWLCLeEgFTDWypSYhn5CqWo4iMTg==].
 That clause states, "The Citizens of each State shall be entitled to all Privileges
and Immunities of Citizens in the several States."
Why do I raise the issue of freedom of movement?  Well, it occurs to me that while
the courts have stipulated with any number of cases of the last couple of centuries
that we are free to move among the states, there is an equivalent number of cases
articulating that the states can regulate movement.  So, for example, we are not
 free to drive our cars throughout the United States without holding a valid "driver's
license".  The license is earned by virtue of the fact that we all need to pass 
a basic test related to our driving ability.  Hmm?  Is there a parallel on licensure
of gun ownership?  How flawed is my thinking?  Something needs to be done from my
perspective.  The ability to simply purchase guns willy nilly is akin to having 
the latitude to drive down the street as fast I want.  Now, does that seem reasonable?
Beyond the driver's license metaphor and the issue of lone wolf terrorism, there
 is also the issue of mental health.  I applaud US House Speaker Paul Ryan (R-WI)
who during the formative days of his leadership called for Congress to overhaul 
the US mental healthcare system. His comments came in response to the Planned Parenthood
shootings in Colorado.  Quite rightly, Speaker Ryan pointed out that the common 
thread for many of the shootings were "these tragedies...[of]...mental illness".
  Hopefully, his comments were not simply a throw-away in the midst of a tragedy
 but more a statement of intent for a renewed focus on the abysmally poor state 
of mental health services across the USA.  The focus deserves our consideration...
Preventable Hospital-Acquired Conditions Decrease - There is good news on the hospital-acquired
conditions problem which has plagued the industry for any number of years.  Over
 the period of 2010 to 2014, the rate dropped 17% resulting in the prevention of
 87,000 premature deaths and saving $20 billion in health care costs.  The report
[http://r20.rs6.net/tn.jsp?f=00189E6-v_2JAa_mxU_AqOQjOJKUqIhczlUobRq9z4hxpYmuYSavnTsqMBm-YOQ-L9RupO6YXwnYXGIqYqCFrFerUF9KoaXIusgYSqGQO8NiJpeqK_KU8S7fUFn1Enm7E9sWKAXwCbxH4eDyQ1_hGP_0RXSztA3lcYTv89T_J-lE7b4TtqOGHk25l_aLrCRvq3Ske-o2X_IAC6Z_3rrkJ3u3icFLYdtkUKdX5a5c-PIQb-ymEjh_i_EiGCJUdAip7b7QipNxSE5B7GvaaLVMXkqk53W4OuMMDm4kgg6VKzeFVAg8yktjyG95W5IRdWzLILNQHapPqOl-GIiUA7Io9ZKrMnb4Lmg1fL-ZqmhDDjisPZXV8Pp46pSN7N_tPoYkZnOsVAF5TnPdV5EgnPV0CRNDyUJ5IDTXyD-fRVToI7enJDjjIiQw1yjzhuI4EL17kV-G6AVDXYvc1bph-pzUPfJ_erRR0U1PAzjw-8MX0ieyNz4HPZLRIRS_-Y-x6v_O5Y-IEM7k2dvEGWKlpIcohv343-_3B_qP4OKVY9zCx5t44FehsXyisR0F4tILbN3AQOk6rkC_5wofpgejwnA2pC8RdSItwBo655SLfn5pSRGJjQrZkMnsvYtOJmg1EjrauNWvCU0WzhJDfF43prd6fcETw==&c=plhmGMfs4BKFNcCyeFht-oHVzlfyZT0HUg_-j7-HQ9Nj4i2DEtEgmg==&ch=GR8SAlx4sMpsSISb3jM5nVWIoevWLCLeEgFTDWypSYhn5CqWo4iMTg==]
was issued by the Agency for Healthcare Research and Quality (AHRQ), which noted
 that the types of conditions include "adverse drug events, catheter-associated 
urinary tract infections, central line-associated bloodstream infections, pressure
ulcers, and surgical site infections."  The work is not over as Richard Kronick,
 MD, Director for the Agency noted in an interview with Kaiser Health News where
 he noted that "the improvements we saw from 2010 to 2013 were very likely the low-hanging
fruit, the easy problems to solve."  I quite agree but I've been advocating for 
a long time that focusing on "low hanging fruit instead of high hanging fruit" is
where we need to start if we want to drive better outcomes at lower cost.  Quality
begins by taking small steps that lead to large steps.  We need to embrace the results
and up our game!!
Trying To Take It Apart, Bit By Bit - Ever since it passed Congress, the so-called
"ObamaCare" has been under the watchful eye of committed Republicans who intend
to dismantle it.  No matter that there are no other solutions being put forward,
 the idea is simply to dismantle it either wholesale or in pieces.  Although the
 front page of the Wall Street Journal highlighted some of the smaller provisions
like the care of cats and dogs, the more important story of the newly unveiled 
budget-and-tax deal were those measures which tweaked the Affordable Care Act.
Unlike previous efforts; however, the latest tweaks will implement a two-year delay
in the Cadillac tax, which was supported by large numbers of both Democrats and
Republicans.  The Cadillac tax is a uniquely American phenomenon whereby the
 federal government intends to levy a tax on employer-sponsored plans starting
in 2018 that exceed a certain price point.  In other words, if your health insurance
is too rich, there will be a tax on it.  A more mundane revision was the restrictions
placed on the risk-corridors program for the new healthcare exchanges with the
 intent of reducing the financial risk for insurance companies.  These are
 simply two of the more noteworthy changes which Congress passed.  The bigger question
is what comes next?
Well, it depends - naturally!!  The tweaks represent relatively minor modifications
of a complex piece of legislation that many are arguing will soon reach a "tipping
point" of no return.  After all, Obama will no longer be President in about 14 months.
 The National Journal [http://r20.rs6.net/tn.jsp?f=00189E6-v_2JAa_mxU_AqOQjOJKUqIhczlUobRq9z4hxpYmuYSavnTsqMBm-YOQ-L9R3K0C5Hcwqhc8v3_7eAu9RaUqnrApLBwrMgpS7SWkZaYv6MSvMUmkyqxUIcNX2nazRwBc-AV21llS28ycg_y1b8cG15FG4BsV1C7z2OdA85L2apWvW4EQgmMUCVqyqD43vyVEhUYqBNf6rDJUpoEDfo4cg5VMZgT3kac2tnQX2TCW_3QMBDbZUA==&c=plhmGMfs4BKFNcCyeFht-oHVzlfyZT0HUg_-j7-HQ9Nj4i2DEtEgmg==&ch=GR8SAlx4sMpsSISb3jM5nVWIoevWLCLeEgFTDWypSYhn5CqWo4iMTg==]
recently published an excellent piece on what it described as "the core" of ObamaCare
- the individual mandate, Medicaid expansion, and subsidies of those who
 purchase insurance.  Those individuals who support the legislation point out that
repeal of the individual mandate would weaken the stability of the insurance markets
by allowing the healthy to opt out of "insurance" thereby creating a pool of insured
that by-and-large would likely consist of sicker individuals.  I agree.  The entire
notion of "insurance" is to create a mechanism so that the risks of a particular
 situation (e.g. healthcare, automobile accidents, floods, disability, etc.) are
 spread among a populace.  The greater the spread, the more reliable the predictability
of cost of insurance for everyone.  In other words, if all of us are in, it's much
more predictable than if some of us are in.
The second issue is the potential rollback of Medicaid expansion which would
 adversely impact the large number of newly insured Americans who are just above
the poverty line - like some of our children.  They work hard, they are making a
 go of it but - just barely.  Given enough time they will earn enough to purchase
health insurance without any subsidy.  But, as the move from recent college grads
in fields where monetary rewards are not high - yet contribute to society - the 
cost of insurance is beyond their reach without subsidization.  In the past, these
types of individuals - often hard working Americans who are just getting started
 in their careers simply rolled the dice when it came to health insurance.  It's
 very clear that reducing subsidies would simply make health insurance unaffordable
for many people in the marketplace.
Advertisement
The omnibus package passed last week by Congress - as my friend David Blumenthal,
MD, President of The Commonwealth Fund put it - are not "body blows to the law."
 He continued, "They are more inconveniences. The law will continue to be implemented
despite these extensions or delays of taxing authorities."  So, while some
changes did in fact pass, they did not really affect the "core" tenets of the original
ObamaCare legislation.
This is likely to be the last major revisitation to the legislation until a new 
President is elected.
Any changes from this point forward will hang in the balance depending upon who 
is elected President in 2016 - either Republican or Democrat.  If a Republican is
elected President, everyone should expect a wholesale battle royal on the merits
 and demerits of the ObamaCare legislation.  And, the battle will be framed around
what type of alternative is put forward by the Republicans.  Simply dismantling 
the legislation is not in the cards from my perspective.  If a Democrat is elected
President, everyone should expect that further tweaking around the areas that need
improvement will begin in earnest.
Do A Little, Get A Lot - So, let me cut to chase on this one: there is no such thing
as too much exercise!! We are coming to that time of year when many of us will engage
in the annual ritual of committing ourselves to exercise.  And, unfortunately, within
weeks we will put our commitments aside and discontinue the worthwhile effort of
 engaging in regular exercise.  However, a recent article in the Journal of the 
American Medical Association (JAMA) [http://r20.rs6.net/tn.jsp?f=00189E6-v_2JAa_mxU_AqOQjOJKUqIhczlUobRq9z4hxpYmuYSavnTsqMBm-YOQ-L9RmdfriyB7MA51RMAzbOhR0VfgH22HJ8-fh8_EqfSws0oQsExgzwEoG0nzky7RdKZaIEE7ymzZTx--S9PkFI9UiiaBNGS50waQaNpw1Tq0C1EIF08NhujYF-jYEuAeCbwLuOugrd7cAreI6zcIngvcjmGBCh7Dl4Q3&c=plhmGMfs4BKFNcCyeFht-oHVzlfyZT0HUg_-j7-HQ9Nj4i2DEtEgmg==&ch=GR8SAlx4sMpsSISb3jM5nVWIoevWLCLeEgFTDWypSYhn5CqWo4iMTg==]
reported that even small amounts of exercise confer incredible - and, needed - health
benefits to any of us who are so inclined.  The research on this topic is replete
with examples where sedentary practices (e.g. sitting in an office chair all day)
results in higher than normal incidence of health problems (e.g. heart disease) 
than for those who engage even in what we might consider minor exercise (e.g. climbing
a couple of flights of stairs each day instead of taking the elevator).  It's been
shown in study after study from bus drivers to longshoremen to general office workers.
All of the studies are showing that exercise - of any type - is a good thing.  It
lowers our body weight, lowers blood pressure, reduces the incidence of diabetes,
along with a host of other healthy benefits.  The JAMA study found that the benefits
of exercise start with as little as 15 minutes of moderate exercise a day (e.g. 
brisk walking, dancing, gardening, housework) or 5-10 minutes of more vigorous exercise
(e.g. jogging, running, tennis). And, there seems to be no upper limit. So, long
 story short - go for it!!
While I am a big advocate of technology and making changes in our healthcare system
to "make it better", I'm also an increasingly strident advocate that we need to 
change the ways of society.  A sedentary society will eventually become a sick society.
 We are moving in that direction.  For example, studies have shown that if we continue
on our current trends, diabetes - in and of itself as a single disease - will consume
the equivalent of the entire budget we spend on healthcare or, nearly 18% of our
 Gross Domestic Product (GDP).  That's one disease folks.  And, the trend does not
consider the amount of funds we will need for dementia, heart disease and other 
low hanging problems.  We cannot spend ourselves out of this problem.  We need to
move ourselves out of harm's way and exercise - even minimal amounts - is the way
to accomplish the goal.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Future Health
Delivering care in the new virtual world...
Sometimes The Small Things In Life Are The Big Things - Those folks at Harvard Medical
School and the Wyss Institute for biologically Inspired Engineering at Harvard University
are involved in some of the most interesting research [http://r20.rs6.net/tn.jsp?f=00189E6-v_2JAa_mxU_AqOQjOJKUqIhczlUobRq9z4hxpYmuYSavnTsqMBm-YOQ-L9RFBFOxc5DPHcU2D7Igc-D24p8on13s1br-4dub7M9MvVuNjxFxYk4CaO7b_un1PMYL62iNRNe80faxz5hKvKomcXKy9JZIu7k9DObpC1m4RHz2ejSl3nv_JOb3LPqKp36IaxQVFTZzUVj6feBfHab51SJIGBF0eHxIqfMS4XNi5rebaGXUN7j6LmuIeAzCqxmDkCsdz3R1FxxZSkSH-9VRgcbC0B5hNnyjdTTHLTzwpIGzU5816LZRyQDUTrv6KWL-5RIuZ42G5UWMAYMheS-WeIyamsRPzfp&c=plhmGMfs4BKFNcCyeFht-oHVzlfyZT0HUg_-j7-HQ9Nj4i2DEtEgmg==&ch=GR8SAlx4sMpsSISb3jM5nVWIoevWLCLeEgFTDWypSYhn5CqWo4iMTg==]
on the planet from my perspective.  Rather than studying big things, the folks at
the Institute are studying "microbes" - those tiny little bacteria and other such
creatures that reside in our guts.  The researchers are working on creating synthetic
mechanisms for rejiggering how cellular functions are carried out via genetic and
metabolic engineering use E. coli - a common organism found in the human gut.  As
Pamela Silver, Ph.D. of the Wyss Institute [http://r20.rs6.net/tn.jsp?f=00189E6-v_2JAa_mxU_AqOQjOJKUqIhczlUobRq9z4hxpYmuYSavnTsqMBm-YOQ-L9RpDDCZpANKqR3WOpS1zw_7WOHLhNdBh2lqeYEut03cUzJ21Ef9lYu8MYhWlAKJmMHo5fhh0aOESVAXe1a4CytcTNCU6_zhdpHpsoqVrjMU1GmDryA-ekTqA==&c=plhmGMfs4BKFNcCyeFht-oHVzlfyZT0HUg_-j7-HQ9Nj4i2DEtEgmg==&ch=GR8SAlx4sMpsSISb3jM5nVWIoevWLCLeEgFTDWypSYhn5CqWo4iMTg==]
noted in announcing the results of their most recent work, "The dream in this field
is to make cell-based computers, using cells that can remember, count, sense, actuate
and complete tasks in a programmable way."
We are finding through the work of the Institute and others in the field that the
human "microbiome" plays a very significant role in our overall health.  It is now
being shown that our predilection to diabetes may, in fact, be the result of the
 types of organisms we "host" inside of our gut.  Also, there is obesity, cancer,
irritable bowel syndrome and a host of other problems.  Now, I don't we should simply
blame the little fellas that live inside of us but we should become much more cognizant
of our little buddies and how they impact our health.
It's increasingly clear that understanding the dynamics of the microbiome community
that resides inside of us is an important predictor of our overall health.  For 
example, through the research on the microbiome, we've learned that the growth rates
of the microbiome fluctuate in response to diet, wellness, exercise and the environment.
 They are also subject to competition with one another.  For example, taking an 
antibiotic that kills off one bacteria may lend the gut to overgrowth of other bacteria
that can potentially have unintended consequences.
Harnessing Google For The Sake Of Health - Most of the time, when we think of "Google",
we think of search engine and "eyeballs" as we search the Internet for information
on anything.  But now, Google is not only involved in driverless cars [http://r20.rs6.net/tn.jsp?f=00189E6-v_2JAa_mxU_AqOQjOJKUqIhczlUobRq9z4hxpYmuYSavnTsqMBm-YOQ-L9Rd2p9kKJ9j6DcjzluHyZ4H2uUly6hSvZMs3NmATtBdqp2z2146FD4dFmDVU4ObbuKHQiAQC8HlB3nSQynDWuA0PN5irpbyGPpfD4IuF9Dldj-tHSp8WWhsTZC3aMyv6SafMT3oZSEaa_npSHA_niksEll7itY17ThIYR3gZIFdvM=&c=plhmGMfs4BKFNcCyeFht-oHVzlfyZT0HUg_-j7-HQ9Nj4i2DEtEgmg==&ch=GR8SAlx4sMpsSISb3jM5nVWIoevWLCLeEgFTDWypSYhn5CqWo4iMTg==],
but is getting involved in the fight against heart disease.  In an announcement 
by Google Life Sciences - a Google spin-off company - and the American Heart Association
[http://r20.rs6.net/tn.jsp?f=00189E6-v_2JAa_mxU_AqOQjOJKUqIhczlUobRq9z4hxpYmuYSavnTsqMBm-YOQ-L9RjE8U_k1Y4-bkirtzOdsNm8ibjNevmW5szt6r3NamuGw4vnZpMmDQD5TynEVeg_sABTXFmpJSTKwYxnKSXkXvgcNoNFIgNS1ipnOb-4HTfOKgZJJICla0wEbB3oPJ7P6erNIWZKhsmIEapiRdzjPm9WfJMukq5_0RT2wSBxBp75FXb3izRqhI4Fq8PNv_7NANF0_W0DWBlRuiAG7F2oyIHeJgDzXOdJ7s&c=plhmGMfs4BKFNcCyeFht-oHVzlfyZT0HUg_-j7-HQ9Nj4i2DEtEgmg==&ch=GR8SAlx4sMpsSISb3jM5nVWIoevWLCLeEgFTDWypSYhn5CqWo4iMTg==],
a 50-50 joint venture by the Association and Google will invest $50 million over
 the next five years to find new ways to fight heart disease.
Google is an innovation company at its core and is making investments in a variety
of biomedical [http://r20.rs6.net/tn.jsp?f=00189E6-v_2JAa_mxU_AqOQjOJKUqIhczlUobRq9z4hxpYmuYSavnTsqMBm-YOQ-L9R88UIr9Mo30tw9nKPHAjeHJOhOBw-n4DBq5kTBEdL5Uzhj2b4hHGxRT79mTTdEdCJhaZyJYdA0D6WFbYVycfbhANMcSbxMhV1JzvebVmLM8D0Z3HrcK_T2GS11SHkU7KD-wGMRDYHwR2NqwzCRHe-yLuPa36eWCtAQQVws6dWyfXHt-iq1EnPZoLiSpU3wB7z1KpxOXKwSYk=&c=plhmGMfs4BKFNcCyeFht-oHVzlfyZT0HUg_-j7-HQ9Nj4i2DEtEgmg==&ch=GR8SAlx4sMpsSISb3jM5nVWIoevWLCLeEgFTDWypSYhn5CqWo4iMTg==]
ventures, including devices such as their new contact lenses [http://r20.rs6.net/tn.jsp?f=00189E6-v_2JAa_mxU_AqOQjOJKUqIhczlUobRq9z4hxpYmuYSavnTsqMBm-YOQ-L9Rqoabnjf7DHrYrlY-S2UYTI1sl0GgmJsanJP-VxgKk-MJY7XJbNsYeF184y765SlDRjf4k0DOpaIzJhAdjq3M_tP6K-YLT83zy81J9D4jfq_IhMdd5hSJKwlzDAKMFp_iPUEPjkb-F6uIkrCe4VwZtGKh6xUiAoR8DGJfvZ_etpLS66N0Z90LFTyDUUp_CoKP&c=plhmGMfs4BKFNcCyeFht-oHVzlfyZT0HUg_-j7-HQ9Nj4i2DEtEgmg==&ch=GR8SAlx4sMpsSISb3jM5nVWIoevWLCLeEgFTDWypSYhn5CqWo4iMTg==]
that are able to monitor blood sugar levels of diabetes and other devices for monitoring
health behaviors.  In announcing their focus on heart disease [http://r20.rs6.net/tn.jsp?f=00189E6-v_2JAa_mxU_AqOQjOJKUqIhczlUobRq9z4hxpYmuYSavnTsqMBm-YOQ-L9RURB0ANvlLtfSPHLQWffLynyH2b7QR7buVM-VQMsmCNenB11V_Ylr4WknwVmV2nlV-t0IHevRKJgKD4Z7J6uxL6sjmywQhjZgSQm8Go0FVguhYRpqlhfyUE2ahIVvT157o1J05B_dU8yuOVvATCD-cqDED-z7-1MATF47ehDx3h5PiU9Q0HHrngPDxpNo_9HsHZ3r_O9Qd9Y=&c=plhmGMfs4BKFNcCyeFht-oHVzlfyZT0HUg_-j7-HQ9Nj4i2DEtEgmg==&ch=GR8SAlx4sMpsSISb3jM5nVWIoevWLCLeEgFTDWypSYhn5CqWo4iMTg==]
- the Google team indicated that in the field of research they want to "...shake
 it up a little bit."  We should expect more "shaking it up" behaviors from Google
and other innovators in the coming years as the ongoing business opportunities for
making society healthier become obvious.
Moving Genomic Analytics From Concept To Reality - It was at the turn of the century,
a mere 15 years ago, that President Clinton announced the landmark achievement of
coding for the human genome.  With computing capability soaring and costs plummeting,
we are now at the point of moving research from concept and bench research to daily
practice.  In fact, several days ago I was involved in an exciting discussion with
a colleague about "the million Vet" project where the Veterans Administration wants
to harness the power of population health analytics on the data of a million Vets
so that we can begin to offer better healthcare services for a group which deserves
our attention.
But, beyond that project, we also have the Precision Medicine initiative announced
by The White House, the United 100,000 Genomes Project and a separate China initiative
on a similar vein - all designed to analyze large amounts of genomic data for large
population sets for the purposes of unveiling disease patterns.  Another example
 is the deCODE Genetics project in Iceland that has demonstrated the power of population-based
genomics.  The project has combined extensive genealogy and medical records data
 with genomic data from more than 150,000 people.  The combination of data has allowed
deCODE to extrapolate the population-based risk factors, including gene variants
 linked to breast cancer, diabetes and Alzheimer's disease.
Then, there are the private initiatives like the partnership between Geisinger Health
System and Regeneron Pharmaceuticals that intend to sequence the genome for more
 than 250,000 people in an effort to identify patterns of care and disease. And,
 it doesn't stop there.  Many of the major cancer centers in the USA and elsewhere
are now engaged in genomic sequencing of cancer patients with the intent of finding
new patterns and monitoring results of treatment protocols.
We are discovering through genomic research, any number of mutations that are responsible
for rare diseases.  But, it not just the rare diseases.  It's also the common diseases
and how they exhibit their characteristics in the clinical setting or how the human
body responds to the use of certain drugs for certain problems.  I keep saying it
over and over, we are going to discover patterns of disease that we did not even
 know existed through the efforts on the new genomic research initiatives.
The costs of genomic testing [http://r20.rs6.net/tn.jsp?f=00189E6-v_2JAa_mxU_AqOQjOJKUqIhczlUobRq9z4hxpYmuYSavnTsqMBm-YOQ-L9RPs78714NebJkfqiHjMFf5gsMCrnju1l01C5Q4wHgR7ZfTOMnsTLSNtEQvmlWAeULhk6W5TjrDrRkmVPoUUbVb_Ab3_EVBJS4HSVYwfBK17Zt-Kd1sJX95LS8Nx7B3ABsRrwN10w5QXJ7tfQQ3pDvkg==&c=plhmGMfs4BKFNcCyeFht-oHVzlfyZT0HUg_-j7-HQ9Nj4i2DEtEgmg==&ch=GR8SAlx4sMpsSISb3jM5nVWIoevWLCLeEgFTDWypSYhn5CqWo4iMTg==]
have plummeted from hundreds of thousands of dollars based on millions of dollars
of research to now less than $1000 for a full testing of your genome - the benchmark
that was set several years ago as the point where consumers would begin to demand
such testing when they incurred health problems.  The cost for an individual test
can be as little as $100 and, for more complex testing, it can reach beyond the 
$1000 mark.  In fact, it is now used are part of newborn screening in many states
for a nominal fee of $15 - 60 per infant.
It's rather complicated to explain but clinical genomics is primarily focused today
on the "typos" that occur in the single-nucleotide variants where we see gene function
disrupted.  The focus on the "typos" allows researchers to explore a subset of sequences
inside of the full genome.  By starting on the small variations and slowly moving
toward the combination of variations, they expect to find associations between our
genome and the expressions of our genome in the coming years.  It's an incredibly
exciting trend that will no doubt uncover many exciting developments in the not-too-distant
future.
Even though researchers have been diligent in collecting extensive amounts of data
over the years, it's not all honey and roses.  For many of us, there are structural
variants, such as duplicated or missing chunks of genome sequence, which can be 
quite difficult to detect with existing sequencing technologies. In fact, every 
individual has millions of variants and, many of those variants do not encode protein,
which is often what is measured.  Instead the variants can control or regulate gene
activity.  As a result, even though they don't create a measureable product (e.g.
a protein), the variant can still contribute to disease. The problem is that the
 degree to which these regulatory regions affect health is not well understood. 
 Or, as Russ Altman, Ph.D. - one of the leading bioinformaticians in the world has
said, "You're shooting yourself in the foot if you're collecting data you don't 
know how to interpret."  The end result is that there are now efforts to solve this
problem.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Weekly Whisk
Musings from a foodie...
Every once in a while, I get to travel back to my birth state and visit relatives.
 Such is the season of the holidays.  Interstate 80 is one of the most traveled 
highways in the world and goes through the heart of Nebraska where I was born.  
In particular, most of my relatives still live in North Platte - the home of Buffalo
Bill Cody.  It's also the location of the Golden Spike tower which provides an overview
of the largest train care distribution site in the world with over 300 trains per
day handled at the yard.  It's an amazing site.
Now, about the food.  It's basic.  It's sustenance.  For those of us who are foodies,
it is not nirvana but when you're on the prairie, you're generally not seeking nirvana.
 Such is the Canteen Bar and Grill - 2102 South Jeffers Street - North Platte, Nebraska
69101-9694 - 308 535 6168
[* * *].  The Canteen's name is derived from the World War II stop in North Platte.
 The transport trains between the coasts stopped in North Platte and the young women
would serve cake, cookies, coffee and other refreshment items to the soldiers as
 they passed through.  My Mom was one of the servers and recalls the events of those
days quite well.  In the same manner, the new Canteen serves up basic food with 
the comfort of Midwestern friendliness coupled with basic, good food.  It makes 
for a nice stop.  Try them out...
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Good, The Bad, And The Ugly
The ongoing saga...
The Good - The passage of the Omnibus Reconciliation Act of 2015 was a useful first
step in Speaker Ryan's new tenure with the US House of Representatives.  Let's hope
the trend continues.
The Bad - The ongoing animosity between the political parties in the United States
is discouraging - at best.
The Ugly - As a Christian, I find the statements about our Muslim neighbors to be
abhorrent!  The problems in Syria and the surrounding area are not of a religious
origin.  In all societies, we can find fanatics on the fringes of any religious 
group.  Witness the killings in Colorado at the Planned Parenthood Clinics.  Are
 we calling for all Christian extremists to be ousted from the country?  No.  This
is not about conservative versus liberal.  This is about what America stands for
 and religious intolerance of any stripe - let alone some of the other utterances
- in America is an embarrassment...
The statements in The Fickenscher Files are the personal views of Kevin Fickenscher,
MD and do not reflect the views or policies of any organization with which he is
 affiliated.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

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