Evidence-Based Medical Practice-How Accurate is the Doctor's Interpretation of Radiographical Images?

X-ray image of an internal carotid artery aneurysm.
 Image credit
Mayfield Clinic

I heard a story of a doctor, a neurosurgeon, who operated on a patient to remove a brain tumour. The preoperative management of the patient was carried very well under this doctor's supervision; but the patient died a few days after the surgery. A post-mortem examination (autopsy) was carried out on the dead patient and it was found that he died from the rupture (very highly possible the neurosurgeon ruptured it during the surgery) of an aneurysm (a condition in which a part of the wall of an artery become inflated like a balloon because of the presence of fatty deposits in between the layers of the wall of the artery) of one of the internal carotid arteries and which has been there before the surgery was done. But this patient was said to have received a good preoperative management, meaning that he underwent X-rays, computed tomography scan and even MRI (magnetic resonance imaging) of the head and neck. Why did the preoperative management team fail to detect the internal carotid artery aneurysm? And why did the neurosurgeon also fail to detect and avoid rupturing it during the surgery?

In Nigeria and some other countries of the world, I think there are two reasons for this costly mistake. One is the poor relationship between the various members of the health management team: this is the major problem facing the healthcare delivery of many developing countries. And the other (which is not really an issue of whether the healthcare system of that country is advanced or not and hence is global) is the human error, an occasional drop of imperfection in that ocean of precision of our care of the patient.

A GOOD Healthcare Team. Image credit to
St. Mary's Good Samaritan Hospital

A harmonious relationship in the multidisciplinary management of the patient is a precious jewel that has been very difficult to mine in the healthcare system of some developing countries. The major root of this problem is the clash of egos among the various professional disciplines that make up the medical management team. With each profession clamouring to be the leader of the team; with some experts in one profession looking down on and treating with contempt the experts in some other profession---one sees a situation where a neurosurgeon verbally insults an anaesthetist during surgery in the theatre, telling him or her that they don't know anything and that he could teach them everything about anaesthesia; a situation in which a surgeon who is not sure of what the details are on an X-ray does not seek the expert advice of the radiologist for proper interpretation before going in to open up the patient, because he feels he knows everything about radiology in addition to his own area of expertise. Fortunately, everyone in the medical management team in this part of the world is beginning to identify this problem and realizing that it is not in the interest of the patient for whom they swore an oath to take care of. Efforts are being made by every one of them to preach the message that each member of this multidisciplinary team is indispensable and that everyone is equally important in our duty of giving the patient the highest of quality medical care.

Perfection in the various protocols guiding each modality of management and care of the patient comes after a long period of repeated trials during which mistakes are made (and whose end-product sometimes is the death of some patients) and lessons are learnt. But the fundamental basic goal of medicine is to give the best care to the patient, which can only be achieved by averting all possible errors that abound in the protocols of each form of patient management and care.

Technology has long been employed to help out in this area, leading to rapid advances in various areas in medicine and which in turn has greatly improved the quality of patient care. And as technology advances in itself; it magnanimously extends what it has gained to medicine. This gesture of generosity was recently witnessed in the area of interpreting X-rays of patients. A group of  medical doctors and IT experts in the Nuclear Medicine department of the Northern Ireland Cancer Centre in Belfast have teamed up to develop an iPad application called Experior, which detects where a doctor is making a wrong interpretation of a patient's X-rays. Experior, which has been reviewed by the Royal College of Radiologists, works by assessing the doctor's ability to interprete X-rays of patients taken in their hospitals through online and real-time comparison with a huge database of similar X-rays validated over time by experts who are authorities in the fields of Radiology and Anatomy; it then sends an instant feedback of that doctor's interpretation to him, highlighting the professional rating of his interpretation, giving him corrective analysis of the interpretation and clues on how to make a better interpretation of subsequent similar X-rays.

Experior Medical App on the iPad. Image credit to Experior Medical

In addition, Experior provides a vast online database of X-rays of the abnormal human anatomy as tests which the medical student, junior doctor and consultant can take, in a time-constrained setting similar to what obtains in the accident and emergency department, to improve their skills at making accurate interpretation of these images and saving patients' lives through properly guided medical care.

The Experior medical app can be used by anyone in the medical field in any part of the world; the only constraint for now is that it is only available for the iPad. If the Experior
Medical group can extend this application to the Android OS, then more doctors, especially in developing countries will have access to it. This will help to avert wrong interpretations of X-ray images, saving patients' lives.

Smart advertisement; Nigerian Telecom operators are dumb advertisers

SMS/MMS ad in Nigeria
Image credit to MobiThinking

"To enjoy pastor.........text 5045 to 4100. Cost #50 per month". This is one of the regular promotional ads most Nigerian phone subscribers get on their mobile phones daily.

Over the years the techniques of advertisement have evolved to ways that bring ads to people without appearing intrusive, unnecessary and like a spam.

Being the custodian of huge data on customer information is both a big responsibility and also a fertile land, under legal terms and conditions, to generate income in the area of advertisement. Companies like Google, Facebook, Amazon and so on have put up several technological strategies for gathering data on hundreds of millions of customers that use their services. These involve collating the customer's name, phone numbers, location, occupation, level of education and information regarding their behaviour towards goods and services both offline and online, and so many other information. However, these companies don't stop in the data gathering process; they go further to process this huge amount of data to generate what I call "goods and services consumption" profile of each customer. With such profile database, these companies target their customers with adverts that cover their areas of consumption interests; this makes the adverts serve the purpose of solutions to the problem of making the best decision in the 'goods and services' market, instead of being an intrusion to these customers' normal activities. In addition, they use special software programs to track the behaviour and response of the customers to the promotional contents targeted at them and subsequently modify their advert strategy at them based on the profiled response. Ever wondered why someone going through Amazon's website from Nigeria would see majorly adverts from Nigerian businesses and not those in the US? This is because these companies have optimized their ad targeting strategy to suit the taste of whoever was visiting their sites or using any of their services.

And this is where our Nigerian mobile telecom companies are far behind. Back in 2009, the Nigerian Communication Commission mandated every mobile network operator in the country to register its subscribers on their data: I registered my phone number with the network I'm subscribed to during which my name, age, address (state of origin and residential address), biometric finger print, webcam photo, occupational status (employed, student, unemployed) and other pieces of information were requested and which I provided. But it still baffles me when our Nigerian mobile telecom companies still send funny, annoying, unsolicited and intrusive promotional contents like the ones I receive daily which do not target my goods and services taste, despite having such a rich customer database.

SMS/MMS ad. Image credit to Onbile

Though online advertisement is slightly different from the SMS and MMS (short message service and multimedia messaging service) advertisement which is one of the advert service platforms run by Nigerian mobile telecom companies, it should adopt the same strategy of sending ads optimized for the taste of different segments of a customer base, employed in online advertising. These companies can profile their subscribers using the information obtained during the registration of their phone numbers into different groups of  "goods and services tastes" such that when targeted with certain ads there would be a robust response to them; they can also develop a program that would monitor the response of these different groups of phone subscribers to ads and then use the information gathered to target ads highly relevant to their tastes; hence, these mobile telecom companies can then sell phone numbers of subscribers with a predicted high taste for particular goods and services to the providers of such goods and services, instead of the current selling of random, unprofiled phone numbers to random advertisers (I don't really like it when I, a student, receive messages on my phone telling me to call a particular code to know more about breastfeeding--I'm not a woman for God's sake, let alone a breastfeeding mother!). However, there are adverts that are general and therefore targeted at every customer.

In addition, any SMS/MMS advert sent to my mobile phone should not be what I would have found out about without it being sent; it should not be what I have already seen frequently advertised on TV or online, because I will not respond to it, if I have already done so through another means. Instead, SMS/MMS adverts should, apart from being highly relevant to me based on my age bracket, occupation, gender, location (where I'm currently residing), be the premium link to the goods and services being advertised: by this, I mean the goods and services should be new in the market, and there should not be many other easy ways of getting to them (for paid services in Nigeria because most people would opt to get such services --music, book, and so on--free if there are means to do so; however, goods and services available for purchase through several outlets can also be advertised via SMS/MMS as it is just another medium of advertisement). Also, such SMS/MMS adverts should not be patterned to exploit customers as is the case with most of the promotional contents from our Nigerian mobile telecom companies currently. Why would I pay fifty naira for a song to be used as caller tune for just one month---it should be for life. If I choose to buy another song for caller tune I do so, and then put the old ones into a form of my 'caller tune library' which I can reuse again as my caller tune; the mobile telecom companies in Nigeria have to make something like this possible. Replicating this suggestion in other SMS/MMS promotional contents by the Nigerian mobile telecom companies will begin to give their customers true value for their money if they choose to respond to such adverts.

Drug Resistance: Man's greatest threat in the survival of the fittest.

Drug Resistance. Image credit to ZME Science

The rate at which microorganisms harmful to our health are adapting to the various treatment modalities (drugs) currently available is very alarming and dreading. It is unfortunate to say that it seems that we're not one step ahead of these tiny, invisible-to-the-naked-eye organisms that are behind the various diseases that have affected humans since the beginning of history.

Prof. Randy Schekman, Nobel Medicine Laureate. Image credit to Nobel.org

Why it seems that we in the medical field are not one step ahead of these tiny organisms there can be many reasons. Topmost among them is the lag in basic fundamental research. Late last year, Professors Randy Schekman, James Rothman and Thomas Suedhof who jointly shared  the 2013 Nobel Prize in Medicine lamented over what they termed a neglect on basic research when the the US National Institute of Health created a Centre for Advancing Translational Sciences. In the words of Prof. Suedhof "......we don't have anything to 'translate' because we just don't understand the fundamental diseases of the brain....". His opinion is buttressed by the fact that there have emerged strains of the tuberculosis-causing organism, Mycobacterium tuberculosis, that are resistant to all known anti-TB drugs; the same could be said of some strains of the Staphylococcus species which cause myriads of diseases in humans. The problem here is that even the most recent drugs used in eradicating these organisms have the chemical structural framework and pharmacodynamics (a drug's way of carrying out its work in the body) that was developed in the 1960s and 70s; and there is no enemy being fought by its adversary with the same tactics over 4 to 5 decades, who will not evolve defence mechanisms that will one day confer on it total immunity from such tactics and also allow it to mount fatal attack on the adversary.

Another reason for this lag in our effort to be ahead of these disease-causing organisms is the lack of a large scale, collective and multidisciplinary undertaking to study in minute details the various ways in which these organisms evolve drug-resisting defence mechanisms. And what I mean here is an undertaking similar to the global Human Genome Project that saw to the successful sequencing of the whole human genome.

Having outlined these two reasons, I would now set out suggestions as regards how we can totally be in control of this fight against these human disease-causing organisms.

Prof. Kary Mullis. Image credit to NNDB

While it may seem that basic research in the area of drug development is not blossoming as we expect it, some tiny silver linnings I can fathom from some corners around the world. The one that comes to my mind is the work being done by the Nobel Chemistry laureate, Prof. Kary Mullis (he won the 1993 Nobel Prize in Chemistry for his invention of the Polymerase Chain Reaction, a technique used to create billions of a single DNA segment in a few hours).His concept of Altermune which he explained on the TED talk show conference is something that will give our tiny, microscopic adversaries a surprisingly lethal blow. Prof. Kary Mullis is taking a new, novel and radical approach towards fighting drug resistance in bacteria and other disease-causing microorganisms. The Altermune concept is a technique that uses an artificially synthesized molecule called Alphamer or Altermune linker to re-direct our own immune system to destroy these invading bacteria and other disease-causing microorganisms. An Alphamer or Altermune linker consists of a short sugar chain (an alpha galactose oligosaccharide)---which normally is not attacked by the body's immune system despite the immune system producing antibodies in response to its exposure---linked to a synthetic DNA segment called an aptamer with a specificity for only a particular strain of a virus or bacterium such that once this particular microorganism (which may be resistant to all available antibiotics, antiviral agents and other drugs in this case) invades the body, the aptamer segment of the Altermune linker binds to it and the antibodies produced in response to the galactose oligosaccharide exposure (but which does not harm it) will in the process be exposed to fresh food (the invading disease-causing organism), destroying it, both personally and by inviting other hungry guys of the immune system---the macrophages, the cytotoxic T cells and the complement system. Prof. Mullis has tested  his new work on mice infected with a strain of Staphylococcus aureus resistant to even the most potent antibiotic---this became his enemy because it killed his professor friend---and recorded almost 100% wipe out of this bacterium from the blood of the mice after a set period unlike in the controls which used various antibiotics such as doxycycline; further studies are going on in other animals such as chicken infected with the flu virus, using Altermune linkers designed for such microorganisms. Human trials will likely start soon, especially if there are emergency cases where the patient could be at the point of death because every other available option has been explored with no results. And this will unleash a whole new field of fighting against microorganisms causing disease in humans (if this works out well in human, Professor Mullis may win another Nobel Prize but this time in Medicine in about ten to fifteen years' time).

Alphamer or Altermune Linker. Image credit to Prof. Kary Banks Mullis

While this is ingenious, there is also great wisdom in exploring other ways so as to have several novel strategies for attacking these current-drug-resistant microorganisms. And I think one possible way to do this is to extend the kind of global interdisciplinary collaboration enjoyed by the Human Genome Project to the study of drug resistance in every known disease-causing microorganisms, not just some small scale collaborative studies that are obtainable currently (however, this is not condemning small scale collaborative researches as they form the foundation for large scale collaborations). Drug resistance by microorganisms comes into play when these organisms undergo mutations. Mutation is a change in the framework of some portions of an organism's genetic architecture responsible for encoding proteins that make up the structure and function vital to its existence and continual survival in the face of factors (drugs and other therapeutic strategies) that threaten them. What if we have what I call the global MutaGenome Project in which researchers from all fields will collaborate at a global scale to map all the genetic mutations in all known disease-causing organisms over generations? These mutations will then be graded on a conventional scale, depending on the extent to which their phenotypic manifestations cause diseases in humans and mount resistance to our therapeutic strategies. By engaging in such large scale endeavour, we create what I call a mutagenomic database from which patterns in which these genetic mutations occur both among similar organisms and across different organism can be outlined, hence enabling us to use mathematical tools---such as the Nash Game Theory, Permutation and Combinations and so on already employed in evolutionary biology---to predict possible future genetic mutational patterns, outcomes, and understand clearly the working dynamics between each particular threat at the molecular level (in the form of therapeutic modalities) and mutational response (resistance development) in these organisms. This could then lead to different predictive therapeutic designs for a particular bacterium over time in response to its possible resistance development options. With this approach we can have centres for MutaGenomics and MutaGenomic Therapy (Mutational Genomics) in universities and research institutes around the world designing novel therapies for various diseases.

This is a very daunting and big ambition. But we did it in the Human Genome Project, and we can also do it in the global MutaGenome Project.