Thursday, December 7, 2023

Drug addiction: not just opioids

 Consumption of addictive drugs seems to come in deadly cocktails these days, which is making interdiction of drugs, and treatment of addiction more complicated.

The NYT has the story:

‘A Monster’: Super Meth and Other Drugs Push Crisis Beyond Opioids. Millions of U.S. drug users now are addicted to several substances, not just opioids like fentanyl and heroin. The shift is making treatment far more difficult.  By Jan Hoffman

"The United States is in a new and perilous period in its battle against illicit drugs. The scourge is not only opioids, such as fentanyl, but a rapidly growing practice that the Centers for Disease Control and Prevention labels “polysubstance use.”

Over the last three years, studies of people addicted to opioids (a population estimated to be in the millions) have consistently shown that between 70 and 80 percent also take other illicit substances, a shift that is stymieing treatment efforts and confounding state, local and federal policies.

“It’s no longer an opioid epidemic,” said Dr. Cara Poland, an associate professor at the Michigan State University College of Human Medicine. “This is an addiction crisis.”


"The incursion of meth has been particularly problematic. Not only is there no approved medical treatment for meth addiction, but meth can also undercut the effectiveness of opioid addiction therapies. Meth explodes the pleasure receptors, but also induces paranoia and hallucinations, works like a slow acid on teeth and heart valves and can inflict long-lasting brain changes.

"The Biden administration has been pouring billions into opioid interventions and policing traffickers, but has otherwise lagged in keeping pace with the evolution of drug use. There has been comparatively little discussion about meth and cocaine, despite the fact that during the 12-month period ending in May 2023, over 34,000 deaths were attributed to methamphetamine and 28,000 to cocaine, according to provisional federal data.


"Like opioids, which originally came from the poppy, meth started out as a plant-based product, derived from the herb ephedra. Now, both drugs can be produced in bulk synthetically and cheaply. They each pack a potentially lethal, addictive wallop far stronger than their precursors."

Wednesday, December 6, 2023

Applying for medical residencies: a consensus statement from Internal Medicine

 The Alliance for Academic Internal Medicine has released a "consensus statement" with many proposals about application and interview caps, and signaling.

Catalanotti, Jillian S., Reeni Abraham, John H. Choe, Kelli A. Corning, Laurel Fick, Kathleen M. Finn, Stacy Higgins et al. "Rethinking the Internal Medicine Residency Application Process to Prioritize the Public Good: A Consensus Statement of the Alliance for Academic Internal Medicine." The American Journal of Medicine (2023).

It also includes a call for data and analysis:

"AAIM proposes increasing internal medicine program preference signals to 15, using tiered signaling with three “gold” and 12 “silver” signals, and setting an interview cap of 15 in the 2024-2025 recruitment season, with participation by all internal medicine programs. The Alliance recommends that all internal medicine programs participate in ACI. AAIM recommends that programs transparently share information about their use of preference signals and other application screening methods and calls for real-time data analysis to explore impact, inform future iterations and identify potential harms.

"The Alliance calls upon ERAS and NRMP as well as Thalamus® and other interview scheduling platforms to transparently share data, to embrace change, and to perform analyses needed to inform this process. For example, recent modeling with eight years of retrospective NRMP data in OBGYN demonstrated that an early match round may increase the number of “mutually dissatisfied applicant-program pairs” and that a multiple-round match process could introduce potential rewards for gamesmanship, a prime factor addressed by the current process.35 AAIM applauds this analysis and hopes that the new collaboration between ERAS and Thalamus® may provide useful interview data to inform this proposal and further interventions."

And here is reference 35 in that last paragraph, about which I've blogged before.

I Ashlagi, E Love, JI Reminick, AE. Roth
Early vs Single Match in the Transition to Residency: Analysis Using NRMP Data From 2014 to 2021
J Grad Med Educ, 15 (2) (Apr 2023), pp. 219-227, 10.4300/JGME-D-22-00177.1

Tuesday, December 5, 2023

Organ & Body Donations: John Oliver

Laugh through the tears with John Oliver:

Monday, December 4, 2023

Convalescent plasma: the picture is getting clearer

 Slowly, there is evidence accumulating that convalescent plasma is helpful in treating patients with severe Covid, if it is administered early.  There is also evidence that it doesn't help much once the disease has become well established, particularly when the primary symptoms become due to the body's own immune reaction.  These caveats help explain why early reports did not find an effect of convalescent plasma--i.e. it helped only a subset of the patients to whom it was administered. But for those it was sometimes life saving. Here is a recent paper from the New England Journal of Medicine.

Convalescent Plasma for Covid-19–Induced ARDS in Mechanically Ventilated Patients by Benoît Misset, M.D., Michael Piagnerelli, M.D., Ph.D., Eric Hoste, M.D., Ph.D., Nadia Dardenne, M.Sc., David Grimaldi, M.D., Ph.D., Isabelle Michaux, M.D., Ph.D., Elisabeth De Waele, M.D., Ph.D., Alexander Dumoulin, M.D., Philippe G. Jorens, M.D., Ph.D., Emmanuel van der Hauwaert, M.D., Frédéric Vallot, M.D., Stoffel Lamote, M.D., et al., October 26, 2023, N Engl J Med 2023; 389:1590-1600 DOI: 10.1056/NEJMoa2209502



Passive immunization with plasma collected from convalescent patients has been regularly used to treat coronavirus disease 2019 (Covid-19). Minimal data are available regarding the use of convalescent plasma in patients with Covid-19–induced acute respiratory distress syndrome (ARDS).


In this open-label trial, we randomly assigned adult patients with Covid-19–induced ARDS who had been receiving invasive mechanical ventilation for less than 5 days in a 1:1 ratio to receive either convalescent plasma with a neutralizing antibody titer of at least 1:320 or standard care alone. Randomization was stratified according to the time from tracheal intubation to inclusion. The primary outcome was death by day 28.


A total of 475 patients underwent randomization from September 2020 through March 2022. Overall, 237 patients were assigned to receive convalescent plasma and 238 to receive standard care. Owing to a shortage of convalescent plasma, a neutralizing antibody titer of 1:160 was administered to 17.7% of the patients in the convalescent-plasma group. Glucocorticoids were administered to 466 patients (98.1%). At day 28, mortality was 35.4% in the convalescent-plasma group and 45.0% in the standard-care group (P=0.03). In a prespecified analysis, this effect was observed mainly in patients who underwent randomization 48 hours or less after the initiation of invasive mechanical ventilation. Serious adverse events did not differ substantially between the two groups.


The administration of plasma collected from convalescent donors with a neutralizing antibody titer of at least 1:160 to patients with Covid-19–induced ARDS within 5 days after the initiation of invasive mechanical ventilation significantly reduced mortality at day 28. This effect was mainly observed in patients who underwent randomization 48 hours or less after ventilation initiation."


Here are my posts on convalescent plasma, and the confusing initial reports about its effects.

Sunday, December 3, 2023

Photos from the daily market design activity at Stanford

Two photos remind me of the day to day market design activity at Stanford. 

Tinglong Dai joined our Wednesday market design coffee and sent along this picture. (You can see who came by plane and who came by bike...)  He wrote about his visit here.

And Matias Cersosimo successfully defended his dissertation on Friday, which  included market design experiments like this one.

 Welcome to the club, Matias.

Saturday, December 2, 2023

Design of (international) kidney exchange: ex-post rejection versus ex-ante withholding

 Here's a paper by several Dutch computer scientists, which seems to be motivated by the problem of international kidney exchange within the EU, in which there are lots of concerns about fairness between countries.  But (as the paper notes) these could also apply to individual transplant centers, in the U.S. context.  The thrust of the paper is that looking for exchanges that won't be rejected ex post in a full information environment may be more productive than looking for ways to incentivize countries or transplant centers to reveal their full sets of patient donor pairs in an incomplete information environment.

Blom, Danny, Bart Smeulders, and Frits Spieksma. "Rejection-Proof Mechanisms for Multi-Agent Kidney Exchange." Games and Economic Behavior (2023).

Abstract: Kidney exchange programs (KEPs) increase kidney transplantation by facilitating the exchange of incompatible donors. Increasing the scale of KEPs leads to more opportunities for transplants. Collaboration between transplant organizations (agents) is thus desirable. As agents are primarily interested in providing transplants for their own patients, collaboration requires balancing individual and common objectives. In this paper, we consider ex-post strategic behavior, where agents can modify a proposed set of kidney exchanges. We introduce the class of rejection-proof mechanisms, which propose a set of exchanges such that agents have no incentive to reject them. We provide an exact mechanism and establish that the underlying optimization problem is 

we also describe computationally less demanding heuristic mechanisms. We show rejection-proofness can be achieved at a limited cost for typical instances. Furthermore, our experiments show that the proposed rejection-proof mechanisms also remove incentives for strategic behavior in the ex-ante setting, where agents withhold information.

Friday, December 1, 2023

Fairness in algorithms: Hans Sigrist Prize to Aaron Roth

 The University of Bern's Hans Sigrist Prize has been awarded to Penn computer scientist Aaron Roth, and will be celebrated today.

Here are today's symposium details and schedule:

Here's an interview:

Aaron Roth: Pioneer of fair algorithms  In December 2023, the most highly endowed prize of the University of Bern will go to the US computer scientist Aaron Roth. His research aims to incorporate social norms into algorithms and to better protect privacy.  by Ivo Schmucki 

"There are researchers who sit down and take on long-standing problems and just solve them, but I am not smart enough to do that," says Aaron Roth. "So, I have to be the other kind of researcher. I try to define a new problem that no one has worked on yet but that might be interesting."

"Aaron Roth's own modesty may stand in the way of understanding the depth of his contributions. In fact, when he authored his doctoral thesis on differential privacy about 15 years ago and then wrote on the fairness of algorithms a few years later, terms like “Artificial Intelligence” and “Machine Learning” were far from being as firmly anchored in our everyday lives as they are today. Aaron Roth was thus a pioneer, laying the foundation for a new branch of research.

"I am interested in real problems. Issues like data protection are becoming increasingly important as more and more data is generated and collected about all of us," says Aaron Roth about his research during the Hans Sigrist Foundation’s traditional interview with the prize winner. He focuses on algorithmic fairness, differential privacy, and their applications in machine learning and data analysis.


"It is important that more attention is paid to these topics," says Mathematics Professor Christiane Tretter, chair of this year's Hans Sigrist Prize Committee. Tretter says that many people perceive fairness and algorithms as two completely different poles, situated in different disciplines and incompatible with each other. "It is fascinating that Aaron Roth’s work shows that this is not a contradiction."


"The first step to improving the analysis of large data sets is to be aware of the problem: "We need to realize that data analysis can be problematic. Once we agree on this, we can consider how we can solve the problems," says Aaron Roth."