Do thiazide diuretics protect against fracture risk?
年紀大的病人，一不小心跌倒，很容易就骨折了。開刀加上復原休息，常常都要半年至一年才有機會回復至原先身體狀況，若有不幸的，甚至就產生更嚴重併發症。所以，看到這篇randomized clinical trial：thiazide可以減少骨折機率，就令我感到興趣了，因為之前有關thiazide降低骨折率只有observation study。
Association of 3 Different Antihypertensive Medications With Hip and Pelvic Fracture Risk in Older Adults: Secondary Analysis of a Randomized Clinical Trial (ALLHAT)
JAMA Intern Med. Published online November 21, 2016.
http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2587085
研究族群是大約22,000位，55歲以上成年人，分別接受降血壓藥，1) thiazide (chlorthalidone), 2) the calcium-channel blocker amlodipine, 3) the ACE inhibitor lisinopril.
在5年追蹤期，共有34位骨盆骨折，307位髖部骨折。分析結果：chlorthalidones組，有較低的骨折率 (hazard ratio, 0.79)
然而，這研究的Limitations 是
1) post hoc 事後檢定，因為ALLHAT研究一開始是設定為降血壓藥、降血脂藥和心臟病關係，不是和骨折的關係。所以，研究搜集的參數缺乏和骨折相關因子進來，例如： menstrual history (women), testosterone levels (men), history of falls (a proximate event in most hip and pelvic fractures), and bisphosphonate use.
2) ALLHAT研究排除了骨折高危險群病人進來 (active coronary artery disease and heart failure and chronic kidney disease)，所以這結論不能延申至以上這三族群病人。
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以前老師們說的：
Calcium excretion is increased by loop diuretics and diminished by thiazide-type diuretics and amiloride
所以，在選擇降血壓藥物時，這研究可以給我們一些用藥參考，特別是有骨折危險考量時。
目前2015, Medicare每年花$34 billion透析費用。
透析死亡率下降 36%，between 2001 and 2013。
The Corporatization of Dialysis Delivery
美國也是有愈來愈多，私人的透析院所，在shopping mall也有。
前二大透析器材供應商占了70%，Fresenius Medical Care and Colorado-based DaVita Healthcare Partners。
這二大供應商共有3,900透析點，幾乎是以下超市的數量總合(Target, Best Buy, and Publix Super Market stores)
這二大供應商共有3,900透析點，幾乎是以下超市的數量總合(Target, Best Buy, and Publix Super Market stores)
根據USRDS，目前每位透析患者年花$88,000費用(透析+住院+急診），這數字超過一般美國家庭平均收入的60%。Fresenius的資料，美國透析患者，一季大約住院10天，(more than double the hospital days for its patients in Asia or Latin America)。(筆者註：台灣透析患者還是照顧得比美國好）
有non-profit 和 for-profit 經營者，non-profit的患者死亡率較低。
The big for-profit operators have also been shown to have much higher mortality rates than nonprofit dialysis centers in the U.S. A 2010 article inHealth Services Research tallied a 19% higher risk of death at Fresenius facilities, and a 24% higher death risk at DaVita facilities, than patients receiving care at the biggest nonprofit chain.
美國的透析患者死亡率比歐洲和日本高，原因可能是：營養不良，和工作人員的訓練不足。
2009, “Why Is the Mortality of Dialysis Patients in the United States Much Higher than the Rest of the World?” U.S. one-year mortality rates were among the highest in the world: 21.7% in 2003, versus 15.6% in Europe and 6.6% in Japan. The authors fingered patient nutrition and staff training as particular causes of the discrepancy.
Cost Growth, and Cutbacks
透析費用逐年成長，Medicare 2011年開始包裹給付，每次$240。
2011, Medicare began bundling dialysis care payments in an attempt to better control expenses, paying about $240 per treatment, or around $37,000 a year.
透析患者若是有私人保險，則一開始透析前30個月由私人保險給付，後來才由Medicare接手（私人保險給付透析的金額較高，約2倍）。
Private payers typically pay at least twice Medicare rates
Home dialysis可以節省透析費用支出，目前Fresenius’ and DaVita’s home dialysis rates hover around 20% and 10%, respectively.
Empowered Dialysis
1) 教病人透析時做瑜伽，增加循環。
Richard Gibney, MD, in Waco, Texas, Fresenius-owned dialysis centersYoga classes for patients as they’re being dialyzed — a response to the rising rates of diabetes among the patients and a need to increase their circulatory performance.
2) Gibney醫師，讓病人自己準備透析用品，設定，打針，以及自己監測透析、回應警報發生時處理，目前他有280位病人是"empowered dialysis"，和傳統由護理人員操作透析相比，這群"empower dialysis"病人，有較少的死亡率和住院率。（瑞典首創‘hunker-down dialysis.’，據說可以減少33%透析費用和增加病人滿意度）
另一家醫療公司試圖用科技來幫忙透析：Outset Medical, based in San Jose, California
Tablo 會減少工資支出，減少medical complications (?)，減少病人因故沒有至院所透析的機會，和透析技術人員的工作機會?（因為病人都可以自己操作機器了）
“I said ‘No, that’s totally wrong. We’re transitioning from you being a worker bee, a madman like you’re running cattle through a chute, to becoming teachers, mentors, and cheerleaders,’ ” he says.
筆者註：我怎麼覺得最後一段是在安慰透析從業人員的？當機器可以和病人配合把透析這件事做好，那還需要那麼多的員工嗎？時事評論一下：華航空姐這次罷工，成功得獲得所要求的權利固然可喜，然而華航高層目前會不會在想，「是不是該請鴻海郭董研發個機器人空姐了呢？」
筆者註：我怎麼覺得最後一段是在安慰透析從業人員的？當機器可以和病人配合把透析這件事做好，那還需要那麼多的員工嗎？時事評論一下：華航空姐這次罷工，成功得獲得所要求的權利固然可喜，然而華航高層目前會不會在想，「是不是該請鴻海郭董研發個機器人空姐了呢？」
Ron Shinkman
Los Angeles–based health care editor and journalist specializing in economics and public policy