Beauty Poisoning

Foreign-made skin-lightening creams, found to contain toxic levels of mercury, are poisoning users as well as the people they live with, according to a report from the Centers for Disease Control and Prevention.

The CDC identified a Mexican-made cream as the likely source of mercury exposure in 22 people in 5 households in California and Virginia. While previous cases have shows similar levels of mercury exposure from skin-lightening creams, this is the first instance where exposure has been measured in non-users, CDC said. The non-labeled creams contained  2%-5.7% mercury.

Skin lightening agents that are readily available for sale in Ghana/ ©2011 Elsevier Inc. All rights reserved.

Among the sample, 15 people ages 8 months to 67 years had elevated urinary mercury concentrations (9 users and 6 non-users). Non-users were exposed to the mercury through contact with cream users or with contaminated household items, the CDC said.  Younger children, compared to older children, had much higher concentrations.

While 15 people had elevated mercury levels, only 6 (all users) exhibited symptoms of mercury exposure. Users of the skin-lightening creams said they had used it as an acne treatment, for skin-lightening, and to fade freckles.

Although mercury-containing creams are banned by the Food and Drug Administration, high levels of mercury have been found in foreign-made skin-lightening creams across the country, including Chicago, New York, Minnesota, and Baltimore.

In 2010, an FDA spokesperson told the Chicago Tribune that with fewer than 500 inspectors dedicated to reviewing imports, banned items often get through anyway. The FDA could not comment before press time.

The CDC advises clinicians who recognize mercury toxicity to consider mercury-containing creams as a possible cause, even for children. Consult a medical toxicologist before beginning treatment, CDC advises.

—Frances Correa (@FMCReporting on Twitter)

Liability Reform: A Broken Promise?

Republicans on the House Energy & Commerce Committee took President Obama to task on Tuesday in a short video that accused him of doing nothing to fulfill a promise made in last year’s State of the Union address to address medical liability reform.

Courtesy Wikimedia Commons/johnfekner/GNU Free Documentation License

With its eery, conspiratorial music and accusatory title fadeouts, I half expected to see Gary Oldman in a bespoke suit proclaim that the Joe Biden is a mole. (That reference may be lost on those of you who have not seen Tinker Tailor Soldier Spy.)

Indeed, in that January 2011 speech, according to a fact sheet issued by the White House,

…the President pledged to work with Republicans to support state reforms of medical malpractice systems to bring down costs and improve care – building on Administration efforts already underway to assess what works in medical malpractice reform.

The House Republicans charge that they’ve reached out to the White House but have had no response.

About 134 House members — Republicans and Democrats — have put their names on a bill to overhaul the medical liability system that was  introduced in Jan. 2011 by Rep. Phil Gingrey (R-Ga.).

Physician organizations have en masse backed that bill, H.R. 5. But it has languished since May last year when it was reported out of the Energy & Commerce Committee.

Meanwhile, the Obama Administration did offer up an olive branch on tort reform in the Affordable Care Act. But nothing has come of that, either.

The ACA authorized $50 million in grants to states looking to demonstrate new models. The Agency for Healthcare Research and Quality was charged with managing the program, and it put out requests for proposal in Nov. 2010. The funds were supposed to be available beginning in Oct. 2011 but, according to an AHRQ spokesperson, Congress has not yet appropriated the funds for the initiative.

That means no grants have been issued under that program, although the AHRQ has funded other liability reform projects through an initiative announced by President Obama in the fall of 2009.

The leading GOP presidential candidates have promised that they will address medical liability reform. But even if a Republican does take the White House in November, the fulfillment of that promise is likely a long way off.

—Alicia Ault

Placing Central Lines and DVTs?

Does the simple act of inserting a central venous catheter induce a hypercoagulable state in patients?

Courtesy Wikimedia Commons/Jsonp/Public domain

Research presented at the Eastern Association for the Surgery of Trauma shows that central venous line insertion significantly decreases clotting time and initial clot formation time and accelerates fibrin cross-linking in both healthy swine and critically ill patients.

The findings indicate that CV catheters induce a systemic hypercoagulable state, probably because of the endothelial injury, which may explain the increased risk for venous thromboembolism associated with central venous lines, said lead author Dr. Mark Ryan, with the University of Miami School of Medicine.

The prospective, observational trial involved eight patients whose blood was drawn from an indwelling peripheral arterial catheter before and 60 minutes after central venous line catheterization and analyzed with thromboelastography (TEG). Ten swine consented to having their blood drawn as well.

The group previously reported that placing a pulmonary artery catheter in critically ill patients and healthy swine significantly decreases the time to initial fibrin formation, thereby inducing a hypercoagulable state.

WENDLING/Elsevier Global Medical News

As in the current study, however, no changes were observed in conventional coagulation parameters, raising questions as to why standard coagulation tests fail to correlate with TEG and whether the prothrombotic state identified by TEG truly indicates an increased risk for deep vein thrombosis, Dr. Ryan said.

Finally, as has been suggested by other investigators, pigs may simply have a very different hypercoagulable state than humans do. I selfishly hope so.

–Patrice Wendling

Keeping Endovascularists Busy

Renal denervation may be the next big thing in endovascular intervention, and not just because of the many patients it might help.

Renal denervation is a new procedure for lowering blood pressure that involves placing a radiofrequency catheter inside both of a patient’s renal arteries and zapping the tissue four to eight times on each side, gently enough not to cause trauma but firmly enough to damage the renal nerves and block sympathetic activity and the kidneys’ renin release. It remains investigational in the United States, where a 500-patient pivotal trial recently started, but it’s been available on a routine basis in Europe since 2010, and according to Horst Sievert, a German interventional cardiologist who’s done many denervations since then, it’s been taking off both in terms of the number of endovascular physicians offering it and the number of patients with drug-resistant hypertension being treated.

image courtesy Wikimedia Commons

Though still off the U.S. market, the prospect of FDA approval within the next couple of years was enough to win renal denervation a special session at ISET 2012 last week in Miami Beach. My news article on those talks is here.

An apparently safe, relatively easy, 60-minute procedure that can durably cut systolic blood pressure by about 30 mm Hg in patients who remain hypertensive despite treatment with multiple drugs is certainly very attractive. It may be even more appealing if early evidence pans out and the treatment also helps normalize glycemic control and reduce hyperinsulinemia in at least some patients.

But when vascular medicine specialist Michael Jaff said at the meeting that renal denervation “could arguably be the most exciting advance in interventional vascular medicine,” and that “in the near term I’m incredibly bullish,” it was hard not to imagine that it was more than optimized patient care that made his pulse quicken.

Endovascular medicine became a medical growth industry more than 30 years ago, when it started to become a routine part of cardiology, a way to less-invasively treat stenotic coronary arteries. Since then, it’s become a major part of all vascular medicine, but in recent years the coronary part showed a definite leveling off. Just last year in a talk at ISET, Martin Leon, one of the world’s foremost interventional cardiologists, declared that endovascular coronary interventions appeared to have reached a volume plateau that would not change anytime soon. He said his early recognition of this trend was a motivation for him to turn his attention to transcatheter aortic valve replacement, which has now emerged as a new way for interventional cardiologists to ply their trade.

Renal denervation may be the next step along the same path. If the pivotal trial results and further clinical experience confirm the early findings of safety and efficacy, and especially if the very early findings of a beneficial glycemic effect also pan out, it may well fulfill Dr. Sievert’s prediction that “renal denervation will become as important as percutaneous coronary intervention.”

Important not just for patients, but for practitioners too. Busy hands are happy hands.

—Mitchel Zoler (on Twitter @mitchelzoler)

Experts Call on Docs to Lead Cost Control

Doctors must play an integral role in reducing health care costs, health policy experts say. At the annual conference of consumer group Families USA, Dr. Atul Gawande and Dr. Ezekiel J. Emanuel said that doctors participating in reducing costs will have a greater affect than the health care law itself.

Dr. Atul Gawande / Frances Correa/ Elsevier Global Medical News

“Washington will not be able to save the costs. They’ll provide the framework, but in your communities, that’s where you’ll do it,” said Dr. Gawande, a health policy researcher and endocrine surgeon at Brigham and Women’s Hospital in Boston. Dr. Gawande said that the Affordable Care Act will provide the data for doctors to identify where to trim costs. Both Dr. Gawande and Dr. Emanuel said doctors can take a leading role in cost control by focusing on the sickest 5% of patients. According to a 2009 report from the Agency for Healthcare Research and Quality, the sickest 5% of patients account for 50% of national health care expenditures.

Dr. Gawande cited the work of Dr. Jeffrey Brenner. By analyzing medical billing data from practices in Camden, N.J., Dr. Brenner, a primary care physician, was able to map out the most impoverished areas with the highest health care costs. With a focused approach that included home visits and the help of social workers, Dr. Brenner decreased one patient’s inpatient hospital time from 7 months in one year to 3 weeks. While under his care, the patient lost 200 pounds, and quit smoking, drinking, and using cocaine. At the same time, the patient’s hospital costs decreased by 60%. Dr. Gawande wrote about Dr. Brenner’s strategy in a January 2011 article in the New Yorker.

Dr. Emanuel, a recognized expert on health and chair of the department of medical ethics and health policy at the University of Pennsylvania, Philadelphia, said rising health care costs threaten many aspects of American society, particularly education, workers’ wages, and the nation’s position in the world, as well as by putting an economic squeeze on middle class. Dr. Emanuel also served as special adviser for health policy to the director of the White House Office of Management and Budget from January 2009 to January 2011, where he helped craft the Affordable Care Act.

Dr. Ezekiel Emanuel / Frances Correa/Elsevier Global Medical News

“If you care about how our kids are going to educated in the future, you have to care about heath care costs,” Dr. Emanuel said, adding that increased health care costs directly affect tuition rates. For example, from 2001 to 2011, employer contributions to health insurance increased by 113%, according to the Kaiser Family Foundation. Meanwhile, tuition for public universities increased 72% over the past decade, according to the College Board. Dr. Emanuel projected that, as health care costs continue to rise, states will be forced to take the money from other programs, leaving education and health care at the greatest risk.

“We can reduce costs without sacrificing access … [doctors] have to be committed to doing that,” Dr. Emanuel said.

H5N1 Flu Moratorium: A Pause that Refreshes?

The announcement last Friday of a 60-day moratorium on H5N1 research underscored the controversy swirling around this work.

The moratorium statement, coauthored by the lead pair of airborne H5N1 flu researchers and 37 other influenza researchers from around the world, also highlighted the degree to which these scientists stand behind the importance and safety of airborne H5N1 research.

image courtesy Wikimedia Commons

 

The statement, published online on Jan. 20 in Science and in Nature, received bylined support from an international group of flu researchers from the United States, the Netherlands, United Kingdom, Japan, China, Canada, Germany, and Italy, including staffers from the Centers for Disease Control and Prevention and the National Institutes of Health.

They said that the airborne H5N1 avian flu research, which first became public knowledge a month ago, “is critical information that advances our understanding of influenza transmission. However, more research is needed to determine how influenza viruses in nature become human pandemic threats, so that they can be contained before they acquire the ability to transmit from human to human, or so that appropriate countermeasures can be deployed if adaptation to humans occurs.”

The authors acknowledged the “perceived fear” about possible escape of the ferret transmissible H5N1 that labs in Rotterdam and Madison, Wisc., created, and they reaffirmed that “these experiments have been conducted with appropriate regulatory oversight in secure containment facilities by highly trained and responsible personnel to minimize any risk of accidental release.”

Finally, the moratorium group explained what they hoped to achieve with their 60-day pause: “We recognize that we and the rest of the scientific community need to clearly explain the benefits of this important research and the measures taken to minimize its possible risks. We propose to do that in an international forum in which the scientific community comes together to discuss and debate these issues.”

An interview that also ran in Science on Friday with Ron Fouchier, the Rotterdam virologist who leads one of these H5N1 studies, quoted him as saying that an international forum will be organized in the next couple of weeks, and that he hopes it will include representatives from the World Health Organization and the U.S. government. In the interview with Martin Enserink, Fouchier said that the idea for the moratorium began with himself, Yoshihiro Kawaoka, who independently also produced an air-transmissible H5N1 strain in ferrets, and Adolfo Garcia-Sastre, a flu researcher at Mount Sinai Medical Center in New York.

Fouchier also drew the inevitable comparison between this moratorium and the one called by recombinant DNA researchers prior to their historic 1975 meeting at the Asilomar Conference Center in California.

What seems most notable about the moratorium statement is the number and diversity of the signatories, and their willingness to stand fully behind this work despite the criticisms leveled against it over the past month. The upcoming public forum is something to look forward to.

—Mitchel Zoler (on Twitter @mitchelzoler)

Do Trauma Patients Need An Aspirin?

Acute traumatic injury has been shown to produce a prothrombotic state that predisposes trauma patients to an increased risk of venous thromboembolic events. But are these patients also at increased risk for stroke?

Researchers at the University of Louisville report that trauma patients were 1.6 times more likely to develop a cerebrovascular accident (CVA) after admission than medical and surgical controls matched for known CVA risk factors such as age, hypertension, diabetes, atrial fibrillation, and tobacco use.

On logistic regression, trauma was the only significant risk factor for CVA between the two groups, Dr. Jason W. Smith reported at the recent meeting of the Eastern Association for the Surgery of Trauma.

By Patrice Wendling/Elsevier Global Medical News

Dr. Smith called for more studies concerning the etiology and management of post-traumatic hypercoagulability and suggested that “CVA prophylaxis may be warranted in select trauma patients.”

The analysis identified 64 strokes after admission among 7,633 trauma admissions from 2008-2010, for an overall CVA rate of 0.8%. Out of this group, 23 strokes were found to be related to TBI and blunt cervical vascular injury, leaving 41 patients with non-injury related CVA in the analysis. The medical/surgical controls included 14,121 patients obtained from the university’s hospital database over the same time period.

When compared with a second control group of 120 trauma patients matched for Injury Severity Score and mechanism of action, the 41 trauma-related CVA patients presented with significantly more stroke risk factors, including older age, pre-existing hypertension, diabetes, and tobacco use.

Their chance of placement in an extended care facility also skyrocketed from 28% to 81%, while mortality rates more than tripled from 7% in controls to 22% in the trauma-related CVA patients, Dr. Smith and his co-authors reported.

The one bright spot was that on follow-up in the medical/surgical analysis, trauma patients had higher six-month post-CVA functional assessment compared with the controls.

–Patrice Wendling

A Little Respect Goes a Long Way

There’s often truth in humor, as was the case in a slightly tongue-in-cheek talk by Dr. Eric “Billy” Baum of the University of Alabama at this year’s Caribbean Dermatology Symposium in Puerto Rico.

Dr. Baum’s talk, ostensibly on practice and financial pearls, was peppered with funny sports quotes and pearls about saving money by combining family vacations with CME meetings.

Read more in The Mole blog on SkinandAllergyNews.com. …

Image courtesy of The Tango! Desktop Project via wikimedia commons

—Heidi Splete (on Twitter @hsplete)

Early Look: Caffeine for Cancer Prevention

Dr. Paul Lizzul and Dr. Allan Conney, along with their colleagues, are in the early stages of research that hints at broad implications for preventing squamous cell and basal cell skin cancer. After starting in the lab and progressing with animal models, they took a hypothesis about the effect of caffeine on actinic keratoses and applied it to humans in a recent phase I study. They shared some thoughts on this research with the Skin & Allergy News blog, the Mole:

The Mole: What prompted you to conduct this study?

Dr. Lizzul: Skin cancer of the nonmelanoma type (i.e., squamous cell and basal cell carcinoma) is the most common skin cancer and is most often a result of sunlight exposure. Ultraviolet B light is believed to be mostly responsible for these cancers. Many squamous cell skin cancers are curable if detected early. However, many people still suffer from these cancers and some also die from them. Actinic keratoses are precancerous skin tumors that mainly result from long-term sun exposure in susceptible persons. They have the potential to progress to squamous cell carcinoma. Finding effective methods of preventing UV-induced cancers and precancerous lesions would have a major impact on the total amount of human cancer.

Chemistry of caffeine image courtesty of Icey, ClockworkSoul via wikimediacommons

The Mole: Could you briefly explain your hypothesis?

Dr. Conney: In studying the effect of tea on UVB carcinogenesisis in an animal model, we found that caffeine was the major active constituent, and that pure caffeine inhibited carcinogenesis in this animal model. Topical caffeine was also active. Topical caffeine inhibited carcinogenesis in mice pretreated with UVB with a high risk of skin cancer in the absence of further UVB. Mechanistic studies showed that caffeine enhanced apoptosis (programmed cell death) in UVB-treated epidermis and in tumors. We hypothesize that topical caffeine will inhibit proliferation and stimulate apoptosis in the actinic keratoses.

Dr. Lizzul: The hypothesis to be tested in this study is that treatment of actinic keratoses with caffeine for 2 weeks will enhance apoptosis and inhibit the growth of these skin lesions in humans. The purpose of this study is to determine the effects of topical applications of caffeine on apoptosis (programmed cell death), proliferation, and the ATR/Chk1 pathway in actinic keratoses in human skin in vivo.

Our collaborators at Rutgers University found that treatment of UVB-pretreated high-risk mice with caffeine topically once a day, 5 days a week for 18 weeks inhibited the formation of keratoacanthomas and squamous cell carcinomas, decreased the size of the tumors, and enhanced apoptosis in the tumor. 

At Rutgers University, Drs. Yaoping Lu, Yourong Lu, and Allan Conney are participating in the study.

(Read more at “The Mole” blog on SkinandAllergyNews.com.) 

 —Heidi Splete (on Twitter @hsplete)

Should Physicians Prescribe Positivity?

Scott Jordan Harris  is a U.K.-based blogger, editor, book author, movie critic, and sports writer. Remarkable, considering that he spends most of his time in bed. His primary diagnosis is myalgic encephalomyelitis (ME), also known as chronic fatigue syndrome.

In a piece he wrote last week for the BBC’s website, Mr. Harris said that keeping a diary in which he focuses on the positive aspects of his life — at the suggestion of a doctor – keeps him “sane.”

©froglegs/Fotolia.com

“My depression told me my existence was filthy and barren…. After a few months of storing up the previously unrecorded richness of my life, my diary simply disproved that. I knew from re-reading the pages I’d written that I was doing interesting things — and I began to ensure I kept doing them simply to have something to write about. The diary was better than therapy; it pushed me forward through mental pain that had been holding me back.”

He added, “Doctors unaware of the realities of the lives of the chronically ill often suggest we waste what little energy we have noting down exactly how unwell we feel each day, how much we sleep and how little we do, so that they may study the results. These doctors are to be smiled at, and nodded to, and instantly ignored.”

So should physicians advise patients with chronic conditions to keep positive diaries?  I asked two experts.  Dr. Daniel Clauw, a rheumatologist who directs the University of Michigan’s Chronic Pain and Fatigue Research Center, referred me to his associate, Afton Hassett, Psy.D.

“That was a compelling story in the BBC and it actually does reflect my clinical and research experience as a pain psychologist,” Dr. Hassett told me.

Negative and positive affect (emotions) have been well-studied  in health in general and chronic and acute pain states in particular. There are numerous studies suggesting that positive affect plays an important role in pain outcomes. While few formal studies have evaluated the effectiveness of the exact intervention Mr. Harris described, there are studies   supporting the efficacy of similar positive psychology interventions for depression, Dr. Hassett said.

“Enhancing positive affect is likely a good thing for one’s mental and physical health. Sometimes just keeping a gratitude journal like the BBC article writer noted is all it takes. I always tell people to write down three different things each day for which you are grateful. After the first week or so you really start looking for the small wonders in your life: a great cup of coffee, a kind gesture from a complete stranger, the first tiny yellow flowers of spring.”

Courtesy Wikimedia Commons/4028mdk09/Creative Commons License

But Dr. David Spiegel, a psychiatrist who heads the Stanford University Center on Stress and Health, urges caution regarding positive psychology.   “I think the drumbeat for upbeat can be a little overwhelming… I agree with [Mr. Harris] that just focusing on how bad you feel you can dig yourself into a pit, but at the same time you can’t deny your feelings. The worst thing you can do to a depressed person is to tell them to cheer up.”

However, Dr. Spiegel, who works with breast cancer patients, noted that “you can help them by saying let’s give dimension to what’s bothering you, but also put that in perspective, and see other things that are good, that are positive. So it’s not one or the other…Happiness is not the absence of sadness.”

Dr. Spiegel said that advising patients with chronic conditions to keep a diary in general is an “interesting idea,” and that there is a literature base  for the medical benefits of journaling.

He advised that physicians suggest to their patients, “See if it helps you to have a daily journal of your journey through this illness, what your problems were and what your little victories were, and what you did that helped you deal with it and get beyond it.”

—Miriam E. Tucker (@MiriamETucker on Twitter)