Category Archives: Pathology

Whose Rights Are at Stake?

The Supreme Court heard arguments Tuesday in support of the 2007 Vermont statute limiting the release of the information detailing which drugs doctors prescribe. This information is maintained by pharmacies, which sell it to data-mining agencies, that in turn sell it to drug companies, for marketing purposes. Patient information is excluded from the data, doctor’s information is not.

Under the Vermont law, this information can be released only with the consent of the doctor. However, once data collection firms like IMS Health and interested parties like Pharmaceutical Research Manufacturers of America, challenged the statute, the issue became a question of free speech.

In the case of Sorrell v. IMS Health Inc., data-mining firms claim they have First Amendment rights to buy and sell the information for their marketing use.

However, the state’s attorney’s office likened the release of the confidential information to disclosing a doctor’s tax returns, patient files, or a competitor’s business information, arguing that First Amendment rights in the case apply to protecting doctor’s information. But since the information is given away to parties including insurance companies, journalists, and law enforcement, the court wasn’t too convinced.

” … just don’t tell me that the purpose is to protect their privacy,” said Justice Antonin Scalia. “[A doctor's] privacy isn’t protected by saying you can’t sell it but you can give it away.”

Justice John Roberts said Vermont is trying to reduce health care costs by “censoring” information doctors hear about brand-name drugs, with the intent that they will prescribe more generics, a measure Justice Scalia added was a restriction on free speech.

Vermont Assistant Attorney General Bridget Asay responded that “the purpose of the statute is to let doctors decide whether sales representatives will have access to this inside information” on the prescribing habits of physicians.

Attorneys general of several states, the federal government, AARP, medical associations, privacy groups, and the New England Journal of Medicine have filed briefs in support of the Vermont statute, according to a brief by Cornell (N.Y.) University Law SchoolThe National Association of Chain Drug Stores, the Association of National Advertisers, the Associated Press, and Bloomberg have filed in support of the data mining firms.

In an age in which personal data can mined through social networks and search engines, this case could set the precedent concerning how much personal information can be used for marketing. A decision is expected by June.

 Tell us what you think. 

–Frances Correa (@FMCReporting on Twitter)

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Promising Technology Might Help Identify Asthma Earlier

It’s not ready for prime time, but a radiation-free MRI technique could eventually be used to predict which high-risk children will develop asthma, based on data presented by Dr. Daniel Jackson at a press conference at the annual meeting of the American Academy of Allergy, Asthma, and Immunology, in San Francisco.

courtesy of flickr user kquedquest (creative commons)

MRI has been used to assess lung function in adults, but Dr. Daniel Jackson and his colleagues at the University of Wisconsin, Madison, hypothesized that they could obtain similar lung function data from children that could be used to predict asthma risk.

Using a technique developed by study co-author Sean Fain, Ph.D., 43 children aged 9-11 years underwent MRIs after inhaling hyperpolarized helium. The children were selected from the Childhood Origins of Asthma (COAST) project, a long-term observational study of a birth cohort of children at increased risk for asthma.

Using the technique, “we were able to look at the architecture of the lungs,” Dr. Jackson said at the press conference, as areas of the lungs that are not well-ventilated appear black on the MRI. The children’s lungs were assigned defect scores based on the MRI observations.

Children who already had asthma were significantly more likely to have defects than those who didn’t have asthma. But the more interesting finding was that girls were significantly more likely to have higher defect scores compared to boys, whether or not they had asthma.

What does this mean for disease expression? Dr. Jackson said that the next steps call for imaging the children again at age 12-13 years. Although the helium imaging technology is not ready for diagnostic use, it might serve as a biomarker for girls in particular who are at risk for developing persistent asthma after puberty, Dr. Jackson said.

For an excerpt from Dr. Jackson’s comments at the press conference,  click below.

–Heidi Splete (on twitter @hsplete)

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Renegade Science

I’m not going to sugar-coat it, because Dr. Mark A. Smith never would.

He was a no-BS guy.

Dr. Mark A. Smith spent his life looking for the answers only science can provide Photo by Renjith Krishnan

When he died in a hit-and-run accident just before Christmas, the Alzheimer’s research world lost one of its most outspoken leaders – the author of more than 800 scientific papers, most of which challenged mainstream thought about the disease.

The accident that claimed his life happened around 2 a.m. on Dec 19.  Dr. Smith – professor of pathology at Case Western University and the director of basic science research at its Memory and Cognition Center – was walking home from a local bar. Another man, driving home from the same bar, struck Dr. Smith, apparently killing him on impact, according to a police report quoted in the Chagrin Solon Sun, a local newspaper.

The driver, Daniel V. Neesham, didn’t stop. Instead he drove home. Ironically, he apparently died in his house soon after. A preliminary coroner’s report suggested that he might have died from a drug overdose, but the final results may not be known for months, Solon Sun reporter Joan Rusek told me.

When we put questions about his death aside, when we put the tragedy aside, when we put aside sympathy and sadness – what remains of Mark A. Smith?

Science.

In 2005, when I started to report on the snowballing of antiamyloid drugs, Dr. Smith was one of a tiny handful of researchers who weren’t jumping on the amyloid bandwagon. “There are a few of us who don’t worship at the Church of the Holy Amyloid,” he said in an interview that year. “There is a thought that amyloid plaques are a response to the disease, rather than the cause of the disease, and that they could even be performing some kind of protective function. It’s certainly less sexy theory, but it’s out there.”  He was always good for a quote – some witty, some funny, and some perhaps not entirely suited for publication.

As enthusiasm for antiamyloid drugs gathered steam, he stuck to his scientific guns, continually pointing out studies hinting that beta amyloid might not be the be-all and end-all of Alzheimer’s. His own research suggested that getting rid of amyloid plaques might even do more harm than good – a theory that may have played into the failure of an experimental immunotherapy. Testing stopped abruptly in 2002, when about 6% of those receiving it developed encephalitis, despite later autopsies that clearly showed decreasing amyloid load.

Swimming upstream won Dr. Smith his controversial reputation – something he took not only with good grace, but a certain amount of pride. Last summer,  Forbes reporter Robert Langreth called him a “renegade” over his stance that antiamyloids could actually harm patients.

And despite the 2005 predictions of nearly every top researcher – that we would have Alzheimer’s “licked” within 5 years – the disease rages on. In the last 4 years, four highly anticipated antiamyloid treatments failed their phase III trials. Nor could Dimebon, a drug presumed to stimulate failing neuronal mitochondria, live up to its promising phase II data. All along the way, Dr. Smith pursued his own line of inquiry, focusing on oxidative stress as the disease’s initiating event.

One of his most recent papers suggested that preventing Alzheimer’s with antioxidant therapy could be much easier than curing it with antiamyloid therapy.  Reactive oxygen species damage metabolically active cells – like neurons – the quickest, he said, sparking a cascade of self-perpetuating events that cause even more oxidative stress and the inevitable mental decline of Alzheimer’s. Treating early with potent antioxidants might avoid the downward spiral , he theorized.

Even if Dr. Smith’s ideas ultimately prove incorrect, his consistent pecking at the amyloid theory, coupled with the multiple drug failures, are nudging Alzheimer’s research onto a different path. The idea of preventing neuronal damage before it occurs is quickly overriding the drive for an antiamyloid disease-modifying drug.

Which brings us back around to science, and our most basic question: What exactly is it?

Science is faith, backed up by fact. Belief buttressed with data. Like democracy, it can be loud and messy. Dissenting voices clash, but ultimately work together to uncover reality. World-changing discoveries can’t be made without mistakes along the way, without collisions of opinion and thought, without “renegades” who refuse to jump on the latest research bandwagon – those who pursue, instead, their own ideas.

Ultimately, as generations of parents have warned, “The truth will out.”

And dissenters like Dr. Mark A. Smith will help make that happen.

- Michele G. Sullivan (on Twitter @MGsullivan)

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A Little Mohs Respect

The Mohs technician – a non-physician (often even a non-healthcare worker) – occupies a unique place in the medical pantheon.

The Mohs surgeon’s right hand must be as steady as the surgeon’s own, capable of working with the most minute wafers of tissue, just a cell or two thick. A natural tinkerer who can adjust a highly complicated machine whenever its temperamental temperament gets out of whack. A perfectionist whose urge for the precision can never be shaken by deadlines, fussy patients, or cranky docs who just want to get out of here already.

At a Mohs surgery training course, sponsored by the American Society of Mohs Surgeons,  I learned first-hand (no pun intended) about what the tech brings to this fascinating area of surgery.

Alexander Lutz, the owner of Travel Tech Mohs Services, Inc., Carson, Calif., put it well during his talk on the issue: “It’s a rare relationship between and physician and non-physician, even more so than a surgeon with his surgical nurse or tech. The nurse might be helping the surgeon, but you aren’t depending on them to complete the surgery. With a Mohs technician, you are.”

A physician who wants to learn Mohs surgery can choose to hire and train a formally educated lab tech or histotechnician – or pick a staff person to train. It can be a nurse or medical assistant, or even the office manager. 

Knitting could be a sign of tech talent.

Photo courtesy Loggie-log/Wikimedia Commons

Mr. Lutz gave some pointers on picking the right trainee. Two characteristics are key: manual dexterity and a perfectionist personality. “In my experience, good Mohs techs have these things in common. I always ask if they have a hobby that shows dexterity-like knitting, musical instruments, or even juggling.”

And though the perfectionist personality part might drive the doc nuts in a personal relationship, it  will serve both well in the surgical suite. The success of Mohs surgery – and even the life of a human being – depends on those beautiful clear margins. The surgeon can only create those margins if there are plenty of beautiful slides to guide the surgery. And only a dedicated, skilled technician can make those beautiful slides.

— Michele G. Sullivan (on Twitter @MGSullivan)

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Not Just Surviving: More Cancer Doctors Tune in To Patients’ Post-Treatment Lives

The 2010 Breast Cancer Symposium, held last week in National Harbor, Md., dedicated an entire session to survivorship. The specific topics included sexuality, survivorship in older patients, management of osteonecrosis of the jaw, and physical activity, diet, and weight.  

courtesy of flickr user N!els (creative commons)

This is encouraging. It seems like more doctors are paying increasing attention to the quality of cancer patients’ lives after their treatments are over. Dr. Michael Krychman of Newport Beach, Calif., emphasized the importance of individualizing sexual problems in cancer survivors. The decrease in estrogen after cancer treatment can cause a range of sexual problems for which there are a range of solutions even at the most basic level, such as choosing the right lubricant for vaginal dryness, he said.

 

 

The physical activity talk stood out in light of recent guidelines issued by the American College of Sports Medicine (ACSM). Dr. Rachel Ballard-Barbash of the National Cancer Institute mentioned the guidelines and emphasized the value of a variety of types of exercise—cardiovascular activity, resistance training, and flexibility—for cancer survivors.

My colleague Kerri Wachter (@knwachter on Twitter), covered the ACSM’s June meeting, and blogged about how the recommendations said that there’s no reason why cancer patients can’t get out and do whatever exercise feels good to them. Kerri also conducted a video interview with Kathryn Schmitz, Ph.D., of the University of Pennsylvania, lead author on the ACSM guidelines.

Dr. Ballard-Barbash said that even though studies of exercise interventions for cancer patients haven’t shown significant weight loss, they have shown improvements in cardiovascular fitness and physical function. And let’s not underestimate the psychological benefits of exercise in general, and the comfort and joy of returning to a favorite activity in particular.

–Heidi Splete (@hsplete on twitter)

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I See What You Mean

From the annual meeting of the Heart Rhythm Society, Denver:

Physicians planning to attend the upcoming annual meetings of the American Academy of Family Physicians, Society of Diagnostic Medical Ultrasound, or American Public Health Association at Denver’s Colorado Convention Center should prepare themselves for Shock and Awww when they encounter the big blue bear, a whimsical 40-foot tall sculpture peering through the glass to see what’s going on inside.

The sculpture by British-born University of Denver artist Lawrence Argent  is titled, “I See What You Mean.” Commissioned under the city’s 1%-for-public-art program, the big blue bear weighs 10,000 pounds and is composed of more than 4,000 polymer and concrete interlocking triangles over a steel frame. Argent began with a small plastic toy he scanned and converted into a digital computer file, which he then sculpted electronically.

The big blue bear has become a popular, feel-good tourist attraction. It also serves as a convenient meeting point for conventioneers who become disoriented by the conference center’s long, white, largely unmarked corridors.

– Bruce Jancin

Photo by Bruce Jancin

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Hospitals Moving “Moo” Off the Menus

(Courtesy NASA Goddard Space Flight Center)

Here’s a happy Earth Day item: Four hospitals in the San Francisco Bay Area reduced their meat purchasing for menus by 28% in a pilot study, thereby avoiding significant amounts of associated greenhouse gas emissions and saving hundreds of thousands of dollars in costs.

Most of the drop in greenhouse gases came from reduced purchases of beef, which is a notorious producer of gases that contribute to global warming.

The study is the first attempt to evaluate the “Balanced Menus” program, which was created by the San Francisco Bay chapter of Physicians for Social Responsibility and has been rolled out to 32 hospitals across the United States by the nonprofit organization Health Care Without Harm. The Johns Hopkins Center for a Livable Future partnered with Health Care Without Harm to conduct the study.

A hospital meal (not in one of the study hospitals) by flickr user VirtualErn (Creative Commons).

Two hospitals reduced meat (beef, pork and chicken) in its cafeterias or cafes, one hospital reduced meat in inpatient menus/meal services, and one hospital did both. The Balanced Menu program also had them try to replace the remaining meat on their menus with purchases from sustainable and grass-fed meat producers instead of industrialized meat sources.

The study estimated that in a year’s time, the reduced meat purchases would avoid a total of 1,004 tons of carbon dioxide-equivalent greenhouse gas emissions. That’s roughly equivalent to not using 102,454 gallons of gasoline, or growing 23,354 tree seedlings for 10 years. Although the study did not account for greenhouse gases associated with whatever food replaced that meat, no food makes gas like beef, so there’s no doubt the planet came out ahead.

They also calculated that the less-meat, better-meat program saved the four hospitals $21,080 per month in costs even after including increased purchases of fish and vegetable sources of protein. My calculator suggests that’s $252,960 per year.

What about the patients? No complaints there, only anecdotal reports of compliments. Plus changing the meat-heavy U.S. diet could help combat rising rates of diabetes, obesity, and some cancers. According to Department of Agriculture statistics, the U.S. food supply contains 58% more red meat and chicken (8.7 ounces per person per day) than is called for in dietary guidelines that cover meat, poultry, nuts, beans, and eggs (5.5 ounces per person per day).

One of the lessons learned in the pilot study, the investigators noted, is that hospitals should involve clinicians early in the process of menu development. If you’re a clinician who is looking for one small, achievable Earth Day action that could make a big difference, consider showing this study to your hospital team. They (and the planet) may thank you.

–Sherry Boschert (@sherryboschert on Twitter)
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