Day: 09/25/2015

Young Medical Phenoms: 9 People Under 20 Who Have Contributed Amazing Things To Medicine

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It is often suggested that young people may hold the key to solving some of the world’s greatest dilemmas due to their creative capacity. The nine young minds in the slideshow above give weight to that argument. Making a name for yourself in the world of medicine is no easy task these days. Doing so before the age of 20 is what you would call extraordinary. Click “view slideshow” to see some of the brightest and youngest minds whose contributions to science and medicine are just beginning.

view the slideshow. URL:http://www.medicaldaily.com/young-medical-phenoms-9-people-under-20-who-have-contributed-amazing-things-medicine-353020

Do Babies Feel Pain Like Adults? MRI Research Offers New Insights

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Babies experience some aspects of pain in a similar way that adults do, new MRI research suggests.

Novel MRI research has determined that infants have patterns of pain-related brain activity similar to adults but with a much lower pain threshold. The study findings highlight the importance of developing effective pain management strategies for infants, researchers said.

Infants—particularly those born prematurely—are sometimes subjected to painful procedures, like line and tube placement and repetitive blood draws. A 2014 Neonatology study from the Netherlands found that each infant in the neonatal intensive care unit averaged more than 11 painful procedures per day. Compared with adults, less is known about how infants experience pain, which has led to a lack of recognition in clinical practice. MRI has been used to study pain-related brain activity in adults, but is difficult to perform on infants because it requires the subject to remain still during imaging.

For the new study, researchers from the Department of Paediatrics at the University of Oxford, U.K., were able to address this issue by enlisting the help of the babies’ parents. A report on the research appears in the April 21 online edition of the journal eLife.

“Until recently, researchers didn’t think it was possible to study pain in babies using MRI because, unlike adults, they don’t keep still in the scanner,” said study lead author Rebeccah Slater, Ph.D., associate professor of paediatric imaging at the University of Oxford. “However, as babies less than a week old are more docile than older babies, we found that their parents were able to get them to fall asleep inside a scanner so that we could study pain in the infant brain using MRI.”

The study compared 10 healthy infants between one and six days old and 10 healthy adults aged 23 to 36 years. In most cases one or both parents stayed with the babies and a trained medical professional was always present. Babies were cuddled and nursed to get them to fall asleep inside the MRI scanner. Researchers used a special bean bag to help keep the babies’ heads still and earphones to reduce the scanner sound.

The Oxford researchers used Blood Oxygenation Level Dependent (BOLD)-based MRI, a technique in which the signal changes in intensity depending on the oxygen level in the blood.

“Brain activity causes a local increase in blood flow, bringing with it oxygenated blood that causes the images to get a little brighter,” said Stuart Clare, Ph.D., university research lecturer at the University of Oxford. “This non-invasive method doesn’t require any extra equipment—just a researcher with a stopwatch to provide the stimulus at the right time.”

To monitor head motion, researchers also used Prospective Acquisition CorrEction (PACE), a vendor-supplied technology that tracks the subject’s movement from scan to scan making minor adjustments to the imaging prescription to ensure that the region of interest is always in view.

“At first we thought that this technology would make a big difference in the study—but, provided the babies are settled in the scanner, which happened most of the time—it would be possible to do a study like this without it,” Dr. Clare said.

During scanning, subjects were poked on the bottom of their left foot with special retracting rods that can be applied at several different force settings. Each stimulus was administered 10 times for about one second each.

When researchers compared MRI scans from the babies with those of adults exposed to the same intensity stimulation, they found that 18 of the 20 brain regions active in adults experiencing pain were active in babies. Scans also showed that babies’ brains had the same response to a weak poke as the adults did to a stimulus four times as strong, suggesting that they may have a much lower pain threshold than adults.

“This is particularly important when it comes to pain: obviously babies can’t tell us about their experience of pain and it is difficult to infer pain from visual observations,” Dr. Slater said. “Historically it was thought that babies’ brains may not be developed enough for them to really ‘feel’ pain—that any reaction is just a reflex. Our study provides evidence that this is not the case.”

Reexamining Pain Prevention Strategies

The findings highlight the importance of pain prevention strategies in infants, researchers said. As recently as the 1980s it was common practice for babies to be given neuromuscular blocks without pain relief medication during surgery.

“Thousands of babies across the U.K. undergo painful procedures every day, but there are often no local pain management guidelines to help clinicians,” Dr. Slater said. “Our study suggests that not only may babies experience pain but they may be more sensitive to it than adults. If we provide pain relief for an older child undergoing a procedure, then we should look at giving pain relief to an infant undergoing a similar procedure.”

Rachel Edwards, one of the parents involved in the study, was motivated to participate after her first son Rhys was born four weeks early and had to go to a special unit where he received more than 10 heel lances a day without any pain medication. Wanting to know more about how babies feel pain, she gave permission for her newborn son Alex to take part in the study.

“Before Alex went in I got to feel all the things he would feel as part of the study including the pencil-like retracting rod,” she recalled. “It wasn’t particularly painful; it was more of a precise feeling of touch.”

There are numerous pain management strategies for infants, and not all carry the risks associated with powerful drugs. For instance, studies have shown that a small amount of a sweet, sucrose-based solution placed in the infant’s mouth is a safe and effective strategy for management of short-term pain. Pain or stress-reducing strategies like those outlined in the Newborn Individualized Developmental Care and Assessment Program are also helping to raise awareness.

In the future, the Oxford researchers hope to identify a neurological pattern of pain-related brain activity in babies’ brains similar to that shown in adults in recent MRI studies.

“This could enable us to test different pain relief treatments and see what would be most effective for this vulnerable population who can’t speak for themselves,” Dr. Slater said.

“This intriguing study brings together developmental neuroscience and cutting-edge neuroimaging to advance our understanding of pain,” added Raliza Stoyanova, Ph.D., science portfolio advisor for Wellcome Trust, the London-based biomedical research charity that funded the research. “The finding that brain networks similar to those found in adults are activated in babies exposed to pain stimuli suggests that babies may feel pain in a similar way. We may need to re-think clinical guidelines for infants undergoing potentially painful procedures.”

 

Saving lives at 18 of the world’s suicide ‘hot spots’

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Since the Golden Gate Bridge was built in San Francisco in 1937, more than 1,600 people have jumped off it and died. The bridge is one of many sites around the world that are considered suicide hot spots because people use them frequently to take their own lives.

A new analysis suggests that several different types of interventions could help reduce the risk of suicide at these hot spots, typically bridges, cliffs or other high places.

Jane Pirkis, a professor at Australia’s University of Melbourne in the Melbourne School of Population and Global Health, and colleagues in Australia and Hong Kong looked at studies on the number of suicides before and after interventions were in place in 18 different hot spots in the United States, Canada, Australia, New Zealand, China and Europe.

The researchers found that installing barriers at bridges and railway platforms was associated with a reduction in suicide risk of 93%, and providing signs with help line numbers at these sites could reduce the risk by 61%.

“These numbers are phenomenal,” said Dr. Eric D. Caine, director of the Injury Control Research Center for Suicide Prevention at the University of Rochester Medical Center. Caine was not involved in the new study, but wrote a commentary about it. Both were published on Wednesday in the journal Lancet.

However, interventions at suicide hot spots will not have a big impact on the overall suicide rate because they are only involved in a small percentage of suicides overall, Caine said. Of the approximately 40,000 people who take their own lives every year in the United States, most use guns (52%), hanging (25%) or poisoning (16%), and only a small number jump from a tall height (2%) or in front of a moving object (1%).

Although it is important to put interventions in place at common suicide locations, “we have got to have a strategy where fewer people come to suicide attempts, (because) once someone is determined to die, it is much harder to intervene,” Cain said. This strategy should be multifaceted and include improving mental health services and helping people who are abused, he added.

The authors of the Lancet article urged interventions at suicide hot spots, “not only to prevent so-called copycat events, but also because of the effect that suicides at these sites have on people who work at them, live near them, or frequent them for other reasons.”

The current analysis suggests that three types of strategies can have big effects: reducing access to the sites, providing information about getting help and making it easier for another person to intervene.

Reducing access

One of the most studied interventions for reducing deaths at suicide hot spots involves reducing access. It was associated with between 62% and 99% fewer suicide deaths in 10 different studies.

One of the studies found that Beachy Head, one of the highest sea cliffs in the United Kingdom, had about 16 suicides a year in the 1980s and 1990s. But in the months after road access was blocked in 2001 — because of concern over an outbreak of foot-and-mouth disease in animals — the number dropped to zero. At the Jacques Cartier Bridge in Montreal, annual suicides decreased from 10 to 2.6 after the construction of a tall fence.

It is not surprising that these physical barriers help reduce suicide deaths, said Steven Vannoy, associate professor of counseling and school psychology at University of Massachusetts Boston. “If people encounter something that slows them down, that makes them have to be conscious of what they’re doing, that may psychologically cause them to not do it,” he said. People want to think the suicide will be easy and effective, he added.

Other suicide hot spots where barriers were linked with fewer suicides were:

• Ellington Bridge in Washington

• Memorial Bridge in Augusta, Maine

• Bloor Street Viaduct in Toronto

• Clifton Suspension Bridge in Bristol, England

• Canton Hospital in Baden, Switzerland

• Muenster Terrace in Bern, Switzerland

• Gateway Bridge in Brisbane, Australia

• Gap Park in Sydney

• Grafton Bridge in Auckland, New Zealand

• Lawyers Head cliff in Dunedin, New Zealand

• The underground railway system in Hong Kong

Families praise suicide barrier approval

Families praise suicide barrier approval 01:02

The Golden Gate Bridge does not currently have any barriers in place, although a plan has been approved to build a steel net 20 feet below where people jump. “There is a good reason to believe it would reduce the number of suicides,” Vannoy said.

Offering help

Several studies have looked at the impact of encouraging people to get help, such as installing signs with numbers for suicide hotlines and crisis telephones in the hotspot area.

At the Mid-Hudson Bridge in upstate New York, there were five suicides per year on average in the years before signs and crisis phones were installed, compared with 2.3 suicides after.

Signs providing numbers for help had similar effects at a car park in southern England where people would go to poison themselves on car exhaust.

However, crisis telephones had the opposite effect on the Skyway Bridge in St. Petersburg, Florida, where 3.7 people per year took their own lives before phones were installed in 1999, compared with 8.2 people after. The authors of the analysis suggest this increase could have been due to a website that promoted suicides using the bridge, which became popular around the same time the phones were added.

Patrolling the area

Some sites have stationed police officers on bridges and cliffs to help intervene in suicide attempts. But studies have only looked at the effects of these efforts in combination with installing fences or crisis phones and not on their own.

In a study in Cheung Chau, an island off Hong Kong, programs that included police patrols as well as phone hotlines were found to reduce the number of suicides from about 8.7 to 1.7 per year. The area is considered a suicide hot spot because people rent holiday apartments where they poison themselves with carbon monoxide.

Having a person intervene could probably be very effective, but somebody would have to be present at all times, Vannoy said. “Just having a witness there can slow somebody down and make them think about what they’re doing,” he said, adding that most people who want to attempt suicide do not want others to see them.

Having someone patrol a suicide hot spot could be a much less expensive strategy, and possibly more cost-effective, than projects like the steel net below the Golden Gate Bridge, Vannoy said.

‘Countless’ Patients Harmed By Wrong or Delayed Diagnoses

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Evidence is incomplete, but still shows most patients will be impacted by the problem at some point in their lives.

Doctor showing digital tablet x-ray to patient

Most people experience at least one diagnostic error during their life, according to a new report investigating wrong or delayed diagnoses.

The Institute of Medicine on Tuesday released a ground-breaking report calling wrong or delayed diagnoses a vast “blind-spot” in U.S. healthcare and blaming them for harming countless patients each year.

The report, called “Improving Diagnosis in Health Care,” asserts that diagnostic errors occur daily in every health care setting nationwide, yet they have never been adequately studied. No one knows how many people suffer from misdiagnoses or delays that affect their care.

Despite the sketchy evidence, the authors conclude that “most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences.”

“This problem is significant and serious [yet] we don’t know for sure how often it occurs, how serious it is or how much it costs,” says Dr. John Ball, of the American College of Physicians, who chaired the committee that carried out the analysis. He called the lack of evidence one of the committee’s most “surprising” and distressing findings.

 Advocates hailed the report for calling attention to a problem that has been neglected for decades despite its importance to doctors and patients alike.

“It’s huge that diagnosis is finally getting the attention it deserves,” says Helen Haskell, co-chair of the patient committee at the Society to Improve Diagnosis in Medicine, who was invited by the committee to review a draft of the report. “There are lots of people who think our failure to tackle this is one reason why patient safety hasn’t progressed farther.

“Improving Diagnosis in Health Care,” is the latest installment in a series which began with “To Err is Human: Building a Safer Health System,” which made national headlines 16 years ago by estimating that 44,000 to 98,000 people die from preventable medical errors each year. Each report in the series has focused on lapses responsible for poor quality health care and how to correct them.

At least 5 percent outpatients are incorrectly diagnosed by their doctors, a new study says.

RELATED

At Least 1 in 20 Americans Misdiagnosed by Their Doctors, Study Finds

Despite the committee’s inability to offer even a rough estimate of the pervasiveness of faulty diagnoses–a limitation likely to disappoint patient advocates and others who were anticipating the committee’s answer to that question–the report does offer some indications of the problem’s seriousness.

Studies show:

  • About 5 percent of adults who seek outpatient care annually suffer a delayed or wrong diagnosis.
  • Postmortem research suggests that diagnostic errors are implicated in one of every 10 patient deaths. Not every death is scrutinized, however, so the findings can’t be generalized to all hospital patients.
  • Chart reviews indicate that diagnostic errors account for up to 17 percent of hospital adverse events.
  • Diagnostic errors are the principle cause of paid malpractice claims and are almost twice as likely to end in a patient’s death than claims for other medical mishaps. They also represent the biggest share of total payments.

Getting the right diagnosis is critical, because it is the starting point for every other health care decision. Sometimes diagnostic errors or delays stem from poor judgment, including “shortcuts that people take,” such as a physician who makes superficial assumptions based on past experience rather than current information, Ball says.

Often diagnostic errors result from poor coordination of care. “Not all errors are individual human errors,” he says. “They occur in a system that leads you into [certain] kinds of errors.” He cited the emergency room, a chaotic setting with a constant stream of patients and information, where doctors, nurses, technicians and laboratory personnel must multi-task amid countless distractions.

One vital check on the accuracy of a diagnosis is following up with the patient, a cycle that promotes better care and reinforces learning, says Dr. Donald Berwick, president emeritus and senior fellow at the Institute of Healthcare Improvement. “The diagnosis is the hypothesis, the treatment is a test. If we don’t know what happened to the patient it’s difficult to improve either our diagnosis or treatment.”

The glut of tests–some ordered by doctors who are practicing defensive medicine to protect against malpractice lawsuits–compounds the problem. “There’s a tremendous reliance on tests,” says Haskell, of the Society to Improve Diagnosis in Medicine. “You have to know to order the right test, and the test has to be interpreted correctly all along the line. It’s a complicated system with a lot of opportunities for error.”

Clumsy health information technology, including electronic medical records, also represents a “barrier to good health care,” Ball says, because information isn’t easily accessible and is often presented in a confusing manner.

Berwick, who also reviewed the report for the institute, cited one crucial omission–the committee decided not to address over-diagnosis, a diagnosis that is made that is not helpful to patients. “They might not define that as an error,” he says, “But I think the task of addressing over-diagnosis is critical.”

Finally, Berwick says, it’s important to factor into any assessment of medical errors the heavy administrative demands placed on doctors. “Physicians today spend so much time filling out forms, seeking approvals and ordering things–you can’t increase work pressure so much without expecting errors to increase.

There is no easy fix, the report concludes. What’s required is a major reassessment of the diagnostic process and a commitment to change. It must begin with a common definition of what constitutes a diagnostic error–and the data to figure out possible remedies and measure progress.

“What I like is that the report emphasizes that teamwork is necessary to have a system that works,” says Haskell. “You have to have coordinated care, patient involvement and the involvement of non-physician personnel.”

Absent a better solution, Haskell says, “you need to do your own research to find out what tests are needed and be sure they’re being done. You need to get the results.”

“Patients bear the financial burden of all this,” she adds. “Patients or their insurers. The medical system profits from it.”

The Indescribable Scent Of Dead Bodies: Researchers Identify Unique Gases Emitted By Decomposing Human Flesh

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Although being able to distinguish the unique smell of decomposing human flesh may not be high up on your to-do list, the ability to tell the smell of a rotting human from that of a rotting animal plays an important role in our ability to find missing bodies following crimes and natural disasters. In a recent study, however, researchers were able to identify specific chemical compounds associated with decomposing humans, which could help develop better ways to search out human cadavers.

If you’ve ever been unlucky enough to catch a whiff of a dead human body, it’s something you’re not likely to have ever forgotten. However, when it comes to describing what exactly you just smelled, things can get tricky. According to a recent study currently published in the online journal PLOS ONE, researchers from the University of Leuven in Belgium are getting closer to identifying that certain je ne sais quoi of rotting human flesh after identifying key gases emitted during the decomposition process.

For the project, analytical chemist Eva Cuypers and her team set aside samples of human tissue in a jar to rot in a closet for several months, Science magazine reported. The researchers would periodically take samples of the air from the jars in order to analyze the various gases released during the decomposing process. Samples of pig, mouse, mole, rabbit, turtle, frog, sturgeon, and bird tissues were also observed as they decomposed.

To the untrained nose,  all dead and rotting organisms smell more or less the same: disgusting. However, on a chemical level different animals give off entirely different odors.Science magazine reported that the scent of decomposing pig flesh is most closely related to that of humans because we have similar microbes in our guts, the same percentage of body fat, and similar hair.

Analysis of the gases collected from the different decomposing specimens revealed a clear chemical and unique chemical byproduct given off by each organism. Over the course of six months, Elien Rosier, one of Cuypers’s graduate students, was able to collect 452 organic compounds given off by the decomposing specimens. However, of these, eight compounds were only found in the flesh of pigs and humans, and five compounds were found to be unique to human flesh. According to Agapios Agapiou, an analytical chemist at the University of Cyprus in Nicosia who was not involved in the study, this is the first time scientists have been able to understand the differences in decomposing human and pig flesh exposed to the exact same conditions.

Although a cadaver may no longer be alive, its decomposing flesh is anything but dead. Instead, it’s filled with an array of bacteria and enzymes that begin to break down the flesh. The bacteria help to break down the dead flesh by eating away at it, and an awful-smelling gas is the byproduct of this process, How Stuff Works reported.

The Belgian Disaster Victim Identification Team asked the Leuven researchers to investigate gases associated with human decomposition in the hopes that identifying these gases would lead to more effective ways of finding lost bodies.

“The mixture of [these] compounds might be used in the future to more specifically train cadaver dogs,” Cuypers explained, as reported by Science. “The next step in our research is to see whether the same compounds are found in buried, full decomposing bodies in the field and to see whether dogs trained on the mixture respond more specific[ally] to human decomposing bodies.”

Along with helping to better train canine, understanding the chemicals involved with human decomposition could also help to develop artificial body sniffers. As reported by the Daily Mail, researchers are currently working on developing “electronic noses” that would theoretically detect the compounds of decomposing bodies in order to help locate victims of natural disasters of murder. Although there are many shortcomings in this still early stage of research, the team believes its recent work is a step in the right direction.

A Radical New Paradigm for TB?

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Correspondence in the July 16th issue ofThe New England Journal of Medicine (NEJM) 1,2 suggests significant progress in the development of 2 drugs to fight extremely, or extensively, drug-resistant tuberculosis (XDR-TB). These scientific advances may be just the tip of the iceberg in an innovative global effort to eradicate all forms of TB—including multidrug-resistant TB (MDR-TB), which is resistant to isoniazid and rifampin, and XDR-TB, which is also resistant to any fluoroquinolone and at least 1 of 3 injectable second-line drugs (capreomycin, kanamycin, and amikacin).3

NEJM Updates and Commentary

The NEJM letters provide updates on linezolid, an agent currently approved in the U.S. for treatment of certain bacterial infections, and delamanid, a drug conditionally approved by the European Medicines Agency for MDR-TB. Following up on their previously published 4-month study results,4 Lee and colleagues reported that at 1 year, 71% (27 of 38) of patients who had linezolid added to their background regimen were cured of XDR-TB infection.4

image

In another letter, Gupta and researchers reported a post-hoc analysis of cases of XDR-TB culled from 3 trials that tested delamanid for MDR-TB. In their analysis, 65% (11 of 17) of patients with delamanid added to their background treatment regimen for 6 months or more were cured.2

What impact will these reports have on the management of XDR-TB?

Commenting on behalf of the World Health Organization (WHO), Karin Weyer, MD, coordinator of WHO’s Global TB Programme Unit for Laboratories, Diagnostics, & Drug Resistance, says, “The paper on linezolid suggests potential in using a lower dose of the drug to reduce its well-described serious adverse effects; however, given the limited data (as acknowledged by the authors), the findings are not sufficient to indicate a change in clinical practice, and more controlled trials are necessary.” She points out that delamanid is one of the drugs that the WHO recommends for MDR-TB, giving the clinician more options to design an effective treatment regimen.

Building a Global Armamentarium

Another expert in this field, C. Robert Horsburgh, Jr., MD, Professor of Epidemiology, Biostatistics, and Infectious Diseases at Boston University, also stresses the need for drugs. He says, however, that, “The advantage for patients with XDR-TB is that it’s unlikely that they would have encountered these drugs before, so resistant isolates are unlikely.”

Dr. Horsburgh adds that Lee and colleagues reported that cases of linezolid resistance developed in patients treated with linezolid.4

Albert A. Rizzo, MD, Senior Medical Advisor, American Lung Association, and Chief, Pulmonary and Critical Care Medicine Section, Christiana Care Health System, in Newark, Delaware, says, “The updates on linezolid and delamanid are encouraging in supporting the efficacy of these drugs when used in combination with WHO-recommended background regimens of medications for treating MDR- and XDR-TB. These 2 drugs have the ability to increase the sputum conversion rate more quickly, which can be an indication of more likely cure. This is particularly important in the MDR and XDR strains.”

But even if large-scale prospective clinical trials support the efficacy of these drugs against XDR-TB, they don’t solve the global problem. The 3 experts cited above referred to the potentially game-changing work of the TB Alliance, an organization charged with creating global solutions to TB drug development.

A Completely New Strategy

Mel Spigelman, MD, President and Chief Executive Officer of the TB Alliance, compared the research described above with the approach of the Alliance: “The work coming out now is excellent science and will lay the groundwork for things down the road. The challenge is, we need treatments for drug-resistant TB that can be translated into dramatic effects around the world. In most parts of the world, current treatment regimens are too expensive, take too long, and require too much sophisticated medical supervision. Adding a drug to the current MDR- or XDR-TB therapy will just make the regimen more expensive, complex, and less feasible in different parts of the world.”

But these very same drugs, and others currently under investigation, can be used in a new way that may radically alter TB treatment.

“One of our Phase 2 clinical trials, Nix-TB,5 uses new drugs in a different way,” Dr. Spigelman says. “The 3-drug regimen we’re testing—linezolid, bedaquiline, and pretomanid—is designed to be administered orally once a day. In the mouse model it cured TB in 3 to 4 months. If it works in man, it could reduce the cost of treatment for drug-resistant TB by 95% or more.”

All TB treatment—for TB, MDR-TB, and XDR-TB—here and in developing countries will shift dramatically if a well-tolerated, simple, short “universal regimen” is developed. “Our goal is to provide a new regimen, like the one above, to which no one is resistant,” says Dr. Spigelman. To lessen the likelihood of resistance to the new regimen, the Alliance will seek to develop a fixed-dose combination.

Problem solved?

Dr. Weyer is very encouraged by the progress so far. “The novel drug regimen being developed by the TB Alliance could be one of the few game-changers in TB treatment, should the trials prove its efficacy and safety, and feasibility is later confirmed in the field.”

But implementation of the universal regimen is at least 10 years off, predicts Dr. Horsburgh. In the meantime, he stresses the importance of susceptibility testing to identify the right regimen, and patient support to ensure compliance with it.

For now, says Dr. Rizzo, “The best advice is to use the most effective agents and have them administered in a correct, compliant manner for the needed duration to achieve cure.”

Published: 08/20/2015

References:

  1. Lee M, Cho SN, Barry CE III, et al. Linezolid for XDR-TB—final study outcomes. N Engl J Med. 2015;373:290-291.
  2. Gupta R, Geiter LJ, Wells CD, et al. Delamanid for extensively drug-resistant tuberculosis. N Engl J Med. 2015;373:291-292
  3. TB Alliance. MDR-TB/XDR-TB.
  4. Lee M, Lee J, Carroll MW, et al. Linezolid for treatment of chronic extensively drug-resistant tuberculosis.N Engl J Med. 2012;367:1508-1518.
  5. TB Alliance. TB Alliance launches “Nix-TB” clinical trial to test new XDR-TB treatment.

Weird Medical Practices: 5 Rituals People Practice Despite Having No Proven Benefits

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Urine
Why would anyone drink their own urine?

Humans have been participating in rituals since the beginning of time. Some (most) of them have been proven not to have any health or other benefits, but we did them anyway, going on faith that they would accomplish what we needed them to. Not all weird rituals have gone the way of bloodletting, though, and some are even thriving today. Take a look at four of the weirdest rituals and therapies that really haven’t been proven to have any health benefits.

Eating The Placenta

PlacentaA biohazard or a snack? bethbernier (pixabay)

The placenta is the first organ that forms after a woman conceives. It connects her to the growing fetus and delivers nutrients, oxygen, and hormones to it while taking away the waste it makes. The only organ in the body that is made, then discarded, the placenta is pretty much useless after a woman gives birth.

Those who support eating the placenta claim it raises a mother’s energy post-birth, and it can improve the quality of her breast milk. They also say it can help with hormone regulation and ward off postpartum depression and insomnia. Women sometimes dehydrate the placenta and have it crushed into powder and sealed into capsules. Some mothers with stronger stomachs cook the placenta like any other meat and add it to stews, chilies, or patties. There is no evidence of anyone eating it raw (think Daenerys Targaryen with the horse heart), but never say never.

The truth is, though, there is very little research to back up these claims. It’s true the placenta has fats and proteins, but those things can be found in a healthy diet. Advocates of placenta-eating like to point out that many animals eat their placentas — but animals do a lot of things us humans don’t. Due to the lack of clinical trials, researchers often take anecdotal evidence to indicate a placebo effect, where women feel benefits of a “treatment” just because they were expecting to.

Drinking Your Own Urine

UrineTo some, urine should be saved instead of going in here. sharyn morrow (CC BY-NC-ND 2.0)

Urotherapy, or drinking one’s own urine, dates back to multiple ancient cultures. In the past, urine was believed to be capable of disinfecting cuts and acting as a treatment for many ailments, including acne, cancer, indigestion, and migraines.

Again, there is no medical evidence to support any of these claims, but urine still has its advocates, who say the liquid can cure everything from the common cold to AIDS. Some claim the medical industry is simply keeping urotherapy a secret because there is little financial profit in it.

Urine is hardly a miracle drink, though, since it can be teeming with bacteria after it exits the body, and experts don’t even recommend drinking it while in a life or death situation. The sodium content of urine is so high it may in fact accelerate dehydration rather than save you.

Detoxification

DetoxDetoxing may feel great, but is it actually de-toxifying you? Mikorad (pixabay)

Sorry, detox people, but there is very little evidence that popular detoxification diets actually eliminate toxins from the body. Typically, a detox diet involves a strict intake of raw fruits and veggies, along with fruit juices and water. Some diets call for additional herbs or supplements to be taken along with the fresh food.

Many people say they feel more energized and refreshed after “detoxing,” which makes sense if the person is eliminating highly processed foods, fats, and sugars. Simply avoiding high-calorie, low nutrition foods, however, can result in the same benefits without the detox diet. The idea that a detoxification can actually get rid of toxins is still up in the air.

Rebirthing Therapy

RebirthPillows and blankets hardly equal a rebirth, and they can be dangerous. amanda tipton (CC BY-NC-ND 2.0)

Rebirthing therapy is a form of breath work therapy used to treat attachment disorder in children, a disorder in which a young child is having a hard time forming relationships with their parents. The therapy is supposed to simulate the womb and the birth process, utilizing blankets and pillows to cover the child. The patient is supposed to push their way out and be “reborn” into a new bond with their parents.

The therapy has never been proven to yield any benefits, and little to no clinical research has been done on any such therapy. Even worse than being useless, though, is that rebirthing therapy can actually be harmful. The tragic case of 10-year-old Candace Newmaker exhibited the dangers of the therapy after the girl was suffocated beneath the weight of blankets, pillows, and several adults sitting on top of them. This resulted in rebirthing therapy being banned in the state of Colorado, and the U.S. House urging every state to ban the practice.

Psychic surgery

Psychic SurgerySurgery to get rid of evil spirits? carjens (pixabay)

Psychic surgery is one form of spiritual healing that has gained popularity all over the world, including the U.S. The “surgery” isn’t really a surgery at all — it’s only the pretense of a practitioner cutting an incision into a patient with their bare hands. They then lead the patient to believe they have removed tissue and spontaneously healed the wound.

Sometimes the surgery does involve a real incision, though, and a practitioner will often hold up foreign objects (glass and metal, for example) and explain to the patient that an evil spirit was responsible for the material’s presence in the body.

Widely regarded as medical fraud by the likes of the Federal Trade Commission and various cancer agencies, psychic therapy (surprise) has no clinical research to back up its usefulness.

Guideline: Apgar Scores Alone Not a Neonatal Diagnostic Tool

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Recommendations also address neonatal resuscitation and cord blood sampling.

Clinicians should not use the Apgar score to predict neonatal outcomes or to diagnose asphyxia, and should use the expanded Apgar score form whenever possible, according to a joint recommendation statement issued by the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG).

The AAP’s Committee on Fetus and Newborn and ACOG’s Committee on Obstetric Practice continued to recommend that Apgar scores not be used to predict neonatal mortality or neurologic outcome, and should not be the sole determinant in a diagnosis of asphyxia. These updated recommendations were published in both Pediatrics andObstetrics & Gynecology.

This was an update to the 2006 recommendation statement. The revision also recommends that clinicians obtain umbilical arterial blood samples from a clamped section of the cord for an infant with an Apgar score of less than 5 after 5 minutes. The expanded Apgar score form is particularly helpful in this case, as it allows clinicians to record time of birth, cord clamping, and initiation of resuscitation. The update also recommends submitting the placenta for future examination.

These recommendations incorporated findings from the 2014 Neonatal Encephalopathy and Neurologic Outcome report, and the 2011 Neonatal Resuscitation Program guidelines.The guidelines state that the Apgar score should not be used to determine the need for resuscitation or which steps are necessary, as any resuscitation must be initiated prior to the 1-minute Apgar score.

The committee also clarified asphyxia as a process, not an endpoint, and emphasized that Apgar score alone is not the sole determinant of asphyxia. They cite many other factors involved in diagnosing an intrapartum hypoxic-ischemic event, including abnormalities in:

  • Umbilical arterial blood gas results
  • Clinical cerebral function
  • Neuroimaging studies
  • Neonatal electroencephalography
  • Placental pathology
  • Hematologic studies
  • Multisystem organ dysfunction
  • Non-reassuring fetal heart rate monitoring patterns

The authors noted that an acute hypoxic-ischemic event is not consistent with an Apgar score of 7 or higher at 5 minutes, a category I (normal) or category II (indeterminate) fetal heart rate tracing and normal umbilical cord arterial blood pH (+/-1 SD).

Examining other neurologic outcomes, the committee cites several population-based studies where an Apgar score of 5 or less at 5 and 10 minutes is associated with an increased risk of cerebral palsy. This risk was as high as 20 to 100 fold compared to infants with an Apgar score of seven to 10 at 5 minutes.

Unchanged from the 2006 edition are recommendations that any Apgar score of 0 beyond 10 minutes of age is “useful” in determining whether continued resuscitation efforts are needed. In addition, an Apgar score of 0-3 at 5 minutes is still considered “a nonspecific sign of illness” and one of the first signs of encephalopathy, but is not a specific indicator for “intrapartum compromise.”

The authors reiterated the need for clinicians to monitor Apgar scores on both an individual and trend level. They cite individual case reports for identifying needs for educational programs and improvement in perinatal care symptoms, and trends in Apgar scores for assessing the impact of quality improvement interventions.

Stroke Rounds: Clamping Methods Equal in CABG?

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Postop stroke risk similar in single-center observation, but the issue remains controversial.

The partial clamping method for on-pump coronary artery bypass grafting (CABG) was not associated with higher risk of stroke as a complication in an observational study, but experts said the data don’t settle the issue.

The 30-day observed postoperative stroke rates came out a similar 1.5% with single aortic clamping and 1.4% with combined partial aortic clamping (17 of 1,107 patients versus 10 of 712 patients, P>0.99), as predicted from the nearly identical preoperative stroke prediction scores in the single center cohort.

Mortality rates at 30 days were likewise “equally low” (1.9% versus 1.8%, respectively,P>0.99), Danny Chu, MD, of the University of Pittsburgh, and colleagues reported online in JAMA Surgery.

“In patients with significantly compromised myocardial function who are undergoing complex cardiac operations, partial aortic clamping may provide a safe alternative,” the group concluded.

The issue has been controversial, they noted, because a small single-institutionrandomized trial showed better cerebral protection with single aortic clamping, whereas “several high-volume, high-performing cardiac surgery centers continued to perform on-pump CABG using the partial aortic clamping technique with relatively low stroke rates.”

The reason for conflicting studies is “not the aortic clamping; it is the patient,” each with her or his unique atherosclerotic burden in the ascending aorta and arch, Michael D. Crittenden, MD, of the VA Health Care System in St. Louis, Mo., argued in an accompanying editorial.

“Aortic manipulation is one of many risk factors for embolic stroke,” he wrote. “Clearly, patients undergoing anaortic surgery are not spared this complication. The study by Chu and colleagues highlights the fact that there are factors beyond aortic manipulation that we have yet to control.”

Timothy Gardner, MD, medical director of Christiana Care Health System’s Center for Heart & Vascular Health in Newark, Del., and a past president of the American Heart Association, wasn’t so equivocal.

From Chu’s findings, “it would be incorrect to assume that partial aortic clamping is safe for all patients,” he told MedPage Today.

“Experienced cardiac surgeons understand the importance of reducing aortic manipulation in a patients with atherosclerotic involvement of the ascending aorta,” he said. “As has been demonstrated in many reports, such patients are best managed with a single aortic clamping for both distal and proximal grafting.

“In the report by Chu et al, the single clamp patients were older and had increased risk factors for stroke compared to the partial clamp patient group. There likely was some selection bias in the surgeons’ decision to use the single clamp technique versus partial clamping.”

The retrospective cohort study included 1,819 patients receiving conventional on-pump, arrested-heart CABG for the first time as an isolated, non-emergent procedure at a single U.S. major academic medical center.

Among those patients seen during the study period from January 1, 2005, to December 31, 2013, the procedure was done with a single aortic clamp for 1,107 and with side-biting partial aortic clamping for 712.

“To validate our findings, a prospective randomized trial designed to assess aortic clamping strategy for performing proximal coronary anastomosis as well as risk of postoperative stroke and distal embolic burden in CABG operations appears justified,” Chu’s group acknowledged.

“In the meantime, let’s hope that surgeons are not mislead by the authors’ unqualified conclusion statement that ‘no significant differences in post-op stroke were identified regardless of aortic clamping method used,'” Gardner cautioned

Watching the Apple Watch

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After Apple, Inc.’s high-profile entry into the marketplace in April 2015, most of us are now aware of “smart watch” technology.

Once the initial hype had dissipated, it seemed that only hard-core techies continued to tweet and blog about it … with one notable exception. Dan Diamond, executive editor of the Advisory Board Company’s “Daily Briefing” newsletter for healthcare executives, has been watching Apple Watch technology even before its official launch — and his observations are very enlightening.

Recent surveys show that more than 50% of consumers are interested in buying wearable technology such as fitness monitors and, like its competitors, the Apple Watch offers health apps:

  • Apple Health provides an easy-to-read dashboard of the wearer’s health and fitness data
  • Apple HealthKit synchronizes 22 health and fitness apps on the watch and, with the wearer’s permission, makes the device accessible to physicians, hospitals, technology developers, and others.

Last month, Apple was reportedly engaged in high-level talks about the possibility of the Cloud-based HealthKit becoming the health data hub for some of the nation’s leading hospitals.

For Diamond, the implications and value proposition for hospitals and physicians are unclear.

Although the technology sounds transformative, he cautions that physicians and hospitals don’t know how to use the data or if it has value to them; centralized data from health trackers (e.g., information on calorie counts and step taken) will not necessarily help physicians and accountable care organizations to manage their highest cost patients.

While Apple’s vision for HealthKit may come as no surprise, its ResearchKit has real potential for what some call “creative destruction” — a process through which something brings about the demise of whatever existed before.

Apple believes that this technology will change the way researchers identify participants for their clinical trials by allowing more than 700 million Apple users (worldwide) to “opt in” to clinical trials via their Apple Watches or iPhones.

In theory, ResearchKit will improve real-time, accurate data collection in clinical trials, and, because of users’ propensity for wearing their devices (or keeping them at arm’s reach) 24/7, Apple’s strategy might succeed.

Perhaps because of Apple’s iconic stature, many well-respected organizations have already been willing to experiment with ResearchKit; for instance:

  • When Apple announced five clinical trials last spring, there was record demand from potential participants — more than 7,000 in 6 hours, according to Sage Bionetworks.
  • Apple collaborated with the University of Rochester, Xuanwu Hospital, and Capital Medical University in a design incorporating ResearchKit in a Parkinson’s disease study.
  • Apple has created apps for: diabetes research in partnership with Massachusetts General Hospital; asthma research in partnership with Mount Sinai Hospital and Weill Cornell Medical College; cardiovascular disease research in partnership with Stanford University and the University of Oxford; and breast cancer in partnership with the Dana-Farber Cancer Institute, UCLA School of Public Health, and Penn Medicine.

Despite these pioneering collaborations, Diamond predicts that this technology will not become the industry standard any time soon for several reasons: HealthKit’s healthcare data model and measures lack sophistication; patients remain skeptical about pharmaceutical industry research; and, importantly, when “consumers” become “human subjects,” Health Insurance Portability and Accountability Act (HIPAA) issues must be addressed by ResearchKit developers.

The bottom line is that we in the healthcare industry should take note as this technology evolves — and watch the Apple Watch.