July 19, 2007, 10:13 PM CT

Coaching for doctor office visits

Asking more questions during a visit to the doctor might help patients get care that is more satisfactory, but a number of patients are not sure where to start.

A new review of 33 studies observed that giving patients question checklists or providing in-office coaching can help them ask more questions of their health care provider and get more information that is useful often extending the length of the consultation as well.

For outcomes like satisfaction, the patients response is likely to cover the whole experience in the clinic coaching and consultation and thus the patients will feel like they got a better deal than usual as they had a nice time with the coach, said lead review author Paul Kinnersley.

The review appears in The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

When interventions took place immediately before a consultation, they resulted in a small but significant increase in the duration of the office visit. Interventions that occurred some time before the consultation had no effect......... Posted by: Emily      Read more         Source

July 19, 2007, 10:05 PM CT

New Avenues For Hiv Treatment, Vaccines

The first genome-wide association study of an infectious disease, conducted by an international group of scientists through the Center for HIV/AIDS Vaccine Immunology (CHAVI), has yielded a new understanding of why some people can suppress virus levels following HIV infection. The clearer picture of host responses to the virus achieved through this examination of genomes could lead to improved HIV therapies and provides new targets for vaccine developers, says Elias A. Zerhouni, M.D., director of the National Institutes of Health (NIH). CHAVI, which is led by Barton Haynes, M.D., of Duke University, Durham, N.C., was established in 2005 by the National Institute of Allergy and Infectious Diseases (NIAID), part of the NIH.

CHAVIs host genetics team, led by David Goldstein, Ph.D., also of Duke University, included researchers from several European countries and Australia who formed a consortium, EuroCHAVI, to perform this study. The researchers identified three gene variants, two of which are associated with an infected persons ability to control HIV viral load and a third that is implicated in disease progression to AIDS. The research is being published by Science on the Science Express Web site on Thursday, July 19.

CHAVI is designed to foster collaborative research to overcome roadblocks that have impeded HIV vaccine development, says NIAID Director Anthony S. Fauci, M.D. The insights into genetic factors influencing host control of HIV revealed by this work exemplify the power of such collective investigations......... Posted by: Emily      Read more         Source

July 17, 2007, 10:40 PM CT

Hospital Stays Can Help Motivate Smokers To Quit

Hospitalized patients make a great captive audience for smoking cessation efforts, as per a new systematic review.

The scientists observed that when smokers become hospital inpatients, regardless of the reason for admission, they are receptive to efforts to help them to quit smoking after discharge and more likely succeed in the long run.

Smokers know that smoking is harmful to a persons health, but a number of of them dont really think that smoking is harmful to their own health until they get sick, said lead author Nancy Rigotti, M.D., director of the Tobacco Research and Treatment Center at Massachusetts General Hospital and associate professor of medicine at Harvard Medical School.

The aim of the systematic review was to evaluate how effective smoking cessation programs are when directed to patients admitted to a hospital.

The review appears in the current issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates research in all aspects of health care. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing trials on a topic.

Smoking cigarettes increases the risks of a number of health problems, such as cancer, heart disease and lung disease and a number of patients with these conditions end up in the hospital. A hospital stay is a good time to get their attention, the reviewers say, when cessation programs might be more successful because they target a teachable moment when illness makes smokers feel vulnerable to the health risks of smoking......... Posted by: Emily      Read more         Source

July 17, 2007, 10:19 PM CT

Measles Vaccinations Need to be Repeated In HIV-Infected Children

HIV-infected children may require repeat measles vaccination for protection, as per new research from the Johns Hopkins Bloomberg School of Public Health and other institutions. The scientists observed that only half of the HIV-infected children who survived without antiretroviral treatment maintained protective antibody levels 27 months after receiving measles vaccine. By comparison, 89 percent of children without HIV maintained their immunity, as did 92 percent of the HIV-infected children who were revaccinated in a mass measles immunization campaign during the 27 months of follow-up. The study results were published online June 19, 2007, by The Journal of Infectious Diseases, and will be included in the August 1, 2007, printed issue of the journal.

"Despite recent progress in measles control, measles remains an important cause of child mortality in sub-Saharan Africa," says William Moss, MD, MPH, lead author of the study and an associate professor in the Bloomberg School of Public Health's Department of Epidemiology. "The measles virus needs only a small proportion of susceptible children to sustain transmission and cause an outbreak. Vaccinated children with HIV could be susceptible to measles because of their waning immunity, impeding measles elimination efforts in regions with high HIV prevalence"......... Posted by: Emily      Read more         Source

July 12, 2007, 10:28 PM CT

How Hiv Interferes With Infected Cell Division

Dr. ric A. Cohen, a researcher at the IRCM (Institut de recherches cliniques de Montral), and his team will publish on Friday, July 13, in PLoS Pathogens a discovery that could lead to the development of a new class of drugs to combat HIV.

Human immunodeficiency virus type 1 (HIV-1) causes AIDS by depleting essential immune cells called CD4+T lymphocytes in infected individuals, resulting in a compromised immune system. At the center of this process is the HIV protein, viral protein R (Vpr), which stops infected CD4+T cells from dividing and as a consequence compromises their immune function. In addition, by arresting cell division, Vpr helps HIV to harness the infected cells resources to enhance viral replication. The way Vpr exerts this effect is by interacting with cellular proteins that control cell division.

Dr. Cohen and his team have identified a novel cellular protein complex targeted by HIV-1 Vpr to stop infected cell division. This protein complex, designated DDB1-CUL4-VprBP, is involved in a process called ubiquitination. Ubiquitination is a mechanism by which a small protein called ubiquitin is conjugated to cellular proteins in order to modulate their biological activity or induce their degradation. The scientists demonstrated that association of Vpr with this ubiquitinating complex, also called an E3 ubiquitin ligase complex, is essential for the defect in cell division induced by Vpr. Further characterization of this protein complex as well as the elucidation of the mechanism by which it affects cell division may open new avenues for therapeutic intervention against HIV......... Posted by: Emily      Read more         Source

July 12, 2007, 10:27 PM CT

Laser used to help fight root canal bacteria

High-tech dental lasers used mainly to prepare cavities for restoration now can help eliminate bacteria in root canals, as per research reported in the recent issue of The Journal of the American Dental Association (JADA).

The study, conducted by scientists in Austria, credits the development of miniaturized, flexible fiber tips for allowing the laser to be used in endodontic (root canal) therapy.

Dr. Ulrich Schoop and a team of scientists in the dental school at the University of Vienna used 60 extracted human teeth with one root each to test the effects of laser irradiation on root canals using an erbium, chromium:yttrium-scandium-gallium-garnet (Er,Cr:YSGG) laser.

Dr. Schoop and his colleagues inoculated the root canals with one of two types of bacteria (Enterococcus faecalis and Escherichia coli) and then irradiated the canals using either a 1- or 1.5-watt power setting.

The team observed that the laser reduced the amount of E. coli at the lower power setting and reduced it to below the detection level at the higher setting. It also was effective in eliminating E. faecalis.

Scientists found, too, that the laser removed the smear layer and debris from the root canal walls and that the temperature rise during irradiation was within safe borders......... Posted by: Emily      Read more         Source

July 12, 2007, 10:21 PM CT

A New Target For Muscular Dystrophy Drug Therapy

Scientists at the University of Pennsylvania School of Medicine report how the gene for utrophin, which codes for a protein very similar to dystrophin, the defective protein in Duchenne muscular dystrophy (DMD), puts the brakes on its own expression in muscle cells, thereby suggesting a new target for therapy. The findings were published online in Molecular Biology of the Cell, in advance of print publication.

The production of utrophin slows in fetal muscles soon after birth, after which dystrophin takes over as the primary muscle-associated protein. How this normal utrophin silencing occurs has been a mystery, until now. If the brakes on utrophin production could be removed by drug intervention, then increased utrophin expression could substitute for dystrophin as a possible treatment for DMD, which affects 1 in 3,500 males.

Utrophin is normally made at the junction where nerves meet muscles, an area called the neuromuscular junction or synapse. In the present study, the Penn team discovered that silencing is applied by a protein called Ets-2 repressor factor (ERF) sitting on a small piece of the utrophin gene called the N-box.

"We demonstrated that ERF significantly reduces or represses the activity of utrophin's N-box in muscle cells of mice," says senior author Tejvir S. Khurana, MD, PhD, Associate Professor of Physiology and Member of the Pennsylvania Muscle Institute. When the N-box was deleted from the utrophin gene, ERF had no effect on silencing the utrophin gene, as measured by an increase in utrophin gene-promoter activity. In another experiment in which ERF was repressed, the scientists found utrophin mRNA production increased......... Posted by: Emily      Read more         Source

July 10, 2007, 5:03 AM CT

Being born in the USA may not be good for Hispanic health

Mexicans-Americans born and raised in the United States are more likely to suffer from conditions such as diabetes, hypertension and high cholesterol than those who emigrate from Mexico, as per a new study from the University of Southern California.

The difference may be due to poor nutrition and less physical activity among native-born Mexican-Americans. Also individuals who leave Mexico for the United States may be fitter than the ones who stay behind.

One possible explanation is that people who immigrate are healthy to begin with and they may also have come here with better health habits, said Eileen Crimmins, lead author of the study and professor of gerontology at USC. The generation born here has adopted American traits such as smoking and eating at fast food restaurants that were not as accessible in more traditional parts of Mexico.

In a comparison of risk factors across ethnic groups, scientists from the USC Davis School of Gerontology and the UCLA School of Medicine observed that U.S. born Mexican-Americans are significantly worse off not just than whites but also Mexican-born immigrants. The only group at greater risk for disease than the U.S.-born Mexican-American community is the black population.

The research appears in the current issue of the American Journal of Public Health and addresses a contradiction found in other studies known as the Hispanic Paradox a claim that Hispanics in the United States are healthier than whites despite being poorer and less educated......... Posted by: Emily      Read more         Source

July 10, 2007, 5:02 AM CT

Depression often untreated in Parkinson's disease patients

While depression appears to be common in early Parkinsons disease (PD), it is often not treated or diagnosed, as per newly released research. A contingent of scientists from across North America observed that just over 27 per cent of PD subjects screened positive for depression, while 40 per cent of subjects depression went untreated.

This study, authored by Bernard Ravina, MD at the University of Rochester and funded by the National Institutes of Health in the USA, is the first to systematically examine the impact of depressive symptoms in early, untreated PD. Prior research has observed that depression, in some form, affects up to 50 per cent of patients with PD and is linked to increased disability and reduced quality of life.

Our results show that depression in PD appears to be under diagnosed, particularly at the early stages of PD. That may be because symptoms of depression, such as fatigue and insomnia, may be attributed to PD rather than as symptoms of depression, said Dr. Richard Camicioli, assistant neurology professor at the University of Alberta and a co-author of the study. As seen in this study, a number of treated patients remained depressed and may require more intensive psychiatric therapy.

Depression was also found to be linked to impairment on daily life activities, such as eating, bathing and dressing......... Posted by: Emily      Read more         Source

Tue, 10 Jul 2007 04:42:19 GMT

Andrew Wakefield, MMR, Autism and the GMC

Like it not, the MMR and Autism debate is once again about to explode into the public arena. Dr Crippen does not like it for, although I cannot fault the wishes of the medical profession and many others to call Andrew Wakefield to account, the process is going to give yet another airing to his unsustainable and discredited views.

The problem with Andrew Wakefield is that he is not mad.

It would much easier if he were. And he is not unqualified. It is easy to lampoon the likes of Patrick Holford, who founded the "Institute for Optimum Nutrition" and then awarded himself the Diploma of the Institute for Optimum Nutrition.

Andrew Wakefield is a qualified doctor, a Fellow of the Royal College of Surgeons and a Fellow of the Royal College of Pathologists.

What did he do wrong?

Along with colleagues who should have known better, he submitted a "scientific" article to the Lancet. The editor of the Lancet, who should have know better, published it. Scientific articles in learned journals such as the Lancet are normally reviewed by experts (peer review) before publication.

Wakefield's article was not properly peer reviewed.

To the layman - and in this case the layman is often a distraught parent desperate to find a reason for their child's autism - the article is plausible.
Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children
A J Wakefield, S H Murch, A Anthony, J Linnell, D M Casson, M Malik, M Berelowitz, A P Dhillon Sounds good, doesn't it? Read it in full here. It describes some complicated science which someone without medical qualifications would find hard to understand. And it contains a little bombshell, all the more powerful for being understated.

The original Watson and Crick article on the structure of DNA concludes with their now famous modest understatement,
"It has not escaped our notice that the specific pairing we have postulated immediately suggests a possible copying mechanism for the genetic material."
Andrew Wakefield slipped in his now infamous "modest understatement."
We have identified a chronic enterocolitis in children that may be related to neuropsychiatric dysfunction. In most cases, onset of symptoms was after measles, mumps, and rubella immunisation.Both these "modest statements" reverberated around the world. One was utterly bogus. Even if it were accepted that the data upon which Wakefield based his paper was correct - and it was not - the conclusions he reached are unsustainable. Irresponsible and unsustainable. The fallacy of the incorrect syllogism. Temporal relationships do not prove causal relationships.

• I ate an apple and the next day it rained.
• I gave my child an immunisation and the next day he grazed his knee.
  
• I gave my child the MMR immunisation and the following month he was diagnosed as autistic.

Trisha Greenhalgh is a well-respected family doctor and academic, who writes regularly in the BMJ. Her particular interest is communication, clarity of expression and scientific honesty. If you read only one article on Wakefield, read this one (in full here)
In conclusion, the Wakefield study was scientifically flawed on numerous counts. I am surprised that neither the editor nor the reviewers spotted these flaws when the paper was submitted. Had they done so, the public would have been saved the confusion and anxiety caused by false credibility conveyed by publication of the study in this prestigious journal.

Professor Trisha Greenhalgh OBE MD FRCP FRCGP
It gets worse.

There is a background suggestive of moral and financial corruption which has been extensively described by Brain Deer, the investigative journalist. Full details here.

It is this background, more than the incorrect conclusions, that has finally brought Andrew Wakefiled in front of the GMC. The GMC does not regard its remit as extending to arbitrating between competing scientific theories generated in the course of medical research.

The charges Andrew Wakefield and his colleagues face are about honesty and include:

• undertook research during the period 1996-98 without proper ethical approval
• failed to conduct the research in accordance with the application submitted to the ethics committee
• failed to treat the children admitted into the study in accordance with the terms of the approval given by the ethics committee.
• permitted a programme of investigations to be carried out on a number of children as part of the research study, some of which were not clinically indicated when the Ethics Committee had been assured that they were all clinically indicated. These investigations included colonoscopies and lumbar punctures. It is alleged that the performance of these investigations was contrary to the clinical interests of the children.
• acted dishonestly and irresponsibly in failing to disclose in the Lancet paper the method by which they recruited patients for inclusion in the research which resulted in a misleading description of the patient population in the Lancet paper.
• allegations that Dr Wakefield was involved in advising solicitors acting for persons alleged to have suffered harm by the administration of the MMR vaccine. It is alleged that Dr Wakefield's conduct in relation to research funds obtained from the Legal Aid Board ("LAB") was dishonest and misleading.
• allegations that Dr Wakefield failed to disclose his involvement in the MMR litigation, his receipt of funding from the LAB and his involvement in a Patent relating to a new vaccine to the Editor of the Lancet which was contrary to his duties as a senior author of the Lancet paper.
• allegations that Dr Wakefield acted unethically and abused his position of trust as a medical practitioner by taking blood from children at a birthday party to use for research purposes without ethics committee approval, in an inappropriate social setting, and whilst offering financial inducement. (see here)
  

The GMC hearing is due to start next week on 16th July. Full details of the hearing and the charges are currently available on the GMC site here.

Andrew Wakefield drew his "conclusions" from a study of 13 children. I prefer a more authoritative paper which studied 27,749 children.
METHODS. We surveyed 27 749 children born from 1987 to 1998 attending 55 schools from the largest Anglophone school board. Children with pervasive developmental disorders were identified by a special needs team. The cumulative exposure by age 2 years to thimerosal was calculated for 1987-1998 birth cohorts. Ethylmercury exposure ranged from medium (100-125 g) from 1987 to 1991 to high (200-225 g) from 1992 to 1995 to nil from 1996 onwards when thimerosal was entirely discontinued. Measles-mumps-rubella coverage for each birth cohort was estimated through surveys of vaccination rates. The immunization schedule included a measles-mumps-rubella single dose at 12 months of age up to 1995, and a second measles-mumps-rubella dose at 18 months of age was added on after 1996.They found no connection between MMR and autism.

They found no connection between mercury and autism.

And this was not a small study of thirteen children, or of a handful of children bribed to give blood samples at a birthday party. It was a study 27, 749 children born over an eleven year period.

The full paper can be read here.

I can understand, but not support, the angry parents who are desperate for something to "blame" for their child's autism. I cannot understand, and I condemn, the sections of the media that continue to give Andrew Wakefield a supportive and sympathetic hearing.

Andrew Wakefield is mobilising his resources (considerable - see Brian Deer here) and his lawyers and will use the GMC hearing as a public forum to air his views. Even if he is struck off the medical register, to many people he will be a martyr.

And once again, I fear, the uptake of MMR will drop off and once again we will start seeing cases of measles and its occasional serious neuro-pathological sequelae.

Measles

Sub-acute sclerosing pan encephalitis

There will be more deaths. Avoidable deaths.

What more can I say?

I could say that I have four teenage children and they have all had the MMR immunisation. Twice.

It would have helped if Tony and Cherie Blair had been able to say the same about young Leo, wouldn't it?

But life is not like that.Labels: Andrew Wakefield, autism, fraud, GMC, MMR, patents Posted by: Dr John Crippen      Read more     Source