Thursday, June 23, 2016

New Ways to Treat Pain Meet Resistance - The New York Times

A few months ago, Douglas Scott, a property manager in Jacksonville, Fla., was taking large doses of narcotic drugs, or opioids, to deal with the pain of back and spine injuries from two recent car accidents.

The pills helped ease his pain, but they also caused him to withdraw from his wife, his two children and social life.

"Finally, my wife said, 'You do something about this or we're going to have to make some changes around here,'" said Mr. Scott, 43.

Today, Mr. Scott is no longer taking narcotics and feels better. Shortly after his wife's ultimatum, he entered a local clinic where patients are weaned off opioids and spend up to five weeks going through six hours of training each day in alternative pain management techniques such as physical therapy, relaxation exercises and behavior modification.

Mr. Scott's story highlights one patient's success. Yet it also underscores the difficulties that the Obama administration and public health officials face in reducing the widespread use of painkillers like OxyContin and Percocet. The use and abuse of the drugs has led to a national epidemic of overdose deaths, addiction and poor patient outcomes.

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Wednesday, June 22, 2016

Google will help your self-diagnosis with new symptom search | The Verge

If some part of your body itches or burns, you've probably searched for free medical advice on Google. But an overload of results can have you mistaking an allergic reaction for an STD — or vice versa. Either way, it's no fun.

Over the next few days Google is rolling out a feature called symptom search, which is designed to show better results on the Google app for iOS or Android. A search that includes a description like "child with knee pain" will return a list of related conditions.

Typing in simple symptoms like "headache" will show a general description of your problem, options for self-treatment, and suggestions on whether or not you should go to see a doctor. Many search results will show you a condition card, which Google launched last February, and these may or may not include illustrations. Other search results will appear as cards that you can swipe on or drop-down menus that you can tap to see more information.

Google says that about 1 percent of its searches are symptom-related, so it wanted to do a better job of sending people useful results. The company created this list of symptoms by turning to its web results to find health conditions, then compared these with the medical information from doctors that it uses for its Knowledge Graph. Google also got help from experts at Harvard Medical School and Mayo Clinic.

In the future, Google plans on expanding this symptom search from US- and English-only to other countries and languages. The company also hopes to bring this to the desktop browser in the future. course, numerous companies already offer symptom-checking apps, so Google may have a tough time getting some people to switch from long-time habits with WebMD or Symptomate.

Testing Drugs on Mini-Yous, Grown in a Dish - The Atlantic

In a lab in the Netherlands, Jeffrey Beekman is testing drugs on people with cystic fibrosis—sort of. He's not giving the patients themselves any medicine; instead, he's building small replicas of their organs using their own cells. He's creating miniature versions of them in a dish.

Cystic fibrosis, an incurable, life-shortening genetic disorder, is caused by mutations in a single gene called CTFR. These genetic faults lead to unusually thick mucus and other bodily fluids, which clog a patient's airways and pancreas. There's no cure, but a new drug called Kalydeco can help people breathe more easily by rectifying the problems caused by CTFR mutations. When the U.S. Food and Drug Administration approved Kalydeco, in 2012, it was billed as the year's "most important new drug" by Forbes.

But Kalydeco doesn't work for everyone with cystic fibrosis. The disease can be caused by almost 2,000 different mutations in the CTFR gene, which vary considerably in their effects. Some cause mild symptoms in just one organ, others trigger full-blown cystic fibrosis. On its own, Kalydeco can treat people with eight of these mutations, who account for 5 percent of the 85,000-strong patient pool. When given with another drug, Orkambi, it might also help the 45 to 50 percent of patients with the most common mutation, F508del.

Not bad, but that still leaves a lot of people without options, especially if their mutations are very rare. To see if drugs like Kalydeco and other CFTR-modulators can help these underserved patients, doctors would need to run clinical trials. But that's almost impossible, says Beekman, because there are so few of these patients, and they're scattered throughout the world.

His solution was to build organoids—three-dimensional mini-organs that are grown in the lab from stem cells. Over the last 8 years, scientists have built organoids of retinas, stomachs, livers, kidneys, and even brains. These blobs recapitulate many of the complex features of their parent organs, so you can use them to study how those organs form normally, and how that process goes awry in genetic disorders.

The crucial thing about organoids is that they are personalized blobs. They're made from an individual's cells, so they have all the same mutations that person has. They're not just brains and stomachs in a dish, but your brain and your stomach in a dish. And scientists can use them to predict not just how people will cope with a new drug, but how you specifically will respond.

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Monday, June 20, 2016

Drug company-sponsored meals tied to more prescriptions | Fox News

Doctors who received even one free meal from a pharmaceutical salesperson were more likely than others to prescribe the drug being promoted, even when a generic equivalent was available, according to a new study.

Each year in the U.S., $73 billion is spent on brand name drugs for which there is an equivalent generic available, and patients pay for $24 billion of that amount themselves, said senior author Dr. R. Adams Dudley of the University of California, San Francisco.

"That's an awful lot of money," Dudley told Reuters Health by phone.

The brand name drugs and the generics are "so similar that there's no benefit," from using the brand name versions, he said.

Dudley's team analyzed industry payment data from late 2013 and prescribing data for that year from doctors treating Medicare patients with common drugs for heart problems or depression.

For each class of drug, the researchers chose the most prescribed brand name. For the heart drugs, they chose Crestor (known generically as rosuvastatin) to represent the statins, Bystolic (nebivolol) for the beta-blockers, and Benicar (olmesartan) for angiotensin-converting enzyme inhibitors, or ACE inhibitors. They chose Pristiq (desvenlafaxine) to represent antidepressants known as selective serotonin and serotonin-norepinephrine reuptake inhibitors (SNRIs).

National organizations in the U.S. and U.K. have deemed these brand-name drugs to be no better than their generic forms, Dudley said.

Almost 280,000 doctors received a total of more than 60,000 payments associated with the four target drugs. The vast majority of the payments - 95 percent – were in the form of sponsored meals, on average less than $20 each.

Almost 9 percent of statin prescriptions were rosuvastatin. The other drugs in the study were prescribed less often.

But doctors who received even one sponsored meal from one of the pharmaceutical companies were more likely to prescribe the target drug over a generic alternative, compared to doctors who did not receive sponsored meals. As the number of meals and meal value increased, relative prescribing rates also increased, according to a report in JAMA Internal Medicine.

"Payments for food and beverages are by the far the most frequent type of industry payments to physicians in the United States, totaling about $225 million in 2014, the most recent year for which data are available," said Dr. Robert Steinbrook, an editor at JAMA Internal Medicine and a professor at Yale University School of Medicine.

"Recent research, including the new study being published in JAMA Internal Medicine, has convincingly shown an association between industry payments to physicians and the prescribing of brand-name drugs," Steinbrook said by email.

A 30 day supply of rosuvastatin costs about $250, while a generic drug in the same class may cost $150 or less.

"You should ask your doctor, is there a generic that's just as good whenever you start a new medicine," Dudley said.

It's not clear from this study whether receiving meals caused doctors to change their prescribing patterns, but "humans are very responsive to gifts," he said. "Normal human behavior is reciprocity."

Often a pharmaceutical salesperson will give a doctor a presentation about a new or existing drug and offer to do so over a free lunch, or snacks, and doctors are more likely to listen to their pitch if they can eat lunch at the same time, Dudley said. The salesperson then focus on the positive aspects of the drug they promote, rather than talking about how it has no benefit over generic.

This is sometimes a doctor's only means of learning about new pharmaceutical developments, at least in the U.S., Dudley said.

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Google plays doctor by identifying your medical symptoms - CNET

You can now ask Google to help diagnose what ails you.

Starting Monday, Google's mobile site as well as its iOS and Android apps will introduce a feature that aims to track down information on medical symptoms. Instead of having to search for a condition, you can search for a certain symptom, such as "my stomach hurts."

In response, Google provides an overview of potential conditions, possible treatments, directions on how to get more information online and which type of doctor may be able to help.

When you search for medical ailments, Google typically points you to specialized sites such as WebMD, the Mayo Clinic and Medline Plus. But you sometimes have to cull through pages and pages of information to get what you seek. Finding and viewing all the information in one single place can simplify your search.

To build the new feature, Google put together a list of symptoms found in search results, everything from "headache on one side" to "bruise around eye" to "lower back pain." Google then checked those symptoms against medical information gathered from doctors for its Knowledge Graph, an advanced feature that tries to deliver and display a more comprehensive collection of data.

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Birth Control via App Finds Footing Under Political Radar - The New York Times

A quiet shift is taking place in how women obtain birth control. A growing assortment of new apps and websites now make it possible to get prescription contraceptives without going to the doctor.

The development has potential to be more than just a convenience for women already on birth control. Public health experts hope it will encourage more to start, or restart, using contraception and help reduce the country's stubbornly high rate of unintended pregnancies, as well as the rate of abortions.

And as apps and websites, rather than legislative proposals or taxpayer-funded programs, the new services have so far sprung up beneath the political radar and grown through word of mouth, with little of the furor that has come to be expected in issues involving reproductive health.

At least six digital ventures, by private companies and nonprofits, including Planned Parenthood, now provide prescriptions written by clinicians after women answer questions about their health online or by video. All prescribe birth control pills, and some prescribe patches, rings and morning-after pills. Some ship contraceptives directly to women's doors.

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Thursday, June 16, 2016

A Call for Reform | America Magazine

It may be difficult to believe a profession that commands the salary and social status of U.S. physicians is in crisis, but there is widespread and growing discontent within this guild. While serious reform is afoot for the health care system writ large, the clinicians at its center (or at its top) are receiving scant attention.

In The Finest Traditions of My Calling, Abraham Nussbaum offers a plea to see that true reform of the health care system will be possible only if we also seek a renewal of the physician's practice. With compelling narratives from his own experience as a psychiatrist, Nussbaum's entreaty is easy to believe.

The author's central argument rests on the premise that none of the innovations currently being discussed can truly transform medicine. We tinker at the edges with value-based payment reform, electronic health records and population health. We obsess over quality improvement measures and evidence-based practice. We invest in programs designed to bring the humanities back into education, to wed the art with the science of medical practice.

The author suggests, "The advances in knowledge in twentieth-century medicine began…when physicians began to see like scientists. And I suspect that medicine will advance once more only when physicians change their self-perception again." The sine qua non for us to realize medicine's future is this new vision—or, perhaps more correctly, it is an old vision, renewed.

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Survey shows lots of people save leftover painkillers - Futurity

More than half of patients who get a prescription for opioid painkillers have leftover pills and keep them to use later, a practice that could potentially exacerbate the United States' epidemic of painkiller addiction and overdoses.

Researchers reporting in JAMA Internal Medicine also found that nearly half of those surveyed reported receiving no information on how to safely store their medications to keep them from children who could accidentally ingest them or from someone looking to get high.

One in five respondents said they had shared their medication with another person, many saying they gave them to someone with pain. Nearly 14 percent said they were likely to share their prescription painkillers with a family member in the future and nearly 8 percent said they would share with a close friend.

"The fact that people are sharing their leftover prescription painkillers at such high rates is a big concern," says Colleen L. Barry, who directs Johns Hopkins University's Center for Mental Health and Addiction Policy Research. "It's fine to give a friend a Tylenol if they're having pain, but it's not fine to give your OxyContin to someone without a prescription."

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NYTimes: The Parasite Underground

When Vik was in his late 20s, blood started appearing in his stool. He found himself rushing to the bathroom as many as nine times a day, and he quit his job at a software company. He received a diagnosis of severe ulcerative colitis, an inflammatory condition of the colon. Steroids, which suppress inflammation, didn't work for him. Sulfasalazine suppositories offered only the slightest relief. A year and a half after his diagnosis, Vik's gastroenterologist warned him that because his disease was poorly controlled, he risked developing a condition called toxic megacolon: His inflamed intestines might rupture, leading to blood infection, septic shock or death.

The doctor recommended infusions of cyclosporine, a powerful immune-suppressant drug. Vik looked it up and learned that the drug, often given to transplant recipients, in rare instances can increase the risk of fatal infection and certain cancers. And if cyclosporine didn't work, the next intervention would probably be the surgical removal of his colon. Vik might have to wear a colostomy bag for the rest of his life.

"I had a feeling there had to be a better way," he told me recently. (Worried about being stigmatized, Vik asked that I identify him only by his first name.) He began researching ulcerative colitis and discovered that the prevalence of inflammatory bowel disease — an umbrella term that includes both ulcerative colitis and Crohn's disease — had increased markedly in the United States over the 20th century. Yet the disease was less common in the developing world. He learned that exposure to dirt and unsanitary conditions early in life seemed to protect against these and other inflammatory diseases later. And then he encountered an explanation for the correlations in the research of a scientist named Joel Weinstock.

Weinstock, a gastroenterologist now at Tufts University, thought that parasites were to blame. But it wasn't their presence in the human digestive system that was causing the rise; it was their absence. To survive for years in another animal, parasitic worms, known as helminths, counter their hosts' defenses. Because an out-of-control immune response against native bacteria was thought to drive inflammatory bowel disease, Weinstock's insight was that parasites' ability to disarm the immune system might prevent the disorder. The broader implication was that the disappearance of parasites — largely eradicated from American life in the early 20th century through improvements in sanitation — might have left our immune systems unbalanced, increasing our vulnerability to all types of inflammatory disorders.

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Wednesday, June 15, 2016

Listening for What Matters: Avoiding Contextual Errors in Health Care - Saul J. Weiner, Alan Schwartz

Our book, Listening for What Matters: Avoiding Contextual Errors in Health Care, published January 2016, is now available from Oxford University Press USA.

We argue that physicians are not all prepared to understand patients' individual life contexts and tailor their medical care to the patient. This problem is real, pervasive, costly, and not addressed by the American health care system or process of medical education. Using the results of hundreds of medical visits in which actors and real patients wore hidden recorders, the book give examples of crucial patient context that physicians failed to appreciate and the medical errors that can result from this failure. It tells the stories of patients whose care was compromised by these failures, and the research that revealed the magnitude of the problem. It explains how these errors can be minimized through changes in how doctors are trained, changes in how medicine is practiced and paid for, and ways for patients to assert their individual circumstances during visits.

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