Wednesday, February 10, 2016

You can train your body into thinking it’s had medicine | Mosaic

Marette Flies was 11 when her immune system turned against her. A cheerful student from Minneapolis, Minnesota, she had curly brown hair and a pale, moon-shaped face, and she loved playing trumpet in her high-school band. But in 1983, she was diagnosed with lupus, a condition in which the immune system destroys the body's healthy tissues.

It ran rampant, attacking her body on multiple fronts. She was given steroids to suppress her immune system; the drugs made her face swell up, and her hair fell out onto her pillow and into her food. But despite the treatment her condition worsened over the next two years, with inflamed kidneys, seizures and high blood pressure. She suffered frequent headaches and her whole body was in pain.

By 1985, antibodies were attacking a vital clotting factor in Marette's blood, causing her to bleed uncontrollably. It got so bad that her doctors considered giving her a hysterectomy, because they were worried that when her periods started she might bleed to death. She took drugs including barbiturates, antihypertensives, diuretics and steroids but her blood pressure kept rising. Then her heart started to fail, and her doctors reluctantly decided give her Cytoxan, an extremely toxic drug.

Cytoxan is very good at suppressing the immune system. But it causes vomiting, stomach aches, bruising, bleeding, and kidney and liver damage, as well as increased risk of infections and cancer, and at the time its use in humans was experimental. Karen Olness, a psychologist and paediatrician now at Case Western Reserve University in Ohio, was helping Marette to cope with the stress and pain of her condition, and she was concerned that if lupus didn't kill the teenager, this new drug might. Then Marette's mother showed Olness a scientific paper she had seen. It claimed to have slowed lupus in mice – but with just half the usual dose of Cytoxan.

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Tuesday, February 9, 2016

Manulife seeks to trade health data for insurance premium discounts - The Globe and Mail

Manulife Financial Corp. is bringing its fitness trackers and financial incentives to the Canadian market.

The country's largest life insurer has struck an exclusive agreement with wellness program provider Vitality Group to offer savings on life insurance premiums to customers who prove that they are taking steps to improve their health, such as getting vaccinated and going for cancer screenings.

This new type of insurance launched in the United States last spring through Manulife's subsidiary, John Hancock Financial Services, and now its coming north of the border.

Manulife aims to make insurance more fun for customers, with an app that offers encouragement and digital pats on the back, as well as a free wearable fitness tracker for signing up. Manulife is still determining which devices it will offer in Canada, but in the United States it partnered with Fitbit.

"Part of the program is helping [customers] to set goals, and then helping follow them on the goals," said Marianne Harrison, head of Manulife Canada. "Our strategy here in Canada is really around health and wealth, and trying to bring those things together."

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Monday, February 8, 2016

NYTimes: ‘The Good Death,’ ‘When Breath Becomes Air’ and More

These recent weeks have seen the publication of five books about death: one by a historian; two by hospice workers; one by a widow; one by a man who is dying himself. Several of them quote Dylan Thomas's "Do Not Go Gentle Into That Good Night" to advocate resilience, then map the fine line between denial and succumbing. In "Death's Summer Coat," Brandy Schillace complains, "The modern Westerner has lost loss; death as a community event, and mourning as a communal practice, has been steadily killed off." Examining rituals of bereavement across cultures and across time, she suggests that everyone else has been better at the rites of farewell than we are. Our postindustrial disavowal of mortality is described by Simone de Beauvoir, who wrote, "For every man, his death is an accident and, even if he knows it and consents to it, an unjustifiable violation." Schillace, a research associate at the Dittrick Museum of Medical History, points toward the confusion that has emerged in a technological age when brain death, heart death and other definitions becloud our understanding of expiry itself, observing that by current legal definitions, the same person could be alive under American law and dead under British law. We don't know what death means or even what it is.

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Five books explore the way we are shaped by our knowledge of mortality.

Monday, February 1, 2016

DNA Got a Kid Kicked Out of School—And It'll Happen Again | WIRED

A Few weeks into sixth grade, Colman Chadam had to leave school because of his DNA.

The situation, odd as it may sound, played out like this. Colman has genetic markers for cystic fibrosis, and kids with the inherited lung disease can't be near each other because they're vulnerable to contagious infections. Two siblings with cystic fibrosis also attended Colman's middle school in Palo Alto, California in 2012. So Colman was out, even though he didn't actually have the disease, according to a lawsuit that his parents filed against the school district. The allegation? Genetic discrimination.

Yes, genetic discrimination. Get used to those two words together, because they're likely to become a lot more common. With DNA tests now cheap and readily available, the number of people getting tests has gone way up—along with the potential for discrimination based on the results. When Colman's school tried to transfer him based on his genetic status, the lawsuit alleges, the district violated the Americans With Disabilities Act and Colman's First Amendment right to privacy. "This is the test case," says the Chadam's lawyer, Stephen Jaffe.

When Colman was born in 2000, DNA analysis of newborns was still rare. But he had a congenital heart problem that led to extra tests. That, in turn, led doctors to discover that he carried some genetic markers associated with cystic fibrosis. His markers are no guarantee of a disease though, and Colman never developed any cystic fibrosis. Still, his parents disclosed the information when filling out a medical form to enroll Colman in school.

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Wednesday, January 20, 2016

Unequal Lives, Unequal Deaths - The New York Times

In my first year of practice in palliative medicine, I made house calls to patients in South Los Angeles. My patients all lived in neighborhoods that ranked among the city's lowest in both income and life expectancy. In these neighborhoods, people die an average of 10 years earlier than those who live less than 10 miles away. Many of my patients felt that they had barely lived their lives when I showed up, ostensibly to help them "die with dignity."

Death may be humanity's great equalizer, but the inequalities suffered in life – leading to a shorter life expectancy – become inequalities in the experience of dying as well.

When I began my career, I had na├»vely assumed that, if time were short, who wouldn't prefer the familiarity of home and palliative medicine's focus on quality of life to the chaotic mess of the hospital? But I've learned that even when my patients accept hospice services, the proverbial "good death at home" is often out of their reach. Fully experiencing the benefits of home hospice requires resources: involved, dedicated family members. Money to afford caregivers, particularly in the absence of involved family members. A neighborhood whose local pharmacy actually stocks opiate medications for severe pain. Insurance that covers stays in nursing homes so that family members can simply be family members instead of caretakers.

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You Are Stronger Than You (and Your Therapist) Think - The New York Times

I'm a psychiatrist who has spent most of the past 30 years treating patients with moderate to severe mental illness. But I've also administered care for the Massachusetts Department of Mental Health, Harvard Medical School and several insurance companies, and so I'm often asked for advice by colleagues who feel their patients need more help than an insurer is willing to pay for. In addition to offering technical advice, I often become, in essence, the therapists' therapist, at least in terms of their treatment choices. And sometimes those interactions are as intense as therapy itself. 

Recently, one such colleague was desperately worried about a patient whom he had treated weekly for years after a serious suicide attempt. He felt that they had made great, gradual progress, both through medication and talk therapy. Because she was a victim of childhood sexual abuse, however, there was lingering vulnerability. Now her insurer had decided that she did not need more than 12 sessions a year, and this had thrown her into a panic. It appeared to the therapist that all the years of progress were unraveling before his eyes. He felt that weekly sessions were necessary to prevent her from relapsing, as did she, but he couldn't persuade the insurance company, and now his panic level was matching hers.

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Tuesday, January 12, 2016

NYTimes: Illumina Creating Company to Develop Early-Stage Cancer Detection Test

Some people see it as the holy grail in oncology — a simple blood test that can detect any kind of cancer at an early stage, when it is easiest to treat and possibly cure.
Illumina, the world's largest maker of DNA sequencing machines, said on Sunday that it was forming a company to attempt to develop such a test.
The company, called Grail, has raised over $100 million, mostly from Illumina and the venture capital firm Arch Venture Partners, but also from Microsoft's co-founder, Bill Gates, and Jeffrey P. Bezos, the founder and chief executive of Amazon. Grail, which is majority-owned by Illumina, has also assembled a prominent roster of advisers.
"If this pans out, this could be a real game changer," said Dr. José Baselga, the physician in chief at Memorial Sloan Kettering Cancer Center, who will head the company's science advisory board.
But some experts said that developing such a test would be a daunting task. Even Dr. Baselga seemed skeptical that a pan-cancer screening test could be ready by 2019, the goal of Illumina's chief executive, Jay T. Flatley. Screening for particular types of cancer may be easier, Dr. Baselga said.
The approach to be used takes advantage of the fact that DNA from cancerous cells can be found in the blood, albeit in minute amounts. The blood test, using intensive DNA sequencing, would look for patterns of telltale mutations.
Many companies are developing similar tests, known as liquid biopsies, that use a blood sample to replace or supplement a conventional biopsy, in which a sample of the tumor is extracted from the body by needle or surgery. In just the last week, one company, Guardant Health, said it had raised nearly $100 million in its latest funding round while another, Exosome Diagnostics, said it had raised $60 million.
But so far, liquid biopsies are mainly used for patients already known to have cancer. The tests help determine the particular mutations in the tumor to help select the best drugs to use. Or they are used to monitor whether treatment is effective or to check for a recurrence.
Detecting early-stage cancer, although an eventual goal of many liquid biopsy companies, is considered more difficult. Many cells, not just cancerous ones, shed DNA into the bloodstream, and many noncancerous cells have mutations that are also found in tumors.

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Sunday, January 3, 2016

Heart doctors are listening for clues to the future of their stethoscopes - The Washington Post

The stethoscope is having a crossroads moment. Perhaps more than at any time in its two-century history, this ubiquitous tool of the medical profession is at the center of debate over how medicine should be practiced.

In recent years, the sounds it transmits from the heart, lungs, blood vessels and bowels have been digitized, amplified, filtered and recorded. Four months ago, the Food and Drug Administration approved a stethoscope that can faithfully reproduce those sounds on a cellphone app thousands of miles away or send them directly to an electronic medical record.

Algorithms already exist that can analyze the clues picked up by a stethoscope and offer a possible diagnosis.

But whether all this represents the rebirth of diagnostic possibility or the death rattle of an obsolete device is a subject of spirited discussion in cardiology. The widespread use of echocardiograms and the development of pocket-size ultrasound devices are raising questions about why doctors and others continue to sling earphones and rubber tubing around their necks.

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Thursday, December 31, 2015

The Terrible Beauty of Brain Surgery - The New York Times

I arrived in Tirana, Albania, on a Sunday evening in late August, on a flight from Istanbul. The sun had set while the plane was midflight, and as we landed in the dark, images of fading light still filled my mind. The man next to me, a young, red-haired American wearing a straw hat, asked me if I knew how to get into town from the airport. I shook my head, put the book I had been reading into my backpack, got up, lifted my suitcase out of the overhead compartment and stood waiting in the aisle for the door up ahead to open.

That book was the reason I had come. It was called "Do No Harm," and it was written by the British neurosurgeon Henry Marsh. His job is to slice into the brain, the most complex structure we know of in the universe, where everything that makes us human is contained, and the contrast between the extremely sophisticated and the extremely primitive — all of that work with knives, drills and saws — fascinated me deeply. I had sent Marsh an email, asking if I might meet him in London to watch him operate. He wrote a cordial reply saying that he seldom worked there now, but he was sure something could be arranged. In passing, he mentioned that he would be operating in Albania in August and in Nepal in September, and I asked hesitantly whether I could join him in Albania.

Now I was here.

Tense and troubled, I stepped out of the door of the airplane, having no idea what lay ahead. I knew as little about Albania as I did about brain surgery. The air was warm and stagnant, the darkness dense. A bus was waiting with its engine running. Most of the passengers were silent, and the few who chatted with one another spoke a language I didn't know. It struck me that 25 years ago, when this was among the last remaining Communist states in Europe, I would not have been allowed to enter; then, the country was closed to the outside world, almost like North Korea today. Now the immigration officer barely glanced at my passport before stamping it. She dully handed it back to me, and I entered Albania.

In the arrivals hall, a young man dressed in a bright white shirt came over.

"Welcome to Albania, Mr. Knausgaard. My name is Geldon Fejzo. Mr. Marsh and Professor Petrela are waiting for you at the hotel. The car is right outside."

The car was a black Mercedes, with leather seats and air conditioning. It turned out that Fejzo had just completed his medical training as a neurosurgeon. He was 31 and had studied in Florence. He had also worked as an intern for a few months at a London hospital with Mr. Marsh, as he called him, in the manner long preferred by British surgeons.

"What is he like?" I asked.

"Mr. Marsh?"

I nodded.

"He's a fantastic person," Fejzo said.

Marsh was in Tirana to demonstrate a surgical procedure he helped pioneer, called awake craniotomy, that had never been performed in Albania. The procedure is used to remove a kind of brain tumor that looks just like the brain itself. Such tumors are most common in young people, and there is no cure for them. Without surgery, 50 percent of patients die within five years; 80 percent within 10 years. An operation prolongs their lives by 10 to 20 years, sometimes more. In order for the surgeon to be able to distinguish between tumor and healthy brain tissue, the patient is kept awake throughout the operation, and during the procedure the brain is stimulated with an electric probe, so that the surgeon can see if and how the patient reacts. The team in Albania had been preparing for six months and had selected two cases that were particularly well suited to demonstrating the method.

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As Home Births Grow in U.S., a New Study Examines the Risks - The New York Times

With a growing number of American women choosing to give birth at home or in birthing centers, debate is intensifying over an important question: How safe is it to have a baby outside a hospital?

A study published Wednesday in The New England Journal of Medicine provides some of the clearest information on the subject to date.

The study analyzed nearly 80,000 pregnancies in Oregon, and found that when women had planned out-of-hospital deliveries, the probability of the baby dying during the birth process or in the first month after — though slight — was 2.4 times as likely as women who had planned hospital deliveries.

Out-of-hospital births also carried greater risk of neonatal seizures, and increased the chances that newborn babies would need ventilators or mothers would need blood transfusions.

On the other hand, out-of-hospital births were far less likely to involve cesarean sections — 5.3 percent compared with 24.7 percent in a hospital. They also involved fewer interventions to augment labor, and mothers had fewer lacerations.

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