Thursday, July 14, 2011

Medical 2.0 Pills - Ramblings of a Geek on Medicine, Genetics and Web Tools

Medical 2.0 Pills is a free microblogging project, aiming to be a quick reference tool and friendly resource for readers involved in Medicine and online medical geeks in general.

Medical 2.0 Pills features debates on Medicine, essays on Medical Genetics, tips and links to online web 2.0 / medicine 2.0 resources, all in an brief and essential style.

Medical 2.0 Pills is indeed enthusiasticaly "social web" oriented.

The author is currently a med student, geneticist wannabe and - as you might have already assumed - a web 2.0 geek. He is a great supporter of prevention of disease through a healthy and physically active lifestyle (he keeps tracks of his efforts on dailymile).

Doctor and Patient: When Hospital Overcrowding Becomes Personal -

Early in my residency, I realized that like Pavlov's Russian dogs of yore, the other surgeons-in-training and I had developed a conditioned response to our electronic pagers. Our blood would rush and our breath disappear at the sight of one five-digit extension on our beeper's screen.

The emergency room was calling.

It wasn't that we disliked the E.R. Some of our most memorable training experiences occurred there. It was just the sheer crowding of that area of the hospital that made our stomachs drop.

Day and night, the hallways of the E.R. were lined with gurneys, sometimes parked two rows deep. Patients were forced to wait, or "board," on those flimsy narrow stretchers until a bed became free at the "Inn," as the E.R. staff referred to the rest of hospital.

Stuck for hours and sometimes entire days, these patients were surrounded by the groans, cries and hacking coughs of others who waited with them. Doctors and nurses did what they could, pinning curtains around two stretchers to create makeshift semiprivate rooms and dimming the lights to bring some sense of calm to the chaos. But there were always more new patients, and the "boarders" would be left to continue their wait, calling out to whoever approached to ask for water, a bedpan or an extra blanket to keep warm in the chilly corridors.

None of my colleagues were surprised when we heard one day that a patient had died in those halls waiting for a bed. "I'm not sure there's much more we can do about this overcrowding," an E.R. nurse later confided to me. "It's not like we can turn people away; that's against the law."

Since 1986, when Congress passed a bill that made emergency care a legal right, emergency rooms have served as the safety net of the American health care system. But providing such care has become increasingly difficult in recent years. More and more hospitals are being forced to close their emergency departments, a major source of lost revenue, even as the demand for them continues to rise.

Once seen primarily as a problem of urban medical centers that affected only the poor and medically underserved, emergency room closings and overcrowding are increasingly viewed in a different light. More and more experts now believe that the current crisis in emergency care is a canary in the health care coal mine, a warning of more vexing challenges ahead for medicine in general.

And those challenges have the potential to affect every single one of us personally, patient and doctor.

The far-reaching implications were made painfully clear last month in The New England Journal of Medicine. In an eloquent and moving essay, Dr. John Maa, an assistant professor of surgery at the University of California, San Francisco, and a national leader in improving emergency care, describes the all-too-familiar story of a 69-year-old woman who is admitted to the E.R. for a procedure to correct an irregular heartbeat. Her operation is delayed because she has to board for a full day while waiting for a real bed. During the delay, she suffers a major stroke and dies.

The woman, we learn, was the author's mother.

"Emergency room overcrowding and boarding are formidable challenges that even I, as a surgeon dedicated to emergency care, couldn't address for my mother," Dr. Maa said recently. "What about other patients who don't have a physician as a family member?"

The major challenge for any patient in the emergency room is a reimbursement system that offers little incentive to decrease crowding or minimize boarding. Hospitals prefer patients who come in electively for scheduled procedures, at least from a financial perspective. For one thing, they are far more likely to be well insured than those admitted through the emergency room. By boarding E.R. patients in crowded halls, hospitals can offer the required emergency care for all while minimizing the effect on their bottom lines.

"It becomes a question of who can keep our hospital afloat," said Dr. Renee Y. Hsia, an assistant professor of emergency medicine at the University of California, San Francisco, and an author of two recent major studies on theemergency care crisis. "Being an emergency doesn't necessarily move you up to the head of the line."

In the last few years, several initiatives have attempted to address the overcrowding and boarding issues. In England, a new law limits the length of emergency room visits to four hours. Some American hospitals are reserving beds for emergency admissions and "smoothing admissions," distributing elective admissions more evenly throughout the week rather than clustering them on Monday mornings. Dr. Maa has led a "surgical hospitalist" initiative in his hospital that has now spread to hundreds of other hospitals across the country; it ensures that emergency rooms have a dedicated surgeon who will see patients within 30 minutes of arrival to speed their admission, discharge or follow-up care.

As promising as these efforts are, they have also revealed one thing: Truly effective changes won't occur until we have addressed the lopsided repercussions of a system that allocates care based on insurance coverage rather than clinical status. "In emergency care, in order to be efficient, you have to be equitable," Dr. Hsia said. "But as long as elective admissions take priority over emergency ones, then we will see the kinds of consequences that Dr. Maa's mother suffered."

Those consequences, as Dr. Maa showed us, can be deadly. And they can happen to anyone.

Empowered Patient - The Wise Patient's Guide to Being an Empowered Patient

Patients find more and more that their healthcare is being compromised. Patient safety issuesmoney issues, lack of time andcommunication with their doctors... These days, wise patients are empowered patients, learning everything they can about the healthcare system, the obstacles to good care, and the steps they can take to get the best care possible.

If you are over the age of 45, you'll remember Dr. Marcus Welby. He was the skilled and kindly TV doctor who was able to solve most medical problems within the one hour he appeared each week on the small screen.

In those days, many of us thought our family doctors and general practitioners were just like Marcus Welby. They were mostly men, paternalistic and kindly, they seemed to know everything there was to know about taking care of us, they smiled at us when we arrived, they took their time and answered our questions, and most of us got well.

Times Have Changed

There are few Marcus Welbys practicing medicine today. The world of medicine has transitioned to a system that takes control away from both patients and their doctors, giving rise to a new paradigm that requires patients to take more responsibility for their medical care than in the past.

The move toward patient empowerment in America seems to have begun with the Civil Rights movement in the 1970s. It was a slow beginning, until 1999 when the Institute of Medicine, an agency of the US government, issued a report called To Err is Human which reported the deaths of between 44,000 and 98,000 Americans each year due to medical errors. Thus the flames of patient empowerment were fueled, and the movement began to grow.

Patient Empowerment Defined

Patient empowerment has a handful of definitions. Most focus on the concept of the patienttaking an active role in his own disease management, and supporting that participation by learning all he can about his disease or condition and treatment options.

Until the past few years, the thought that a patient would participate so fully was unheard of. Today, many patients realize that this level of participation is vital to maintaining health in the face of medical problems or challenges.

As an empowered patient, you'll need to:

  • Take responsibility. Realizing that you know your body better than anyone else, you will refer to all the resources at your disposal -- from people to the printed word -- and you will use that knowledge to help make decisions about your treatment that are your decisions to make.

  • Set goals. Understanding that the human body does not always react the way we expect it to; therefore, it's best to set a treatment goal and work toward that goal. In some cases a patient can have a goal to heal, another may simply want to manage a disease or condition, or another may need to learn to cope with a new medical problem.

  • Collaborate with others. You'll be an active participant on your own healthcare team, including providers, support personnel, payors, even other patients, knowing that the collaboration helps you in the decision-making aspects of your diagnosis and treatment processes.

  • Gather evidence. Including resources that range from observation, to recording symptoms and family histories, to participating in medical tests, to discussions with providers and other patients, to using the Internet and libraries for researching relevant diseases, conditions and treatments.

  • Be a smart healthcare consumer. Sometimes the challenges a patient faces are related more to customer service and costs of service than they are to the health aspects of care. Understanding health insurance choices or learning when to walk away from a doctor's practice when necessary, are examples of these kinds of choices.

  • Stay safe in the healthcare environment. We often read about major medical errors, but millions of "smaller" mistakes take place every day. Administration of the wrong drugs,acquiring infections in hospitals, even surgeries gone bad -- these are all examples of the safety problems an empowered patient should be aware of.

  • Understand and support the tenets of patient advocacy. In the bigger picture, you can take advantage of those who have learned about your medical problems before you, and you can help patients who come after you find better medical outcomes. Advocacy runs the gamut from government and not-for profit organizations, to individual navigators that help patients transition through the steps of their diagnosis and care.

  • Comply with decisions. Since you will have collaborated with knowledgeable members of your healthcare team to arrive at decisions, you will feel confident in the compliance aspects of your care.

The Empowerment Tipping Point

With more than 30 years of history, patient empowerment is approaching its tipping point. More and more, patients are realizing they can improve their medical outcomes by taking responsibility for their own healthcare decisions in partnership with their providers, and participating fully in the process.

Is the Internet replacing our own memory? - Blogs

Can't remember the name of the movie you saw last year starring Emily Deschanel's sister? Or that recipe you used for chicken salad last week?

With an Internet connection and a few keystrokes, you can probably figure out the answer in a matter of minutes, tops. But the flip side, suggests new research in the journal Science, is that when you rely on having information stored somewhere, you may be less likely to remember it yourself.

"We are becoming symbiotic with our computer tools, growing into interconnected systems that remember less by knowing information than by knowing where information can be found," the study authors write.

But before you freak out about machines doing all your remembering for you, consider that people have always relied on each other for retrieving information, even before computers.

In fact, in any group of two or more people who know each other, there develops what's called transactive memory systems. That means that you use other people as external memory, because they have specific knowledge and expertise that you don't.

"The internet, when you think about it, is people putting content online. And so what it's doing is, it's allowing us to have access to much more external memory. Our network of people is just vastly expanded.," said Betsy Sparrow, assistant professor of psychology at Columbia University and lead author of the study.

In one of Sparrow's experiments, participants read and typed trivia statements that could be found online, such as "An ostrich's eye is bigger than its brain." Participants were told that the statements would be saved to different folders with generic names such as "Facts, etc." They then had to write down as many of the statements as they remembered and were asked to name the folder in which the information had been saved.

Remarkably, people were much better able to recall the folder names of the trivia statements than the trivia itself. In other words, people remembered the "where" better than the "what."

As with people accustomed to looking up their questions on resources such as Wikipedia and Google, participants may have expected information to remain available indefinitely, and so the source of the information stuck with them better than the trivia statements themselves, the study authors said.

Another experiment showed that people seem to remember information better if they believe it won't be accessible later, and more easily forget items that they believe will always be available.

"I thought that telling people to try to remember it, even though it would be accessible, would do something. It did absolutely nothing," Sparrow said.

But Sparrow isn't worried that relying on external memory systems like the Internet is going to cause our brains to atrophy. There might be things that we used to know and forget, but we'll still hang on to what's useful on a daily basis, she said.

"The stuff that we're experts in, that we're the source for other people, is stuff I think we'll always remember, regardless of whether it's online or not," she said.

More Men Suffer From Eating Disorders - Health News - redOrbit

Of the approximately 1.6 million people in Britain affected by an eating disorder, up to 20 percent of those are male, according to British eating disorders charity Beat. British health service (NHS) figures show a 66 percent rise in hospital admissions for men in England affected by some form of eating disorder over the last 10 years, Reuters is reporting.

Exact figures are difficult to pin down due as many men are reluctant to seek treatment for an eating disorder and a failure to diagnose the illnesses in males.

Beat told Reuters in via email: “The 66 percent increase in hospitalization of men in England with eating disorders is the tip of the iceberg.”

“There are many others who find it difficult to acknowledge that they have the illness or to seek help,” The charity said.

“That, coupled with the fact that not all GPs (General Practitioners) recognize the symptoms in males shows that there are still many people unable to access the treatment they so desperately need.”

The Royal College of General Practitioners says it wants doctors to be more aware of the problem because it is usually seen as a female issue, BBC News reports. “If doctors see a young man who is thin they are more likely to think that he is depressed,” a spokesperson said.

Doctor Claire Gerada says that the rise in male eating disorders is because image has become more of an issue. “Men are much more aware of their bodies, they are much more into dieting and how they look,” she said. She is also concerned that these issues can develop for young men while they are away at college.

The increasing numbers challenge the commonly held assumption that illnesses like anorexia and bulimia only affect women. Cultural pressure to have an ideal body is among the many factors that can trigger eating disorders and UK charities are keen to stress that this body dissatisfaction is not confined to females.

“Exercise is a major factor with eating disorders in men who can become obsessed with exercising every day. Males are under similar pressures to women nowadays to achieve that ‘perfect shape’."

Ben Porter, now 20, suffered with anorexia and bulimia since the age of 14. “I had the usual anxieties about body image,” he said. “I just felt very inadequate about the way that I looked and felt I wasn’t fitting in at school,” he told BBC News.

When he finally went to his doctor, Porter claims he felt they were only concerned with the physical health issues rather than the psychological aspect of his disease.

Ben, who is 5’ 10”, explains how things became serious when he began losing weight drastically, “I fell in to a cycle that continued until it became unbearable for everybody.

“I didn’t realize what I was doing to myself and was abusive to my body at the time. The point was to look good and pursue a perfect image but I was doing the opposite.”

Ben was put on an NHS waiting list but when his situation became desperate, he went for private treatment. He is now showing signs of improvement and has reached one of his targets, which is to eat fries for the first time in five years.

Ben says he would like schools to address the issue and for them to teach body confidence to boys as well as girls. “Male anorexia and male eating disorders are a severe problem and it needs to be addressed as not just being a female disorder but something that can affect anybody,” he said.

Understanding Male Eating Disorders - Kenneth L. Weiner, MD

In an article in this month's Marie Claire magazine, Dr. Ovidio Bermudez, a colleague of mine at Eating Recovery Center and a nationally recognized eating disorders expert, noted the heightened prevalence of eating disorders in non-traditional demographic groups. He explained that the health care community has moved away from thinking of eating disorders as a "Caucasian, upper-middle-class, 'princess' disease" toward recognizing these illnesses as an "everybody's disease."

Underscoring this fact is the rising incidence of eating disorders among the male demographic, challenging the traditional conception of eating disorders as a woman's illness. In recent years, data point to the increasing number of men and boys presenting with anorexia nervosa, bulimia nervosa and related food and body image disorders. In fact, research suggests that male eating disorders now account for at least 10 percent of all cases. Interestingly, despite significant biological, psychological and sociological differences between men and women, the etiology of eating disorders remains fairly constant between the two genders.

From a biological standpoint, anorexia and bulimia are equally inheritable in men and women, with approximately 40 to 60 percent of the risk of these disorders resulting from an individual's underlying genetic makeup. Anorexia, in particular, has been found to be as inheritable as schizophrenia or bipolar disorder. Because of the inheritability of eating disorders, males that begin a diet or exercise regimen often find themselves on a slippery slope that will almost always activate the latent genetic predisposition that sets them up to have an eating disorder.

Like in their female counterparts, eating disorders in men and boys are often supported by psychological and sociological pressures, such as traditional gender roles and socially accepted ideals of masculinity. Just as media messages targeted to women and girls promote unrealistic ideals of beauty and tips for achieving the coveted thin physique, males are bombarded with media messages about masculine ideals of strength and six-pack abs. The pursuit of these elusive ideals, or the recognition that perfection eludes them, can often result in a feeling of isolation from which eating disorders can often emerge.

Regardless of gender, early intervention in eating disorders is incredibly helpful in achieving lasting recovery. While these aren't addictive disorders, they're compulsive disorders, meaning if an eating disorder has enough time to embed itself in one's identity and lifestyle, it becomes even more difficult to interrupt eating disorders behaviors and treat successfully. When seeking male eating disorders treatment, it's important to seek recovery resources with experience in addressing this fundamentally underserved eating disordered population and an understanding of their unique recovery challenges.

Wednesday, July 13, 2011

An Eye-Opening Adventure in Socialized Medicine | NeuroTribes

I woke up in a rented room in London in the middle of the night, feeling like my eyes had been packed with hot sand and the lids were somehow glued together. When I pried them apart, the whites of my eyes were an angry crimson.

Maybe it was nothing. I'd been told that the pollen counts in the UK this summer are sky high. A raging heat wave in a city that doesn't really do air-conditioning (like my gloriously fogbound town of San Francisco) didn't seem to be helping. But when I squinted in the bathroom mirror, I saw a greenish-white discharge collecting around my tear ducts. This looked like more than a bad case of hay fever.

Then I remembered that one of the cognitive psychologists I'd come to London to interview mentioned that she'd recently had a bad eye infection. I Googled "conjunctivitis." It dawned on me that the bottle of water I drank in her office may have been a mixed blessing.

But what to do? I was far from home with lots of work to do and no idea how to see a doctor locally. Thankfully, I didn't have any appointments for a couple of days, and have health insurance from Kaiser-Permanente through my spouse's employer. But I knew that getting reimbursed for treatment by a doctor outside the Kaiser network can be complex; what about an out-of-country doctor?

When I dialed the 800 number on my Kaiser card to find out what to do, an automated voice from AT&T informed me that I would be billed at the standard international calling rate of $1 a minute. After navigating a maze of call-center prompts, I sat on hold for 15 minutes.

The first Kaiser rep who took my call fired off a barrage of questions. Was I experiencing "blind spots, double vision, floaters, hallucinations, or any other problems" with my vision? Yes — the goopy discharge from my tear ducts was making it hard to see, and I said so. But that turned out to be the wrong answer. The Kaiser rep simply repeated her question in a more brittle tone of voice and added, "Just answer yes or no."

Yes, I was having problem with my vision, but not "double vision, floaters, or hallucinations." Judging by the structure of the question, I suspected that it was designed to fish for a different sort of problem than the one I had, such as evidence of entopic phenomena that might indicate something awry inside the eyeball, or even in the brain. I didn't want to end up shunted onto the wrong track in the voicemail maze. "Floaters, hallucinations, and double-vision, no," I explained, "but problems with my vision yes, because the discharge from my tear ducts…"

"Sir," she cut me off sternly. "These are yes or no questions. Answer either yes or no or I will not be able to help you." I furiously tried to calculate which falsely binary oversimplifications were the right ones.

More ...

The Good Short Life With A.L.S. -

I HAVE wonderful friends. In this last year, one took me to Istanbul. One gave me a box of hand-crafted chocolates. Fifteen of them held two rousing, pre-posthumous wakes for me. Several wrote large checks. Two sent me a boxed set of all the Bach sacred cantatas. And one, from Texas, put a hand on my thinning shoulder, and appeared to study the ground where we were standing. He had flown in to see me.

"We need to go buy you a pistol, don't we?" he asked quietly. He meant to shoot myself with.

"Yes, Sweet Thing," I said, with a smile. "We do."

I loved him for that.

I love them all. I am acutely lucky in my family and friends, and in my daughter, my work and my life. But I have amyotrophic lateral sclerosis, or A.L.S., more kindly known as Lou Gehrig's disease, for the great Yankee hitter and first baseman who was told he had it in 1939, accepted the verdict with such famous grace, and died less than two years later. He was almost 38.

I sometimes call it Lou, in his honor, and because the familiar feels less threatening. But it is not a kind disease. The nerves and muscles pulse and twitch, and progressively, they die. From the outside, it looks like the ripple of piano keys in the muscles under my skin. From the inside, it feels like anxious butterflies, trying to get out. It starts in the hands and feet and works its way up and in, or it begins in the muscles of the mouth and throat and chest and abdomen, and works its way down and out. The second way is called bulbar, and that's the way it is with me. We don't live as long, because it affects our ability to breathe early on, and it just gets worse.

At the moment, for 66, I look pretty good. I've lost 20 pounds. My face is thinner. I even get some "Hey, there, Big Boy," looks, which I like. I think of it as my cosmetic phase. But it's hard to smile, and chew. I'm short of breath. I choke a lot. I sound like a wheezy, lisping drunk. For a recovering alcoholic, it's really annoying.

There is no meaningful treatment. No cure. There is one medication, Rilutek, which might make a few months' difference. It retails for about $14,000 a year. That doesn't seem worthwhile to me. If I let this run the whole course, with all the human, medical, technological and loving support I will start to need just months from now, it will leave me, in 5 or 8 or 12 or more years, a conscious but motionless, mute, withered, incontinent mummy of my former self. Maintained by feeding and waste tubes, breathing and suctioning machines.

No, thank you. I hate being a drag. I don't think I'll stick around for the back half of Lou.

I think it's important to say that. We obsess in this country about how to eat and dress and drink, about finding a job and a mate. About having sex and children. About how to live. But we don't talk about how to die. We act as if facing death weren't one of life's greatest, most absorbing thrills and challenges. Believe me, it is. This is not dull. But we have to be able to see doctors and machines, medical and insurance systems, family and friends and religions as informative — not governing — in order to be free.

And that's the point. This is not about one particular disease or even about Death. It's about Life, when you know there's not much left. That is the weird blessing of Lou. There is no escape, and nothing much to do. It's liberating.

I began to slur and mumble in May 2010. When the neurologist gave me the diagnosis that November, he shook my hand with a cracked smile and released me to the chill, empty gray parking lot below.

It was twilight. He had confirmed what I had suspected through six months of tests by other specialists looking for other explanations. But suspicion and certainty are two different things. Standing there, it suddenly hit me that I was going to die. "I'm not prepared for this," I thought. "I don't know whether to stand here, get in the car, sit in it, or drive. To where? Why?" The pall lasted about five minutes, and then I remembered that I did have a plan. I had a dinner scheduled in Washington that night with an old friend, a scholar and author who was feeling depressed. We'd been talking about him a lot. Fair enough. Tonight, I'd up the ante. We'd talk about Lou.

The next morning, I realized I did have a way of life. For 22 years, I have been going to therapists and 12-step meetings. They helped me deal with being alcoholic and gay. They taught me how to be sober and sane. They taught me that I could be myself, but that life wasn't just about me. They taught me how to be a father. And perhaps most important, they taught me that I can do anything, one day at a time.

Including this.

I am, in fact, prepared. This is not as hard for me as it is for others. Not nearly as hard as it is for Whitney, my 30-year-old daughter, and for my family and friends. I know. I have experience.

I was close to my old cousin, Florence, who was terminally ill. She wanted to die, not wait. I was legally responsible for two aunts, Bessie and Carolyn, and for Mother, all of whom would have died of natural causes years earlier if not for medical technology, well-meaning systems and loving, caring hands.

I spent hundreds of days at Mother's side, holding her hand, trying to tell her funny stories. She was being bathed and diapered and dressed and fed, and for the last several years, she looked at me, her only son, as she might have at a passing cloud.

I don't want that experience for Whitney — nor for anyone who loves me. Lingering would be a colossal waste of love and money.

If I choose to have the tracheotomy that I will need in the next several months to avoid choking and perhaps dying of aspiration pneumonia, the respirator and the staff and support system necessary to maintain me will easily cost half a million dollars a year. Whose half a million, I don't know.

I'd rather die. I respect the wishes of people who want to live as long as they can. But I would like the same respect for those of us who decide — rationally — not to. I've done my homework. I have a plan. If I get pneumonia, I'll let it snuff me out. If not, there are those other ways. I just have to act while my hands still work: the gun, narcotics, sharp blades, a plastic bag, a fast car, over-the-counter drugs, oleander tea (the polite Southern way), carbon monoxide, even helium. That would give me a really funny voice at the end.

I have found the way. Not a gun. A way that's quiet and calm.

Knowing that comforts me. I don't worry about fatty foods anymore. I don't worry about having enough money to grow old. I'm not going to grow old.

I'm having a wonderful time.

I have a bright, beautiful, talented daughter who lives close by, the gift of my life. I don't know if she approves. But she understands. Leaving her is the one thing I hate. But all I can do is to give her a daddy who was vital to the end, and knew when to leave. What else is there? I spend a lot of time writing letters and notes, and taping conversations about this time, which I think of as the Good Short Life (and Loving Exit), for WYPR-FM, the main NPR station in Baltimore. I want to take the sting out of it, to make it easier to talk about death. I am terribly behind in my notes, but people are incredibly patient and nice. And inviting. I have invitations galore.

Last month, an old friend brought me a recording of the greatest concert he'd ever heard, Leonard Cohen, live, in London, three years ago. It's powerful, haunting music, by a poet, composer and singer whose life has been as tough and sinewy and loving as an old tree.

The song that transfixed me, words and music, was "Dance Me to the End of Love." That's the way I feel about this time. I'm dancing, spinning around, happy in the last rhythms of the life I love. When the music stops — when I can't tie my bow tie, tell a funny story, walk my dog, talk with Whitney, kiss someone special, or tap out lines like this — I'll know that Life is over.

It's time to be gone.

Dudley Clendinen is a former national correspondent and editorial writer for The Times, and author of "A Place Called Canterbury."

Stinky socks could eradicate malaria

The odour of stinky socks is repulsive to humans, but African scientists have discovered it's as sweet and seductive as roses to mosquitoes.

Now the young Tanzanian scientist who discovered that is trying to build a cheap, yet sophisticated, mosquito trap to aid the global war on malaria -and Canada has stepped in to help him

Fredros Okumu, who leads the project at the Ifakara Health Institute, received a $775,000 grant Wednesday from Grand Challenges Canada and the Bill & Melinda Gates Foundation.

His team came up with the idea after seeing how mosquitoes were drawn to smelly socks. They persuaded volunteers in Ifakara, in southeast Tanzania, to donate socks they had worn for at least 10 hours. They then placed them inside boxes hung with insecticide-laced drapes outside people's homes in rural Tanzania.

Okumu said mosquitoes work through smell rather than sight.

"In their attempts to get blood from these devices, 74 to 95 per cent of all of those who landed in them were killed," he said.

His team has developed a device using a synthetic version of the sock stink and hope to make it simple and cheap enough to be made and sold by villagers.

"This project is a bold idea, one that's creative, innovative and counterintuitive," says Grand Challenges Canada CEO Dr. Peter Singer. "Who could have thought a life-saving technology could be lurking in your laundry basket?"

"We use a synthetic attractant to mimic a real human being," Okumu said. That will draw mosquitoes into a garbage-can-sized box, where an insecticide will kill the bugs.

"Mosquitoes go in thinking it's a human being, but they don't find any blood.

"Instead they get contaminated and die."

Okumu's research found that mosquitoes are drawn to humans by the scent composed of ammonia, lactic acid, carbon dioxide and other substances released by skin, sweat and breath.

The synthetic attractant using those chemicals to mimic human foot odour, Okumu's research has found, attracts four times more mosquitoes than real humans.

Malaria kills some 800,000 people per year, affecting Africans -and African children -in particular.

"This is an outdoor mosquito control strategy," he said. "The primary focus is to develop something to complement the current primary malaria controls tools: the nets and insecticide sprays used inside houses."

Okumu said the trap -called the odour-baited mosquito landing box -works best when there are 20 or more per population of 1,000. The traps are built by local carpenters using local materials, and can be produced for between $4 and $27.

Singer says the 29-year-old PhD student is exactly the type of innovator Grand Challenges Canada is looking to support.

"Fredros Okumu is a young, innovating, dedicated person who is trying to solve African problems with African innovation," he said. "We strongly believe that innovators in low-and middle-income countries are best suited to solve their own problems."

Okumu said he will use the grant money to improve his prototype, train additional carpenters, and study where the traps should be placed to be most effective.

Tuesday, July 12, 2011

Despite Zostavax, Drive Against Shingles Meets Few Goals -

Five years have passed since the Food and Drug Administration approved a vaccine against shingles. By now, experts had expected a substantial proportion of people older than 60, the most vulnerable population, to be protected from outbreaks of this nasty viral disease and the persistent, debilitating pain it can leave behind.

Indeed, the vaccine, called Zostavax, could so sharply reduce the number of adults who suffer from shingles — currently more than one million a year — that in March, the Food and Drug Administration approved its use by those ages 50 and older. But even with this weapon at the ready, the campaign against shingles has bogged down. Some experts say it never really got under way.

A combination of factors has dissuaded many physicians' offices and clinics from carrying Zostavax. And its manufacturer, Merck, has been unable to produce sufficient quantities to meet even modest demand.

Intermittent shortages that last months have kept the company from consistently marketing the vaccine and have forestalled public health campaigns that could have built awareness of the need for it.

"It really, really has been frustrating," said Dr. Rafael Harpaz, an epidemiologist at the federal Centers for Disease Control and Prevention. "There hasn't been a single year since the vaccine was licensed in 2006 that there's been no problem with supply."

As a result of these obstacles, just 10 percent of adults 60 and older were vaccinated against shingles in 2009, the most recent federal survey reports — far fewer than scientists and public health officials originally had hoped. (By comparison, two-thirds of those 65 and older got a flu shot that year.)

And with Zostavax again in short supply, a C.D.C. advisory committee in June declined to vote on whether to recommend the vaccine for people in their 50s, even though the F.D.A. had already approved it for that group.

"Maybe it's not appropriate to expand a vaccine when it's not available to the people who can most benefit from it," Dr. Harpaz said. "How much more disease might you cause by diverting vaccine to a younger group at lower risk?"

This stalemate was not what researchers had in mind when they began gearing up to test the vaccine in 1992. If ever there was an opportunity to advance public health, they knew, this was surely it. Virtually the entire adult population harbors the virus that causes shingles, called varicella zoster, and each one faces a one-in-three chance of developing shingles at some point.

The virus causes childhood chickenpox, then goes dormant for decades. When reactivated in later adulthood — how that happens is not well understood, though the risk rises with age — the virus causes a hallmark rash. The lesions typically last 7 to 10 days and heal in two to four weeks, but the scarring and pigment changes can be permanent.

About half of shingles victims describe the pain as "horrible" or "excruciating," the C.D.C. has reported. In 10 percent to 25 percent of cases, the virus attacks an eye and can permanently impair vision.

The severity of symptoms increases with age: 18 percent of all patients experience postherpetic neuralgianerve pain which can linger for months or even years after the rash clears, according to one decade-long Minnesota study.

Among those over age 79, the incidence of shingles climbs to 33 percent. Prompt treatment with antiviral drugs can reduce the severity of the outbreaks but hasn't been shown to prevent the neuralgia, which can disrupt sleep and work and, if it continues, lead to depression and social isolation.

"You can have your life ruined," said Dr. Michael Oxman, an infectious disease researcher who led the first large clinical trial demonstrating the vaccine's effectiveness.

Researchers and federal regulators long ago agreed, therefore, that their priority is to protect older adults. In 2005, to much fanfare, Dr. Oxman and his colleagues at 22 research sites reported that the vaccine produced a 51 percent reduction in outbreaks of shingles and a 67 percent reduction in postherpetic neuralgia in patients age 60 and older.

The researchers also found that the vaccine was less likely to prevent disease in those over age 80. Yet a subsequent community study of more than 300,000 adults age 60 and older at Kaiser Permanente health centers in California — more closely reflecting real-world conditions — found that the vaccine reduced shingles by 55 percent across all age groups.

"The burden of the disease is so great that reducing it by half is a real public health benefit," said Dr. Harpaz of the C.D.C.

The vaccine also lowered the rate of ophthalmic cases and of hospitalizations, indicating that even when it doesn't prevent shingles, "the vaccine can alleviate symptoms," said Hung-fu Tseng, a research scientist at Kaiser Permanente and lead author of the study.

But although Merck managed to ship two million doses in the first half of this year, more than in any previous full year, Zostavax is once more in scant supply.

The vaccine is made with a live attenuated virus that has proved difficult to grow in bulk, and also is needed to make the childhood chickenpox vaccine, said Dr. Eddy Bresnitz, global medical affairs director of Merck Vaccines.

The company is spending $1 billion to increase production and has built a new manufacturing plant in Durham, N.C. But it won't be fully licensed and operational until 2013, Dr. Bresnitz said.

Even when it's available, Zostavax is the most expensive adult vaccine, selling for about $160 a dose, not counting the cost of an office visit and injection. Few insurers will currently cover the cost for patients under age 60.

Because the vaccine must be stored frozen and few doctors' offices are equipped with freezers, many patients must turn to pharmacies for the shot. Fortunately, pharmacies can bill Medicaredirectly, under Part D, whereas physicians are reimbursed under Part B and therefore may require patients to pay for the vaccine themselves, then file for reimbursement.

That outlay alone discourages many older adults from getting vaccinated, research has shown. Patients in their 50s also must shoulder the cost, since many insurers are reluctant to covervaccinations the C.D.C. hasn't officially recommended. Every year, shingles strikes 200,000 adults ages 50 to 59.

"If someone 52 came to me worried about shingles, I'd vaccinate him," Dr. Oxman said. "The only toxicity I'm aware of is to the wallet."

Patients may also require an eventual booster, since it is not yet clear how long the vaccine remains effective.

But that's a less urgent matter than getting people at risk vaccinated in the first place.

Directly or indirectly, "the public foots the bill for all this research," Dr. Oxman added. "So I'm disappointed that a much higher proportion of those who would benefit from the vaccine haven't gotten it. We ought to be able to do a lot better than this."

Monday, July 11, 2011

A Kaleidoscope of Generics Puts Patients to the Test -

Later this year, when the popular statin Lipitor becomes available as a generic drug, many who have taken it faithfully will get a surprise. No longer will their cholesterol-lowering pills be oblong and white.

If they choose a generic alternative, their pills will be anything but that color and shape, and their appearance may change from refill to refill as pharmacists switch among generic competitors.

The result may well be confusion among patients, who often take multiple drugs and have trouble keeping track of them if their shapes and colors change all the time, two researchers at Harvard University say.

With generics accounting for 70 percent of all drugs on the market, the seldom-discussed issue of their ever-changing appearances affects almost anyone who fills a prescription.

"If a patient is on five medications, which is not that unusual, there are over 3,000 possible combinations of pills to navigate," said Dr. Jeremy A. Greene, a physician and historian of science at Harvard Medical School, referring to the number of ways of combining five pills of different shapes or colors.

When patients get confused, many stop taking their drugs. "Everyone has seen a patient who has gone off of a medication because it changed color," Dr. Greene said. "It can lead to disastrous outcomes."

In an article in the current issue of The New England Journal of Medicine, Dr. Greene and Dr. Aaron S. Kesselheim, a physician and lawyer at Harvard Medical School, ask why generic pills look different from their brand-name equivalents and from competitors that the Food and drug Administration certifies as being bioequivalent — having the same effect on the body.

The question seems to have caught many drug makers off guard. Kate Connors, a spokeswoman for the Pharmaceutical Research and Manufacturers of America, a trade group that represents makers of brand-name drugs, said, "We have never seen this come up as an issue."

Bob Lee, a trademark lawyer for Eli Lilly, said patients should know when they are taking something other than a brand-name drug, and a different shape or color communicates this point.

Different appearances also help prevent counterfeiters from flooding the market with look-alikes, he said. By suggesting that generics should look the same as the brand-name drug, Mr. Lee said, the Harvard researchers are advocating a solution that will not help patients.

"What they are really arguing for is a deception," Mr. Lee said.

The shape and color of a particular pill has become a valuable part of its marketing, so much so that generic drug manufacturers sometimes will license the right to make an "authorized" generic — pills that look exactly like the brand-name drugs they are competing with.

Prasco, a maker of authorized generics in Ohio, buys drugs from brand-name manufacturers and puts them in its own bottles. They are identical to the drugs patients are used to, said a company spokeswoman, Kimberly Carroll.

"Wouldn't you like a generic option that provides the identical experience as the brand?" the company asks doctors on its Web site.

A drug's appearance, said Dr. Greene, "has become one more thing that can be sold on the market." The purpose of an authorized generic, he said, is to tell consumers, "Yes, it's a generic, but you can trust it."

He and Dr. Kesselheim report that the idea that generics should look different from the brand-name drugs they replace emerged in the 1960s and 1970s. Some pharmacists began covertly substituting generic pills that looked just like brand-name drugs but were not as effective. Courts agreed that companies had a right to protect the appearance of their drugs.

But in the 1970s and 1980s, the Food and Drug Administration began regulating generic drugs and requiring that they be bioequivalent to their brand-name products they replaced.

As a result, said Dr. Greene, "the problem of poor quality generics became less of a public health concern."

But once in control of the appearance of their brand-name drugs, manufacturers began using a pill's shape and color as a marketing tool. For example, Pfizer featured its distinctive pill for erectile dysfunctionViagra, in its advertisements, making sure patients knew it was blue and diamond-shaped.

AstraZeneca advertised the gastric acid blocker Prilosec as "the purple pill." When it went off patent in 1989, the company began marketing its replacement, Nexium, as "the new purple pill." Prilosec, on the other hand, was colored pink after it became available as an over-the-counter drug.

Generic drug makers who license an "authorized" generic can start selling their drug as soon as the brand-name drug's patent expires. Not so for most generic drug makers. They compete to get their documentation to the F.D.A. when a drug is going off patent, said David Belian, a spokesman for the Generic Pharmaceuticals Association, an industry group. The first company to get the Food and Drug Administration's approval to sell its generic drug receives, in return, a period of six months when its drug is the only generic on the market, unless an authorized generic also has been licensed.

If so, that six-month period can be a significant advantage for the authorized generic. In the six months after the antidepressant Paxil went off patent, there were two generics on the market. One was authorized and looked just like Paxil. It ended up with two-thirds of the market.

The Generic Pharmaceuticals Association opposes letting authorized generics on the market immediately, during the time when the first ordinary generic is supposed to have the market to itself.

"Exclusivity should be just that," Mr. Belian said.

But Prasco says that authorized generics bring prices down by increasing competition in that six-month period. And look-alike generics make life easier for patients, Ms. Carroll said.

Dr. Greene, however, wonders whether an endlessly multiplying array of drug shapes and colors really makes sense for consumers.

"The current situation reflects an approach to public health law that made sense a half-century ago, but is no longer in sync with how people manage disease with generic drugs today," he said.