Saturday, May 24, 2014

Can the Nervous System Be Hacked? -

One morning in May 1998, Kevin Tracey converted a room in his lab at the Feinstein Institute for Medical Research in Manhasset, N.Y., into a makeshift operating theater and then prepped his patient — a rat — for surgery. A neurosurgeon, and also Feinstein Institute's president, Tracey had spent more than a decade searching for a link between nerves and the immune system. His work led him to hypothesize that stimulating the vagus nerve with electricity would alleviate harmful inflammation. "The vagus nerve is behind the artery where you feel your pulse," he told me recently, pressing his right index finger to his neck.

The vagus nerve and its branches conduct nerve impulses — called action potentials — to every major organ. But communication between nerves and the immune system was considered impossible, according to the scientific consensus in 1998. Textbooks from the era taught, he said, "that the immune system was just cells floating around. Nerves don't float anywhere. Nerves are fixed in tissues." It would have been "inconceivable," he added, to propose that nerves were directly interacting with immune cells.

Nonetheless, Tracey was certain that an interface existed, and that his rat would prove it. After anesthetizing the animal, Tracey cut an incision in its neck, using a surgical microscope to find his way around his patient's anatomy. With a hand-held nerve stimulator, he delivered several one-second electrical pulses to the rat's exposed vagus nerve. He stitched the cut closed and gave the rat a bacterial toxin known to promote the production of tumor necrosis factor, or T.N.F., a protein that triggers inflammation in animals, including humans.

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Friday, May 23, 2014

The MacGyver Cure for Cancer -

Two decades ago, David Walmer went on a volunteer mission with his church to Haiti. He was sent to paint walls at a hospital in the seaside town of Léogâne, but when the people there learned that Walmer was a doctor — he was a fertility specialist at Duke University — they asked him to spend the week with a local obstetrician-gynecologist named Jean-Claude Fertilien. Walmer was shocked by what he saw: Fertilien finishing a hysterectomy with the aid of a flashlight when the hospital generator failed to restart, for instance, or when an anesthesiologist wasn't available for an emergency C-section, the doctor just numbing the skin and cutting. At one point, Walmer was called to the bedside of a young woman in her mid-20s with undiagnosed cervical cancer who had gone into septic shock. There was nothing to be done for her, and she died right in front of him. Walmer was appalled. In the United States, cervical cancer is considered a preventable disease.

"You have 10 years to detect this disease before it becomes untreatable," Walmer says. "And it's easy to detect. It develops on the outside of the cervix, which you can see."

At the end of his week in Haiti, Walmer, who is a boyish 61, put a question to Fertilien: "I'm a busy guy. But if there's one little thing I can help you out with, what would it be?"

"Cervical cancer," Fertilien said.

Walmer had no expertise with the disease — he divided his time between seeing patients and doing lab work, analyzing the biology of the uterine lining — but he told Fertilien he would do his best.

Back at Duke, he pressed colleagues to let him work alongside them and learn about the disease. He knew that an effective screening program would be the biggest single fix he could propose. In the U.S., screening is typically done with Pap smears — a quick swab of a woman's cervix to screen for the cellular changes that foreshadow cancer. If abnormal cells are found, a doctor will usually perform a colposcopy, in which the cervix is examined using a specialized magnifying lens, a colposcope, to see if disease is visible. Before the widespread adoption of Pap smears in the 1950s and '60s, cervical cancer was the top cancer killer among women in the U.S. Now, when caught in time, the diagnosis and treatment are pretty straightforward: Paint the cervix with acetic acid — essentially vinegar — which turns abnormal areas white. Confirm the presence of disease with a biopsy. Then freeze or remove the abnormal cells.

Thanks to early detection (and helped by the vaccine for HPV, or human papillomavirus), the mortality rate for cervical cancer in the U.S. is relatively low. Not so in developing countries, where it kills almost 250,000 women every year. Haiti has one of the highest rates of cervical cancer in the world. Walmer knew that a national screening program would save countless lives, but deploying colposcopes across the impoverished nation was not feasible. They're expensive, they require reliable electricity and they're too big to be easily carted around to the ramshackle clinics throughout the country. A battery-powered, portable and affordable alternative was needed.

At the time, in the mid-1990s, Walmer was teaching young doctors how to reverse sterilization surgeries by repairing women's fallopian tubes. He used loupes, or surgical glasses, to see the tubes properly. "I realized, I've got these magnifying lenses right here, and they don't require any electricity," Walmer says. A solution began to take shape in his mind. He bought a halogen headlamp at a bike shop and a green filter at a camera store. He figured that by switching back and forth between green and white light he would be able to provide the contrast needed to identify precancerous lesions on the cervix and the pattern of blood vessels that indicate something suspicious.

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Thursday, May 22, 2014

People With Chronic Illness Fare Worse Under Cost-Sharing -

Most health care plans ask that you spend some money out of your pocket whenever you use the health care system. This is known as cost-sharing, and it exists because research has shown us that people are, in general, less likely to spend their own money than someone else's. Cost-sharing works its way into insurance today through co-pays, deductibles and co-insurance.

Cost-sharing works for most people, because most people are healthy. Healthy people who use health care are often doing so inefficiently. They often don't need the care they ask for, because they're well. One way we use cost-sharing poorly, though, is that we apply it to all insurance beneficiaries equivalently. We treat them all the same, no matter how sick or healthy they are.

study just published in JAMA Pediatrics looked at how children with asthma obtained care under different levels of cost-sharing, and how much stress their families were under financially because of their child's illness. It's important to understand that children with asthma, by definition, require care.

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Wednesday, May 21, 2014

How Being Poor Makes You Sick - Olga Khazan - The Atlantic

When poor teenagers arrive at their appointments with Alan Meyers, a pediatrician at Boston Medical Center, he performs a standard examination and prescribes whatever medication they need. But if the patient is struggling with transportation or weight issues, he asks an unorthodox question:

"Do you have a bicycle?"

Often, the answer is "no" or "it's broken" or "it got stolen."

In those cases, Meyers does something even more unusual: He prescribes them year-long memberships to Hubway, Boston's bike sharing program, for just $5 per year—a steep discount from the regular $85 price.

"What we know is that if we are trying to get some sort of exercise incorporated into their daily routine, [the bike] works better than saying, 'Take x time every day and go do this,'" Meyers told me.

The bike-prescribing program is paid for by the city. For patients without bank accounts, Boston even puts up its own city credit card. Meyers thinks the two-wheeled solution tackles several problems at once.

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Tuesday, May 20, 2014

When Doctors Treat Patients Like Themselves -

Many years ago I spent a lunch hour in a doctors' dining room eavesdropping on two white-coated men of a certain age idly discussing a colleague who worked at the city hospital next door.

While they themselves saw mostly insured patients, she worked exclusively among the destitute, a de facto one-woman charitable health organization. Most of the hospital community thought she was a saint. These two doctors, to put it mildly, were not impressed.

"It's easy to do that kind of work," one concluded, putting down his napkin and standing up. "The hard thing is taking care of patients who are exactly like you."

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Stanford engineer invents safe way to transfer energy to medical chips - Stanford University

A Stanford electrical engineer has invented a way to wirelessly transfer power deep inside the body, and then use this power to run tiny electronic medical gadgets such as pacemakers, nerve stimulators or new sensors and devices yet to be developed.

The discoveries reported May 19 in the  Proceedings of the National Academy of Sciences culminate years of efforts by Ada Poon, assistant professor of electrical engineering, to eliminate the bulky batteries and clumsy recharging systems that prevent medical devices from being more widely used.

The technology could provide a path toward a new type of medicine that allows physicians to treat diseases with electronics rather than drugs.

"We need to make these devices as small as possible to more easily implant them deep in the body and create new ways to treat illness and alleviate pain," said Poon.

Poon's team built an electronic device smaller than a grain of rice that acts as a pacemaker. It can be powered or recharged wirelessly by holding a power source about the size of a credit card above the device, outside the body.

New generation of sensors

The central discovery is an engineering breakthrough that creates a new type of wireless power transfer – using roughly the same power as a cell phone – that can safely penetrate deep inside the body. As Poon writes, an independent laboratory that tests cell phones found that her system fell well below the danger exposure levels for human safety.

Her lab has tested this wireless charging system in a pig and used it to power a tiny pacemaker in a rabbit. She is currently preparing the system for testing in humans. Should such tests be approved and prove successful, it would still take several years to satisfy the safety and efficacy requirements for using this wireless charging system in commercial medical devices.

Poon believes this discovery will spawn a new generation of programmable microimplants – sensors to monitor vital functions deep inside the body; electrostimulators to change neural signals in the brain; and drug delivery systems to apply medicines directly to affected areas.

Drug therapy alternatives

William Newsome, director of the Stanford Neurosciences Institute, said Poon's work created the potential to develop "electroceutical" treatments as alternatives to drug therapies.

Austin Yeebatteryless electrostimulator next to medicinal pills

A batteryless electrostimulator next to medicinal pills for size comparison. The new powering method allows the device to be wirelessly powered deep inside the body.

Newsome, who was not involved in Poon's experiments but is familiar with her work, said such treatments could be more effective than drugs for some disorders because electroceutical approaches would use implantable devices to directly modulate activity in specific brain circuits. Drugs, by comparison, act globally throughout the brain.

"To make electroceuticals practical, devices must be miniaturized, and ways must be found to power them wirelessly, deep in the brain, many centimeters from the surface," said Newsome, the Harman Family Provostial Professor and professor of neurobiology at Stanford.

He added, "The Poon lab has solved a significant piece of the puzzle for safely powering implantable microdevices, paving the way for new innovation in this field."

How it works

The article describes the work of Poon's interdisciplinary research team that included John Ho and Alexander Yeh, electrical engineering graduate students in Poon's lab; Yuji Tanabe, a visiting scholar; and Ramin Beygui, associate professor of cardiothoracic surgery at Stanford University Medical Center.

The crux of the discovery involves a new way to control electromagnetic waves inside the body.

Electromagnetic waves pervade the universe. We use them every day when we broadcast signals from giant radio towers, cook in microwave ovens or use an electric toothbrush that recharges wirelessly in a special cradle next to the bathroom sink.

Before Poon's discovery, there was a clear divide between the two main types of electromagnetic waves in everyday use, called far-field and near-field waves.

Far-field waves, like those broadcast from radio towers, can travel over long distances. But when they encounter biological tissue, they either reflect off the body harmlessly or get absorbed by the skin as heat. Either way, far-field electromagnetic waves have been ignored as a potential wireless power source for medical devices.

Near-field waves can be safely used in wireless power systems. Some current medical devices like hearing implants use near-field technology. But their limitation is implied by the name: They can transfer power only over short distances, limiting their usefulness deep inside the body.

What Poon did was to blend the safety of near-field waves with the reach of far-field waves. She accomplished this by taking advantage of a simple fact – waves travel differently when they come into contact with different materials such as air, water or biological tissue.

For instance, when you put your ear on a railroad track, you can hear the vibration of the wheels long before the train itself because sound waves travel faster and further through metal than they do through air.

With this principle in mind, Poon designed a power source that generated a special type of near-field wave. When this special wave moved from air to skin, it changed its characteristics in a way that enabled it to propagate – just like the sound waves through the train track.

She called this new method mid-field wireless transfer.

In the experiment, Poon used her mid-field transfer system to send power directly to tiny medical implants. But it is possible to build tiny batteries into microimplants, and then recharge these batteries wirelessly using the mid-field system. This is not possible with today's technologies.

Co-author Ho noted, "With this method, we can safely transmit power to tiny implants in organs like the heart or brain, well beyond the range of current near-field systems."

A Cancer Treatment in Your Medicine Cabinet? -

We believe that it might be possible to treat breast cancer— the leading cause of female cancer death — with a drug that can already be found in nearly every medicine cabinet in the world: Aspirin.

In 2010, we published an observational study in The Journal of Clinical Oncology showing that women with breast cancer who took aspirin at least once a week for various reasons were 50 percent less likely to die of breast cancer. In 2012, British researchers, by combining results from clinical trials that looked at using aspirin to prevent heart disease, found that aspirin was also associated with a significantly lower risk of breast cancer death.

And yet, until now, there have been no randomized trials (the gold standard of research) of aspirin use among women with breast cancer.

It's not hard to see why: Clinical trials are typically conducted on drugs developed by labs seeking huge profits. No one stands to make money off aspirin, which has been a generic drug since the Treaty of Versailles in 1919, and which costs less than $6 for a year's supply.

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