Lately, Doctor Pundit has been reporting some tidbits from the arena of medical research. Here are a few more to make the wires for 9/1.

• Is it really possible? For now you’ll just have to ask the mice taking it. Metformin, the country’s most widely used antidiabetic agent, could lead to the prevention of lung, breast, and prostate malignancies. | LINK
• Speaking of cancers, are certain heritable forms of breast cancer prevented by a certain surgical technique? | LINK
• Again, on the topic of cancer: an anti-tumor drug may be altered to serve as the basis for a novel agent to prevent the formation of senile plaques seen in the central nervous system in virtually all Alzheimer patients. | LINK
• Finally, on the lighter side of things — the all-star line-up for the “Stand Up to Cancer” telethon is almost finalized. | LINK

The huge drive to immunize the masses against threat of H1N1 in the 2009/10 influenza season (which the WHO has officially declared concluded) has created more than a watershed moment in 21st century public health response to a potential biological catastrophe, it has also touched off a political debate that’s just getting started. And it all has to do with authoritarian mandate of the vaccine for healthcare workers.

Contrary to popular thought, many healthcare workers do not receive the vaccine; in fact, approximately 40 percent of said workers actively refused [PDF link] the vaccine last year — during infection’s peak. This notion does not sit well with a couple of policy organizations — one academic and one medical. Both groups say mandatory influenza vaccine should be a condition of employment. The groups stress increased availability of the vaccine, a steadier supply of healthy workers to administer care in times of a crisis, and an overall decrease in the incidence of influenza-related deaths in already compromised inpatients with other medical problems.

Already, the state of New York is hard at work in developing regulatory actions for its public healthcare workers. | LINK

Just how effective are vaccines at keeping mass pandemics of infectious disease abated? Well, it may not be so easy to estimate.

[T]he number of annual flu-related deaths in the United States has ranged from a low of about 3,300 to a high of about 49,000. This is a revision of the static estimate of 36,000 annual deaths that has been reported consistently for years by the U.S. Centers for Disease Control and Prevention.

The CDC has revised its projections on the preventive care of the seasonal influenza vaccine, moving from statistical dead targets to ranges of mortality among influenza outbreak figures. Its projections cover most of the past 30 years (up to 2007, and not inclusive of last year’s H1N1 pandemic). | PDF  LINK to latest issue of CDC’s Morbidity & Mortality Weekly

Pharma company Eli Lilly recently scrapped further development of an anti-Alzheimer drug designed to fight the disease from the plaque mechanism; its compound would inhibit the enzyme responsible for catalyzing the process in forming the amyloid plaques pathognomonic for the disorder.

Their reasoning? That the enzyme also works on the formation of other proteins in the brain that have no consequence in the natural histopathological history of the disease. Scientists working on the R&D for this drug have also gone as far as to question this hypothesis as a valid point of research into anti-Alzheimer development. The implications of these second thoughts have yet to be fully realized, but there could be an immediate effect on other Pharma companies researching similar treatments for degenerative dementia should they decide to follow like concerns. | LINK

HIV is once again in the news lately — first with news of a new strategy to combat the infection with enhanced vaccination research, the commitment of HHS in reallocating funds for HIV research on a global scale, and now the creation of the first “national HIV strategy” by a sitting president.

In the report, the administration calls for steps to reduce the annual number of new H.I.V. infections by 25 percent within five years. [..] [T]he administration will redirect money to areas with the greatest need and population groups at greatest risk, including gay and bisexual men and African-Americans.

Obviously, simple “redirection” of federal funds for medications and treatments of HIV/AIDS is not the final mechanism of care access for the millions of patients afflicted with this chronic disease; it is unclear where these funds will provide an absolute siphon for spending. Kudos to the administration in its efforts to reacquaint an entirely new generation of Americans on the urgency of this disease, but it’s got a long way to go to reduce sharply its transmission rates and healthcare policy atrophy in this area. | LINK

The research into HIV and AIDS vaccinations may be getting a literal shot in the arm, as new mechanisms involving autoimmunity could hold the answers to neutralization of the infection at a greater rate than studied in previous eras. The ability for some with the disease to mount a hightened autoimmune response to the viral burden is the focus of scientists wishing to develop vaccines that fight the gamut of the infection’s trajectory — not just in specific, static phases of disease.

Of course, the ability of HIV to mutate at a rapid clip does pose challenges. (In one trial, scientists have noted a camouflage-type of mechanism the HIV virus is able to utilize with an enveloping sugar molecule to avoid detection.) At any rate, the boldness and bullish nature of the scientific community at this point in HIV/AIDS research is refreshing and exciting. There’s also always the hope that this specialized research into a disease-free organism will naturally occur as a result. | LINK

Although the results of a study from the Annals of Internal Medicine are out today noting an increase in the rate of sexually transmitted infections (STIs) among those taking drugs for erectile dysfunction, this item “hot off  the wires” practically invites the media to take a stance assuming direct causation.

Jokes aside — and you can assume that lead-ins are probably replete with them — the compelling numbers^[1] suggest a greater problem afoot: the overall numbers of sexually active men over 55 years of age is increasing. Re-evaluating incidence and prevalence rates to include this ever-burgeoning population will only become more commonplace in medical education as this retrospective study underscores one major point: the necessity of other types of trials studying the effects of preventive practices toward STIs in those much younger and applying them to this patient population. | LINK

1. Researchers followed over 1M men (average age of 60) by examining their insurance records. Among non-users of drugs like Viagra, 106 in 100,000 contracted an STD. That number increased to 214 in 100,000 for men who were using Viagra, Cialis or Levitra — the major drugs to treat ED. [↩]

Some headlines prior to the Independence Day holiday. Normal posting resumes here at Doctor Pundit on July 6. Have a happy and safe holiday weekend!

• Veterans Admin admits to the debacle surrounding dirty dental instruments placing hundreds of patients at risk of HIV transmission. [LINK]
• Minnesota nursing strike may be averted, but time will tell if threat to strike was more of a bluff. Hospitals and nurses pledged to work within the constraints of internal governance. [LINK]
• How’s healthcare reform going? Just fine, according to some. [LINK]
• How influential will states’ insurance commissions be when regulating insurers’ medical loss ratios in the age of reform?
  

  The medical-loss ratio measures how much of premiums insurers pay out for medical care versus administrative costs. The new law requires that insurers use at least 80% of the premiums from individuals and small businesses to pay for medical care and profit-taking, and 85% of premiums from larger employers. Health insurers are waiting for regulators to clarify how companies must account for the numbers—whether they can average the MLRs of their subsidiaries, for instance.

  [LINK]

• Study: Genes key to longevity. [LINK]

The battlelines are drawn in the latest medicolegal war which tests how far patient activism can go when the patient asks for, rather demands, a particular treatment regimen unproven in the pantheon of well-studied and documented clinical medicine. The treatment of Lyme disease, an infectious disorder in which the deer tick (found in abundance here in Minnesota) acts as a vector of transmission, is under fire from patient activist groups who say that they aren’t being treated effectively for the disorder’s possible long-term effects, which can be disabling.

Pity the role of infectious disease experts who are often called upon to consult and produce national guidelines based upon sound medical and clinical research. These intrepid physicians now have to navigate and overcome the legislative process which appears to be siding with patients who feel as though they are being maltreated. In Minnesota, the state medical board (which regulates, disciplines, and licenses physicians) has had to initiate a moratorium against actions that may arise out of patient complaints with respect to the treatment of Lyme disease. Elsewhere, activist groups are gaining steam and appear to be influencing its evaluation, classification, and treatment^[1] without the involvement of physician specialists and experts…and with the support of lawmakers. | LINK

1. which often involves the unproven use of chronic antibiotics, for a year or more.. [↩]

Diabetes mellitus, type 2 is an epidemic problem in the United States, with at least 21M people diagnosed, a problem made more complex with very disappointing new trial data.Two new reports from the ACCORD trial released yesterday show that lowering either blood pressure or cholesterol below current guidelines does not provide additional benefit and, in fact, increases the risk of side effects. A third arm of the study, known from two years ago, shows that excessively lowering blood sugar levels actually increases the risk of heart disease.

This is very frustrating news, given that the pipeline for novel therapies is not advancing at a rate congruent enough with the increasing incidence since the start of this century. Is aggressive management of other risk factors of cardiac disease and strokes actually harmful to these patients? While these developments throw into question far-reaching guidelines on the issue, some physicians in response are taking results of these negative studies (here and here) [PDF] and applying them on a case-by-case basis. | LINK

It’s one thing for medical researchers to suspect an answer they set out to prove is within the scope of the methods by which they conduct the study. It’s quite another when the results of said study give a totally unexpected conclusion. This is perfectly illustrated in this week’s NEJM, in which investigators show that cardiologists are essentially inappropriately heading right for the high-cost (and apparently low-value) procedure known as the angiogram in attempting to diagnose coronary disease.

Out of almost 400 000 patients studied, investigators found that 4 out of every 10 patients who underwent this procedure (which involves invasive catheterization) had absolutely no findings of disease (blockages). Not exactly half, but you get the idea. Although it’s clear that these subspecialists must do a better job in stratifying the most appropriate patients for this procedure, what’s even more salient is the fact that coronary angiograms — being an invasive procedure — are not without risk. Their implementation carries an approximate risk of 1% of an acute coronary event (ie., heart attack), not to mention the amount of radiation exposure involved. | LINK

I’m not a big fan of medical dramas. From my earliest memory as a child, I can recall my mother’s whimsy with the TV show “Medical Center”. At the tender age of five, I never really understood her fascination with the show at that time (although I’m sure the eye candy was a big part of the draw for her, if you know what I mean); perhaps it was the fact that she was a registered nurse and could relate on some visceral level. Okay, that’s probably stretching things a bit — as medical dramas in the 1970s didn’t utilize the high-powered medical knowledge and muster of physician consultants in the manner they do today.

Well, one would think in this age of “transparency” and disclosure among source materials for dramatization, consultants would make sure medical pathology portrayed on television would be as accurate as possible. Don’t they owe it to the audience (along with a riveting storyline)? According to a study getting some Internet meme ink, they do.

There were 59 seizures in the 327 episodes included in the study. Inappropriate responses — such as holding a patient down, trying to stop involuntary movement, or putting something in the person’s mouth — occurred in about 46 percent of the seizure depictions. Appropriate first-aid management was shown about 29 percent of the time, while the appropriateness of first aid couldn’t be determined in 25 percent of the seizure scenes, the study authors noted.

Using current and relatively recent dramas as subjects for the study, the authors note that emergency first aid for seizure was appropriately given about 50% of the time. Perhaps the bigger issue here is why this was studied in the first place. If society relied on medical drama to provide the appropriate instruction rather than, say, medical school; then healthcare reform would probably take on an entirely different meaning. | LINK

In the upcoming NEJM, a large prospective study makes the case for the consideration of dementia as a certain cause of death for the mostly elderly patients who suffer from it. Ever since the disorder was first described by its namesake Alois Alzheimer, MD 102 years ago; it has always been thought of as an unfortunate comorbid “condition” of which advancing age itself was a risk factor. The complexity of the diagnosis made early attempts to formulate effective treatments virtually impossible. Toward the middle of the 20th century the focus of caring for the patient who suffered from dementia shifted to palliation and suppression of other comorbidities which could hasten its clinical effects.

At the end of the last century, breakthroughs in neurobiological research opened the doors to classes of drugs that have largely been successful for controlling debilitating symptoms — without, however, effecting retardation of the disease, or even a cure. Thus the stage was set for a redefinition of sorts for this illness. Authors of the study have delineated the course of dementia (not necessarily following Alzheimer patients, but studying the constellation of disorders that make up its syndrome — Parkinson’s, stroke related dementia, and other organic causes) as one of a terminal nature. They are sounding a clarion call for re-education of the public on what they call a termainal condition which requires effective palliation, at the very least.

At the moment, treatment (which may include some reversal of the pathology) of Alzheimer dementia is being heavily researched. Until the time comes for a certain cure for all causes of dementia, the importance of accurately diagnosing and crafting essential care plans for those who suffer from its horrible effects is the most effective treatment there is. Hopefully, by mid century, the estimated 17 million who will fall prey to dementia will have not only the treatments but also the resources to prevent its early mortality so prevalent in this population today. | LINK