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Archive for the ‘Medicine’ Category

Flattery to deceive

Posted by Callum Anderson on 14 April, 2010

Is orange juice a new superfood? Perhaps in some situations it can benefit the body. But the term ‘superfood’ often belies negligible effects in vivo.

A paper by Husam Ghanim, Chang Ling Sia, Mannish Upadhyay, Kelly Korzeniewski, Prabhakar Viswanathan, Sanaa Abuaysheh, Priya Mohanty and Paresh Dandona at the State University of New York at Buffalo (evaluated by our wonderful Faculty of course), suggests that consuming orange juice alongside a fatty, high-carbohydrate meal could limit the adverse effects of all that junk food.

On a slightly related note – while writing this post I was directed by RPG towards a list of The 40 Deadliest Fast Food Meals – and I wonder how much orange juice we might have to drink to alleviate the effects of the top entry? The article clogging, 1300 calorie, 38 grammes-of-saturated-fat-Baconator Triple from Wendy’s!

Right – back to more serious pontification now.

The paper hinges around a comparison of orange juice, water and glucose drink alongside a fatty, high carbohydrate meal and the subsequent production of reactive oxygen species by polymorphonuclear cells, measures of cytokine and endotoxin activation in mononuclear cells, and plasma levels of endotoxin and matrix metalloproteinase.

Bruce Bistrian of the Beth Israel Deaconess Medical Center says in his evaluation

Orange juice reduced the oxidative stress and prevented the formation of pro-inflammatory components, including the increase in plasma endotoxin, compared to either water or glucose. Somewhat surprisingly, there was no increase in plasma glucose with orange juice as found with the meal plus water or the meal plus glucose, despite the substantial carbohydrate and caloric load.

And he added

it is likely that the authors’ suggestion that the mechanism for the antiinflammatory actions was due to the flavonoids naringenin and hesperidin present in orange juice is correct.

So the flavonoids in orange juice may be preventing inflammation after an unhealthy meal, in short limiting the damage.

However, I would not go as far as to suggest that orange juice is particularly brilliant in this respect, especially as the highest concentrations of hesperidin are found in the white parts and peel of oranges, which do not provide a particularly appetising juice. Furthermore, this article suggests that grapefruit provides a significantly higher concentration of naringenin than orange.

But criticism aside; the mention of flavonoids in this paper got me thinking more generally about these so called superfoods. And then more specifically about a press release I saw doing the rounds recently concerning rhubarb. Scientists are inherently aware that test tube or laboratory work does not always transfer into the real world. And the rhubarb press release is a good example of why.

Rhubarb was christened as a new superfruit by some sections of the media due to its high concentration of polyphenols. And the point of these chemicals is that in test tube study, they scavenge free radicals and show other benefits when used in high concentration. But they also have currently undefined mechanisms by which they may reduce the risk of cancer or heart disease. I would be very surprised however if these benefits effectively make the transfer from vitro to vivo. Basically, the concentration levels of ingested polyphenols are usually extremely low, and may be too low in many cases to make any real difference.

A recently published paper by Balz Frei entitled Controversy: What are the True Biological Functions of Superfruit Antioxidants? highlights further problems when flavonoids in particlular find their way into the body. He says

Flavonoids are poorly absorbed into blood and rapidly eliminated from the body; thus, flavonoids have low eventual biological availability.

So really, despite having high levels of helpful chemicals; once ingested, concentration of many of these so called ‘super’ chemicals still lags way behind more common cellular antioxidants.

So eating rhubarb is not going to affect chemical levels for particularly long, because the unique chemicals simply don’t hang around for very long in the body. And this is why I really like the paper by Ghanim et al. Ghanim and his team acknowledge the short bioavaliability of flavonoids and test them in a situation where their effect is clearly measurable against the high calorie meal.

Perhaps I am being too harsh here? In the rhubarb press release, Dr Nikki Jordan-Mahy does admit that the real application of her research lies away from ‘Superfoods’. She says

But if we can extract the polyphenols they may be useful in helping to fight cancer along with chemotherapy.

And this point hits the nail on the head, we need to be thinking how to extract and concentrate these chemicals to make them worthwhile, and in the meantime, the mainstream media needs to understand that positive laboratory tests do not always signify benefits in vivo.

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Migraines, magnets and a vocabulary straight from science fiction

Posted by Callum Anderson on 30 March, 2010

Whenever Richard Lipton releases a new migraine study I always receive it with interest. Partly because his work is pretty cutting edge and and he leads an excellent team, but partly because migraine science can sometimes sound like an encounter of the third kind in a science fiction novel.

Migraines are typically defined as one sided, throbbing headaches, typically accompanied by other symptoms, ranging from a non-specific ‘aura’ to zigzagging or flashing lights, a specific smell, nausea or sensitivity to light or sound.

According to some research , migraines affect close to 12% of the world’s population.

Well, Professor Lipton and his team at Albert Einstein College of Medicine have certainly not let us science fiction fans down this time either, publishing a randomised, double-blind, parallel-group, sham-controlled trial in which a hand-held transcranial magnetic stimulation device is used to treat the migraine.

Image by Andy Field (Hubmedia) via Flickr

Image by Andy Field (Hubmedia) via Flickr

The interesting thing about this study is that it tests a “handheld device” capable of alleviating migraine aura. So in theory, the study could lead to development of a product that allows sufferers to treat themselves at home rather than rely on a clinician. This is especially useful for something like a migraine which tends todevelop and subside rapidly.

The study randomized participants by computer, handing approximately half (99) a sham stimulation and the others (102) were given the sTMS device.
Those who used the real device had less pain and recurring headaches and were less likely to need medication. Of 164 patients who treated at least one attack with the real or fake stimulation devices, 39 percent of those who used the real device reported no pain after two hours compared to 22 percent of those who used the fake device.

Here are the results

37 patients did not treat a migraine attack and were excluded from outcome analyses. 164 patients treated at least one attack with sTMS (n=82) or sham stimulation (n=82; modified intention-to-treat analysis set). Pain-free response rates after 2 h were significantly higher with sTMS (32/82 [39%]) than with sham stimulation (18/82 [22%]), for a therapeutic gain of 17% (95% CI 3-31%; p=0.0179). Sustained pain-free response rates significantly favoured sTMS at 24 h and 48 h post-treatment. Non-inferiority was shown for nausea, photophobia, and phonophobia. No device-related serious adverse events were recorded, and incidence and severity of adverse events were similar between sTMS and sham groups.

When (and even if) this treatment comes onto the market, it remains unclear, how much it will cost, and Neuralieve don’t have any pricing details on their website.

I am tentatively guessing that a technology in infancy like this won’t be particularly affordable for a good few years, but with more trials comes more corporate interest and it is important to consider that the potential market for something like this could be as high as the aforementioned 12% of population, which globally, represents a huge number.

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Placebo experimentation and LUTS

Posted by Callum Anderson on 23 March, 2010

A couple of interesting evaluations have made their way past my desk this week, both from Faculty of 1000 Medicine. The first evaluation is of a very interesting paper, originally published in German, which reports results of a questionnaire. The title of the paper is Uncontrolled placebo experimentation in a university hospital, and the results certainly shocked me (I wonder if they would have the same effect on a practicing physician?)

So what percentage of practitioners do you think would admit to regularly treating with placebos in a ‘university hospital’?

The paper reported that 72% of participants admitted to regularly using placebos.

And this despite only 62% of the same group believing that placebos worked “often” (as opposed to 3% – “forever”; 35% – “Sometimes”.)

All those with medical knowledge are aware that placebos do work, and often work better than drugs with active compounds. This paper had me digging through a 2008 copy of the BMJ and the paper [subscription required] entitled What is the placebo worth? in which David Spiegel put forward the case that the most significant part of the placebo is the doctor-patient interaction.

He says

Perhaps the ratcheting down of the time that doctors spend with patients and our modern overemphasis on procedures is “penny wise and pound foolish.” Patients might respond better to real as well as placebo interventions if they were associated with a good doctor-patient relationship.

So perhaps placebo treatment has a place in medicine for some conditions. Spiegel specifically notes that a patient with a condition such as irritable bowel syndrome might be best treated by a doctor with an empathetic ear and time to listen to their story.

I think we still have a tremendous amount to learn about placebos, and studies such as the one conducted by Bernateck et al. imply that despite this obvious lack of understanding their use in clinical situations is relatively commonplace. With more research, and a better understanding of placebos, they could represent a very useful alternative treatment. Perhaps in a case where the clinician has reason to reduce the daily dose of certain pharmacological treatments for some reason or another; or simply in a case where psychophysiological treatment is a more sensible option.

However, a hospital setting is not the right place for experimentation, especially when the results of this survey suggest an assumption amongst medical practitioners that patients typically exaggerate symptoms.

Keeping on the same track – well sticking to medicine at least – another important paper, evaluated in Faculty of 1000 by Julian Wan, concerns an interesting and ubiquitous clinical situation: women presenting with lower urinary tract symptoms (LUTS). This randomized-controlled-trial seeks to establish if any improvements to current diagnostic procedures can be made.

A recent trend in general practice has been for patients to present to their doctor much earlier than has been typical previously. This makes it very difficult for the doctor to diagnose the condition without sending off for formal testing or culture, and as a result, antibiotics are typically prescribed by symptom alone.

This paper looked at  309 non-pregnant women aged 18-70 all presenting with LUTS (dysuria, nocturia, cloudy/foul smelling urine etc.) The women were randomized into five management approaches: empirical antibiotics, delayed empirical antibiotics, targeted antibiotics, dipstick result or midstream urine analysis. It certainly covers an appealing research topic, especially as LUTS represent a very common clinical situation.

As Faculty of 1000 member Julian Wan says

For many practitioners, it is common practice to simply prescribe by symptom without formal testing or culture. There is surprisingly little published about this very common approach, and no large scale randomized trial based on symptom relief and ‘delayed’ antibiotic prescribing.

In a nutshell, the conclusion is that there is no advantage from the perspective of alleviating symptoms in sending out routine midstream urine samples. The approach put forward is empirical delayed prescription to reduce antibiotic use, and targeting with a dipstick test rather than sending the samples off to a lab.

What I really like about this paper is that it makes surprising conclusions, but uses a significant evidence based study to make them. A study like this certainly makes me think that there is still plenty of research to be made into other common conditions. Medicine can sometimes be prone to treat according to status quo, and perhaps with more evidence based research, we could learn to treat more effectively?

Posted in f1000, Medicine | Tagged: , , , | 1 Comment »

Is it a cancer drug or not?

Posted by stevepog on 16 March, 2010

The media faces constant criticism from medical specialists and  advocacy groups whenever it trumpets the latest new wonder drug to cure any form of cancer.

Many spurious claims have over the years been splashed across the UK Daily Mail’s front page, prompting backlash from organisations such as the National Health Service, Cancer Research UK and even the appearance of a Facebook group with more than 40,000 members criticising the Mail’s cancer cure/cause agenda.

But the recent news that pharma giant Roche was revising its position on Avastin after the drug failed in a late-stage study, evaluating the blockbuster as a treatment for advanced stomach cancer, was an example of where the stock market, media expectations of a miracle cure and a pharma giant collided.

The Wall Street Journal said the announcement had the effect of:

‘undermining market expectations the drug could reach annual peak sales of more than eight billion Swiss francs ($7.48 billion)’

Roche’s PR team has had the very difficult job of trying to push the share price back up and regain investors confidence. One of their newest stabs at this crisis communications was a release today stating that

‘the eyesight of two patients with a rare condition was saved through the groundbreaking use of the drug Avastin’

At the time of writing, the news is only 20 minutes old so and there is little detail contained on how many people have been involved in trials by Southampton ophthalmologist Dr Andrew Lotery, only to state that his research on treating Sorsby’s Fundus Dystrophy (SFD) has been accepted by US journal Retinal Cases & Brief Reports. The release goes on:

He (Lotery) said it was the first time the drug had been used to treat the rare genetic condition(SFD) which caused the two patients, both in their 30s, to suffer blurred vision and a general deterioration of sight.
Avastin halts the growth of blood vessels and stems bleeding and is commonly injected with good results into the eyes of patients with “wet” age related macular degeneration (AMD) – the leading cause of blindness in the western world in people over 50

Avastin has already been trialled successfully in conjunction with chemotherapy in ovarian cancer sufferers so the prospect of another potential target would be welcomed by the shareholders but more importantly, by sufferers of the targeted conditions. But this is a situation where the media needs to tread carefully and wait for stronger research to appear before latching onto another cure-all drug.

New antibiotic treatments for gastric cancer

On another cancer story, Yoshio Yamaoka, an F1000 Medicine faculty Member from Japan, has looked recently at the use of various drugs to treat Helicobacter pylori infection, which often leads to gastroduodenal ulcers, gastric cancer and associated diseases.

While there are positive signs from a large multicenter trial in Japan of H. pylori antibiotics on patients with gastric cancer, Yamaoka warned that practitioners should exercise caution with regard to widespread antibiotic treatment saying,

‘if all infected persons are to be treated, we should consider the increase in frequency of antibiotic resistance and unexpected consequences such as esophageal adenocarcinoma, asthma, and autoimmune disease’

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Effects of a continuous work-flow on residents in the intensive care unit

Posted by Callum Anderson on 11 March, 2010

It is well known that the average physician in training will be expected to work more than a few 24 hour shifts during their training. It is also well known that sleep deprivation affects performance (how much? Now that’s the real question, but I digress).

I read a paper, evaluated by Faculty of 1000 member Samuel Ajizian, in which a team of scientists led by R Sharpe at the University of British Columbia have studied the effects of a continuous work-flow on residents in the intensive care unit.

Although monitoring performance of sleep deprived workers is a popular research subject (see, here, here and here), there are a couple of nice aspects to this study. Firstly, the use of a realistic total patient simulation is novel to this type of study; much of the previous body of research has focussed on more general cognitive testing and surgical simulators. The participants also assessed their own performance at various stages of the study allowing the researchers to see if the physicians could notice a drop in performance for themselves.

The simulation included performing advanced cardiac life support scenarios and management of a simulated critically ill patient.

I could spot a potential problem with this paper however. And I was not surprised to read the following statement

For the advanced cardiac life support scenarios, the mean number of major errors committed… decreased during the study period.

We have what looks like (and is subsequently judged to be) a significant ‘learning effect’, and I am surprised the team couldn’t have found a way to assuage this, perhaps by demonstrating the simulation and training physicians before observation?

Results from the patient management scenario followed expectation

The mean number of errors went up from 0.92 +/- 0.90 in the first session to 1.58 +/- 0.79 in the fourth session (p = 0.9).

Another interesting aspect of this study was that Sharpe and his team asked the physicians to conduct subjective self assessment at various stages. Compare the following results of personally assessed global score (again from patient management) with the number of errors displayed above

mean global score decreased from 56.8 ± 14.6 to 49.6 ± 12.6 (p = .02).

A discrepancy between the mean number of errors and the mean global score can be seen here, strongly suggesting that our ability to judge personal performance is not nearly as accurate at hour 20 as it is at hour 1.

Although I wouldn’t like to make any serious judgements from this paper alone, I think there is significant room for further research in this area, especially using realistic patient simulation.

Ajizian also noted in his evaluation that it would be interesting to [repeat this study and allow the residents unlimited access to their preferred caffeine source].

Doing so might provide us with some better data, especially as we tend to work under the influence of caffeine even when we aren’t particularly tired. I wonder if performance levels might correlate to the intensity or the type of stimulant used. Perhaps coffee offers a greater mental boost for physicians than tea? Any anecdotal evidence is welcome below.

Sharpe R, Koval V, Ronco JJ, Dodek P, Wong H, Shepherd J, Fitzgerald JM, Ayas NT. The impact of prolonged continuous wakefulness on resident clinical performance in the intensive care unit: a patient simulator study. Crit Care Med 2010 38:766-70

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Have we overlooked the drinking cup?

Posted by Callum Anderson on 3 March, 2010

One of the things I love about scientific knowledge is that it is always in a state of flux. Theories are constantly being amended, rejected or confirmed by the community. In short, there is always room for more research regardless of how well trodden the ground may be.

In this vein, I read an interesting paper, evaluated by Faculty of 1000 member Phil Fischer (link to evaluation free for 3 months).

Simonne Rufener and a team based jointly at the University of Bern, Swiss Tropical Institute in Basel and Institute of Aquatic Sciences and Technology at Dübendorf have published a field study which expands significantly on previous research.

Every year, some 1.6 million people die due to diarrhoea associated with contaminated drinking water. In countries without running water, where drinking water must be collected at source, plenty of research has shown that the water is often contaminated at various stages before consumption, even if the source is relatively free from contamination (see here, here, and here).

The paper hypothesizes that in-house recontamination of drinking water after treatment is a significant, often overlooked problem in the developing world. The team visited 81 households in Bolivia and took 347 water samples from current sources, treated water, transport vessels and drinking vessels. Looking at levels of E. coli at various stages of the water journey, the Rufener and his team were able to show that disinfection at source, or even at home prior to consumption, did not effectively reduce bacteria levels. In fact the paper makes the point that even after home based water treatment such as boiling or SODIS

Only 36% of the treated water samples were free from E. coli

The real conclusion to acknowledge is that disinfecting water at source or at home will continue remain a relatively ineffective treatment while the majority of drinking vessels are still contaminated with E. coli. In the future, we may find solutions which combine water-source interventions, with effective hygiene education to help reduce levels of bacteria in the drinking cup itself.

Rufener S et al J Health Popul Nutr 2010 28 :34-41

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Is there an alternative?

Posted by Callum Anderson on 19 February, 2010

I read an article recently in a well-known London newspaper which raised an issue I have been thinking about for a long time. What happens when unregulated medicine actually causes more harm than good?

I won’t name names (although the original article does), but in a nutshell, a woman was prescribed pills by a practitioner of Chinese medicine containing the (subsequently banned) substance [aristolochic acid] to treat her acne. On the one hand the pills did their job, and the acne cleared up, but on the other hand they were destroying her kidneys, inducing urinary tract cancer and eventually led to a heart attack. The woman now needs dialysis treatment three times a week and is no longer able to work.

The problem here stemmed from the fact that the sale of Chinese medicine is completely unregulated, and it is pretty unlikely that a practitioner selling the pills is going to have a subscription to Mutagenesis, in which a 2002 article reported the following

It is concluded that there is significant evidence that AA is a powerful nephrotoxic and carcinogenic substance with an extremely short latency period, not only in animals but also in humans. In particular, the highly similar metabolic pathway of activation and resultant DNA adducts of AA allows the extrapolation of carcinogenesis data from laboratory animals to the human situation. Therefore, all products containing botanicals known to or suspected of containing AA should be banned from the market world wide.

And anyway, this study proved to be too little, too late. By the time the ban was in place, the woman had been taking the pills for a little over five years, and the damage was irreversible.

Now I’m not suggesting that we should blanket ban alternative therapies because of one mistake (albeit a pretty huge one). And as my esteemed colleague RPG has previously noted, many alternative remedies have active ingredients which really do work.

However, I can’t help feeling that if alternative medicine (and I use the term ‘medicine’ with the lightest touch) wants to be taken seriously, it really needs to become self-regulating, and ensure things like this can’t happen again.

What form might that regulation take? Well for a start we could insist that all practitioners of alternative medicine are registered with and accredited by their respective council. For Chinese medicine this would be The Chinese Medicine Council, UK. Secondly we need to give these independent bodies real power, the ability to blacklist practitioners and ban substances without exception, and ensure that the medicine suppliers are subject to rigorous product testing before bringing new products to market.

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Food for thought

Posted by Callum Anderson on 17 February, 2010

A recent evaluation on Faculty of 1000 Biology highlights a novel advance in the fight against adolescent obesity.  In what could be considered the first behavioural trial to treat obesity (i.e. not based on a drug treatment), a team led by Anna L Ford at The Bristol Care of Childhood Obesity Clinic found that by retraining the eating habits of obese patients, sustained weight loss can be achieved.

The trial centres around a new technology called the Mandometer, which has previously been marketed as a device to cure Anorexia-Bulimia.

Mildly humorous instructional video.

The device is essentially a set of weighing scales, linked to a computer, which monitors how much you are eating and how fast you are eating it. Participants record how full they feel on a 100 point scale at various times throughout the meal, and the device then tells them to eat more slowly or quickly depending on their answers.

In recent years, we have come to redefine Anorexia-Bulimia as a behavioural or psychological rather than a medical condition. This study puts forward the argument that it may well be time to look at obesity in the same manner.

As the authors say

An intervention aimed at slowing down speed of eating and reducing portion size through retraining eating behaviour is a useful adjunctive therapy to standard lifestyle modification in obese adolescents.

Now it isn’t particularly surprising that when told what to eat, and how quickly to eat it, the trial participants lost weight. Nor is the conclusion that behavioural based eating interventions are a good way to sustain weight loss a real revelation. However this trial does offer some hope for making sure that patients retain a healthy weight after observation has ended, mainly because the device can be used at home and without supervision. Perhaps technology based solutions may provide a fruitful area of study in the future?

Posted in f1000, Literature, Medicine | Tagged: , , , | 4 Comments »

On the run-12Feb10

Posted by rpg on 12 February, 2010

Cancer Causes Cancer!

Well, that was the headline we should have gone with. It is of course a hat tip to the Daily Mail, a tabloid publication that is desperate to tell the UK population that just about everything causes cancer. (I found that website by googling ‘cancer causes daily mail’, which is in itself quite a neat headline. Unfortunately I think we’re closer to curing cancer than curing the Daily Mail. Oh well.)

So, we know that tumours have this nasty habit of sending out malignant cells into the rest of the body. They break off from the primary site and get into the blood and lymphatic systems, occasionally washing up in convenient organs where they can settle down and create new tumours, or metastases. This is partly why cancer is so difficult to cure: you can cut out the original malignant growth, zap it with X-rays and take all sorts of evil drugs (‘evil’ because they are designed to kill cells, and you’re made up of cells; and discrimination between the cancer cells and normal cells is a huge problem); but if one metastatic cell survives, you have to start all over again. And if it’s managed to find a home deep in a bone, or the brain, or somewhere equally inaccessible, it’s game over.

It turns out things are even worse than that. Circulating tumour cells, if they find their way back to their original ‘home’, can actually stimulate growth of the original cancer. Nasty. As the authors say,

Tumor self-seeding could explain the relationships between anaplasia, tumor size, vascularity and prognosis, and local recurrence seeded by disseminated cells following ostensibly complete tumor excision.

‘Ostensibly complete tumor excision’—that’s right, because no matter how good your surgeon is, you can never be sure you’ve cut every last bit out; or that some cells haven’t already gone walkabout.

The good news is that certain cytokines derived from the tumour, IL-6 and IL-8, act to attract the circulating cells, and that they get back in via the matrix metalloproteinase collagenase I (MMP-1) and fascin-1 (it’s the actin cytoskeleton again! These guys get everywhere). If we can find a way to selectively block these pathways we should be able to start thinking about appropriate therapeutic approaches. Gentlemen (and ladies), start your (grant-writing) engines.

Kim, M., Oskarsson, T., Acharyya, S., Nguyen, D., Zhang, X., Norton, L., & Massagué, J. (2009). Tumor Self-Seeding by Circulating Cancer Cells Cell, 139 (7), 1315-1326 DOI: 10.1016/j.cell.2009.11.025

Twitter storm

It’s been pretty hectic on the twittertubes this week. Following a random conversation at the Scholarly Kitchen I suggested writing papers in 140 characters would be a wheeze. I turned it into a competition, and we had an amazing response. Check back on Monday to find out who’s the lucky winner of a bag of f1000 swag.

Badger Wars

vermin shooting verminI don’t have a lot to say about badger culling to prevent/reduce bovine TB (except maybe to say that killing vermin with a high-powered rifle and decent ‘scope is one of the most humane ways of doing this).

I just like the sound of a ‘randomized badger culling trial’. Oh, and when someone ‘explains’

This trial was undertaken in very specific circumstances and it could be misleading to extrapolate the findings to any future control program.

you can be pretty sure there’s a vested interest or extreme prejudice somewhere. Even when the trial shows that there’s no economic benefit.
Jenkins, H., Woodroffe, R., & Donnelly, C. (2010). The Duration of the Effects of Repeated Widespread Badger Culling on Cattle Tuberculosis Following the Cessation of Culling PLoS ONE, 5 (2) DOI: 10.1371/journal.pone.0009090

Valentine’s Day

Just a reminder to all you chaps out there—it can’t hurt to buy some flowers, even if you don’t want to buy into the whole commercialization thing. A nice dinner doesn’t cost you much either, and could pay dividends in the romance stakes. But at the very least, show you really care by getting checked out:

Take a test for #Valentine‘s Day. Sexual health appointments across Lincolnshire within 48 hours. Call 01522 539 145

It gets pretty lonely up there in Lincolnshire. Have a good weekend, and I hope it’s full of lovehearts and kisses. Failing that, a beer or three can have much the same effect.


Posted in Friday afternoon, Literature, Medicine, Random, Science | Tagged: | 1 Comment »

Money

Posted by rpg on 21 January, 2010

The distribution and uptake of antivirals and vaccination was in the news quite a bit before Christmas. H1N1 swine flu didn’t turn out to be the Armageddon some commentators were forecasting, but I don’t think it’s overstating the case to say that we dodged a bullet there. In cases like this we might expect the government to give a clear message, based on the best possible epidemiology. No, please, stop laughing. After all, the UKian government was right about the MMR combined vaccine, even if they did handle the situation incredibly poorly.

And that’s a problem, isn’t it? In our culture we don’t trust what the government tell us anymore. That may or may not be a good thing, but it certainly creates problems for public health policy, especially in a potential epidemic situation. Sometimes it’s quite clear what the right thing to do is, but how do we get them to do it?

A paper just published in PNAS and reviewed on f1000 (link free for three months) sets out an economic framework for controlling transmissible and evolving diseases. Now, I’m not an epidemiologist (you should possibly go and talk to my mate Bill if you’re that interested), and the argument therein apply more to a healthcare system that is not free at point of care (Obama’s reforms notwithstanding), but it’s an interesting paper nonetheless.

Antibiotic treatment for otitis media

“public policies such as taxing and subsidizing goods are frequently used to correct (for public benefit) the private actions of individuals when externalities, or side effects, of these actions exist.”

By comparing four different scenarios and addressing negative externalities, the authors predict where financial dis/incentives should be applied for maximum public health benefit. The scenarios discussed here are

  1. Tetanus: infectious but not transmissible between humans, and no herd immunity
  2. Measles: infectious, effective vaccination that generates a herd effective by reducing transmission
  3. Otitis media: non-transmissible, but unnecessary antibiotic treatment can lead to the negative externality of antibiotic resistance
  4. Pandemic influenza: antiviral treatment generates negative (resistance) and positive (reduced transmission) externalities.

Antiviral treatment for pandemic flu

There’s a whole heap of math in this paper, and although (or perhaps because) I’m supposed to be coming up with robust formulae for our rankings on the main site, it makes my brain hurt.

I find the thesis that economic impact can be leveraged to get maximum public health benefits an interesting one. I’m not sure how that would apply to the UK, for example, where the cost of healthcare is more-or-less invisible.

Infectious diseases tend to evolve quite rapidly when we attempt to control them, whether we use antibiotics, other drugs or prophylactic vaccinations. The framework expounded in this paper should prove to be readily applicable to a wide range of such diseases. Assuming, of course, that the authorities responsible for public health have the appropriate fiscal executive power, and access to current and accurate scientific information…

Read the rest of this entry »

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