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CDC, Chronic Disease, Health Policy, In the News, Infectious Disease, Public Health

To screen or not to screen for hepatitis C

Hep CIn the past few years, newer, more effective treatments have been introduced for hepatitis C – a disease that can lead to chronic liver problems and in the worst cases, liver cancer. In 2012, the Centers for Disease Control and Prevention recommended screening for the disease in anyone born between 1945-1965, since about three-quarters of cases occur in this age group, the Baby Boomers. Last year, the World Health Organization also called for more screening for the disease.

But in a recent analysis piece in The BMJ (formerly the British Medical Journal), several scientists, including Stanford epidemiologist John Ioannidis, MD, DSc, lay out the case that universal screening in this age group may not be warranted. A story in the San Francisco Chronicle today quotes Ioannidis:

“The question is whether these aggressive screening policies are justified and whether they would result in more benefit than harm,” said Dr. John Ioannidis...“We know very little about the potential harms of these drugs, especially in the long-term. And we don’t know how they will translate into long-term benefits.”

Ioannidis and his colleagues suggest that instead of rolling out widespread screening programs, researchers, as soon as possible, start a randomized trial to test the usefulness of screening and who may benefit from it.

On top of the medical uncertainties of the new treatments, they’re expensive, costing about $84,000 for the 12-week treatment. But they’ve been shown to cure patients of their hepatitis C infections at the end of that 12 week stint. Not all people who contract the disease will develop chronic infections, but a majority – two-thirds -will. Twenty percent of those cases will go on to develop severe liver disease.

Advocates of universal screening say that the new screening strategy could identify many people who don’t know they’re sick – symptoms from hepatitis C chronic infections can take years to manifest. But Ioannidis and his colleagues note that many people will get unnecessary treatment and that the long-term uncertainties of the treatment should be taken into consideration.

Previously: Despite steep price tag, use of hepatitis C drug among prisoners could save money overallA primer on hepatitis CFor patients with advanced hepatitis C, benefits of new drugs outweigh costsDrugs offer new hope for hepatitis C and Program examines hepatitis C, the “silent epidemic”
Photo of hepatitis C virus by AJ Cann

Addiction, Pain, Public Health, Research

Medical marijuana and the risk of painkiller overdose

Medical marijuana and the risk of painkiller overdose

medical marijuanaAfter a study published this fall showed that that opioid overdoses (e.g., with painkillers such as Oxycontin) occur at lower rates in states with legalized medical marijuana, many people interpreted the results as proof that using medical marijuana lowers an individual’s risk of overdose. For example, some speculated that marijuana allows people in pain to forgo using opioids or at least use them in lower doses. Other suggested that medical marijuana reduces users’ consumption of alcohol and anti-anxiety medications, both of which make opioid use more likely to lead to overdose. Still others hypothesized that medical marijuana improves mental health, reducing the risk of intentional opioid overdose (i.e., suicide attempts),

However, all of this speculation was premature. Many things that are associated when geographic areas are compared are not associated in the lives of the individuals who reside in those areas. For example, geographic areas with higher rates of cigarette smoking and higher radon exposure have lower cancer rates, even though individuals who smoke and/or get exposed to radon have higher rather than lower risk of cancer.

The only way to understand the influence of medical marijuana on individuals’ risk of opioid overdose is to actually research individuals, and that is what an Australian team has done. In a recently published study of more than 1,500 people who were on prescribed opioids for pain, they examined experiences with medical marijuana.

Seeking pain relief from medical marijuana was common in the sample, with 1 in 6 participants doing so and 1 in 4 saying they would do so if they had ready access to it. The results did not support the idea that medical marijuana users are at relatively low risk of opioid overdose. Indeed, on every dimension they appeared to be at higher risk than those individuals who did not use medical marijuana for pain.

Specifically, relative to individuals who only used opioids for pain, the medical marijuana users were on higher doses of opioids, were more likely to take opioids in ways not recommended by their doctor, were over twice as likely to have an alcohol use disorder and four times as likely to have a heroin use disorder. Medical marijuana users were also over 50 percent more likely to be taking anti-anxiety medications (benzodiazepines), which when combined with opioids are particularly likely to cause an overdose.

Neither did the medical marijuana users have better mental health. Almost two-thirds were depressed and about 30 percent had an anxiety disorder.   These rates were half again as high as those for non-medical marijuana users.

Medical marijuana thus appears to be commonly sought for pain relief among people who are taking prescribed opioids for pain. But in this population, it’s a marker for much higher rather than lower risk for opioid overdose.

Addiction expert Keith Humphreys, PhD, is a professor of psychiatry and behavioral sciences at Stanford and a career research scientist at the Palo Alto VA. He has served in the past as a senior advisor in the Office of National Drug Control Policy in Washington, DC. He can be followed on Twitter at @KeithNHumphreys.

Previously: Assessing the opioid overdose epidemicTo reduce use, educate teens on the risks of marijuana and prescription drugs and Study shows prescribing higher doses of pain meds may increase risk of overdose
Photo by David Trawin

Health Costs, Pain, Public Health, Research

Study examines trends in headache management among physicians

Study examines trends in headache management among physicians

4175034274_63cd0d4a7c_zAn estimated 12 percent, or 36 million Americans, suffer from migraines, resulting in an economic loss of $31 billion each year due to lost productivity, medical expenses and absenteeism.

Making lifestyle changes, such as exercising regularly, getting adequate sleep, reducing stress and cutting food triggers from your diet, have been shown (.pdf) to be effective ways to manage headache symptoms. But research recently published in the Journal of General Internal Medicine shows that physicians are increasingly ordering medical tests and providing referrals to specialists instead of offering counseling to patients on how changing their behavior could relieve their pain. Medical News Today reports:

The study, which analyzed an estimated 144 million patient visits, found a persistent overuse of low-value, high-cost services such as advanced imaging, as well as prescriptions of opioids and barbiturates. In contrast, the study found clinician counseling declined from 23.5 percent to 18.5 percent between 1999 and 2010.

The use of acetaminophen and non-steroidal anti-inflammatory drugs like ibuprofen for migraine remained stable at approximately 16 percent of the medications. Meanwhile, the use of anti-migraine medications such as triptans and ergot alkaloids rose from 9.8 percent to 15.4 percent. Encouragingly, guideline-recommended preventive therapies – including anti-convulsants, anti-depressants, beta blockers and calcium channel blockers – rose from 8.5 percent to 15.9 percent.

Unlike with the treatment of back pain, researchers found no increase in the use of opioids or barbiturates, whose usage should be discouraged, although they were used in 18 percent of the cases reviewed.

Researchers also found a significant increase in advanced imaging such as CT scans and MRIs, from 6.7 percent of visits in 1999 to 13.9 percent in 2010. The use of imaging appeared to rise more rapidly among patients with acute symptoms, compared to those with chronic headache.

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Cancer, Public Health, Research, Stanford News, Technology

Stanford researchers explore new ways of identifying colon cancer

Stanford researchers explore new ways of identifying colon cancer

B0006254 Human colon cancer cellsAfter my aunt died from colorectal cancer several years ago, my father was primed when his doctor suggested he get screened for colon cancer himself, and it’s a good thing he did. The doctor who performed the colonoscopy (a visual exam of the rectum and colon) found a large precancerous polyp.

If my father had skipped out on being screened, he would likely have been dead in five years. He was lucky that the polyp was easily visible during the exam, but not all lesions that turn out to be cancerous are. Some pre-cancerous areas are flat or depressed and much harder to see on colonoscopies or sigmoidoscopies.

Now, a team of Stanford researchers led by Matthew Bogyo, PhD, a professor of pathology and microbiology and immunology, are working on ways to make these less obviously cancerous regions on the colon more visible during screenings. They’re doing so by developing compounds that begin to fluoresce – or glow – when they attach themselves to enzymes called cysteine cathepsins. Present in nearly all cells of our bodies, cysteine cathepsins are abundant in and around cancerous tumor sites. “They’re regulators of inflammation,” Bogyo said when we spoke recently. “When a tumor starts to form, you get inflammation, and the tumor benefits from this inflammatory response. We take advantage of that inflammation, using these enzymes as markers.”

The researchers studied how well the compounds, called quenched fluorescent probes, identified lesions in two strains of mice – one, a specially bred strain of mice that produce a higher number of intestinal polyps and the other a wild-type mouse in which colon cancer is induced by a orally administered drug – as well as in human tissue samples. Their study was published today in the scientific journal Chemistry and Biology. A statistical analysis of the results showed that the probe was highly effective at identifying true cases of intestinal lesions and had a low rate of false positives. “Optical contrast agents allow us to see where lesions are and pick out problem areas,” Bogyo told me. “When they are ‘found’ by these enzymes, they turn bright.” Although it’s hard to compare a test like this to current methods of colorectal cancer screening, which do not involve the use of contrast agents, Bogyo is encouraged by the study’s results.

Bogyo noted that he was surprised that the probe worked just as well identifying lesions in mice intestines when it was applied topically to the inside surface of the intestines as when it was injected into the bloodstream. This opens up the possibility that – if approved for use in humans – it could simplify how the probe is used. A colonoscopist could simply spray the contrast agent out of the end of the endoscope to get a confirmation of potentially dangerous lesions.

Getting these kinds of probes into human use is still years away. Currently, no other targeted optical contrast agents are approved for human use, and the process of gaining approval from the Federal Drug Administration, much like developing a new drug, can be an expensive and arduous one. The probes would need to be tested for safety in animals and eventually humans before they could be approved for widespread use.

But the field is a promising one, and Bogyo is not the only researcher pursuing contrast agents as cancer-screening tools. He is optimistic and is currently exploring companies that may want to invest in developing cysteine cathepsin contrast agents for human use. Incorporating contrast agents into current practices “would move the field forward and make colonoscopy more accurate and rapid,” he said.

Previously: Researchers explore colonoscopy’s effect on the incidence of colorectal cancer, No day on the beach: A colon cancer survivor’s story, The cost-effectiveness of screening colon-cancer patients for Lynch disorder and Bacterial balance in gut tied to colon cancer risk
Photo of colon cancer cells by Wellcome Images

Health and Fitness, Parenting, Pediatrics, Pregnancy, Public Health

Exercising during pregnancy may reduce children’s risk of hypertension

Exercising during pregnancy may reduce children's risk of hypertension

7619293834_c18e2bee15_zRegular physical activity during pregnancy has been shown to benefit both mom and baby: Past studies found that exercise can help expectant mothers manage weight gain, sleep better, improve circulation and reduce swelling or leg cramps and increase their endurance in preparation for childbirth. A growing body of evidence also suggests that maternal exercise can boost babies’ brain development and influence a child’s health into adulthood.

Now findings (subscription required) published in the Journal of Sports Medicine and Physical Fitness show that by exercising, moms may reduce their children’s risk of developing high blood pressure, or hypertension. The Michigan State University researchers say their findings are significant because earlier studies have shown babies with low birth weight are more likely to have poor cardiovascular health and an increased risk of hypertension. PsychCentral reports:

[Researchers] initially evaluated 51 women over a five-year period based on physical activity such as running or walking throughout pregnancy and post-pregnancy.

In a follow up to the study, they found that regular exercise in a subset of these women, particularly during the third trimester, was associated with lower blood pressure in their children.

“This told us that exercise during critical developmental periods may have more of a direct effect on the baby,” [said lead author James Pivarnik, PhD].

The finding was evident when his research team also discovered that the children whose mothers exercised at recommended or higher levels of activity displayed significantly lower systolic blood pressures at eight to 10 years old.

“This is a good thing as it suggests that the regular exercise habits of the mother are good for heart health later in a child’s life,” Pivarnik said.

Previously: Extreme pregnancy: A look at exercise and expectant moms, Could exercise before and during early pregnancy lower risk of pre-eclampsia?, Are women getting the message about the benefits of exercising during pregnancy? and Pregnant and on the move: The importance of exercise for moms-to-be
Photo by Nathan Rupert

Genetics, In the News, NIH, Public Health, Research

The genomics revolution and the rise of the “molecular stethoscope”

The genomics revolution and the rise of the “molecular stethoscope”

ATCGBack in 2012, Stanford bioengineer Stephan Quake, PhD, and colleagues sequenced the genome of a fetus using only a maternal blood sample for the first time. Technology Review later recognized the work as one of the “10 Breakthrough Technologies 2013.”

In a recently published opinion piece (subscription required) in the Wall Street Journal, Quake and Eric Topol, MD, a professor of genomics at the Scripps Research Institute, discuss the method and how it exemplifies the potential of the genomics revolution to provide scientists and clinicians with a new type of stethoscope that allows one to see “inside the body at the molecular level.” They write:

The prenatal molecular stethoscope is the first truly widespread clinical application to result from the human-genome project. The National Institutes of Health has an opportunity to build on this new knowledge of “alien” DNA in healthy individuals, and determine whether it may change their clinical course—the molecular-stethoscope approach. Meanwhile, whole genome sequencing of the germ-line, or native, DNA from populations is under way, with seven ongoing world-wide projects, each sequencing the native DNA from 100,000 or more individuals. It’s projected that nearly two million people will be sequenced by 2017.

Already, the scientific literature is brimming with new applications of the molecular stethoscope. Two studies in the New England Journal of Medicine in December showed that more than 10% of healthy people over age 65 carried so-called somatic mutations in their blood cells, and that these individuals had more than a tenfold increased risk of subsequently developing a blood-based cancer.

Previously: Stanford-developed eye implant could work with smartphone to improve glaucoma treatmentsA simple blood test may unearth the earliest signs of heart transplant rejection and Step away from the DNA? Circulating *RNA* in blood gives dynamic information about pregnancy, health
Photo by Stefano

Infectious Disease, otolaryngology, Public Health, Research, Science, Stanford News

New version of popular antibiotic eliminates side effect of deafness

New version of popular antibiotic eliminates side effect of deafness

About five years before he died, my father was prescribed gentamycin, one of the most commonly used class of antibiotics called aminoglycosides, for a heart infection of unknown origins. The antibiotic successfully cured him of the life-threatening infection, but it also left him with a life-changing side effect, one with the strange-sounding name of oscillopsia.

Oscillopsia is a balance disorder that creates the illusion of an unstable visual world in its patients that can be quite disabling. For my father, it messed with his tennis game in the remaining years of his life and forced him to sit on the couch when he would rather have been running around with his grandchildren. But he was lucky. In addition to balance disorders, side effects from these cheap and extremely effective antibiotics that have been used for decades worldwide, include high rates of deafness and kidney damage.

ChengNow, Stanford researchers led by otolaryngologoist Alan Cheng, MD, (pictured at left) and Tony Ricci, PhD, have made a modified version of these drugs that successfully treats infections without the side effects of deafness and kidney damage. In a press release on the study, which was published Friday in the Journal of Clinical Investigation, I wrote about a boy (whose story is also told in this Stanford-produced video) who lost his hearing from these antibiotic treatments during his battle with cancer:

On Christmas Eve, 2002, Bryce Faber was diagnosed with a deadly cancer called neuroblastoma. The 2-year-old’s treatment, which, in addition to surgery, included massive amounts of radiation followed by even more massive amounts of antibiotics, no doubt saved his life. But those same mega-doses of antibiotics, while staving off infections in his immunosuppressed body, caused a permanent side effect: deafness.

“All I remember is coming out of treatment not being able to hear anything,” said Bryce, now a healthy 14-year-old living in Arizona. “I asked my mom, ‘Why have all the people stopped talking?’ He was 90 percent deaf.

These are extremely important life-saving drugs, Ricci, a basic scientist and expert on the biophysics of the inner ear, told me. But they could be so much better if patients didn’t have to risk their toxic side effects. So far, the new versions of the drug that he and colleagues developed have only been tested in mice, but the hope is to conduct clinical trials as soon as is safely possible. “If we can eventually prevent people from going deaf from taking these antibiotics, in my mind, we will have been successful,” Ricci said. “Our goal is to replace the existing aminoglycosides with ones that aren’t toxic.”

The new drugs have not yet been tested as to whether they still cause balance disorders. That’s on the docket for the future. But my article describing this wedding of basic science with clinical treatment is a hopeful reminder of the importance of modern-day scientists to public health.

Previously: Listen to this: Research upends understanding of how humans perceive sound; Stanford developed probe aids study of hearing and Studying the inner ear and advancing research in developmental biology

Behavioral Science, Public Health, Sleep

Six simple ways to improve your sleep for the holidays

Six simple ways to improve your sleep for the holidays

IMG_5595The holiday season is usually one of the busiest – and often most stressful – times of the year. It’s also a season that often brings poor sleep. To improve your health and your mood, consider six simple ways that you can maintain healthy sleep during the hustle and bustle of the holidays and even discover the resolve to improve your sleep in 2015.

1. Go to bed when you’re sleepy.

It seems obvious, but it isn’t always easy to do: Sleep most easily comes when we are feeling sleepy. Insomnia, characterized by difficulty falling or staying asleep, can plague us throughout the year. With the added stress of the holidays, it can be even harder to fall asleep.

Many insomniacs will start to go to bed earlier, or stay in bed long after waking, to make up for lost sleep. This desperation often thins out sleep and makes it less refreshing. Imagine showing up for a holiday feast after having snacked all day. You wouldn’t have much of an appetite. If you spend too much time in bed, or take naps, you similarly will show up for the eight-hour feast of sleep without much interest.

Prolonged wakefulness helps to build our drive for sleep and staying up a little later until you feel sleepy can ease insomnia.Preserving 30 to 60 minutes to relax before bed can also aid this transition.

2. Ease yourself into a new time zone to prevent jet lag.

If you’re flying across the world, or even across the country, you may find that your sleep suffers. This is due to our body’s natural circadian rhythm, which regulates the timing or our desire for sleep. This rhythm is based in genetics, but it is strongly influenced by environmental cues, especially morning sunlight exposure.

If you suddenly change your experience of the timing of light and darkness by hopping on a jet plane, your body will have to play catch up. As a general rule: “West is best and east is a beast.” This points out that westward travel is more tolerated because it’s nearly always easier to stay up later than it is to wake up earlier.

Another rule of thumb is that it takes one day to adjust for each time zone changed. If you travel across three time zones, from San Francisco to New York City, it will take about three days to adjust to the new time zone. This adaptation can be expedited by adopting the new time zone’s bedtime and wake time before you depart. If you’re like most people, your best intentions might not lead to pre-trip changes.

Never fear: To catch up once you arrive, delay your bedtime until you are sleepy, fix your wake time with an alarm, and get 15 minutes of morning sunlight upon awakening.

3. Put an end to the snoring.

Whether you’re staying in grandma’s spare room or sharing a hotel suite, close quarters during the holidays may call attention to previously unnoted snoring and other sleep-disordered breathing like sleep apnea.

Remember that children should never chronically snore; if they do, they should be seen by a sleep specialist. Adults don’t have to snore either. Snoring is commonly caused by the vibration of the soft tissues of the throat. If the airway completely collapses in sleep, this is called sleep apnea. This may lead to fragmented sleep with nocturnal awakenings and daytime sleepiness. It is also commonly associated with teeth grinding and getting up to urinate at night.

When sleep apnea is moderate to severe, it may increase the risk of other health problems including hypertension, diabetes, heart attack, stroke, and dementia. It’s more than a nuisance, and if you or a loved one experience it, further evaluation and treatment is warranted.

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Behavioral Science, Health and Fitness, Nutrition, Obesity, Public Health, Research

Perceptions about progress and setbacks may compromise success of New Year’s resolutions

3336185391_60148a87fa_zMy physical therapist is constantly telling me to pause during the workday and take stretch breaks to counter act the damage of being hunched over a computer for hours on end. After every visit to his office, I vow to follow his advice, but then life gets busy and before I know it I’ve forgotten to keep my promise.

So I decided that one of my New Year’s resolutions will be to set an alarm on my phone to serve as a reminder to perform simple stretches throughout the day. Keeping in mind that a mere eight percent of people who make resolutions are successful, I began looking for strategies help me accomplish my goal. My search turned up new research about how the perception of setbacks and progress influence achievement of behavior change. According to a University of Colorado, Boulder release:

New Year’s resolution-makers should beware of skewed perceptions. People tend to believe good behaviors are more beneficial in reaching goals than bad behaviors are in obstructing goals, according to a University of Colorado Boulder-led study.

A dieter, for instance, might think refraining from eating ice cream helps his weight-management goal more than eating ice cream hurts it, overestimating movement toward versus away from his target.

“Basically what our research shows is that people tend to accentuate the positive and downplay the negative when considering how they’re doing in terms of goal pursuit,” said Margaret C. Campbell, lead author of the paper — published online in the Journal of Consumer Research — and professor of marketing at CU-Boulder’s Leeds School of Business.

Given these findings, researchers suggest you develop an objective method for measuring your progress and monitor it regularly.

Previously: Resolutions for the New Year and beyond, How learning weight-maintenance skills first can help you achieve New Year’s weight-loss goals, To be healthier in the new year, resolve to be more social and Helping make New Year’s resolutions stick
Photo by Laura Taylor

Nutrition, Parenting, Public Health

“Less is more”: More holiday eating tips from a Stanford nutrition lecturer

"Less is more": More holiday eating tips from a Stanford nutrition lecturer

cake-buffet-58682_1280My grandmother is fortunate enough to live within an easy drive of the Shady Maple Smorgasbord, a Pennsylvania Dutch-style dining extravaganza in Lancaster County. It’s the size of a large auditorium, packed with tables and two gigantic buffet lines. It’s the biggest restaurant, serving the most food, to the most people, that I’ve ever seen.

For dinner, each day the buffet includes: “46 salad bar items, 3 soups, 8 homemade breads & rolls, 4 cheeses, 8 meats, 14 vegetables, 10 cold desserts, 3 hot desserts, 8 pies, 6 cakes, sundae bar & many beverages.” Plus the daily specials. On Tuesday, for example, there’s also: “salmon, Cajun catfish, cod, oyster stew, beef brisket, New York strip steak and baked potatoes.”  A surfeit of tastiness, abundance beyond words — mmmm, mmmm, let’s go!

Not so fast, Stanford-based dietician, Maya Adam, MD, would say. “Size matters. We can enjoy absolutely any food, as long as its consumed in moderation,” she writes in a Healthier, Happy Lives Blog post, published today by Stanford Children’s Health.

That means no King Size KitKat and no seconds at the smorgasbord dessert line, either. Try using smaller dishes, Adam suggests. Cut servings in half, eat half, save some for later or share with a friend. And pay attention to the food. No texting, TV watching or mindlessly shoveling food into your mouth. Savor each bite, Adam writes:

The truth is, when we eat real, fresh food in modest amounts (even if it’s cooked with a pat of butter and a sprinkle of salt) it doesn’t take much to leave us feeling completely satisfied.

Don’t flip out if you just can’t resist that smorgasbord. But practice moderation — that’s the real way to think big about food.

Previously: Diabetes and nutrition: Healthy holiday eating tips, red meat and disease risk, and going vegetarian, Where is the love? A discussion of nutrition, health and repairing our relationship with food and “Less is more”: Eating wisely, with delight, during the holidays 
Photo by Hans

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