Ebola vs. COVID-19: public health lessons from Liberia

There is a plethora of literature, addressing public health policies regarding COVID-19. The following paragraphs are excerpted from an article by Anfaara et al. published in Social Science and Medicine, January 2025

"Like elsewhere in the world, care work is gendered, with women bearing the brunt of caregiving during disease outbreaks or health emergencies. However, in Liberia, we argue that the inadequacies of the health system and past political administrations further exacerbated the care burden on women. While this aligns with our theoretical framework, it is noteworthy that despite both governments (Sirleaf and Weah) representing the elite ruling class in Liberia, our participants seem to credit one administration for being more responsive to disease containment. For instance, our participants perceived the Sirleaf administration's willingness to include grassroots organisations and other major stakeholders in Ebola management as a collective effort and a critical reason for the success of Ebola containment. This is probably because, during the initial crisis stage of Ebola, the Sirleaf administration created the National and County-level Ebola task force to brainstorm and initiate strategies to mitigate the spread of Ebola before the arrival of international support. Women's groups, in particular, were invited to be part of the national Ebola response, and there was regular Ebola messaging and communications from the government during this period; as well, on multiple occasions, Sirleaf called for an "all-hands-on-deck" approach to Ebola containment (WHO, 2015; BBC, 2014). Study participants observed that similar strategies were not fully implemented during the COVID-19 pandemic.

 

Certainly, the Weah administration implemented some of the post-Ebola disease management strategies to contain COVID-19. These included early surveillance, implementing a state of emergency, and restricting local and international travel (Babalola et al., 2022). Yet, participants perceived the administration's approach to COVID-19 management as unitary due to its exclusion of grassroots community-based groups in its response strategies and the government's promotion of alternative COVID-19 remedies. It is possible that the Weah's administration promotion of an alternative solution to COVID-19 containment (see News Public Trust, 2020) may have undermined vaccine uptake and reinforced conspiracy theories about the disease. This experience is not unique to Liberia; in fact, many studies have shown that leadership by positive examples reinforce scientifically proven disease management strategies while negative examples erode trust (Kutor et al., 2022; Nyenswah et al., 2016)."

Anosognosia

 From Greek origin meaning "without knowledge of the disease." You may also hear it called "lack of insight." What it boils down to is that the person is unaware of their condition and unable to accept it.
This is not a stubborn attitude or driven from denial. It is the brain being incapable of processing the fact that their thoughts and moods don’t reflect reality. Accompanied with confabulation (generation of fabricated stories that the patient believes to be true), and blindness are suggestive of damage to occipital lobes of the brain.

Publication Ethics: Unintended consequences of sanctions

The latest changes to US sanctions on Iran, designed to discourage the country from developing nuclear weapons, seem to have caused confusion, leading to some journal editors effectively boycotting research from Iranian medical practitioners and academics.

Regulations set out by the US Office of Foreign Assets Control state that US citizens are authorised to engage in ordinary transactions related to written publications as long as the parties to the transactions are not employed by the Iranian government. Most Iranian universities, hospitals, and research centers are government owned but the regulations specify that the sanctions do not apply to any academic and research institutions or their staff.

Nevertheless, Iranian doctors have told the BMJ that several papers have been refused by journals in the US and Australia in recent months because of the sanctions.

The editor of the Journal of Allergy and Clinical Immunology (JACI), which is owned by Elsevier, explained in an email to an assistant professor in the department of paediatrics at Tehran University of Medical Sciences that the journal could not accept his paper because “US owned journals are unable to handle scientific manuscripts which are authored by Iranian scientists, employed by the Government of Iran.”

Papers from Iranians are also known to have been turned down by the American Journal of Cardiology (also published by Elsevier), the Journal of Ocular Pharmacology and Therapeutics (published in the US by Marie Ann Liebert), and the Australian journal Ophthalmic Epidemiology (published by Informa Healthcare in the UK), all of whom explained that US sanctions prevented them from considering the research.

Dove Medical Press (an open access online publisher whose headquarters are in the UK and editorial office is in New Zealand) turned down a paper saying that “international sanctions currently in place against Iran mean that Dove Medical Press is no longer able to process manuscripts received from Iranian authors.”

“We do not make this decision lightly and have consulted with the authorities both here in New Zealand and in the United Kingdom before making our decision,” said Jeanette Pearce, Dove’s New Zealand based operations manager.

“It is not ethical to treat Iranian researchers this way,” Behrooz Astaneh, acting editor of the Iranian Journal of Medical Science, told the BMJ. “These people want to disseminate data they have obtained in very difficult circumstances because of the sanctions. Research publication should be on merit and have nothing to do with politics.”

Protecting editors

According to a report from Science magazine, Elsevier advised its US editors in April against handling any papers authored by employees of the government of Iran and in an email shown to the BMJ, the editor of JACI explained, “our publisher precludes taking any articles from authors based at Iranian institutions or hospitals.” Yet, Elsevier says it believes in the “free flow of ideas and information as a principle for science and for society” and chief lawyer, Mark Seeley, told the BMJ that the company continues to publish papers from Iranian academics and researchers affiliated with academic or medical institutions. Elsevier decided it was necessary to make “narrowly crafted exceptions” because of the potential for personal liability on the part of its US editors.

Asked if some US editors had possibly misunderstood the publisher’s guidance on this, Seeley responded that the problem was over “the exact definition of ‘government employees’ other than academics and practitioners. Seeley said the company was seeking greater clarity but had not yet received it.

John Sullivan of the US Treasury told the BMJ that “The focus of our sanctions is the Iranian regime and its support for terrorism and its illicit nuclear programme. Our sanctions do not target academic or informational materials.”

A different view

Other American health publications, including the two leading journals the New England Journal of Medicine and Journal of the American Medical Association, said they were continuing to publish Iranian submissions on merit.

“Different journals have adopted very different strategies on this,” Elaheh Malakan Rad, associate professor of paediatric interventional cardiology at the Children’s Medical Centre in Tehran, told the BMJ. “There needs to be clear guidance on the ethical issue here.”

The Committee on Publication Ethics (COPE), which advises editors on handling ethically sensitive issues, discussed problems surrounding Iranian authors in a June meeting and affirmed the need, already previously agreed because of other concerns, that clearer guidance is needed. COPE is planning to add a paragraph to its code of conduct stating that, “Editorial decisions should not be affected by the origins of the manuscript, including the nationality, ethnicity, political beliefs, race, or religion of the authors. Decisions to edit and publish should not be determined by the policies of governments or other agencies outside of the journal itself.”

The United Kingdom government has also changed its sanctions recently and continually updates a list of banned authors and institutions thought to be involved in Iran’s nuclear programme. However, the BMJ continues to take papers on merit and has chosen in some instances to waive the usual author fee charged for open access publication of research because of regulations over bank transactions with Iran.

“The BMJ is against academic boycotts and has no restrictions on publishing articles from authors in Iran,” the BMJ’s editor, Fiona Godlee, said in a statement posted on bmj.com. “We have noted the UK’s restrictions on trading with Iran and are also aware of the new US restrictions. These may have implications for whether we can levy an author fee from an author in Iran. We will decide this on a case by case basis.”

Richard Horton, the editor of the Lancet (which is owned by Elsevier) said: “TheLancet welcomes and encourages research from scientists in all countries, including Iran. Indeed, we are currently working to strengthen our links with Iranian medical and public health scientists.”

by: Sophie Arie

@BMJ

The Dilemma of Breast Cancer Screening

By : Kevin Pho
The American College of Obstetricians and Gynecologists (ACOG) recently released their recommendations for breast cancer screening.
Previously, they had recommended a mammogram every 1 to 2 years for women between the ages of 40 to 49.
Now, they recommend more intensive screening:
Due to the high incidence of breast cancer in the US and the potential to reduce deaths from it when caught early, The American College of Obstetricians and Gynecologists (The College) today issued new breast cancer screening guidelines that recommend mammography screening be offered annually to women beginning at age 40. Previous College guidelines recommended mammograms every one to two years starting at age 40 and annually beginning at age 50.
This contradicts the 2009 recommendation from the USPSTF, which recommended an individualized approach and against routine screening for women aged 40-49.
No wonder patients are confused.
In our society, which values tests and generally believes that earlier cancer detection is better care, the ACOG recommendations were met with media acclaim.
Gary Schwitzer, for instance, points out the bias in CNN’s reporting the guidelines, and specifically takes senior medical correspondent Elizabeth Cohen’s Tweet on the issue to task:
On many occasions that we’ve written about on this blog in recent years, CNN has demonstrated a bias in favor of screening – touting benefits, minimizing harms. Sanjay Gupta’s badgering of US Preventive Services Task Force member Lucy Marion will always stand out in my mind – and in the minds of many of who saw it – as opinionated “attack” journalism that reflects the polarization we often see in politics now creeping (leaping?) into health care and into health care journalism.
As to which guideline to believe, physicians will be divided. I suspect that physicians who practice more strict evidence-based medicine will go with the USPSTF recommendations, while gynecologists will follow their college’s more aggressive recommendations.
Although I’m a proponent of clinical guidelines, obtaining the needed consensus will be difficult. There are too many proverbial cooks in the pot, with every medical society releasing potentially conflicting recommendations and confusing both doctors and patients.
@KevinMD

The Risks and Benefits of 5α-Reductase Inhibitors

Authors : Marc R. Theoret, M.D., Yang-Min Ning, M.D., Ph.D., Jenny J. Zhang, Ph.D., Robert Justice, M.D., Patricia Keegan, M.D., and Richard Pazdur, M.D.
The use of 5α-reductase inhibitors for prevention of prostate cancer continues to be widely discussed within the scientific and medical communities. Much of this discussion has been fueled by the findings of two large randomized, placebo-controlled trials — the Prostate Cancer Prevention Trial (PCPT) with finasteride and the Reduction by Dutasteride of Prostate Cancer Events (REDUCE) trial . Together, these trials showed an overall relative reduction of 23 to 25% in prostate-cancer diagnoses, a seemingly significant benefit from drugs aimed at preventing one of the most common cancers in men. However, the observed reduction resulted from a decreased incidence of only low-grade prostate cancer (Gleason score, ≤6). In fact, in both trials, there was an absolute increase in the incidence of high-grade prostate cancers in the chemoprevention group.
Evaluating the potential chemopreventive benefits of 5α-reductase inhibitors and assessing the potential increased risk for high-grade prostate cancers have been central issues for the Food and Drug Administration (FDA). There has been much hope for an FDA-approved chemopreventive agent for prostate cancer, and there is clearly ongoing off-label use of 5α-reductase inhibitors for this indication. The FDA has been actively evaluating the relevant data and held a meeting of its Oncologic Drugs Advisory Committee to address this topic in December 2010.

Both chemoprevention trials were conducted in men who were at risk for prostate cancer but did not have diagnosed prostate cancer at study entry. The FDA’s analysis of the trials confirmed that there was a relative reduction of approximately 25% in the overall incidence of prostate cancer and a significantly increased incidence of high-grade prostate cancers. During the FDA review of the REDUCE trial, we requested that biopsy specimens be reassessed, according to the modified Gleason scale, by an independent pathologist who was unaware of the earlier scores. The central pathologist for PCPT performed this reassessment. The use of modified Gleason scores is consistent with current recommendations for prostate-cancer grading and the grading system used in PCPT; modified Gleason scores were not originally reported in the REDUCE trial.
The reassessment revealed no reduction in the incidence of tumors with modified Gleason scores between 7 and 10 — a finding that was consistent with the published data. However, an absolute increase of 0.5% in the incidence of tumors with modified Gleason scores of 8 to 10 (relative risk, 2.06; 95% confidence interval [CI], 1.13 to 3.75) was observed with dutasteride treatment. This increase is similar to the absolute increase of 0.7% in the incidence of such tumors observed with finasteride treatment (relative risk, 1.70; 95% CI, 1.23 to 2.34) .These results suggest that one additional man would receive a diagnosis of high-grade prostate cancer (modified Gleason score, 8 to 10) for every 150 to 200 men treated long-term with a 5α-reductase inhibitor.

It has been suggested that detection bias, attributable to the fact that 5α-reductase inhibitors reduce serum levels of prostate-specific antigen (PSA) and prostate volume, led to an increase in detection of high-grade prostate cancer in the finasteride group of the PCPT. Indeed, the sensitivity of an elevated PSA level (a PSA level above 4 ng per milliliter in the placebo group or, in the finasteride group, above the adjusted value designed to correct for a finasteride-induced PSA reduction of approximately 50%) for the detection of prostate cancer, including high-grade tumors, was increased in the finasteride group of the PCPT. The observation that the increased risk of high-grade tumors (modified Gleason score, 8 to 10) with finasteride or dutasteride persisted in analyses of scheduled biopsies independent of PSA results argues against PSA-related detection bias as the cause of the observed increase in the incidence of high-grade tumors. Approximately 56% of all prostate cancers in the PCPT and 90% of those in the REDUCE trial were diagnosed by means of scheduled biopsies.
As for detection bias due to 5α-reductase inhibitors’ reduction of prostate volume by approximately 20%, it is possible that core needle biopsies may uncover more cancers, including high-grade tumors, in smaller prostates because of increased sampling density. Proponents of this hypothesis accounted for the intergroup difference in prostate volume either by statistically adjusting for prostate volume at the time of biopsy (using logistic-regression analysis or the Peters–Belson method) or by circumventing any potential for sampling bias by extrapolating from the Gleason scores for a subgroup of patients who had had prostatectomies to patients without prostatectomy data (weighted imputation estimation). These analyses resulted in estimates of the relative risk of high-grade prostate cancer (Gleason score, 7 to 10) in the finasteride group ranging from no increase to a relative decrease of 27%. Since conventional criteria define “high-grade” as a Gleason score of 8 to 10 and 75% of the increase in tumors with modified Gleason scores of 7 to 10 observed in the finasteride group involved tumors with a score between 8 and 10, the FDA repeated the same analyses, statistically adjusting for prostate volume and using a modified Gleason score of 8 to 10 as the definition of a high-grade tumor. The results of those analyses do not support the contention that increased sampling density is responsible for the increased incidence of high-grade tumors in the finasteride group (see table for opposing risk estimations for tumors with a modified Gleason score of 7 to 10 and those with a score of 8 to 10). Although questions concerning detection bias remain, none of the post hoc exploratory analyses provide convincing evidence that the increased incidence of high-grade disease observed in both trials can be dismissed.
Analyses of these trials indicate that the reduction in prostate-cancer risk with both drugs was limited to tumors with a modified Gleason score of 6 or lower. Prospectively collected data in REDUCE showed that 80% of such tumors met the Epstein pathological criteria for “very-low-risk” disease, which indicates that a reduction in their incidence is unlikely to be clinically significant. An analysis of biopsies performed in response to an elevated PSA level or an abnormal digital rectal examination, as would be done in clinical practice, revealed a smaller reduction in the relative risk of prostate cancer (14%; 95% CI, 4 to 23%) than that reported for all cancers in men receiving finasteride. Therefore, the trade-off inherent in using a 5α-reductase inhibitor for prostate-cancer prevention is the acceptance of one additional high-grade cancer in order to avert three to four potentially clinically relevant lower-grade cancers.

The conclusion drawn by the advisory committee in December was that finasteride and dutasteride do not have a favorable risk–benefit profile for the proposed use of chemoprevention of prostate cancer in healthy men. The FDA agrees with this assessment. The effects of finasteride or dutasteride on the incidence of metastatic prostate cancer and prostate-cancer–specific morbidity and mortality have not been evaluated.
Strategies for reducing cancer risk expose people who do not have and may never develop cancer to a drug and its potential adverse effects. In these circumstances, a high level of certainty about benefits and risks of intervention is warranted. The labels of approved 5α-reductase inhibitors, which are currently indicated for the treatment of symptomatic benign prostatic hyperplasia and male-pattern hair loss, have been modified to include the observation of high-grade prostate cancers in the relevant trials. In addition, health care professionals prescribing 5α-reductase inhibitors to men who opt for PSA screening should be aware that these agents reduce PSA values and that any increase in the PSA level above the lowest value obtained may signal the presence of prostate cancer, even if the value remains in the normal range for men not taking such an agent.

ADT for Prostate Cancer

In the 1990s, reversible androgen suppression with the use of luteinizing hormone–releasing hormone analogues and oral antiandrogen agents was shown to induce apoptotic regression in androgen-responsive cancers, potentially improving the prospects of local control and the duration of survival free of metastatic disease.
Clinical Pearls

How can short-term androgen deprivation be achieved?
In this study, patients assigned to short-term androgen-deprivation therapy (ADT) received flutamide at a dose of 250 mg orally three times a day and either monthly subcutaneous goserelin at a dose of 3.6 mg or intramuscular leuprolide at a dose of 7.5 mg for 4 months.
How more effective was ADT with radiotherapy as compared to radiotherapy alone for patients with localized prostate cancer in this study?
According to the results of this study, the 10-year rate of overall survival was 62% among patients receiving radiotherapy plus short-term ADT (the combined-therapy group) versus 57% among patients receiving radiotherapy alone (hazard ratio for death with radiotherapy alone, 1.17; P=0.03). The addition of short-term ADT was associated with a decrease in the 10-year disease-specific mortality from 8% to 4% (hazard ratio for radiotherapy alone, 1.87; P=0.001).
Morning Report Questions
Q. Which group of patients benefited the most from ADT in this study?
A. The addition of short-term ADT to radiotherapy conferred the greatest clinical benefit in the intermediate-risk subgroup, with an increase in the 10-year rate of overall survival from 54 to 61% and a reduction in the 10-year disease-specific mortality from 10 to 3%.
Q. What are adverse effects of ADT?
A. In prospective studies, short-term ADT caused measurable muscle loss, fat accumulation, decreased insulin sensitivity, and increased cholesterol and triglyceride levels.
@NEJM

What Patients Need To Know About Osteoporosis

Osteoporosis is a condition that is sure to become increasingly diagnosed as our population ages.
Osteoporosis is significant because it is associated with an increased risk of bone fracture, including fracture of the hip and vertebra, which are the cause of significant morbidity, mortality, loss of independence and medical expense in the elderly. In current clinical practice, osteoporosis is diagnosed on the basis of either the occurrence of a low-impact or fragility fracture, or on the basis of measured low bone mineral density (BMD). A low-impact fracture is one that occurs after a fall from standing height or less; a fragility fracture occurs spontaneously or with no trauma (cough, sneeze, sudden movement).
Bone strength is determined by bone density, bone “quality,” and bone microarchitecture. Of these features, bone density, or mass, is what we are able to measure. Osteoporosis is defined by World Health Organization criteria based on a person’s bone density by dual energy x-ray absorptiometry (DXA). Osteoporosis occurs when bone density is below 2.5 standard deviations from the mean for non-Hispanic white women between ages 20 and 29 (T score < -2.5). Osteopenia is defined by bone density of between 1 and 2.5 standard deviations below the mean for non-Hispanic white women in their twenties (T score of -1 to -2.5).
In recent years a variety of effective medications have been developed and approved for treatment of low bone density. Nonetheless, there are still significant gaps in our knowledge. Recently, the FDA issued a warning about an increased risk of “atypical fractures” that has been observed amongst women who take bisphosphonates, the most commonly prescribed drugs for osteoporosis. A few years ago these drugs were also linked to another rare problem, osteonecrosis of the jaw. This was primarily described in cancer patients and those on cancer medications, but the finding got patients, dentists, and oral surgeons quite worked up over the potential risks.
In clinical practice there is significant variation in the practice of screening for and treating osteoporosis and its precursor, osteopenia. According to national epidemiological data from NHANES III over 56% of women over age 50 have reduced bone density, of these 16% have osteoporosis. In their 80s 87% of women have reduced bone density and 44% of have osteoporosis. The key to prevention and treatment is trying to figure out who and when to treat aggressively to best prevent fractures. Current guidelines by the US Preventive Services Task Force support screening women at age 65. However, many post-menopausal women under age 65 are also at risk and the conservative evidence-based USPSTF guidelines do not comment on which of these women should also be screened. Other professional guidelines, such as those issued by the National Osteoporosis Foundation, support screening younger women who are post-menopausal and who have risk factors.
A variety of clinical tools exist to help women quantify their osteoporosis risk.
Osteoporosis risk factors include:
• Low body weight (<57 kg)


• Asian or Caucasian ethnicity


• Personal history of fragility fracture


• Family history of osteoporosis 


• Smoking


• Drinking > 2 glasses of alcohol per day


• Excessive caffeine intake


• Certain medications (glucocorticoids)


• Sedentary lifestyle


• Amenorrhea (lapses in menstruation prior to menopause)


• Eating disorders


• Marathon running


• Dietary deficiencies of calcium and vitamin D


• Chronic health conditions (chronic liver and kidney disease, rheumatoid arthritis)




Many women fall into these increased risk categories and thus are screened before age 65 leaving them with a diagnosis of osteopenia or osteoporosis and creating the conundrum of what to do for the remainder of a woman’s life.
In general, most women with osteopenia should not receive pharmacologic therapy unless they are higher risk, or have already suffered a fracture. Instead, they should be counseled to institute behavioral measures, such as increased weight-bearing exercise and increases in calcium and vitamin D supplementation. When these women should be rescreened is not clear, but probably no more often than every two years. Tracking the rate of bone density decline may help identify women who subsequently should receive drug therapy.
Effective pharmacologic treatments for osteoporosis are available and are, in general, well tolerated. Medication options include the bisphosphonates: alendronate, residronate, ibandronate and zoledronic acid, hormonal treatments (estrogen and selective estrogen receptor modulators), and recombinant parathyroid hormone (teriparatide). Of these options, the oral bisphosphonates, alendronate (Fosamax) and residronate (Actonel), have the most evidence supporting their efficacy in fracture prevention, and are considered first line. These drugs, however, can be somewhat inconvenient to administer because of their poor bioavailability that requires them to be taken on an empty stomach for best absorption. In addition, they are associated with gastrointestinal side effects—specifically esophagitis, and for this reason are contraindicated in patients with precancerous changes of the espophagus, “Barrett’s Esophagus.” For patients who experience gastrointestinal side effects the intravenous bisphosphonate, zoledronic acid may be administered every one to two years.
Hormonal therapies, such as estrogen, are effective treatment for low bone density. However, as indicated by the results of the Women’s Health Initiate, their use has been associated with an increased risk of breast cancer and cardiovascular disease. Raloxifene, a selective estrogen receptor modulator (SERM), is approved for both prevention and treatment of osteoporosis. Its use, while associated with a reduction in breast cancer risk, is also associated with an increased risk of thomboembolism. Its effect on cardiovascular disease appears to be neutral.
The appropriate duration of therapy and frequency of monitoring patients who are on pharmaceutical treatment are areas that remain ill-defined. Studies have indicated that 5 years of alendronate may be adequate for many average risk women. However, my experience in clinical practice is that many women are left on these drugs for years and years. Some have advocated drug “holidays” after five years of therapy. The largest randomized controlled trial looking at alendronate use and fracture outcomes was 10 years in duration, which in my view calls into question the safety of prolonged use.
Many questions remain about how to approach the treatment of aging bones to prevent the debilitating outcome of bone fracture. Seasoned clinicians have seen the problems that may occur in some cases with treating large populations of well patients for normal life processes (postmenopausal estrogen replacement therapy). Let’s hope that future research will address the question of when to treat with medication and for how long with further precision. Until then let’s use appropriate caution when prescribing medicine for normal senior bones.


by : Juliet K. Mavromatis

Phyllodes Tumor

Findings: Mammogram shows a lobular hyper dense mass with partially circumscribed and partially obscured margins. No calcifications visible

Meaning : leaf-like in Greek, phyllodes tumors demonstrate papillary growth of epithelial lined stroma
Key point: Large rapidly growing circumscribed mass without calcifications
Mammography :Phyllodes tumors appear as a dense, round or oval masses with circumscribed or lobulated borders on mammography. Indistinct margins favor malignant transformation. Calcifications are rare but when present are coarse.
Ultrasonography: demonstrates an oval, round, or lobulated hypoechoic mass. Cystic spaces favor malignancy. Increased vascularity can be common .

T1W1/T2W1 :Phyllodes tumors appear heterogeneously hypointense on T1WI with slit like areas of increased T2WI representing fluid. Enhancement is typically rapid and suspicious kinetics can be observed in approximately 33% of cases.
Differential Diagnosis:
Typically occurring in younger women, fibroadenomas also appear as oval or lobulated mass but have dense, coarse calcifications, homogeneous echogenicity, and more moderate enhancement characteristics.
While there is some overlap with phyllodes tumors demonstrating malignant transformation, breast carcinoma is more likely to demonstrate indistinct margins. Pleomorphic calcifications also favor carcinoma.
Primary sarcoma of the breast is distinguished from phyllodes tumors by the absence of epithelial components. The clinical course of primary sarcoma of the breast is similar to malignant phyllodes tumors.

Ultrasound shows an irregularly shaped mass with heterogeneous echogenicity and ill-defined borders.

Treatment: is by surgical excision with greater than 1 cm margins. Mastectomy may be required for large tumors. Axillary node dissection is usually unnecessary. With respect to adjuvant therapy, radiation reduces local recurrence. Chemotherapy has demonstrated no benefit.

Migraine : Update on New Therapies

Drugs with a better efficacy or side–effect profile than triptans may soon become available for acute treatment. The future may also look brighter for some of the very disabled chronic migraineurs thanks to novel drug and neuromodulation therapies.

•The oral calcitonine gene–related peptide antagonist Telcagepant is efficacious in acute treatment.
•Triptans, as other drugs, are more efficient if taken early but nonsteroidal anti–inflammatory drugs and analgesics remain useful for acute treatment, according to several meta–analyses.
•Single–pulse transcranial magnetic stimulation during the aura rendered more patients pain–free (39%) than sham stimulation (22%) in one study.
•Topiramate could be effective for migrainous vertigo, but it did not prevent transformation to chronic migraine in patients with high attack frequency.
•Onabotulinumtoxin A was effective for chronic migraine and well tolerated, but the therapeutic gain over placebo was modest; the clinical profile of responders remains to be determined before widespread use.
•Occipital nerve stimulation was effective in intractable chronic migraine with 39% of responders compared to 6% after sham stimulation. This and other neuromodulation techniques, such as sphenopalatine ganglion stimulation, are promising treatments for medically refractory patients but large controlled trials are necessary.
•One study suggests that outcome of patent foramen ovale closure in migraine might depend on anatomic and functional characteristics.

study by : Magis D et al

@Current Opinion in Neurology

Leukotriene Antagonists as Effective as Other Asthma Therapies?

Leukotriene-receptor antagonists may be as effective as inhaled corticosteroids for first-line treatment of asthma and as effective as long-acting beta agonists for add-on therapy, according to two "real-world" trials reported in the New England Journal of Medicine.

The two trials included individuals aged 12 years and older with asthma. In one, some 300 patients beginning asthma therapy were randomized to open-label treatment with either a leukotriene antagonist or an inhaled glucocorticoid. In the other, roughly 350 patients already taking an inhaled glucocorticoid were randomized to add-on therapy with a leukotriene antagonist or a long-acting beta agonist.

The primary endpoint — asthma-related quality of life at 2 months — was similar between treatment groups. However, the researchers report that at 2 years, outcomes did not quite meet equivalence criteria.

Editorialists note that leukotriene antagonists likely work well in real-world settings because of their ease of use (i.e., pill vs. inhaler).

Appeals Court Overturns Stem Cell Research Ban

Opponents of taxpayer-funded stem cell research lost a key round in a U.S. appeals court Friday.

In a 2-1 decision, a panel of the court of appeals in Washington overturned a judge's order that would have blocked taxpayer funding for stem cell research. The judges ruled that opponents of taxpayer-funded stem cell research are not likely to succeed in their lawsuit to stop it.
The panel reversed an opinion issued last August by U.S. District Judge Royce Lamberth, who said the research likely violates the law against federal funding of embryo destruction.
"We're thrilled with this decision and look forward to allowing federally funded scientists to continue with their work without political constraints," said Sean Tipton, a spokesman for the American Society for Reproductive Medicine.
Researchers hope one day to use stem cells in ways that cure spinal cord injuries, Parkinson's disease and other ailments. Opponents say the research is a form of abortion because human embryos must be destroyed to obtain the stem cells.
The 1996 law prohibits the use of taxpayer dollars in work that harms an embryo, so private money has been used to cull batches of the cells. Those batches can reproduce in lab dishes indefinitely, and the Obama administration issued rules permitting taxpayer dollars to be used in work on them
The lawsuit was filed by two scientists who argued that President Obama's expansion jeopardized their ability to win government funding for research using adult stem cells — ones that have already matured to create specific types of tissues — because it will mean extra competition.

Lamberth, the chief judge of the U.S. District Court in Washington, issued a preliminary injunction in August to block the research while the case continued.
The Obama administration immediately appealed and requested the order be stopped. The appeals court quickly ruled that the research could continue at the National Institutes of Health while the judges took up the case.
The opinion tossing out Lamberth's ruling was written by Judge Douglas Ginsburg, nominated to the court by President Ronald Reagan, and supported by Judge Thomas Griffith, a nominee of President George W. Bush. The dissent came from Judge Karen LeCraft Henderson, a nominee of President George H.W. Bush; she agreed with the lower court judge that the lawsuit was likely to succeed.
As a result of the appellate ruling Friday, the original lawsuit can continue before Judge Lamberth, but the taxpayer-funded research also will go on. Lamberth hasn't thus far either held a trial or issued a final ruling, which he could do based on court filings without taking testimony.
Once the cells are culled, they can reproduce in lab dishes indefinitely. So government policies said using taxpayer dollars to work with the already-created batches of cells is allowed.
The Obama administration has expanded the number of stem cell lines created with private money that federally funded scientists could research, up from the 21 that President George W. Bush had allowed to at least 75 so far. To qualify, parents who donate the original embryo must be told of other options, such as donating to another infertile woman.
Congress twice passed legislation specifically calling for tax-funded stem cell research, which President Bush vetoed.

@AP

Pic : Judge Royce Lamberth

Alzheimer's Association

It's always satisfying to pursue worthy ideas and join a right cause.
Lethean Cottage is glad to share some useful information  with the readers in order to improve the public understanding about the disease.
if you're willing to join the cause :

Facebook.com/actionalz

twitter.com/alzassociation
and here :you can find some useful information about the disease
and you can add some useful items to your website:use texts,videos,banners,etc so we can make sure as many people as possible have access to the basic information.

Regards

Pedram 

Melanoma : Clinical Pearls and Morning Report Questions

Clinical Pearls


What are the currently approved treatments for metastatic melanoma?
The two therapies approved by the Food and Drug Administration, high-dose interleukin-2 and dacarbazine, are each associated with response rates of only 10 to 20% and a small percentage of complete responses; neither is thought to improve overall survival. In randomized trials, the median survival among patients treated with dacarbazine was less than 8 months.
How prevalent is the v-raf murine sarcoma viral oncogene homologue B1 (BRAF) mutation among patients with metastatic melanoma?
A search for mutations in a component of the MAP kinase pathway in a large panel of common cancers revealed that 40 to 60% of melanomas, and 7 to 8% of all cancers, carry an activating mutation in BRAF.

Morning Report Questions

Q. How effective was the oral inhibitor of BRAF, PLX4032, in treating patients with metastatic melanoma?
A. This trial demonstrated that therapy targeting tumors containing activating V600E BRAF mutations can induce clinically significant tumor regression in patients. PLX4032 induced clinically significant tumor regression in 81% of patients who had melanoma with the V600E BRAF mutation. Responses were observed at all sites of disease, including the bone, liver, and small intestine.
Q. What tumors emerged in patients treated with PLX4032?
A. Eight patients in the dose-escalation cohort (15%) and 10 patients in the extension cohort (31%) developed cutaneous squamous-cell carcinomas — a total of 35 carcinomas. These were reviewed centrally, and all but one either were keratoacanthomas or had features of a keratoacanthoma. The median time to the appearance of a cutaneous squamous-cell carcinoma was 8 weeks; the majority of the carcinomas were resected, and in no case did any lead to discontinuation of treatment.

Cochrane Review Advises Chemo+RT For Early Hodgkin's

Chemotherapy followed by radiation therapy (RT) is the standard treatment for patients with early-stage Hodgkin's lymphoma, and it should remain so, according to a review published February 16 by the Cochrane Collaboration of Oxford, U.K.

A review of the outcomes of 1,245 patients who participated in five randomized clinical trials, published in the Cochrane Library, sought to answer the question of whether radiation therapy, with its risk of causing secondary cancers from radiation exposure, could be eliminated. The conclusion of the multi-institutional team from Denmark, Germany, and Switzerland was that from a short-term perspective, patients who received both treatments were less likely to die or have local recurrence compared to those who only received chemotherapy.

The clinical trials took place from the 1970s to 2004 and used a variety of chemotherapy agents, as well as diverse doses and types of radiation therapy. Initial responses by patients to treatments were equally effective in eliminating cancer in large part or entirely, according to lead author Christine Herbst, MD, of the department of internal medicine of the University Hospital of Cologne in Germany.
However, data from the meta-analysis identified differences in outcomes when patients were followed between two and 11.4 years. Patients who received the combined treatment were 40% as likely to die compared to those who had chemotherapy alone, and the hazard ratio for tumor control was similar, at 41%. Complete response rates were similar between the treatment groups.
Although adding radiation therapy increased five-year tumor control and overall survival, patients were exposed to radiation doses that could cause secondary cancers 10 to 30 years following treatment, the authors noted. The meta-analysis performed did not evaluate long-term risks.
by : Cynthia E. Keen

Imaging's Torrid Growth Rate Is Slowing

 Is the era of rapid growth in medical imaging procedure volume over? The volume of advanced imaging services delivered to Medicare beneficiaries decreased in 2009 -- the first decrease in 11 years, according to a study released Wednesday.
Washington, DC-based research and consulting firm the Moran Company found that the volume of advanced imaging services billed within the Medicare system decreased by 0.1% in 2009 compared with 2008, while overall imaging services declined by 7.1% for the same year-to-year comparison.

"It's pretty clear the era of very rapid growth in advanced medical imaging seems to have come to an end at this point in time," said Don Moran, president of the Moran Company. "All the data point to a leveling. It's unclear whether we will see further declines, but the prior growth of these modalities and the advantages they offer to clinicians seems to be peaking."
The study, released today by the Access to Medical Imaging Coalition (AMIC), reviewed Medicare claims data from 1999 through 2009, examining both spending and volume of advanced imaging services, such as CT, MRI, nuclear medicine, and PET, as well as overall imaging services, including mammography.

Declining Volume

The analysis also found that the total volume of mammography screenings decreased by 0.3% in 2009, compared with a 2.8% compound annual growth rate in the past decade. In addition, the total volume of dual-energy x-ray absorptiometry (DEXA) exams fell by 2.2%, while spending on this technique decreased by 16% from 2008 to 2009.
The new findings are comparable to a 2008 analysis of Medicare claims data that showed a 19.2% reduction in Medicare spending on advanced imaging from 2006 to 2007. It also revealed a significantly reduced procedure volume growth rate of only 1.9%, which was less than the overall rate of physician-payment growth.
In addition, a study presented by David C. Levin, MD, and colleagues at the 2010 RSNA meeting found that imaging procedure volume grew at a compound annual growth rate (CAGR) of 1.4% between 2005 and 2008, well down from the 4.1% CAGR experienced between 1998 and 2005.
Imaging industry observers have attributed the slowing growth rate to reimbursement cuts for medical imaging such as those enacted by the Deficit Reduction Act of 2005. The healthcare reform legislation passed in 2010 includes additional reimbursement reductions.
The study shows that "medical imaging has been decimated by these cuts," said Tim Trysla, executive director of AMIC. "The impact of these cuts, even by the government's own estimates, has 'de facto' caused access problems for patients and providers. We are very concerned about choking off the access to these lifesaving technologies."
John Patti, MD, a radiologist at Massachusetts General Hospital in Boston and chair of the American College of Radiology Board of Chancellors, said he and fellow radiologists are concerned with imaging's declining growth rate, because the Medicare population is increasing and the incidence and prevalence of disease remain the same.

Early Diagnosis

"One of the tremendous benefits of advanced imaging over the years is that it has obviated the need for more costly and evasive diagnostic evaluation," Patti said. "This reversal of trend suggests that Medicare patients may not be receiving those appropriate exams and thus the benefit of early diagnosis."
In addition, he said the decrease may have "negative downstream effects on the health of our aging citizens and on the cost of providing the more complex care that may be necessary to treat disease if it is discovered in advanced stages."
One potential victim of the decline is outpatient imaging center owners and operators. Because of reimbursement cuts for outpatient imaging, some physicians have sold or given their imaging activities to hospitals, which are reimbursed at a higher rate under the Hospital Outpatient Prospective Payment System (HOPPS). That scenario, in turn, could lead to less access to advanced imaging services.
In other study data, Medicare spending for advanced imaging services increased by less than half the spending growth for physician services overall. With a 1.2% increase in spending for advanced imaging, compared with 2.6% for services overall, imaging was one of the slowest-growing segments of the physician fee schedule in 2009.


Some Optimism
Despite the volume downturn in 2009, Trysla believes that advanced medical imaging will continue to contribute to patient care. "Medicine will not turn its back on advanced technology, especially with the benefits of early detection of disease, such as Parkinson's disease and cancer," he said. "I think you will see growth through new applications in technology, and medicine will continue to evolve from exploratory surgery toward early and more exact detection."
ACR's Patti also speculated that the dip in growth in 2009 would be temporary. "I don't think there are any physicians who are taking direct care of patients who don't understand the value of advanced imaging," he added. "And, I don't think there are any physicians who are willingly withholding [advanced imaging] from patients."


by : Wayne Forrest

How to Check Your Scientific Paper for Plagiarism?

We were taught in grammar school that plagiarism is wrong. It is stealing someone else’s property.

Imagine in high school asking your mother to buy you “Cliff Notes” so you can copy it word for word. Mother would not have liked that, and it wouldn’t have been right.
To write an essay today, you’ll probably start with a search engine. Instantly, Mr. Google delivers many intelligent commentaries on anything, probably better than you would write. You can copy them piece by piece, paste them into your paper, and, voila!, you’re done!
Except, you stole.
It may not feel like cheating to copy and paste, but it’s little different than copying a book by candlelight with pen and paper.
There is one difference. You can be caught. Guaranteed!
Many high school students now are taught to use a program from www.turnitin.com to test whether their work is plagiarized by checking it against everything that has been published online.
If there is plagiarism, TurnItIn will identify it.
Editors of some scientific journals now use a program called Cross Check powered by www.iThenticate.com.
Steven Shafer is the editor of the research journal Anesthesia & Analgesia. He uses Cross Check to examine every one of the 2,000 annual submissions he receives!
And he finds that around one out of every 10 submissions is at least partly plagiarized.
Oh my! What to do?
Programs like TurnItIn and Cross Check are expensive, but there are free programs as well like www.doccop.com.
Doc Cop — D-O-C C-O-P — chops the text into pieces, and uses Google to search the Internet for matching text.
Since many papers have multiple authors, the only way for the guarantor author to know that the final paper does not contain plagiarized text is to run it through a program like Doc Cop prior to submission.
Authors and potential authors of papers submitted to medical and science journals should follow the lead of students to protect themselves against allegations of plagiarism.
Plagiarism is a form of scientific misconduct, even fraud, and such a finding can be hazardous to your career.
Don’t plagiarize. If you do, you will be caught.


by : George Lundberg
George Lundberg is a MedPage Today Editor-at-Large and former editor of the Journal of the American Medical Association.

Lesson For Those Facing Serious Illnesses

by : Danielle Leach, MPA

“A true friend walks in when everyone else walks out.”
I read that on a magnet on my friend’s refrigerator recently and the simple power of that saying brought me to tears. I have learned that lesson of true friends since my son’s diagnosis of cancer in 2007.
Anyone who has faced a serious illness as a patient or a caregiver knows that you quickly learn who your friends are. They are the ones who are there, who listen instead of trying to fix things, who are present for you in any way you need them. Some people you love will disappoint and not rise to the occasion, and some people you never expected will be your biggest supporters.
It is hard not to resent people who are there in the crisis, and then leave once the immediate crisis is over. There are people who are not there for the long haul, for the good and the bad that a disease may bring. The initial drama draws everyone in, but sends them running afterward.
I have learned, especially when you are living a nightmare, that it takes a special person to stay with you throughout the crisis. A person who keeps checking in and knows the journey is not necessarily over once you are in remission, or when your loved one has passed away. When my son Mason had brain cancer, our family found our true friends. We were surprised by many who walked out, but also by how many true friends walked into our lives because of Mason’s illness. We have learned even after Mason’s death, even three years later, we continue to go through this process of discovering our true friends.
Some people are not capable of handling personal difficulties. We, as patients and caregivers, need to understand not everyone has the capacity or tools to handle a crisis of another. This knowledge does not make it any easier for us as we wade through process of dealing with disease. As a director at Inspire, a company that creates and manages online patient support communities, I see regularly the comments of patients and caregivers who talk about friendships won and lost since diagnosis. Some are surprised and profoundly saddened by the lack of support from those expected to help the most. However, many happily note those friends, family, and even strangers who surprise them with support in a time of great need.
I recall reading about a Florida woman, whose teenage son was undergoing chemo, wrote that her friends avoided her upon learning about her son’s cancer diagnosis. “It’s almost like they were afraid they could catch it,” she said.
Another, a bladder cancer survivor from New Jersey, observed, “A lot of people walk out. . . a good 50% of my ‘pre-cancer’ friends I have never heard from again.” He went on to say, “In my case, I am lucky. I have all strong ones, having cut weak relations a long time ago. I keep only the cream of the crop.”
Sometimes finding others who are dealing with the same issues can be the most helpful strategy. You can often talk online more frankly and honestly with them than with some loved ones or friends. Dealing with an illness can be a lonely and scary process. Participating in support communities often help alleviate some of that loneliness. I have seen repeatedly how these connections are a powerful tool and establish strong personal friendships among members.
If you’re a patient or caregiver, look for the people who are true friends and hold those people close. Craft a strong support network–both in person and online. If you have a chance to do so, be the kind of true friend people are often searching for in their lives when they need it the most.

Danielle Leach is Director of Partnerships at Inspire and is founder of the Mason Leach Superstar Fund, in memory of her son, Mason, who died of pediatric medulloblastoma in 2007.

Lessons From Norman Rockwell

by Brandon Betancourt



This past summer I got a chance to visit Washington DC. While I was there, I saw a Norman Rockwell exhibition at the Smithsonian American Art Museum. As it turned out, the exhibition was the private collection of George Lucas and Steven Spielberg. The exhibition highlighted Rockwell’s masterful storytelling.
I didn’t know much about Norman Rockwell before that day. I knew he was a famous American painter and I had seen a few of his replicas in restaurants. But after seeing the exhibition, I got a deep, deep appreciation of Rockwell and especially, how he was able to communicate an entire story with a single frame.


The old days
My 75 year old grandfather was with me that day and told me how, back in the day, he couldn’t wait to get the Post Magazine to see Rockwell’s cover and to read it cover to cover. He also shared with me how Rockwell’s pictures told stories about growing up, how they instilled patriotism and depicted American family values.




The influence of storytelling
The exhibition and my grandfather’s account reminded me of how powerful storytelling is. Rockwell did it with pictures and to some extend he moved a nation. But could we use storytelling to do other things such as inspire patients, communicate with customers or stir up emotions in people? I think so. Companies do it all the time. And the ones that have stories that resonate with the public are generally some of the most recognizable companies in our society.






Toyota, Hummer, Harley Davidson, American Express & Target
A perfect example of companies telling stories are car manufactures. When a person buys a Prius, they are telling a story to others about themselves. They are telling others, (and themselves) they are environmentally conscious and are doing their part to contribute towards the “green” cause. The opposite end of the spectrum is Hummer vehicles. The person that drives a Hummer is not concerned about the environment. We know at least that much.
On a Prius, one might find a sticker that reads, “my kid is an honor roll student at George Washington Elementary School,” whereas on the Hummer, you may find a similar sticker but it reads “my son can kick your honor roll kid’s ass.” Each car tells a different story.
Harley Davidson motorcycles tell a story of freedom, ruggedness and loudness. American Express tells a story of class, success and refinement. Which is the complete opposite of “Capital One’s” story. Wal-mart’s story is low prices. But despite being in the same business, Target has a completely different story. Target’s story is “design democratization.”






What is the story?
The story is essentially how we think and feel when we see a product or a service and what we tell others (and ourselves) about us when we use the product or service. Clear as mud, right?






What does all this have to do with our medical practices?
Glad you asked. Just like Starbucks creates a warm, hip, comfortable experience to support their story (different from the Dunkin’ Donuts experience), we too can use some of these storytelling elements I learned from the Norman Rockwell exhibition to help us define the narrative we tell our customers and patients.






Lessons From Rockwell
1. Define the story. We have to characterize what our narrative is going to be. For example, Subaru has had multiple advertising campaigns to support their story. Recently, they’ve used: “Love. It’s what makes a Subaru, a Subaru.” That slogan reinforces their story that people who own a Subaru, LOVE Subaru. It also talks about the Love that goes in to making a Subaru. It is not just an ordinary car. More recently, they’ve focused a lot on “safety.” That’s a story as well.
In our medical practices’ we too can define our story. We can have a customer service story or our story can be about being compassionate, loving and caring. We can tell the story about how we embrace holistic medicine or even be known as an obesity and nutrition clinic. A while back I met a dentist that wanted to have a high-tech dentist office. That was his story.
Answer this: What do you want others to think when they hear your practice’s name?


2. Paint the picture. Rockwell used a canvas to tell his story; Spieldberg and Lucas use movies; Apple Inc uses design to tell their story of sophistication, simplicity and innovation.
In a medical practice, we too can paint our picture and tell our story by how we decorate our offices, how we design our advertising, how we answer the phone and how we treat patients.
Painting the picture is simply the vehicle we choose to tell our stories. It can be done in many different ways. It doesn’t matter how we choose to tell our story. Heck, it could even be a simple as creating a blog for your practice. But always have the story at the center.


3. Cast to support your story. One fascinating tidbit about Rockwell was that he casted the people in his paintings much like a filmmaker cast an actor for a role in a movie. Once he found the right person or group of people, he used them as stand-ins while drawing the picture. He knew that the characters he choose would support his vision for the story he wanted to tell. This was brilliant in my opinion.
Let’s say your story is customer service … do you hire people that can support that story or do you have Ms. Grumpy McGee as the front office clerk?
At their retail stores, Apple “cast” geniuses (if you’ve been to an Apple store, you know what I’m talking about) and Starbucks don’t just have servers, they have “baristas.” Both of which help reinforce each company’s story.


4. Pay attention to detail. Norman Rockwell did not leave anything to chance. Everything in his painting was there for a reason. Every single little detail, every prop, even the supporting characters helped tell the story. In fact, for some, the details were what really emphasized the story. In other words, often it was a little detail that made the story complete.
As Walt Disney once said, “There is no magic in magic, it’s all in the details.”


In a medical practice, there are details that can enhance our story or detract from it. It could be the cleanliness of the waiting room chair or the old magazines or the pictures hanging on the wall. It could be how we answer the telephone to how the doctor is dressed to the manicure of the nurse.
We often underestimate details because, well, they are details. But I’m sure many of you can agree that sometimes, one little detail is the difference between a good story and a bad story. Don’t leave the details to chance.
Well, what do you think about this correlation between Norman Rockwell and a medical office? At first, there might not be much of an association when you first think about it. But I think there are many lessons.