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Is this an entry for the Guinness World Book of Records?  They said it was a difficult pregnancy, well gee, I would think so at that age.  Apparently it took her life savings to do this and obviously she's not going to be around more than likely to see the baby much past it’s

New Resources have been added, written and edited by physicians and health care professionals with clinically relevant items.    Permanent Links are located in the right hand reference column…Edited by Volunteer Physicians and Health Professionals and I am happy to also have the Medical Quack feeds syndicated as a reference on their site as well! If you don’t find it here, take a look over there.  BD 

Naturally occurring proteins called "zinc fingers" are being used in a new approach to AIDS treatment. Using modified T-Cells with the zinc fingers, researchers at the Pennsylvania School of Medicine have shown a reduction in viral load in mice.

An international team of researchers has created the first complete high-resolution map of how millions of neural fibers in the human cerebral cortex — the outer layer of the brain responsible for higher-level thinking — connect and communicate.  Slashdot provided the link...

Vijayalakshmi Kunadian MBBS MD MRCP by way of Wikidoc.org--content reproduced here with permission...

This is the week for rivaroxaban: two randomized clinical trials published in the same issue of NEJM--doesn't get much better than that.  Both studies showed improved efficacy over lovenox, same safety profile, for preventing clots after hip and knee surgery.

We have been down this road before with ximelagatran, which made it through a slew of randomized trials only to get shut down by excess liver toxicity.

Hopefully rivaroxaban will prove to be the elusive holy grail of thrombosis prevention and treatment: a safe oral anticoagulant that doesn't need to be monitored like coumadin.  For millions of thrombosis and atrial fibrillation patients, that would be a huge quality of life improvement.

Johnson and Johnson is looking for a late 2008 submission to the FDA for approval.  Good luck, guys!

This by way of this month's Lancet Oncology , a bioengineered virus known as JX-594, injected into liver tumors, causes regression of the tumors by radiographic scans.  This was a phase I study in a small number of volunteers, but this is a unique technique that might just work out.  Too bad the virus has to be directly injected into the tumor--the key problem here is again targeting.  Killing the tumor cell turns out to be the easy part.  The hard part is not killing the rest of the organism.  Also, the delivery part needs to be worked out--people like a pill.  Pills are easy to understand, and have a user-friendly interface, as they say in information technology.  Direct intratumoral injections, not so much.

So, score an early victory for JX-594.  Keep your eyes on this story.

Looks like the White House is back in "Mission Accomplished" mode.

The Presidential June 30th solution to the July 1 physician fee cuts: hold the Medicare claims submitted between July 1 and July 15, and don't pay them at the reduced rate.  Then, Congress has fifteen days to pass emergency legislation to shore up the fee schedule cut.

I found this on Slashdot, of all places, via ScienceDirect via...PNAS!  A mainstream journal!  This found publication May 16th, and has been lightly reported in the lay press.

Apparently, some lab mice are immune to the lethal effects of tumor cell implants.  You can take bone marrow cells, spleen cells, or peripheral macrophages from these "super mice" and transplant them into other mice to protect them from the lethal effects of cancer cells too.  By "protect," I mean the transplanted cells can induce remissions of big tumors in the recipient mice.  Wow.  Here's a representative photo from the publication, sorry it's a little gross...

A patient generously got me a copy of Five Lessons I Didn't Learn from Breast Cancer (and One Big One I Did) by Shelley Lewis.

Though I treat a lot of breast cancer and I hear a lot of verbal narratives about the disease, it's good to once in a while sit and read a well-written narrative.   Ms. Lewis comes up with many insights that are new, and not a few laughs along the way.

The quote that sums up the book in a nutshell is on page 6: "My only growth was the one removed by my surgeon."

Though it will take at least a few more years for this to filter out to the farthest reaches of the internet (my mother-in-law), you can be assured that email is dying, if not already dead.

The problem, in a word, is productivity.  Spam and long-winded messages are not the most productive way to do business any more, and better tools have evolved: social networking sites, wikis, blogs, and instant messaging.  These technologies have each been around for a few years, but now, for the first time, even guys like me are able to implement them for personal use.

Don't believe me--there's a nice article in NYT today written by IBM's social networking guru. They are apparently running a proprietary social networking site called Beehive, and no, it's not available for public consumption.

In my mind, email can't die fast enough.  It stifles communication in large groups, though it's not bad for one-on-one messaging.  It's less personal than a phone call.  I get about 10 junk emails a day, and 10 quasi-junk emails from "Onco-blast" organizations I don't even recognize, hawking everything from online web seminars, to meetings, to advisory boards.  I get an email once a week from the CEO of Genentech about his company's products.  I tried to email him back once--what a joke!  You ask these people to take you off their lists and they don't. 

I even went to the trouble of calling one emailer on the phone about her unsolicited commercial emails about some online CME, and had a very nice, pleasant conversation with the lady, and then promptly got another email from her company that day and another the following day!

This is in addition to the problems of:

• Misspelled email address
• Spam filter ate email
• Attachment too long
• People hitting "Reply-all" instead of "Reply-sender"

So to me, the credibility of email in general is pretty suspect.  We have the new tools of the Web 2.0 era.  Many of them are free!  We should move on!

Looks like temsirolimus is effective for treatment of mantle cell lymphoma: the response rate in relapsed disease is 41%!  Looks like response duration was 6 months.  This from an article published earlier in the month in the journal Cancer.

These results compare favorably with Velcade, which showed 9 month response duration and a 33% response rate, in a larger study.  I wonder whether Wyeth will actually ask the FDA for a formal approval, or whether they will just schtup the drug off label with the usual dinners and lunches.

We went from not having much to offer these patients to now one FDA-approved agent (Velcade/bortezomib), and now an off-label agent, temsirolimus, with promising efficacy in only two years--not bad!

As I suspected, the Rangel bill failed in the Senate yesterday.

Republicans just can't seem to swallow a cut to the Medicare Advantage program to "finance" the reversal of the physician fee cut.

I'd like to see what happens if we introduce legislation to cut the pay yearly to each member of Congress unless some way to finance a reversal of the cut is found.  Something tells me it wouldn't be much of an issue.

The Medicare Advantage program doesn't appear to offer a good value proposition.  We have some of these patients in our office, and my office manager was surprised to hear that the insurance company gets reimbursed 113% of usual Medicare rates.

1. Medicare Advantage recipients don't get any additional services that I as a doctor can see.
2. What are the insurance companies doing with the extra 13%? 
3. Why can't I get 13% extra?

This program amounts to corporate welfare.  We've been trying to make it right again, but many Senate republicans (and the president) seem to think it's ok to fork over $50 billion to the insurance companies for...no benefit.

Here's a list of the Senate republicans that voted against the new Rangel bill:

If any of these guys are in your state, you owe it to your physician brothers and sisters to give them a call today.

I have a little talk I give patients when they ask me about alkaline water, magnets, crystals, or other "out-there" concepts, as applied to medicine.  I tell them that there are many ways people use to learn the truth, and that I have found the scientific method to be the most useful.  If something better comes along, I will use that.  Some people look to anecdote or faith as a way of knowing, and if that works for them, fine.  I'll stick with the scientific method, which is basically the attempt to document measurements rigorously, create hypotheses based on observations, and then test them out with experiments.

Chris Anderson, the editor of Wired magazine,

used his bully pulpit this week to propose that science, as defined as using the scientific method to build models of the world, is dead

.  The rise of the "cloud" concept of data is making science obsolete, he says.  We have enough data out there that we can use mathematical algorithms to search for the answers we need.

Last week, JAMA had an article showing a survival advantage for radiotherapy for recurrent prostate cancer.  The trial was a retrospective one, and looked at outcomes in patients who received salvage radiation treatment, radiation plus hormonal treatment, or no treatment after a PSA elevation relapse of their disease ("biochemical relapse" is what they call this concept) or local recurrence.

Though this was not a randomized trial, it does point to a benefit to radiation treatment even at relapse. 

Looks like Dr. Staudt and company have done it again.  There is a new star in the sky--IRF4 seems to be a major culprit in multiple myeloma. 

This is the same guy who applied genomic technology to clinical oncology in 2000, with a hit Nature paper that inspired a generation of clinician scientists to seek more individualized treatment approaches for their cancer patients.

This was an "LOL" moment on Facebook.  I am still collecting redneck humorous photos (mostly as a reminder of my 14 years in the "true" South, Gainesville, FL, New Orleans, LA, and Atlanta, GA).  Probably a better caption would be "Redneck highchair."

Enjoy.

Patient today clued me in on another health trend, wheatgrass juice, which is most widely available in Jamba Juice stores all over the country.

There is precious little clinical evidence available, which is disappointing, since evidently people have been eating grass and grass extracts for at least sixty years.

There is one tantalizing randomized controlled clinical trial, very small number of patients, which showed improvement in rectal bleeding in ulcerative colitis.  Nice.

Thanks to House Democrats and Republicans for doing the right thing and voting yea on a bill to reverse the Medicare Part B SGR adjustments (cuts) for 18 months.  H.R. 6331 was an earlier version of the Baucus bill, which has a 1.1% SGR increase in store for us.  The latest iteration of the Senate Baucus bill had a .5% increase.  Looks like there was a nice majority, and the hope is that the Senate can get this thing to the President's desk this week.  The White House today threatened to veto the whole shebang, though the House bill passed by a veto-proof margin.  This White House threat is amazing to me, since Senator Baucus' aide indicated to me two weeks ago that his office had been meeting with counterparts from the White House for months to hammer out the details of the bill.  So now, how does the White House start threatening to veto a bill that it helped to shape?

I ordered non-synthetic sunscreen from Amazon.com, and no sooner did it arrive than my wife found this at Target of all places:

Neutrogena Sensitive Skin Sunblock Lotion.  SPF is 30, since it's only 9% Titanium Dioxide, no Zinc.  It has a boatload of other "inactive ingredients" that gave me a little pause--Neutrogena people, any help here?  Can't you make the vehicle cleaner?  The combination Zinc and Titanium sunblock I referenced in my earlier post has an SPF of 38, but either number is pretty good.  The product doesn't show up on the Target.com website, but it was on display at my local Target store, and it was $7 for a 4 ounce bottle, not bad.  They also give you a little "travel" bottle to take with you as a bonus.

It's not as easy as the spray sunscreens as far as squirmy kids are concerned, but it's not as worrisome for the hormonal effects, so the peace of mind factor is a benefit.

Scientists have given a mouse Alzheimer's disease for the first time, by directly injecting a purified extract from brains of human Alzheimer's victims.  Turns out, a particular type of purified protein, called dimer beta amyloid gives rise to mouse Alzheimer's.

It's amazing to me that people haven't done this kind of experiment before, but I'm glad somebody thought of it.

Nature Medicine, advanced online publication today.

Nice clinical trial in Lancet this week.  Phase II, but there was efficacy data.  Survival was not statistically improved when the new medication was added to the existing standard, gemcitabine.  The medicine is a VEGF inhibitor known as Axitinib.  Hopefully with the passage of more time, or recruiting a larger number of patients to a more advanced phase study, we will see clearer efficacy.  This is a small market (31,000 cases a year) to go after, so kudos to Pfizer for continuing development on this important new drug.

We haven't seen too much efficacy in pancreatic cancer yet, and I have not recommended adding Tarceva for eligible patients.  To me, two weeks is just not compelling enough efficacy to justify the toxicity of that medication.

PLoS ONE is running a paper on a computer model of dopamine metabolism in Parkinson's Disease.  The authors claim a high degree of correlation between clinical observations and the computer model, and interestingly, the model even correctly predicts responses to medications.

I am finally happy to be moving away from the "one gene one trait" hypothesis of the late twentieth century.  The number of single genes controlling an entire disease state is very rare, and discoveries of these come maybe once every four or five years.  Most of the time, the genetics of a particular disease is very complex, and computers are good at modeling complex states.  This type of research can't happen fast enough, as far as I'm concerned.

Just for fun, here's a link to the NYT story about the pregnant man, Thomas Beatie. It's a complex story, since he was born a woman, but there's a photo of him doing yardwork, pregnant belly and all.  Apparently this story has been around for a while (nine months?) on the net, but I am just hearing about it now.

Oh, come on, it was just a matter of time, people!

Here is a new picture of a single virus, the first time this has been published.  Of course, the research came out of UCLA.  Nice.  Click the link below to see a larger version of the diagram.  The real benefit is that they are using X-ray diffraction technology, which has been around for years, to get nanometer resolution.  As far as I know, only an Atomic Force Microscope gets you this kind of resolution, but these must be wicked expensive.

Phone call, Friday afternoon.  "You recommended my patient to go on blood thinners after delivery?  She has a Factor V Leiden, but I have a paper in the obstetrical literature that reports we should only be using blood thinners in the highest risk women, such as those with combined Prothrombin Gene Mutation and Factor V Leiden.  You're basically saying there's a higher risk of thrombosis after the pregnancy than during, since we took her off lovenox during the pregnancy?"

Shares of Wyeth spiked on news of tepid findings from a Phase II study of Alzheimer's drug bapineuzumab.  This is one of the leading molecules in Alzheimer's Disease.  The story starts out complicated because not every patient is even eligible for the drug, only those with wild-type Apo-E4.  Of those 40% or so of all Alzheimer's patients, 18-month cognitive decline went from 6 points on a scale to 2 points on a cognitive function scale.

First of all, investors, you realize that these trial results are negative.  NYT reports that the results did not fulfill the criteria Wyeth set for a successful study.  Sounds like a case of believing what you want to believe despite evidence to the contrary.

Good news for those contemplating bariatric surgery: the procedure appears to reduce the risk of cancer by up to 85% for the next five years afterwards.  This by a Dr. Nicolas Christou, who presented as an abstract at a Bariatrics Meeting.  We don't have a lot of details in the Reuters and AP versions of the story--that may have to wait for the NYT coverage.

Tamoxifen metabolism is affected tremendously by the function of CYP2D6, one of the mitochondrial cytochrome p450 enzymes.  So say researchers quoted by Oncology Times this week, though the research was promoted at San Antonio December 2007.

There are apparently a lot of drugs that affect the activity of CYP2D6, so theoretically there could be drug interactions between tamoxifen and some of these medications.  A list of drugs affecting CYP2D6 appears on Wikipedia, though I have not vetted these for accuracy.