Feeds:
Posts
Comments

Archive for August, 2012

Reporter and Curator: Dr. Sudipta Saha, Ph.D.

 

As digital information continues to accumulate, higher density and longer term storage solutions are necessary. DNA has many potential advantages as a medium for immutable, high latency information storage needs. For example, DNA storage is very dense. At theoretical maximum, DNA can encode two bits per nucleotide (nt) or 455 exabytes per gram of ssDNA. Unlike most digital storage media, DNA storage is not restricted to a planar layer, and is often readable despite degradation in non-ideal conditions over millennia. Finally, DNA’s essential biological role provides access to natural reading and writing enzymes and ensures that DNA will remain a readable standard for the foreseeable future.

Storing messages in DNA was first demonstrated in 1988 and the largest project to date encoded 7920 bits. The small scale of previous work stems from the difficulty of writing and reading long perfect DNA sequences, and has limited broader applications. A strategy was developed to encode arbitrary digital information using a novel encoding scheme that utilizes next-generation DNA synthesis and sequencing technologies. An html-coded draft of a book that included 53,426 words, 11 JPG images and 1 JavaScript program was converted into a 5.27 megabit bitstream. Then these bits were encoded onto 54,898 159nt oligonucleotides (oligos) each encoding a 96-bit data block (96nt), a 19-bit address specifying the location of the data block in the bit stream (19nt), and flanking 22nt common sequences for amplification and sequencing. The oligo library was synthesized by inkjet printed, high-fidelity DNA microchips. To read the encoded book, the library was amplified by limited-cycle PCR and then sequenced on a single lane of an Illumina HiSeq. Overlapping paired-end 100nt reads were joined to reduce the effect of sequencing error. Then using only reads that gave the expected 115-nt length and perfect barcode sequences, consensus was generated at each base of each data block at an average of ~3000-fold coverage. All data blocks were recovered with a total of 10 bit errors out of 5.27 million, which were predomi-nantly located within homo-polymer runs at the end of the oligo where there was only single sequence coverage.

This method has at least five advantages over past DNA storage approaches. One bit per base (A or C for zero, G or T for one) was encoded instead of two. This allowed to encode messages many ways in order to avoid sequences that are difficult to read or write such as extreme GC content, repeats, or secondary structure. By splitting the bit stream into addressed data blocks, the need for long DNA constructs were eliminated which are difficult to assemble at this scale. To avoid cloning and sequence verifying constructs many copies of each individual oligo were synthesized, stored, and sequenced. Since errors in synthesis and sequencing are rarely coincident, each molecular copy corrects errors in the other copies. Purely in vitro approach was used that avoided cloning and stability issues of in vivo approaches. Finally, next-generation technologies in both DNA synthesis and sequencing was leveraged to allow for encoding and decoding of large amounts of information for ~100,000-fold less cost than first generation encodings.

The density (5.5 petabits/mm3 at 100x synthetic coverage) and scale (5.27 megabits) of this work compare favorably to other experimental storage technologies while only using commercially available materials and instruments. DNA is particularly suitable for immutable, high-latency, sequential access applications such as archival storage. Density, stability, and energy efficiency are all potential advantages of DNA storage, while costs and times for writing and reading are currently impractical for all but centuryscale archives. However, the cost of DNA synthesis and sequencing have been dropping at exponential rates of 5- and 12-fold per year, respectively – much faster than electronic media at 1.6-fold per year. Hand-held, single-molecule DNA sequencers are becoming available, and would vastly simplify reading DNA-encoded information. The general approach of using addressed data blocks combined with library synthesis and consensus sequencing should be compatible with future DNA sequencing and synthesis technologies. Reciprocally, large-scale use of DNA such as for information storage could accelerate development of synthesis and sequencing technologies. Future work could use compression, redundant encodings, parity checks, and error correction to improve density, error rate, and safety. Other polymers or DNA modifications can also be considered to maximize reading, writing, and storage capabilities.

Source Reference:

http://www.ncbi.nlm.nih.gov/pubmed/22903519

Read Full Post »

 

Harvard Group Using Bio-Rad Digital PCR System as Part of NHGRI-Funded Study of Multi-Allelic CNV

 

Reporter: Aviva Lev-Ari, PhD, RN

August 23, 2012

Researchers in the Department of Genetics at the Harvard University Medical School have been awarded $500,000 by the National Institutes of Health for the first year of a four-year project to study multi-allelic copy number variation in the human genome.

As part of the research, the Harvard team is using a Bio-Rad QX100 Droplet Digital PCR system as one of two methods to analyze multi-allelic CNVs in human cohorts. The researchers are also using a computational method that compares available whole-genome sequencing data.

Steven McCarroll, a professor of genetics at Harvard Med and director of genetics at the Stanley Center for Psychiatric Research at the Broad Institute, is principal investigator on the grant, which is being administered by NIH’s National Human Genome Research Institute.

According to a recently published grant abstract, McCarroll and colleagues seek to analyze multi-allelic CNVs, which involve genes and other functional elements for which three or more segregating alleles give rise to a wide range of copy numbers — between two and 10 — per diploid human genome.

These multi-allelic CNVs have been “refractory to widely used analysis methods and are not assessed in the genome-scale molecular or statistical approaches used to study genetically complex phenotypes in humans,” the researchers wrote.

The project builds on research that McCarroll’s group previously conducted on characterizing multi-allelic duplication CNVs of a megabase-long inversion polymorphism in a particular locus of chromosome 17 called 17q21.31, which contains markers previously associated with female fertility, female meiotic recombination, and neurological disease.

As part of that research, published in the August 2012 issue of Nature Genetics, the group analyzed read depth in the locus by applying an algorithm called Genome Structure in Populations, or Genome STRiP, to whole-genome sequencing data from 946 unrelated individuals sampled as part of the 1000 Genomes Project; and used droplet-based digital PCR to analyze 120 parent-offspring trios from HapMap.

http://www.nature.com/ng/journal/v44/n8/full/ng.2334.html

They found that their measurements of integer copy number varied from two to eight, and were 99.1 percent concordant across 234 genotypes in overlapping samples, thus validating both the computational and digital PCR methods.

More specifically, for the digital PCR assay, the group designed a pair of PCR primers and a dual-labeled fluorescence-FRET oligonucleotide probe to both the CNV locus and a two-copy control locus. Then they used a droplet generator from QuantaLife to compartmentalize the PCR reaction into uniform 1-nanoliter emulsion-based droplets containing zero, one, or very few template molecules for each locus; and a droplet reader from QuantaLife to count the number of positive and negative droplets, comparing the droplet counts of the CNV locus to the control locus to determine absolute copy number.

QuantaLife originally developed the droplet-based digital PCR system, but was acquired in October by Bio-Rad, which rebranded the platform as the QX100 Droplet Digital PCR system (PCR Insider, 10/6/2011).

Annette Tumolo, director of the digital biology center at Bio-Rad, told PCR Insider this week that McCarroll has access to two such platforms, one of which is in use at Harvard and was obtained from QuantaLife, and one of which Bio-Rad sold to the Broad Institute.

Tumolo said that Bio-Rad maintains “an active and positive relationship” with the McCarroll lab. “They’ve gotten great results [with the QX100], and were able to rapidly publish the Nature Genetics paper,” Tumolo said.

Under the new NHGRI grant, McCarroll and colleagues plan to “accurately analyze mCNVs in reference populations” using both the computational and digital PCR approach, the researchers wrote in their grant abstract.

“By analyzing these data in a statistical framework that incorporates information about genotypes, allele frequencies, inheritance, and haplotypes, we will place mCNV alleles onto the haplotype maps created by HapMap and 1000 Genomes, and render mCNVs accessible to genotype imputation to the fullest extent possible,” the grant abstract states.

In addition, McCarroll’s group hopes to “deeply characterize mCNVs at 10 biomedically important loci, to understand these polymorphisms at the levels of population genetics, mutational rates and histories, and relationships to clinical phenotypes. Finally, we will pilot inexpensive in silico genome-wide association studies for mCNVs based on statistical imputation into existing GWAS data sets.”

The end goal of the project is to discover relationships between disease risk and gene dosage, which will help reveal the molecular etiology of human disease, the researchers wrote.

Related Stories

Ben Butkus is senior editor of GenomeWeb’s premium content and the editor of PCR Insider. He covers technologies and trends in PCR, qPCR, nucleic acid amplification, and sample prep. E-mail him here or follow his GenomeWeb Twitter account at@PCRInsider.

 

Read Full Post »

Vascular Medicine and Biology: CLASSIFICATION OF FAST ACTING THERAPY FOR PATIENTS AT HIGH RISK FOR MACROVASCULAR EVENTS Macrovascular Disease – Therapeutic Potential of cEPCs

 

Curator and Author: Aviva Lev-Ari, PhD, RN

 

Classification of Fast Acting Therapies for Patients at High Risk for Macrovascular events

Macrovascular Disease – Therapeutic Potential of cEPCs

 

The two leading therapy classes are:

  1. Cell-based Therapies for angiogenesis and myocardial regeneration
  2. Intracoronary Delivery of Autologous Bone Marrow originating cells to restore Ischemic Tissue

The European Meeting on Vascular Medicine and Biology is a biannual international conference. The 3rd European Meeting on Vascular Medicine and Biology, took place in September 2005 and the next conference will be in 2007. All abstract presentations are published in Supplement 2, JOURNAL OF VASCULAR RESEARCH, Volume 42, 2005.

Review of 355 abstracts of posters presented at the conference has identified the following twenty Research Frontiers in Vascular Biology and Vascular Disease.

One abstract is of special interest to the line of research which focus on endogenous augmentation of cEPCs and to reduction of CVD risk by endogenous induction of regression of atherosclerotic plaques. It was selected by being judged to have the highest potential for commercialization and the potential to replace several therapeutic agents with higher efficacy.

P119 IgG1 antibodies against oxLDL epitopes induce regression of advanced atherosclerotic plaques in LDLR-/- APOBEC mice.

A. Schiopu1, B. Jansson2, P.K. Shah3, R. Carlsson3, J. Nilsson1, G. Nordin Fredrikson1Department of Medicine, Malmö University Hospital, Lund University, Malmö, SE; 2 BioInvent International AB, Lund, SE; 3 Atherosclerosis Research Center, Cedars-Sinai Medical Center, UCLA School of Medicine, Los Angeles, US.

Objective: The purpose of our study was to assess the effects of recombinant human IgG1 antibodies against specific oxLDL epitopes on advanced atherosclerotic lesions in mice.

Methods: We have tested 2 recombinant human IgG1 antibodies directed to malondialdehyde (MDA)-modified ApoB-100 peptide sequences. Three weekly 1 mg antibody doses were injected intraperitoneally starting at 25 weeks in LDLR-/-Apobec mice, which were then sacrificed at 29 weeks of age. IgG1 antibodies directed against fluorescein isothiocyanate, which do not bind to either native or oxidized LDL, and a

baseline group sacrificed at 25 weeks of age, to asses plaque status before immunization, were used as controls.

Results: Both antibodies induced a significant regression of already present atherosclerotic plaques in the descending aorta as compared to baseline. This effect was not present in the isotype control group. The changes did not depend on alterations in weight, cholesterol or triacylglycerol content in mice plasma.

Conclusions: The present study suggests that antibody treatment has the ability to reduce the extent of already present, advanced atherosclerotic lesions. Passive immunization with antibodies directed against oxLDL epitopes might constitute a future fast acting therapy for patients at high risk for acute cardiovascular events.

Twenty Research Frontiers in Vascular Medicine of Human Endothelium

 

Research Frontiers in Vascular Biology and Vascular Disease 

 

  

International Research Projects

Stem Cell biology Embryonic stem cells in cardiovascularrepairEarly differentiation of human endothelial progenitor cellsVessels transmigration of stem cells depends on activation of the endothelium.

Interaction of embryonal endothelial progenitor cells with platelets

Role of smooth muscle cell progenitors on atherosclerotic plaque development and stability.

 

Ischemia  and Reperfusion Connexin 43 and myocardial ischemia/reperfusioninjuryEndothelialreperfusion injuryA possible role for hypoxia-inducible factor 1• in protection against reperfusion injury

 

Genetic Basis of Vascular Disease Cardiovascular genomics and oxidative stressNox1 mediates basic fibroblast growth factor induced vascular smooth muscle cell migrationReactive oxygen species upregulate NOX4, but not NOX2, in endothelial cells

Induction of prolyl hydroxylase 2 by nitric oxide interferes with the hypoxia induced feedback loop of HIF-1• regulation

Protein disulfide isomerase is a central

regulator of NADPH oxidase activity

 

Inflammation Inflammatory mediatorsofvascularInflammationIsoprostanes inhibit in vitro migration and tube formation of endothelial cells via the thromboxane A2 receptor.

Heme oxygenase-1-dependent and

-independent regulation of angiogenic and inflammatory genes expression in human microvascular endothelial cells

 

Tissue Engineering Engineered heart tissueEndothelial tissue engineeringBlood vessel growth and remodeling in in-vivo tissue engineering

The effects of cyclic strain on the cytoskeleton of vascular smooth muscle cells

 

Atherosclerosis Imaging Experimental In vivo imaging ofatherosclerosisHoming ofCD34+ progenitor cells to sites ofangiogenic tube formation using real-time video microscopy.Relation between lipoprotein(a) and fibrinogen and serial intravascular ultrasound plaque progression in left main stems

Cardiovascular Development Controlled by Fluid Shear Stress. A Functionomic Approach.

Dynamics in microvascular alterations in UCP/DTA mice in vivo – from metabolic syndrome to diabetes mellitus type 2

Vascular Cell Signaling TGF-beta in endothelial cell functionandvascular developmentVEGF signaling

 

Atherosclerosis (Clinical / In Vivo) Pathophysiology of cigarette smoking-inducedatherosclerosisThe homeostatic benefits of plaque ruptureEarly coronary atherogenesis as a

consequence of chronic in-vivo proteasome inhibition.

 

Renin-Angiotensin System ACE inhibitorsstimulate endothelialCOX-2expression by aJNK-dependent ACE signalling pathway.A new ACE on the table: ACE2 expression in human atherosclerosis

Role of the ACE gene in renal and vascular complications of diabetes mellitus, experimental study in the mouse.

Bone marrow molecular alterations after

myocardial infarction: impact on endothelial progenitor cells and modulation by ACE inhibition or statin treatment.

Anti-inflammatory properties of Ramiprilat: reduction of monocyte adhesion to angiotensin II-stimulated endothelium is associated with AT1 downregulation.

Activation of phospholipase D by angiotensin II in HUVECS and HMVECS

Pathogenesis of Atherosclerosis Metalloproteinases in vascular pathologywhat we know and what we don’t know.
Stem Cell Therapy Functional assessment of circulatingcellsHuman fetal vascular progenitor cellsaccelerate the healing of ischemic diabetic ulcers

Peri-infarct gene transfer of human tissue kallikrein gene prevents left ventricle dysfunction by stimulating

angiogenesis/arteriogenesis and cardiac stem cell activation and by inhibiting cardiomyocyte apoptosis.

 

Genomics / Proteomics in Vascular Biology Genomic analysis of animal modelsforatherosclerosis.Differential gene expression analysis of tube forming and non-tube forming microvascular endothelial cells in vitro, separated by differences in morphology

Proteomic and metabolomic analysis of

atherosclerotic vessels in ApoE-/- mice

Hypoxic angiogenic transcriptome in human keratinocytes and microvascular endothelial cells: macroarray and real-time PCR analysis.

Gene expression profiling of human red blood cells.

 

Oxidant and Lipid Signaling Lipid modifications in atherogenesis.Epoxyeicosatrienoic acids in vascularHomeostasis

Oxidized phospholipids as modulators of

Inflammation

Chemokines — Cell-Cell Interactions Endothelial cell-to-celljunctionsInterplay ofchemokines and platelets invascular cell recruitment

 

Vascular Development Embryonic vesseldeterminationVascular remodeling: differentiation ofarteries, veins and lymph vessels

 

Vascular Aneurysms and VascularDegradation MMP in aneurysmdevelopmentFurin-likeproproteinconvertases regulate membrane type-1 matrixmetalloproteinase in atherosclerosisNon-viral, electroporation mediated gene

transfer of TIMP-1.ATF, a cell-surface directed MMP inhibitor, suppresses intimal hyperplasia in vein grafts more efficiently than TIMP-1 in vivo.

EMMPRIN regulates MMP activity in

cardiovascular cells. Implications in Acute Myocardial Infarction.

NF-kB promotes monocyte adhesion in vessels exposed to high intraluminal pressure

Diabetes Mellitus and InsulinResistance The endothelial cellglycocalyx indiabetesVasocrine signaling and insulin resistanceEarly arteriogenic defects in a diabetic

ischemic hindlimb model

Diabetes-induced overproduction of reactive oxygen species impairs post-ischemic neovascularization

 

Microparticles / Platelets The significance of membranemicroparticles in vascular pathophysiology andintercellularcommunication.Influences of nuclear receptors on platelet function.

Cellular origin of microparticles in human

atherosclerotic plaques

Apoptotic microparticles derived from

endothelial cells, smooth muscle cells and monocytes induce thrombin generation via different pathways

Smooth Muscle Cells Role of epigenetic mechanisms in control of SMC differentiation in development anddiseaseThe cytoskeletal proteinzyxin is amechanosensitive signaltransducer in vascular smooth muscle cells.Leukotriene-induced migration and

proliferation of vascular smooth muscle cells: implications for atherosclerosis and restenosis

 

Stem Cells Transfer of stem cell-derived endothelial cells retardedneointimal lesions in the injured artery.Stimulation ofreendothelialization viarecruitment of endothelial progenitor cells with selective antibodies against progenitor cell surface markers

Caspase-8 activity is essential for endothelial progenitor cell adherence

Read Full Post »

 

Reporter: Aviva Lev-Ari, PhD, RN

Eric Topol: Get Rid of the Randomized Trial; Here’s a Better Way

Eric J. Topol, MD

WATCH VIDEO

Hi. I’m Dr. Eric Topol, Director of the Scripps Translational Science Institute and Editor-in-Chief of Medscape Genomic Medicine and theheart.org. In our series The Creative Destruction of Medicine, I’m trying to get into critical aspects of how we can Schumpeter or reboot the future of healthcare by leveraging the big innovations that are occurring in the digital world, including digital medicine.

But one of the things that has been missed along the way is that how we do clinical research will be radically affected as well. We have this big thing about evidence-based medicine and, of course, the sanctimonious randomized, placebo-controlled clinical trial. Well, that’s great if one can do that, but often we’re talking about needing thousands, if not tens of thousands, of patients for these types of clinical trials. And things are changing so fast with respect to medicine and, for example, genomically guided interventions that it’s going to become increasingly difficult to justify these very large clinical trials.

For example, there was a drug trial for melanoma and the mutation of BRAF, which is the gene that is found in about 60% of people with malignant melanoma. When that trial was done, there was a placebo control, and there was a big ethical charge asking whether it is justifiable to have a body count. This was a matched drug for the biology underpinning metastatic melanoma, which is essentially a fatal condition within 1 year, and researchers were giving some individuals a placebo.

Would we even do that kind of trial in the future when we now have such elegant matching of the biological defect and the specific drug intervention? A remarkable example of a trial of the future was announced in May.[1] For this trial, the National Institutes of Health is working with [Banner Alzheimer’s Institute] in Arizona, the University of Antioquia in Colombia, and Genentech to have a specific mutation studied in a large extended family living in the country of Colombia in South America. There is a family of 8000 individuals who have the so-called Paisa mutation, a presenilin gene mutation, which results in every member of this family developing dementia in their 40s.

Researchers will be testing a drug that binds amyloid, a monoclonal antibody, in just [300][1] family members. They’re not following these patients out to the point of where they get dementia. Instead, they are using surrogate markers to see whether or not the process of developing Alzheimer’s can be blocked using this drug. This is an exciting way in which we can study treatments that can potentially prevent Alzheimer’s in a very well-demarcated, very restricted population with a genetic defect, and then branch out to a much broader population of people who are at risk for Alzheimer’s. These are the types of trials of the future and, in fact, it would be great if we could get rid of the randomization and the placebo-controlled era going forward.

One of things that I’ve been trying to push is that we need a different position at the FDA. Now, we can find great efficacy, but the problem is that establishing safety often also requires thousands, or tens of thousands, of patients. That is not going to happen in the contrived clinical trial world. We need to get to the real world and into this digital world where we would have electronic surveillance of every single patient who is admitted and enrolled in a trial. Why can’t we do that? Why can’t we have conditional approval for a new drug or device or even a diagnostic test, and then monitor that very carefully. Then we can grant, if the data are supported, final approval.

I hope that we can finally get an innovative spirit, a whole new way of a conditional and then final approval in phases in the real world, rather than continuing in this contrived clinical trial environment. These are some things that can change in the rebooting or in the creative destruction, or reconstruction, of medicine going forward.

Thanks so much for your attention and your continued support of The Creative Destruction of Medicine series on Medscape.

References

  1. Banner Alzheimer’s Institute. Groundbreaking Alzheimer’s disease prevention trial announced. Press release.http://banneralz.org/media/28067/api_prevention_trial_release_5_15_12_final.pdf Accessed July 31, 2012.

On other topics in Medicine:

Topol on The Creative Destruction of Medicine

 

Read Full Post »

 

Reporter: Aviva Lev-Ari, PhD, RN

The Symphony of Science is a musical project of John D Boswell, designed to deliver scientific knowledge and philosophy in musical form. The project owes its existence in large measure to the classic PBS SeriesCosmos, by Carl Sagan, Ann Druyan, and Steve Soter, as well as all the other featured figures and visuals. Continuation of the videos relies on generous support from fans and followers. You can make a donation if you wish to contribute support to the project. Thanks to everybody who has donated – enjoy what you find!

NEWS (8/23/2012):
Thank you all for making our Terra Lumina kickstarter campaign a huge success! We are hard at work on the album. Click here to find out more about it – we’re shooting for a Fall 2012 release and can’t wait to share what’s in store.

Take a look at my recent work with PBS, remixing classic icons including Mr. RogersBob Ross and Julia Child!

The Symphony of Science bundle has been updated to version 1.5! The newest song is now included in this 16-track compilation album which includes a special unreleased track and Symphony of Science wallpaper.Click here to get it!

http://symphonyofscience.com/

 

Read Full Post »

Reporter: Aviva Lev-Ari, PhD, RN

 

HEALTH LAW, ETHICS, AND HUMAN RIGHTS

Ethical Considerations in Studying Drug Safety — The Institute of Medicine Report

Michelle M. Mello, J.D., Ph.D., Steven N. Goodman, M.D., M.H.S., Ph.D., and Ruth R. Faden, Ph.D., M.P.H.

August 22, 2012 (10.1056/NEJMhle1207160)

The tumult arising from revelations of serious safety risks associated with widely prescribed drugs, including rosiglitazone (Avandia, GlaxoSmithKline), rofecoxib (Vioxx, Merck), and celecoxib (Celebrex, Pfizer), has led to widespread recognition that improvement is needed in our national system of ensuring drug safety. Notwithstanding federal legislation in 2007 that strengthened the authority of the Food and Drug Administration (FDA) in the postmarketing period,1 critical weaknesses in the national system persist.

Central to these weaknesses are dilemmas surrounding not only the science but also the ethics of drug-safety research,2 many of which came to the fore in the heated public debate about the Thiazolidinedione Intervention with Vitamin D Evaluation (TIDE) trial, which compared the cardiovascular outcomes of long-term treatment with rosiglitazone with those of pioglitazone (Actos, Takeda) in patients with type 2 diabetes.3 At the request of the FDA, an Institute of Medicine (IOM) committee, on which we served, was convened to examine the ethics and science of FDA-required postmarketing safety research. In this article, we review the key ethics findings from the committee’s May 1, 2012, report4 and offer some reflections on the challenges ahead.

LESSONS FROM THE TIDE TRIAL

In May 2008, the FDA ordered the manufacturer of rosiglitazone, GlaxoSmithKline, to conduct a trial in response to evidence from meta-analyses that rosiglitazone was associated with a higher risk of myocardial infarction and death from cardiovascular causes than placebo or medications that were not based on nonthiazolidinedione comparators.5,6 Other studies suggested that pioglitazone, an alternative thiazolidinedione, was not associated with such risks.7,8 Before enrollment began, some argued that the evidence of the inferior safety of rosiglitazone was strong enough to make the trial ethically unjustifiable. Two FDA epidemiologists wrote in a 2008 memorandum that a head-to-head trial “would be unethical and exploitative” and that even a robust informed-consent process could not overcome the problem.9 This was not the consensus FDA view, which was that the uncertainty regarding the cardiovascular risks associated with rosiglitazone, as well as those associated with pioglitazone, was sufficient to justify a trial.10

These concerns triggered a February 2010 letter from members of Congress to the FDA demanding a justification for the trial and alleging that the consent form did not provide adequate risk information.11 In response, FDA Commissioner Margaret Hamburg expanded the FDA investigation of the safety of rosiglitazone, obtained advice from an FDA advisory committee, and asked the IOM to convene our committee.6 Although the FDA advisory committee recommended that the TIDE trial be continued if rosiglitazone was permitted to remain on the market, in September 2010, the FDA halted the trial and placed stringent new restrictions on the availability of rosiglitazone.12,13

The TIDE experience made the FDA appreciate the need for greater attention to the ethics of postmarketing research. First, it posed questions about what standard of evidence about drug risk justifies a decision by the FDA to require postmarketing research, particularly randomized trials, as well as what evidence could render such trials unacceptable. Second, it raised questions about what ethical obligations the FDA has to patients who participate in these studies. Finally, it highlighted a potential FDA role in ensuring that institutional review boards (IRBs) are completely informed in their efforts to protect study participants. Although major deficiencies with the TIDE consent form were identified by some FDA scientists and, later, by the IOM committee (Table 1TABLE 1Major Deficiencies in the Informed-Consent Form for the TIDE Trial.),4,9 the TIDE investigators countered that it had been approved by “480 ethics committees and IRBs.”14 However, the language of the consent form, the trial design, and the materials supporting the justification of the trial raised a question for the IOM committee about whether these bodies adequately understood the nature of the evidence that gave rise to the trial. The IOM committee proposed a framework for evaluating the ethics of FDA-required postmarketing research15 and made a number of ethics findings and recommendations.4

Ethical Responsibilities of the FDA

The IOM committee began by noting that the public health mission of the FDA gives rise to potentially competing ethical obligations “to protect the public’s health by having strong science on which to base regulatory decisions” and “to protect participants in research that it requires.”4Requiring a postmarketing study is an ethical decision, reflecting a weighing of these values.

The committee described the conditions that must be present to justify a decision to require a postmarketing study. The FDA should require postmarketing research only when, first, the uncertainty about the benefit–risk balance of a drug is so great that a responsible decision about its regulatory status cannot be made on the basis of existing evidence; second, the research will reduce this uncertainty; third, the FDA will use the research results expeditiously to make a regulatory decision; and fourth, sufficient protections for research participants can be ensured.

The committee argued that when the FDA requires a postmarketing study, it assumes a measure of ethical responsibility for the welfare of the study participants; exercise of that responsibility cannot be handed off to contractors or the industry sponsor. The responsibility is particularly strong when the patients’ treatment is determined by the study, such as in a randomized trial, linking any adverse outcomes directly to a regulatory decision to require a study of that type. This determination led to one of the most important recommendations from the IOM committee: the responsibilities of the FDA to research participants mean that it should mandate a randomized design only if the FDA “has concluded that an observational study could not provide the necessary information [to help answer the important public health question at issue], that an RCT [randomized, controlled trial] is likely to generate the information within the necessary timeframe, and that the necessary RCT is ethically acceptable.” This recommendation comports with but adds some further conditions to the current legal authority of the FDA under the FDA Amendments Act of 2007, which empowers the agency to require a randomized trial if it cannot obtain the data it needs from an observational study.1

In light of the critiques of the TIDE trial as inherently unethical, the committee addressed the justifiability of trials in which participants may encounter a net increase in risk, as compared with ordinary clinical care, but no realistic prospect of personal benefit. It argued that such trials can be justified only if they are necessary to answer a critically important public health question, if the potential risk is acceptable and minimized, and if special safeguards are in place, including a highly explicit informed-consent process to ensure that patients understand that they are potentially shouldering additional risk solely to contribute to the public good.

Specific actions that the FDA should take to meet its ethical obligations include specifying the study design, title, end points, and primary analyses; identifying design features that it views as ethically and scientifically indispensable; and, for clinical trials, specifying a safety-monitoring scheme. The committee recommended that the FDA routinely communicate with IRBs about required postmarketing studies — for example, by issuing a letter to accompany IRB applications that conveys information that is material to the IRB’s determination of the ethics of the research, as well as providing additional communications over the life of the study as warranted by new information about the drug or by changes in professional practice. The committee also believed that the FDA was ethically obligated to actually use the findings from required studies to make timely regulatory decisions.

The IOM committee emphasized that the adequacy of the informed-consent process is only one element in the ethics of FDA-required postmarketing research. Other central, and indeed prior, features include ensuring that the selection of participants is equitable and that the level of risk to which they are exposed is acceptable. The committee also recognized, however, that there are challenges to achieving meaningful informed consent in postmarketing trials of drugs for which there is a signal indicating the possibility of drug-related harm. In such cases, there is a suspicion that the benefits of the drug may not justify its risks and often that it may have a worse benefit–risk profile than alternative drugs available to treat the same condition. The committee concluded that for postmarketing trials of such drugs, there are “heightened obligations to ensure that potential research participants understand the risks posed by study enrollment.”4 This was of particular importance for rosiglitazone, because the cardiovascular problem it appeared to cause was the same outcome that good diabetic control was supposed to improve — in other words, if this elevation in risk were real, there could be little offsetting benefit.

The committee recommended several measures to strengthen the consent process in order to maximize patients’ understanding of the context in which the trial is being conducted, including what is already known about the risks associated with the drug. The report discussed both specific disclosures in the informed-consent form and special efforts that could be made to ensure adequate comprehension of complex information regarding risks (Table 2TABLE 2Mechanisms for Strengthening the Informed-Consent Process for Postmarketing Drug-Safety Studies.). To assist IRBs, the committee recommended that the FDA issue guidance interpreting current informed-consent regulatory requirements in the context of required postmarketing studies.

STRENGTHENING POSTMARKETING RESEARCH AND ITS GOVERNANCE

Because a true picture of the benefit–risk profile of a drug only emerges over time, two different IOM committees have stressed the need for the FDA to fully embrace a “life-cycle approach” to drug regulation, in which its obligations to protect public health are taken as seriously once a drug is on the market as they are before approval is granted.4,16 Postmarketing regulatory oversight is assuming heightened importance as the FDA accrues additional authority to fast-track drugs for approval on the basis of more limited evidence than was previously required in order to address unmet medical needs and accelerate innovation.17-19 This changing landscape raises several challenges for ensuring the ethical conduct of research with approved drugs and balancing societal interests in drug innovation and drug safety. We highlight two of these challenges here.

First, not all postmarketing research is ethically equivalent. The TIDE trial represented an iconic kind of postmarketing study: an FDA-required randomized trial to study a drug whose benefit–risk profile was under a cloud of suspicion and at a time when alternative treatments were available, albeit not all well studied. The risks to patients of participating in the trial probably outweighed the prospect of direct benefit. By contrast, when the FDA requires an observational study that uses previously collected data, the clinical experience of the participants is unaffected, the risks incurred are not at the behest of the FDA, and ethical concerns are largely confined to confidentiality and the right to control one’s medical information.

Both of these scenarios can be distinguished from the context in which a phase 4 trial is required as a condition of an accelerated drug approval and is initiated soon thereafter. Here, the trial requirement is not imposed because of a newly emerging concern about a drug already in clinical use but because additional evidence is needed to confirm the initial judgment that the benefits of a new drug are likely to outweigh its risks. Often, this initial judgment is based on the use of a surrogate end point for drug benefit, not on the clinical outcomes that matter most. Especially when the new drug targets an unmet medical need, it may be in the patients’ best interest to take it, pending further timely research. The ensuing trial is undertaken to confirm the improvement in clinical outcomes predicted by the surrogate — a different epistemic and ethical situation than that in which substantial evidence suggests that the surrogate is misleading or that other harms might offset a known clinical benefit.

The volume of phase 4 and other research with FDA-approved drugs is increasing, not only because of the expanded authority of the FDA to require such research but also because of the growing volume of comparative-effectiveness research. In some cases, there may be no or little ethical difference between FDA-required postmarketing research and comparative-effectiveness research initiated by academic investigators. By contrast, a comparative-effectiveness study of two widely used drugs that is not occasioned by heightened concern about the risks of one drug relative to the other is markedly different, ethically, from a study required by the FDA to pursue a safety signal that is already of such concern that practice patterns are shifting, even if both studies use randomized designs.

These differences highlight the need for IRBs to be sensitive to the place where a study falls within the life cycle of a drug and to the reason for the research. Depending on who is initiating the research, for what reasons, and when, the same study design may have very different ramifications for the benefit–risk balance of the study and what patients need to know in order to provide meaningful informed consent. Trials that may be regarded as unethical late in the life cycle because of accumulated evidence can be much easier to initiate earlier if the need for additional research is anticipated and planned at the time of initial approval. In the case of rosiglitazone, this need could have been anticipated from preapproval data showing an adverse effect on serum lipids as well as the use of a surrogate end point (glycemic control) for a first-in-class drug.5,20

Second, the experience with rosiglitazone underscored the fragility of our current system of discovering risks associated with drugs. This system relies heavily on drug sponsors and FDA scientists to conduct safety analyses on the basis of data from clinical trials, some or all of which are not publicly available, and to release findings to the public. It has been shown repeatedly that the published record can misrepresent evidence known to the FDA.21,22 In the case of rosiglitazone, scientists from GlaxoSmithKline and the FDA had information from 42 clinical trials, of which only 7 were published and the others were inaccessible. Triggered by concerns expressed by the World Health Organization in 2006, GlaxoSmithKline conducted and shared with the FDA a meta-analysis of the safety of rosiglitazone that used these data, confirming a possibly elevated risk of ischemic events, but neither these results nor the primary trial results were shared with the public until an unrelated court settlement forced GlaxoSmithKline to release its complete clinical-trial data.23 This access led to the published meta-analysis by independent researchers that made these data and concerns public in 2007.5

It is often the work of independent scientists that has highlighted critical safety problems with approved drugs.5,24-29 Yet currently, data from premarketing studies that are submitted as part of a new drug application or a supplemental new drug application are largely shielded from release to external scientists and the public owing to concerns about a competitive disadvantage to drug sponsors.30,31 The IOM committee stopped short of calling on the FDA to increase public access to such data but recommended that the agency initiate a process to determine ways to “appropriately balance public health, privacy, and proprietary interests to facilitate disclosure” of relevant data.4 Greater transparency would better equip independent scientists to investigate early safety signals.31 Consideration should be given to making drug-safety data from clinical trials available to the public on request once the FDA has reached a decision regarding a new drug application or a supplemental new drug application or once the manufacturer has abandoned the application, unless the manufacturer can articulate a persuasive reason why it would result in competitive harm and the FDA determines that this harm outweighs the public health benefits of releasing the information.

CONCLUSIONS

The experience with rosiglitazone and the TIDE trial offers a lesson in how our current approach to the oversight of drug-safety and postmarketing research can fail both the public and the research participants. Although terminating the TIDE trial was justifiable, it left regulators with highly suggestive but nondefinitive data on the relative safety of rosiglitazone and the closest clinical alternative, pioglitazone.32

Reactive policymaking is tempting but problematic. The history of regulation of human subjects research suggests that rules that are “born in scandal and reared in protectionism”33 often fall short of providing meaningful protections to research participants and that, once adopted, regulations can ossify and become difficult to dislodge. Nevertheless, the IOM committee’s report makes a number of actionable recommendations that the FDA can implement under its existing authority.34 In addition, appointment of an independent ethics advisory board would strengthen the decision making of the FDA as it confronts emerging ethical challenges — both those arising from required postmarketing trials and those stemming from powerful new drug surveillance systems, such as the FDA’s Sentinel Initiative. As the pace of the translation of discoveries from bench to bedside continues to intensify, so too does the imperative for thoughtful ethical governance throughout the life cycle of a drug.

The views expressed in this article are those of the authors and, except where noted, do not represent the official position of the Institute of Medicine or of the committee that produced the report discussed in this article.

Drs. Faden and Goodman chaired, and Dr. Mello was a member of, the Institute of Medicine committee that produced the report discussed in this article.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

This article was published on August 22, 2012, at NEJM.org.

We thank the other IOM committee members for contributing to some of the ideas discussed.

SOURCE INFORMATION

From the Department of Health Policy and Management, Harvard School of Public Health, Boston (M.M.M.); the Departments of Medicine and Health Research and Policy, Stanford University School of Medicine, Stanford, CA (S.N.G.); and the Berman Institute of Bioethics, Johns Hopkins University, Baltimore (R.R.F.).

REFERENCES

    1. 1Food and Drug Amendments Act of 2007, Pub. L. No. 110-85, 121 Stat. 823. (2007).

    1. 2London AJ, Kimmelman J, Carlisle B. Research ethics: rethinking research ethics: the case of postmarketing trials. Science 2012;336:544-545
      CrossRef | Web of Science

    1. 3ClinicalTrials.gov. Thiazolidinedione Intervention with Vitamin D Evaluation (TIDE). 2011 (http://clinicaltrials.gov/ct2/show/NCT00879970?term=NCT00879970&rank=1).

    1. 4Committee on Ethical and Scientific Issues in Studying the Safety of Approved Drugs, Institute of Medicine. Ethical and scientific issues in studying the safety of approved drugs. Washington, DC: National Academies Press, 2012 (http://www.iom.edu/Reports/2012/Ethical-and-Scientific-Issues-in-Studying-the-Safety-of-Approved-Drugs.aspx).

    1. 5Nissen SE, Wolski K. Effect of rosiglitazone on the risk of myocardial infarction and death from cardiovascular causes. N Engl J Med 2007;356:2457-2471[Erratum, N Engl J Med 2007;357:100.]
      Full Text | Web of Science | Medline

    1. 6Hamburg M. Letter to the honorable Charles E. Grassley. March 30, 2010 (http://online.wsj.com/public/resources/documents/Grassley.pdf).

    1. 7Lincoff AM, Wolski K, Nicholls SJ, Nissen SE. Pioglitazone and risk of cardiovascular events in patients with type 2 diabetes mellitus: a meta-analysis of randomized trials.JAMA 2007;298:1180-1188
      CrossRef | Web of Science | Medline

    1. 8Dormandy JA, Charbonnel B, Eckland DJ, et al. Secondary prevention of macrovascular events in patients with type 2 diabetes in the PROactive Study (PROspective pioglitAzone Clinical Trial In macroVascular Events): a randomised controlled trial. Lancet2005;366:1279-1289
      CrossRef | Web of Science | Medline

    1. 9Graham D, Gelperin K. Memorandum to Mary Parks, re: benefit-risk assessment of rosiglitazone vs. pioglitazone. October 7, 2008 (http://www.finance.senate.gov/newsroom/chairman/release/?id=bc56b552-efc5-4706-968d-f7032d5cd2e4).

    1. 10Mahoney K. Advisory committee clinical briefing document: preliminary endocrine medical officer review of the RECORD (Rosiglitazone Evaluated for Cardiac Outcomes and Regulation of Glycemia in Diabetes) Trial, and update on cardiovascular safety information from large clinical trials of rosiglitazone. 2010 (http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/EndocrinologicandMetabolicDrugsAdvisoryCommittee/UCM218493.pdf).

    1. 11Baucus M, Grassley C. Letter to the honorable Margaret A. Hamburg, MD. February 18, 2010 (http://www.finance.senate.gov/newsroom/chairman/release/?id=bc56b552-efc5-4706-968d-f7032d5cd2e4).

    1. 12Woodcock J. Decision on continued marketing of rosiglitazone (Avandia, Avandamet, Avandaryl). 2010 (memorandum) (http://www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/UCM226959.pdf).

    1. 13Woodcock J, Sharfstein JM, Hamburg M. Regulatory action on rosiglitazone by the U.S. Food and Drug Administration. N Engl J Med 2010;363:1489-1491
      Full Text | Web of Science | Medline

    1. 14Food and Drug Administration, Center for Drug Evaluation and Research. Joint meeting of the Endocrinologic and Metabolic Drugs Advisory Committee and Drug Safety and Risk Management Advisory Committee. July 14, 2010 (transcript) (http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/EndocrinologicandMetabolicDrugsAdvisoryCommittee/UCM222629.pdf).

    1. 15Committee on Ethical and Scientific Issues in Studying the Safety of Approved Drugs, Institute of Medicine. Ethical issues in studying the safety of approved drugs: a letter report. Washington, DC: National Academies Press, July 2010 (http://www.nap.edu/catalog.php?record_id=12948).

    1. 16Committee on the Assessment of the U.S. Drug Safety System, Institute of Medicine. The future of drug safety: promoting and protecting the health of the public. Washington, DC: National Academies Press, 2007 (http://www.iom.edu/Reports/2006/The-Future-of-Drug-Safety-Promoting-and-Protecting-the-Health-of-the-Public.aspx).

    1. 17U.S. Senate. Health, Education, Labor and Pension Committee. Food and Drug Administration Safety and Innovation Act (discussion draft), 112th Cong., 2d Sess. 2012 (http://www.help.senate.gov/imo/media/audio/KER12172.pdf).

    1. 18Chen JY, Carter M. Bioethics and post-approval research in translational science. Am J Bioeth 2010;10:35-37
      Web of Science

    1. 19Psaty BM, Meslin EM, Breckenridge A. A lifecycle approach to the evaluation of FDA approval methods and regulatory actions: opportunities provided by a new IOM report. JAMA 2012 May 4 (Epub ahead of print).

    1. 20Misbin RI. Lessons from the Avandia controversy: a new paradigm for the development of drugs to treat type 2 diabetes. Diabetes Care 2007;30:3141-3144
      CrossRef | Web of Science

    1. 21Doshi P, Jefferson T, Del Mar C. The imperative to share clinical study reports: recommendations from the Tamiflu experience. PLoS Med 2012;9:e1001201-e1001201
      CrossRef | Web of Science

    1. 22Rising K, Bacchetti P, Bero L. Reporting bias in drug trials submitted to the Food and Drug Administration: review of publication and presentation. PLoS Med 2008;5:e217-e217[Erratum, PloS Med 2009;6(1):e17.]
      CrossRef | Web of Science | Medline

    1. 23Nissen SE. The rise and fall of rosiglitazone. Eur Heart J 2010;31:773-776
      CrossRef | Web of Science

    1. 24Sackner-Bernstein JD, Kowalski M, Fox M, Aaronson K. Short-term risk of death after treatment with nesiritide for decompensated heart failure: a pooled analysis of randomized controlled trials. JAMA 2005;293:1900-1905
      CrossRef | Web of Science | Medline

    1. 25Sackner-Bernstein JD, Skopicki HA, Aaronson KD. Risk of worsening renal function with nesiritide in patients with acutely decompensated heart failure. Circulation 2005;111:1487-1491[Erratum, Circulation 2005;111:2274.]
      CrossRef | Web of Science | Medline

    1. 26Nissen SE, Wolski K, Topol EJ. Effect of muraglitazar on death and major adverse cardiovascular events in patients with type 2 diabetes mellitus. JAMA 2005;294:2581-2586
      CrossRef | Web of Science | Medline

    1. 27Solomon DH. Selective cyclooxygenase 2 inhibitors and cardiovascular events. Arthritis Rheum 2005;52:1968-1978
      CrossRef | Web of Science

    1. 28Curfman GD, Morrissey S, Drazen JM. Expression of concern: Bombardier et al., “Comparison of upper gastrointestinal toxicity of rofecoxib and naproxen in patients with rheumatoid arthritis,” N Engl J Med 2000;343:1520-8. N Engl J Med 2005;353:2813-2814
      Full Text | Web of Science | Medline

    1. 29Nissen SE, Wolski K. Rosiglitazone revisited: an updated meta-analysis of risk for myocardial infarction and cardiovascular mortality. Arch Intern Med 2010;170:1191-1201
      CrossRef | Web of Science

    1. 30Kesselheim AS, Mello MM. Confidentiality laws and secrecy in medical research: improving public access to data on drug safety. Health Aff (Millwood) 2007;26:483-491
      CrossRef | Web of Science | Medline

    1. 31Krumholz H. The FDA is faster: now let’s make it safer. Outcomes. Forbes.com. May 16, 2012 (http://blogs.forbes.com/harlankrumholz).

    1. 32Punthakee Z, Bosch J, Dagenais G, et al. Design, history and results of the Thiazolidinedione Intervention with vitamin D Evaluation (TIDE) randomised controlled trial.Diabetologia 2012;55:36-45
      CrossRef | Web of Science

    1. 33Levine C. Has AIDS changed the ethics of human subjects research? Law Med Health Care 1988;16:167-173
      Medline

      34

      Food and Drug Administration. Guidance for industry: postmarketing studies and clinical trials — implementation of section 505(o)(3) of the federal Food, Drug, and Cosmetic Act. April 2011 (http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/UCM172001.pdf).

      http://www.nejm.org/doi/full/10.1056/NEJMhle1207160?query=TOC

Read Full Post »

Reporter: Aviva Lev-Ari, PhD, RN

While a staff nurse at Beth Israel Deaconess Medical Center in Boston, MA in 2008, I provided direct care for Morbid Obese patients, above 400 pounds that were transferred to Farr 9 – the Acute Surgery Unit from the PACU following Bariatric Surgery. The first day after a significant surgical intervention was very tough to the patient and very tough for the nurses, three types of analgesic drugs were used including epidural pumps and PCA. Pain medication diffused in the adipose tissue with just moderate amelioration of pain. Few patients had the operation done 10 years ago and needed a repair. Technology had advanced. More studies are needed to ascertain that in presence of morbid obesity and absence of DM, a Bariatric Surgery is THE Treatment for DM Disease Prevention.

Bariatric Surgery — From Treatment of Disease to Prevention?

Danny O. Jacobs, M.D., M.P.H.

N Engl J Med 2012; 367:764-765  August 23, 2012

Bariatric surgery to treat morbid obesity has improved dramatically over the past 60 years — especially over the past several decades. Today’s methods are far safer than the hazardous intestinal bypass procedures that were introduced in the 1950s. Bariatric-surgery techniques have progressed through various iterations of horizontal and vertical stapling of the stomach with or without banding (e.g., vertical banded gastroplasty) to vertical gastric partitioning or creation of a gastric pouch with proximal bypass into a jejunal loop (i.e., the gastric bypass), which is considered to be a reference standard.

Bariatric Surgery for Morbid Obesity.

Bariatric Surgery for Morbid Obesity.

SOURCE INFORMATION

From the Department of Surgery, Duke University School of Medicine, Durham, NC.

Bariatric Surgery and Prevention of Type 2 Diabetes in Swedish Obese Subjects

Lena M.S. Carlsson, M.D., Ph.D., Markku Peltonen, Ph.D., Sofie Ahlin, M.D., Åsa Anveden, M.D., Claude Bouchard, Ph.D., Björn Carlsson, M.D., Ph.D., Peter Jacobson, M.D., Ph.D., Hans Lönroth, M.D., Ph.D., Cristina Maglio, M.D., Ingmar Näslund, M.D., Ph.D., Carlo Pirazzi, M.D., Stefano Romeo, M.D., Ph.D., Kajsa Sjöholm, Ph.D., Elisabeth Sjöström, M.D., Hans Wedel, Ph.D., Per-Arne Svensson, Ph.D., and Lars Sjöström, M.D., Ph.D.

N Engl J Med 2012; 367:695-704  August 23, 2012

BACKGROUND

Weight loss protects against type 2 diabetes but is hard to maintain with behavioral modification alone. In an analysis of data from a nonrandomized, prospective, controlled study, we examined the effects of bariatric surgery on the prevention of type 2 diabetes.

METHODS

In this analysis, we included 1658 patients who underwent bariatric surgery and 1771 obese matched controls (with matching performed on a group, rather than individual, level). None of the participants had diabetes at baseline. Patients in the bariatric-surgery cohort underwent banding (19%), vertical banded gastroplasty (69%), or gastric bypass (12%); nonrandomized, matched, prospective controls received usual care. Participants were 37 to 60 years of age, and the body-mass index (BMI; the weight in kilograms divided by the square of the height in meters) was 34 or more in men and 38 or more in women. This analysis focused on the rate of incident type 2 diabetes, which was a prespecified secondary end point in the main study. At the time of this analysis (January 1, 2012), participants had been followed for up to 15 years. Despite matching, some baseline characteristics differed significantly between the groups; the baseline body weight was higher and risk factors were more pronounced in the bariatric-surgery group than in the control group. At 15 years, 36.2% of the original participants had dropped out of the study, and 30.9% had not yet reached the time for their 15-year follow-up examination.

RESULTS

During the follow-up period, type 2 diabetes developed in 392 participants in the control group and in 110 in the bariatric-surgery group, corresponding to incidence rates of 28.4 cases per 1000 person-years and 6.8 cases per 1000 person-years, respectively (adjusted hazard ratio with bariatric surgery, 0.17; 95% confidence interval, 0.13 to 0.21; P<0.001). The effect of bariatric surgery was influenced by the presence or absence of impaired fasting glucose (P=0.002 for the interaction) but not by BMI (P=0.54). Sensitivity analyses, including end-point imputations, did not change the overall conclusions. The postoperative mortality was 0.2%, and 2.8% of patients who underwent bariatric surgery required reoperation within 90 days owing to complications.

CONCLUSIONS

Bariatric surgery appears to be markedly more efficient than usual care in the prevention of type 2 diabetes in obese persons. (Funded by the Swedish Research Council and others; ClinicalTrials.gov number, NCT01479452.)

Supported by grants from the Swedish Research Council (K2012-55X-22082-01-3, K2010-55X-11285-13, K2008-65x-20753-01-4), the Swedish Foundation for Strategic Research to Sahlgrenska Center for Cardiovascular and Metabolic Research, the Swedish federal government under the LUA/ALF agreement concerning research and education of doctors, the VINNOVA-VINNMER program, and the Wenner-Gren Foundations. The SOS study has previously been supported by grants to one of the authors from Hoffmann–La Roche, AstraZeneca, Cederroth, Sanofi-Aventis, and Johnson & Johnson.

Dr. Lena Carlsson reports receiving consulting fees from AstraZeneca and owning stock in Sahltech; Dr. Bouchard, receiving consulting fees from New York Obesity Nutrition Research Center, Pathway Genomics, Weight Watchers, and Nike, payment for manuscript preparation from Elsevier and Wiley-Blackwell, royalties from Human Kinetics and Informa Healthcare, honoraria from NaturALPHA, and reimbursement for travel expenses from European College of Sports Sciences, Nordic Physiotherapy, Wingate Congress, and Euro Sci Open Forum; Dr. Björn Carlsson, being employed by and owning stock in AstraZeneca; Dr. Sjöholm, owning stock in Pfizer; Dr. Wedel, receiving consulting fees from AstraZeneca, Pfizer, Roche, and Novartis; and Dr. Lars Sjöström, serving as a member of the board of Lenimen, receiving lecture fees from AstraZeneca and Johnson & Johnson, and providing an expert statement on drug effects and weight-loss effects on obesity for AstraZeneca. No other potential conflict of interest relevant to this article was reported.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

Drs. Carlsson and Peltonen contributed equally to this article.

We thank the staff members at 480 primary health care centers and 25 surgical departments in Sweden that participated in the study; and Gerd Bergmark, Christina Torefalk and Lisbeth Eriksson for administrative support.

SOURCE INFORMATION

From the Institutes of Medicine (L.M.S.C., M.P., S.A., Å.A., B.C., P.J., C.M., C.P., S.R., K.S., E.S., P.-A.S., L.S.) and Surgery (H.L.), Sahlgrenska Academy at the University of Gothenburg, and the Nordic School of Public Health (H.W.), Gothenburg, and the Department of Surgery, University Hospital, Örebro (I.N.) — all in Sweden; the Department of Chronic Disease Prevention, National Institute for Health and Welfare, Helsinki (M.P.); and Pennington Biomedical Research Center, Louisiana State University System, Baton Rouge (C.B.).

Address reprint requests to Dr. Lars Sjöström at the SOS Secretariat, Vita Stråket 15, Sahlgrenska University Hospital, S-413 45 Gothenburg, Sweden, or at lars.v.sjostrom@medfak.gu.se.

N Engl J Med 2012; 367:695-704

Read Full Post »

 

Reporter: Aviva Lev-Ari, PhD, RN

Gordon H. Sun, M.D., Jeffrey D. Steinberg, Ph.D., and Reshma Jagsi, M.D., D.Phil.

N Engl J Med 2012; 367:687-690   August 23, 2012

Since the founding of the National Institutes of Health (NIH) and the National Science Foundation (NSF) more than six decades ago, the United States has maintained a preeminent position as a government sponsor of medical research. That primacy is being tested, however, by potent economic challenges. The NIH’s proposed budget for fiscal year 2013 would freeze baseline funding at 2012 levels, continuing a decade-long failure to keep pace with the rising costs of conducting medical research. Across-the-board cuts mandated by the Budget Control Act (BCA) of 2011 will also affect medical research, with the NIH, NSF, and other federal research sponsors sustaining budgetary reductions of about 8% next year.

Cuts to government-funded research will have adverse long-term effects on the health care system and the economy and may irreversibly compromise the work of laboratories long accustomed to receiving stable federal support. Moreover, many medical researchers could transfer their knowledge and resources abroad. In fact, five emerging Asian economic or technological powers — China, India, South Korea, Taiwan, and Singapore — already have medical research policies in place that are filling the void being created by ever more restrictive U.S. funding.

Several U.S.-based economists have justified increasing research budgets on the premise that medical discoveries have intrinsically high economic value. For example, Murphy and Topel have suggested that eliminating deaths related to heart disease had an estimated worth of $48 trillion, and a 1% reduction in cancer-related mortality could save $500 billion.1 Beyond these ambitious goals, however, are more practical arguments favoring support for medical research.

Local and regional economic benefits are one example. A June 2008 analysis by Families USA showed that during the NIH’s fiscal year 2007, nearly $23 billion in grants and contracts supported more than 350,000 jobs, with each dollar generating more than twice as much in direct state economic output in the form of goods and services. The NIH reported that almost 1 million Americans worked in for-profit medical businesses in 2008, earning $84 billion and generating $90 billion in goods and services, reinforcing the importance of preserving the U.S. position as a “knowledge hub” for medical research.2 Nevertheless, BCA cuts next year could result in at least 2500 fewer NIH grants, 33,000 fewer jobs, and a $4.5 billion loss in economic activity.3 Since the NIH’s budget represents less than 1% of overall federal spending, policymakers must reconsider whether shaving 8% from NIH outlays will have a noticeable positive effect on the national deficit or economy.

Fallout from funding cuts could include shifts in the U.S. medical research workforce. In 2000, the National Research Council noted both an overall shortage of medical researchers and inadequate funding for scientists working in the United States, which coincided with a decline in the number of funded NIH grant applications from 31% in fiscal year 2002 to 19% in 2010. This change is particularly critical for postdoctoral researchers, who represent the majority of the U.S. biomedical science workforce. According to the NSF, nearly half the 14,601 new postdoctoral-level researchers who were trained in the United States in 2009 were not U.S. citizens or permanent residents. If U.S. institutions are willing to devote money, training, and infrastructure to support talented, committed researchers, it would be an illogical waste of resources and poor long-term strategy to reduce federal grant mechanisms and wipe out potential job opportunities. Indeed, declining financial support may well encourage medical researchers to seek employment elsewhere.

As compared with the United States, China, India, South Korea, Taiwan, and Singapore have taken a sharply different view of medical research and have developed policies that foster medical research as an engine for economic growth and intellectual innovation (see tableMajor Government Agencies in Asia and Their Budgets for Medical Research.). Their national budgets are heavily based on scientific research and development, and funding is increasing, with budgetary targets ranging from 2 to 5% of their gross domestic products (GDPs). India’s funding goal for medical research alone is 2% of its GDP.

Increased funding for research infrastructure attracts scientists and organizations interested in high-quality research, including clinical trials. During the past two decades, increasing numbers of clinical trials have moved overseas, where benefits can include decreased costs of doing business, fewer administrative regulations, and greater enrichment of international relationships among researchers. The average annual rate of growth in clinical trials has been highest in China — 47% — while the number conducted in the United States has decreased by an average of 6.5% annually.4 In addition, the increased attention paid to Asia by private firms and other nongovernmental organizations has spurred rapid policy-level responses to concerns about the lack of informed consent, transparency, and other ethical issues, thus further strengthening the appeal of conducting research in the region.

Asian policies reflect a recognition of the extrinsic economic benefits of medical research. China and India have advocated for more government-funded medical research to improve health-related outcomes. China has espoused increased spending as part of achieving xiaokang, a Confucian term meaning a moderately prosperous society. In 2007, India inaugurated its Department of Health Research, which coordinates biomedical science and health-services research programs and translates their findings to address public health concerns. Since the signing of the Korean War Armistice Agreement in 1953, South Korea has leaned heavily on government-funded research to reduce poverty, allowing the country to gradually acquire advanced technologies and expertise. Medical research is part of at least two core technology areas in South Korea’s “577 Initiative”: medical technologies, such as neuroimaging, to address the needs of an aging population and research on issues pertaining to national safety and public health, such as infectious-disease preparedness and food safety.

National research and development programs have been a fundamental component of Taiwan’s economic policy for at least five decades. In 2005, the country began developing “intelligent medical care” — similar to earlier U.S. initiatives — which integrates medical information technology with quality-improvement measures. In Singapore, medical research and economic oversight are administratively linked. For example, the Biomedical Sciences Group of the Economic Development Board supports researchers financially and designs strategies that enhance Singapore’s status as a knowledge center, and the private firm Bio*One Capital invests directly in promising medical technologies.

The diverse strategies outlined above allow Asian countries to systematically recruit medical researchers from both home and abroad. China is particularly proactive in enticing Chinese-born, U.S.-educated researchers to return to their native country by offering generous financial and material incentives under its Knowledge Innovation Program. As the vice president of the Chinese Academy of Sciences stated more than a decade ago, modern “research and development is actually a war for more talented people.”5 In 2000, Singapore jump-started its Biomedical Sciences Initiative to attract medical researchers worldwide with a direct $2 billion investment, as well as with tax incentives for internal biotechnology start-ups and global pharmaceutical firms. In Singapore and India, English is the primary language for scientific communications, which alleviates concerns about language barriers.

For two decades, emerging Asian countries have been designing long-term strategies to reap the benefits of medical research. Meanwhile, the United States is relying on short-term solutions to support its medical research infrastructure, such as those offered by the Patient Protection and Affordable Care Act and the American Recovery and Reinvestment Act. Decreased investment in U.S. medical research could lead to long-term economic damage for the United States and the loss of its stature as a global leader in the field. Powerful incentives that can retain an elite biomedical-research workforce are necessary to strengthen the U.S. health care system and economy.

The views expressed in this article are those of the authors and do not necessarily reflect those of the Robert Wood Johnson Foundation, the Department of Veterans Affairs, or the Agency for Science, Technology, and Research.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

SOURCE INFORMATION

From the Robert Wood Johnson Foundation Clinical Scholars Program (G.H.S., R.J.), the Department of Otolaryngology (G.H.S.), and the Department of Radiation Oncology (R.J.), University of Michigan, and the Health Services Research and Development Service, VA Ann Arbor Healthcare System (G.H.S.) — both in Ann Arbor, MI; and the Singapore Bioimaging Consortium, Agency for Science, Technology, and Research, Singapore (J.D.S.).

http://www.nejm.org/doi/full/10.1056/NEJMp1206643?query=TOC

 

 

Read Full Post »

Reporter: Aviva Lev-Ari, PhD, RN

 

NEJM 200th Anniversary Documentary

Getting Better is a 45-minute documentary video that tells three remarkable stories of medical progress — in surgery, leukemia, and HIV/AIDS. Atul Gawande, Vincent DeVita, Tony Fauci, Paul Farmer, and other prominent experts explore research, clinical practice, and patient care, and how health care has continued to get better over the past 200 years. View the film in its entirety, or in segments, now on the 200th anniversary website

http://nejm200.nejm.org/explore/medical-documentary-video/?query=TOC

WATCH THREE VIDEOS – 45 minutes

?query=TOC

The Comments by the Public are an integral part of the video watching experience

From Rough to Refined: The Rise of Surgery (Part 1 of 3)

Targeting Cancer: The Story of Leukemia (Part 2 of 3)

The Plague of Our Time: HIV/AIDS Epidemic (Part 3 of 3)

Read Full Post »

Reported by: Dr. V. S. Karra, Ph.D.

“Emergency treatments for stopping the flow of blood from cuts and other external injuries save thousands of lives each year,” Lavik pointed out. “But we have nothing that emergency responders or military medics can use to stop internal bleeding permanently or at least long enough to get a patient to a hospital. There’s a tremendous need in the military, where almost 80 percent of battlefield traumas are blast injuries. In civilian life, there are many accidents, violence-related injuries and other incidents that result in internal bleeding.”

Lavik’s team, which is at Case Western Reserve University, was inspired by studies showing there are few options to treat soldiers in Afghanistan and Iraq who suffer internal injuries from the roadside bombs known as improvised explosive devices and other blasts. They wanted to develop a treatment military medics could use in the field to stabilize wounded soldiers en route to definitive care in a hospital.

“The military has been phenomenal at developing technology to halt bleeding, but the technology has been effective only on external or compressible injuries,” Lavik said. “An emergency treatment for internal bleeding could provide a broader ability to stop life-threatening hemorrhage.”

Currently, no effective treatments exist that are portable and can stop internal bleeding at the scene, Lavik explained. At the hospital, however, patients typically undergo surgery and receive donated platelets or something called factor VIIa, which helps with clotting, but both can cause immune problems. Factor VIIa also can potentially cause blood clots elsewhere in the body, not just at the site of bleeding, increasing stroke risk. Other alternatives have been developed in the laboratory, but they’ve had similar side effects and are not currently used in hospitals.

Lavik and colleagues are developing synthetic platelets. These are artificial versions of the disc-shaped particles in blood that collect on the jagged edges of cut blood vessels and launch the chain of biochemical events that result in formation of a clot that stops the flow of blood. The synthetic platelets are special nanoparticles, so small that 10 would fit across the width of a single human hair. Their role is to stick to natural platelets and leverage quicker and more efficient clotting at the site of an internal wound.

The nanoparticles are spheres that are made of the same polyester material used in dissolvable sutures, and they disappear from the body after doing their work. The particles have an outer coating of polyethylene glycol (PEG), the same thick, sticky substance used as a thickening agent in skin creams, toothpastes and other consumer products. Researchers then attach a peptide, or small piece of protein, that sticks to platelets. The end product is a white powder that has a shelf-life without refrigeration of at least two weeks — almost twice as long as the donated natural platelets now administered to control bleeding. Unlike donated platelets or factor VIIa, the synthetic platelets do not require refrigeration.

In tests on laboratory rats, stand-ins for humans in such experiments, the artificial platelets worked better than factor VIIa in stopping internal bleeding and increased survival, explained Lavik. Emergency medical technicians or battlefield medics could carry the powder out into the field to treat patients immediately, which could mean the difference between life and death, Lavik noted.

Lavik explained that the development process is ongoing, and it will take several years for the treatment to reach first-responders. So far, the nanoparticles appear safe, and all of the materials used to make them are already approved for medical use.

Erin Lavik, Sc.D., who described the advance toward developing synthetic platelets, said it is among the efforts underway world-wide to treat bleeding from “blunt-force” injuries ― in car accidents like the crash that killed Princess Diana, for instance, and the battlefield blast waves from bombs and other weapons that are the leading cause of battlefield deaths. Sports injuries, falls and other problems likewise can cause internal bleeding.

Progress toward a new emergency treatment for internal bleeding ― counterpart to the tourniquets, pressure bandages and Quick Clot products that keep people from bleeding to death from external wounds ― was reported at the 244th National Meeting & Exposition of the American Chemical Society, the world’s largest scientific society.

source:

http://portal.acs.org/portal/acs/corg/content?_nfpb=true&_pageLabel=PP_ARTICLEMAIN&node_id=222&content_id=CNBP_030545&use_sec=true&sec_url_var=region1&__uuid=47976746-3740-4695-84cf-1c86fe3fbb81

Read Full Post »

« Newer Posts - Older Posts »