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Posts Tagged ‘Centers for Disease Control and Prevention’


Curator: Larry H Bernstein, MD, FCAP

Cause of Death: How Good is the Reliability of the Data Collected?

This is a report on the high error rate in recording of death certificates, which were a standard of quality and a standard for

understanding disease classification since the work of Rokitanski, Virchow, John Hunter, Benjamin Castleman, Averill Liebow, and others.
The autopsy report had a defined structure, and it highlights the pathogenic sequence.  Autopsy rates were high at times of pandemic.
Hand-written reports from the 19th century are still in exitence at the Bellevue Hospital, the first hospital in US to have an ambulance service.
Modern medicine has advanced substantially, but one has to be concerned with whether

  • we can get a true picture of death rates when autopsy rate have plunged to less than 20 percent over the last four decades.

I present the recent article in Medscape Medical News by Diedre Henderson, May 10, 2013 titled Cause of Death: 50% of Medical Residents Fib.

Some 48.6% to 58.4% of residents from more than half of the residency programs in New York City have
knowingly entered the incorrect cause of death on death certificates — errors that have implications

  • for epidemiology,
  • public health research, and
  • disease surveillance — according to result from a recent study.

Barbara A. Wexelman, MD, MBA, from St. Luke’s–Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York City, and coauthors
report their findings in an article published in the May 9 issue of Preventing Chronic Disease, published by the Centers for Disease Control and Prevention.

As fewer autopsies are performed, Dr. Wexelman and coauthors note,

  • death certificates have become even more important sources of information about how Americans die.

Public health researchers rely on death certificates to gauge the leading causes of death and to identify disease outbreaks, and

  • the certificates also influence funding policies and research priorities.

In most teaching hospitals, it falls to resident physicians to complete the forms. To examine their experiences and opinions, the researchers conducted an anonymous, Internet-based, 32-question survey of New York City’s 70 internal medicine, emergency medicine, and general surgery residency programs in May and June 2010. Some 521 residents from 38 residency programs responded to the survey; 178 of the residents were termed “high-volume” respondents, meaning they had completed 11 or more death certificates in the previous 3 years.

Forced to Do It

“Almost half of all respondents (48.6%) and 58.4% of high-volume respondents reported they

  • had identified a cause of death on a death certificate that did not represent the true cause of death.

More than half of the residents (54.0%) reported they were unable to list what they felt to be the correct cause of death

  • after guidance from the admitting department in their hospital,” Dr. Wexelman and colleagues write.

“Of all respondents,

  • 70% believed they were forced to identify an alternate cause of death when
    • the patient died of septic shock (compared with 83.5% of high-volume respondents), and
  • 34.2% believed they were forced to identify an alternate cause when the patient died of
    • acute respiratory distress syndrome (compared with 44.3% of high-volume respondents),”
      the researchers continue.

Only 20.8% of respondents knew

  • they could hedge the death determination by calling it “probable,” “presumed,” or “undetermined.”

When the death certificate system

  • would not accept the true cause of death or
  • hospital admitting staff overruled them,
  • 64.6% of respondents reported cardiovascular disease,
  • 19.5% pneumonia, and
  • 12.4% cancer as the cause of death.

Study participation was voluntary, and residents with stronger feelings about the accuracy of death certificates
may have been more interested in participating. Other study limitations include the potential for recall bias.

 Medical billing solutions: Get paid faster

How do some physicians get paid faster than

  • 75% of multi-specialty group practices nationwide

as surveyed by the Medical Group Management Association and Healthcare Billing Management Association for Days Revenue in AR?

“Residents routinely reported diagnoses on death certificates that did not match their medical judgments.
These errors may have lasting effects on the public health priorities of the community.

Reform is needed both in the training and education of residents and in the system itself,” the authors conclude.

Support for this study was provided by Columbia University College of Physicians and Surgeons.

Prev Chronic Dis. 2013;10:120288. Full text

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Reporter: Aviva Lev-Ari, PhD, RN

Gene found that regenerates heart tissue

DALLAS – April 17, 2013 – Researchers at UT Southwestern Medical Center have identified a specific gene that regulates the heart’s ability to regenerate after injuries.

Scientists led by Dr. Hesham Sadek have demonstrated that the gene Meis1 regulates the regenerative capability of newborn hearts.

Scientists led by Dr. Hesham Sadek have demonstrated that the gene Meis1 regulates the regenerative capability of newborn hearts.

The function of the gene, called Meis1, in the heart was not known previously. The findings of the UTSW investigation are available online in Nature.

“We found that the activity of the Meis1 gene increases significantly in heart cells soon after birth, right around the time heart muscle cells stop dividing. Based on this observation we asked a simple question: If the Meis1 gene is deleted from the heart, will heart cells continue to divide through adulthood? The answer is ‘yes’,” said Dr. Hesham Sadek, assistant professor of internal medicine in the division of cardiology, and senior author of the study.

In 2011, Dr. Sadek’s laboratory showed that the newborn mammalian heart is capable of a vigorous, regenerative response to injury through division of its own cells. As the newborn develops, the heart rapidly loses the ability to regenerate and to repair injuries such as heart attacks.

The research team demonstrated that deletion of Meis1 extended the proliferation period in the hearts of newborn mice, and also re-activated the regenerative process in the adult mouse heart without harmful effect on cardiac functions. This new finding demonstrates that Meis1 is a key factor in the regeneration process, and the understanding of the gene’s function may lead to new therapeutic options for adult heart regeneration. The findings also provide a possible alternative to current adult heart regeneration research, which focuses on the use of stem cells to replace damaged heart cells.

Meis1 is a transcription factor, which acts like a software program that has the ability to control the function of other genes. In this case, we found that Meis1 controls several genes that normally act as brakes on cell division,” Dr. Sadek said. “As such, Meis1 could possibly be used as an on/off switch for making adult heart cells divide. If done successfully, this ability could introduce a new era in treatment for heart failure.”

According to the American Heart Association, almost 6 million people in the U.S. have heart failure, which occurs when the heart cannot pump enough blood and oxygen to support other organs. Heart disease is the leading cause of death for both men and women in the country, according to the Centers for Disease Control and Prevention.

The study received support from the American Heart Association, the Gilead Research Scholars Program in Cardiovascular Disease, the Foundation for Heart Failure Research, and the National Institutes of Health.

The co-first authors of the study are Dr. Ahmed I. Mahmoud, who is now a postdoctoral fellow at Harvard University; Dr. Fatih Kocabas, who is now a postdoctoral fellow at North American College; and Dr. Shalini A. Muralidhar, a postdoctoral research fellow II of internal medicine. Other researchers at UT Southwestern involved in the study are Wataru Kimura, a visiting senior researcher of internal medicine; Ahmed Koura, now a medical student at Ain Shams University in Egypt; Dr. Enzo Porrello, research fellow and faculty member at the University of Queensland in Australia; and Suwannee Thet, a research associate of internal medicine.

About UT Southwestern Medical Center
UT Southwestern, one of the premier academic medical centers in the nation, integrates pioneering biomedical research with exceptional clinical care and education. The institution’s faculty includes many distinguished members, including five who have been awarded Nobel Prizes since 1985. Numbering more than 2,700, the faculty is responsible for groundbreaking medical advances and is committed to translating science-driven research quickly to new clinical treatments. UT Southwestern physicians provide medical care in 40 specialties to nearly 100,000 hospitalized patients and oversee more than 2.1 million outpatient visits a year.

Media Contact: Remekca Owens
214-648-9344
remekca.owens@utsouthwestern.edu

 http://www.utsouthwestern.edu/newsroom/news-releases/year-2013/april/heart-sadek.html?goback=.gde_4842427_member_233989854

Genetics: A gene of rare effect

A mutation that gives people rock-bottom cholesterol levels has led geneticists to what could be the next blockbuster heart drug.

09 April 2013
ADAPTED FROM: PETER DAZELEY/GETTY

When Sharlayne Tracy showed up at the clinical suite in the University of Texas (UT) Southwestern Medical Center in Dallas last January, the bandage wrapped around her left wrist was the only sign of anything medically amiss. The bandage covered a minor injury from a cheerleading practice led by Tracy, a 40-year-old African American who is an aerobics instructor, a mother of two and a college student pursuing a degree in business. “I feel like I’m healthy as a horse,” she said.

Indeed, Tracy’s well-being has been inspiring to doctors, geneticists and now pharmaceutical companies precisely because she is so normal. Using every tool in the modern diagnostic arsenal — from brain scans and kidney sonograms to 24-hour blood-pressure monitors and cognitive tests — researchers at the Texas medical centre have diagnostically sliced and diced Tracy to make sure that the two highly unusual genetic mutations she has carried for her entire life have produced nothing more startling than an incredibly low level of cholesterol in her blood. At a time when the target for low-density lipoprotein (LDL) cholesterol, more commonly called ‘bad cholesterol’, in Americans’ blood is less than 100 milligrams per decilitre (a level many people fail to achieve), Tracy’s level is just 14.

A compact woman with wide-eyed energy, Tracy (not her real name) is one of a handful of African Americans whose genetics have enabled scientists to uncover one of the most promising compounds for controlling cholesterol since the first statin drug was approved by the US Food and Drug Administration in 1987. Seven years ago, researchers Helen Hobbs and Jonathan Cohen at UT-Southwestern reported1 that Tracy had inherited two mutations, one from her father and the other from her mother, in a gene called PCSK9, effectively eliminating a protein in the blood that has a fundamental role in controlling the levels of LDL cholesterol. African Americans with similar mutations have a nearly 90% reduced risk of heart disease. “She’s our girl, our main girl,” says Barbara Gilbert, a nurse who has drawn some 8,000 blood samples as part of Cohen and Hobbs’ project to find genes important to cholesterol metabolism.

Of all the intriguing DNA sequences spat out by the Human Genome Project and its ancillary studies, perhaps none is a more promising candidate to have a rapid, large-scale impact on human health than PCSK9. Elias Zerhouni, former director of the US National Institutes of Health (NIH) in Bethesda, Maryland, calls PCSK9 an “iconic example” of translational medicine in the genomics era. Preliminary clinical trials have already shown that drugs that inhibit the PCSK9 protein — used with or without statins — produce dramatic reductions in LDL cholesterol (more than 70% in some patients). Half-a-dozen pharmaceutical companies — all aiming for a share of the global market for cholesterol-reducing drugs that could reach US$25 billion in the next five years according to some estimates — are racing to the market with drugs that mimic the effect of Tracy’s paired mutations.

Free interview

Stephen Hall talks about Sharlayne’s unusual condition and whether similar cases might lead to a new line of drugs.

Zerhouni, now an in-house champion of this class of drug as an executive at drug firm Sanofi, headquartered in Paris, calls the discovery and development of PCSK9 a “beautiful story” in which researchers combined detailed physical information about patients with shrewd genetics to identify a medically important gene that has made “super-fast” progress to the clinic. “Once you have it, boy, everything just lines up,” he says. And although the end of the PCSK9 story has yet to be written — the advanced clinical trials now under way could still be derailed by unexpected side effects — it holds a valuable lesson for genomic research. The key discovery about PCSK9‘s medical potential was made by researchers working not only apart from the prevailing scientific strategy of genome research over the past decade, but with an almost entirely different approach.

As for Tracy, who lives in the southern part of Dallas County, the implications of her special genetic status have become clear. “I really didn’t understand at first,” she admits. “But now I’m watching ads on TV [for cholesterol-lowering drugs], and it’s like, ‘Wow, I don’t have that problem’.”

A heart problem

Cardiovascular disease is — and will be for the foreseeable future, according to the World Health Organization — the leading cause of death in the world, and its development is intimately linked to elevated levels of cholesterol in the blood. Since their introduction, statin drugs have been widely used to lower cholesterol levels. But Jan Breslow, a physician and geneticist at Rockefeller University in New York, points out that up to 20% of patients cannot tolerate statins’ side effects, which include muscle pain and even forgetfulness. And in many others, the drugs simply don’t control cholesterol levels well enough.

The search for better treatments for heart disease gained fresh impetus after scientists published the draft sequence of the human genome in 2001. In an effort to identify the genetic basis of common ailments such as heart disease and diabetes, geneticists settled on a strategy based on the ‘common variant hypothesis’. The idea was that a handful of disease-related versions (or variants) of genes for each disease would be common enough — at a frequency of roughly 5% or so — to be detected by powerful analyses of the whole genome. Massive surveys known as genome-wide association studies compared the genomes of thousands of people with heart disease, for example, with those of healthy controls. By 2009, however, many scientists were lamenting the fact that although the strategy had identified many common variants, each made only a small contribution to the disease. The results for cardiovascular disease have been “pretty disappointing”, says Daniel Steinberg, a lipoprotein expert at the University of California, San Diego.

Single-minded: Helen Hobbs and Jonathan Cohen’s approach to heart-disease genetics yielded a target for drugs that could compete with statins.MISTY KEASLER/REDUX/EYEVINE

More than a decade earlier, in Texas, Hobbs and Cohen had taken the opposite tack. They had backgrounds in Mendelian, or single-gene, disorders, in which an extremely rare variant can have a big — often fatal — effect. They also knew that people with a particular Mendelian disorder didn’t share a single common mutation in the affected gene, but rather had a lot of different, rare mutations. They hypothesized that in complex disorders, many different rare variants were also likely to have a big effect, whereas common variants would have relatively minor effects (otherwise natural selection would have weeded them out). “Jonathan and I did not see any reason why it couldn’t be that rare variants cumulatively contribute to disease,” Hobbs says. To find these rare variants, the pair needed to compile detailed physiological profiles, or phenotypes, of a large general population. Cohen spoke of the need to “Mendelize” people — to compartmentalize them by physiological traits, such as extremely high or low cholesterol levels, and then look in the extreme groups for variations in candidate genes known to be related to the trait.

The pair make a scientific odd couple. Hobbs, who trained as an MD, is gregarious, voluble and driven. Cohen, a soft-spoken geneticist from South Africa, has a laid-back, droll manner and a knack for quantitative thinking. In 1999, they set out to design a population-based study that focused on physical measurements related to heart disease. Organized with Ronald Victor, an expert on high blood pressure also at UT Southwestern, and funded by the Donald W. Reynolds Foundation in Las Vegas, Nevada, the Dallas Heart Study assembled exquisitely detailed physiological profiles on a population of roughly 3,500 Dallas residents2. Crucially, around half of the participants in the study were African Americans, because the researchers wanted to probe racial differences in heart disease and high blood pressure. The team measured blood pressure, body mass index, heart physiology and body-fat distribution, along with a battery of blood factors related to cholesterol metabolism — triglycerides, high-density lipoprotein (HDL) cholesterol and LDL cholesterol. In the samples of blood, of course, they also had DNA from each and every participant.

As soon as the database was completed in 2002, Hobbs and Cohen tested their rare-variant theory by looking at levels of HDL cholesterol. They identified the people with the highest (95th percentile) and lowest (5th percentile) levels, and then sequenced the DNA of three genes known to be key to metabolism of HDL cholesterol. What they found, both in Dallas and in an independent population of Canadians, was that the number of mutations was five times higher in the low HDL group than in the high group3. This made sense, Cohen says, because most human mutations interfere with the function of genes, which would lead to the low HDL numbers. Published in 2004, the results confirmed that rare, medically important mutations could be found in a population subdivided into extreme phenotypes.

Armed with their extensive database of cardiovascular traits, Hobbs and Cohen could now dive back into the Dallas Heart Study whenever they had a new hypothesis about heart disease and, as Cohen put it, “interrogate the DNA”. It wasn’t long before they had an especially intriguing piece of DNA at which to look.

The missing link

In February 2003, Nabil Seidah, a biochemist at the Clinical Research Institute of Montreal in Canada, and his colleagues reported the discovery of an enigmatic protein4. Seidah had been working on a class of enzymes known collectively as proprotein convertases, and the researchers had identified what looked like a new member of the family, called NARC-1: neural apoptosis-regulated convertase 1.

“We didn’t know what it was doing, of course,” Seidah says. But the group established that the gene coding the enzyme showed activity in the liver, kidney and intestines as well as in the developing brain. The team also knew that in humans the gene mapped to a precise genetic neighbourhood on the short arm of chromosome 1.

That last bit of geographical information pointed Seidah to a group led by Catherine Boileau at the Necker Hospital in Paris. Her team had been following families with a genetic form of extremely high levels of LDL cholesterol known as familial hypercholesterolaemia, which leads to severe coronary artery disease and, often, premature death. Group member Marianne Abifadel had spent five fruitless years searching a region on the short arm of chromosome 1 for a gene linked to the condition. When Seidah contacted Boileau and told her that he thought NARC-1 might be the gene she was looking for, she told him, “You’re crazy”, Seidah recalls. Seidah bet her a bottle of champagne that he was correct; within two weeks, Boileau called back, saying: “I owe you three bottles.”

“The PCSK9 story is a terrific example of an up-and-coming pattern of translational research.”

In 2003, the Paris and Montreal groups reported that the French families with hypercholesterolaemia had one of two mutations in this newly discovered gene, and speculated that this might cause increased production of the enzyme5. Despite Seidah’s protests, the journal editors gave both the gene and its protein product a new name that fit with standard nomenclature: proprotein convertase subtilisin/kexin type 9, or PCSK9. At around the same time, Kara Maxwell in Breslow’s group at Rockefeller University6 and Jay Horton, a gastroenterologist at UT-Southwestern7 also independently identified the PCSK9 gene in mice and revealed its role in a previously unknown pathway regulating cholesterol8.

The dramatic phenotype of the French families told Hobbs that “this is an important gene”. She also realized that in genetics, mutations that knock out a function are much more common than ones that amplify function, as seemed to be the case with the French families. “So immediately I’m thinking, a loss-of-function mutation should manifest as a low LDL level,” she says. “Let’s go and see if that’s true.”

Going to extremes

Hobbs and Cohen had no further to look than in the extreme margins of people in the Dallas Heart Study. In quick order, they identified the highest and lowest LDL readings in four groups: black women, black men, white women and white men. They then resequenced the PCSK9 gene in the low-cholesterol groups, looking for mutations that changed the make-up of the protein.

They found seven African Americans with one of two distinct ‘nonsense’ mutations in PCSK9 — mutations that essentially aborted production of the protein. Then they went back and looked for the same mutations in the entire population. Just 2% of all black people in the Dallas study had either of the two PCSK9 mutations — and those mutations were each associated with a 40% reduction of LDL cholesterol in the blood9. (The team later detected a ‘missense mutation’ in 3% of white people, which impaired but did not entirely block production of the protein.) The frequency of the mutations was so low, Hobbs says, that they would never have shown up in a search for common variants.

When Hobbs and Cohen published their findings in 2005, they suggested that PCSK9 played a crucial part in regulating bad cholesterol, but said nothing about whether the mutations had any effect on heart disease. That evidence came later that year, when they teamed up with Eric Boerwinkle, a geneticist at the University of Texas Health Science Center in Houston, to look forPCSK9 mutations in the Atherosclerosis Risk in Communities (ARIC) study, a large prospective study of heart disease that had been running since 1987. To experts such as Steinberg, the results10 — published in early 2006 — were “mind-blowing”. African Americans in ARIC who had mutations in PCSK9 had 28% less LDL cholesterol and an 88% lower risk of developing heart disease than people without the mutations. White people with the less severe mutation in the gene had a 15% reduction in LDL and a 47% reduced risk of heart disease.

How did the gene exert such profound effects on LDL cholesterol levels? As researchers went on to determine11, the PCSK9 protein normally circulates in the bloodstream and binds to the LDL receptor, a protein on the surface of liver cells that captures LDL cholesterol and removes it from the blood. After binding with the receptor, PCSK9 escorts it into the interior of the cell, where it is eventually degraded. When there is a lot of PCSK9 (as in the French families), there are fewer LDL receptors remaining to trap and remove bad cholesterol from the blood. When there is little or no PCSK9 (as in the black people with mutations), there are more free LDL receptors, which in turn remove more LDL cholesterol.

“We didn’t understand why everybody wasn’t doing what we were doing.”

The UT-Southwestern group, meanwhile, went back into the community looking for family members who might carry additional PCSK9 mutations. In September 2004, Gilbert, the nurse known as ‘the cholesterol lady’ in south Dallas because of her frequent visits, knocked on the door of Sharlayne Tracy’s mother, an original member of the Dallas Heart Study. Gilbert tested Tracy, as well as her sister, brother and father. “They tested all of us, and I was the lowest,” Tracy says. Zahid Ahmad, a doctor working with Hobbs at UT-Southwestern, was one of the first to look at Tracy’s lab results. “Dr Zahid was in awe,” Tracy recalled. “He said, ‘You’re not supposed to be so healthy!’.”

It wasn’t just that her LDL cholesterol measured 14. As a person with two dysfunctional copies of the gene — including a new type of mutation — Tracy was effectively a human version of a knockout mouse. The gene had been functionally erased from her genome, and PCSK9 was undetectable in her blood without any obvious untoward effects. The genomics community might have been a little slow to understand the significance, Hobbs says, “but the pharmaceutical companies got it right away”.

The next statin?

This being biology, however, the road to the clinic was not completely smooth. The particular biology of PCSK9 has so far thwarted efforts to find a small molecule that would interrupt its interaction with the LDL receptor and that could be packaged in a pill. But the fact that the molecule operates outside cells means that it is vulnerable to attack by monoclonal antibodies — one of the most successful (albeit most expensive) forms of biological medicine.

The results of early clinical trials have caused a stir. Regeneron Pharmaceuticals of Tarrytown, New York, collaborating with Sanofi, published phase II clinical-trial results12 last October showing that patients with high LDL cholesterol levels who had injections every two weeks of an anti-PCSK9 monoclonal antibody paired with a high-dose statin saw their LDL cholesterol levels fall by 73%; by comparison, patients taking high-dose statins alone had a decrease of just 17%. Last November, Regeneron and Sanofi began to recruit 18,000 patients for phase III trials that will test the ability of their therapy to cut cardiovascular events, including heart attacks and stroke. Amgen of Thousand Oaks, California, has also launched several phase III trials of its own monoclonal antibody after it reported similarly promising results13. Among other companies working on PCSK9-based therapies are Pfizer headquartered in New York, Roche based in Basel, Switzerland, and Alnylam Pharmaceuticals of Cambridge, Massachusetts. (Hobbs previously consulted for Regeneron and Pfizer, and now sits on the corporate board of Pfizer.)

Not everyone is convinced that a huge market awaits this class of cholesterol-lowering drugs. Tony Butler, a financial analyst at Barclays Capital in New York, acknowledges the “beautiful biology” of the PCSK9 story, but wonders if the expense of monoclonal drugs — and a natural reluctance of both patients and doctors to use injectable medicines — will constrain potential sales. “I have no idea what the size of the market may be,” he says.

“Everything hinges on the phase III side effects,” says Steinberg. So far, the main side effects reported have been minor, such as reactions at the injection site, diarrhoea and headaches. But animal experiments have raised potential red flags: the Montreal lab reported in 2006 that knocking out the gene in zebrafish is lethal to embryos14. That is why the case of Tracy was “very, very helpful” to drug companies, says Hobbs. Although her twin mutations have essentially deprived her of PCSK9 throughout her life, doctors have found nothing abnormal about her.

That last point may revive a debate in the cardiology community: should drug therapy to lower cholesterol levels, including statins and the anti-PCSK9 medicines, if they pan out, be started much earlier in patients than their 40s or 50s? That was the message Steinberg took from the people withPCSK9 mutations in the ARIC study — once he got over his shock at the remarkable health effects. “My first reaction was, ‘This must be wrong. How could that be?’And then it hit me — these people had low LDL from the day they were born, and that makes all the difference.” Steinberg argues that cardiologists “should get off our bums” and reach a consensus about beginning people on cholesterol-lowering therapy in their early thirties. But Breslow, a former president of the American Heart Association, cautions against being too aggressive too soon. “Let’s start out with the high-risk individuals and see how they do,” he says.

Not long after Hobbs and Cohen published their paper in 2006, they began to get invited to give keynote talks at major cardiology meetings. Soon after, the genetics community began to acknowledge the strength of their approach. In autumn 2007, then-NIH director Zerhouni organized a discussion at the annual meeting of the institutes’ directors to raise the profile of the rare-variant approach and contrast it with genome-wide studies. “Obviously, the two approaches are opposed to each other, and the question was, what was the relative value of each?” says Zerhouni. “I thought the PCSK9 story was a terrific example of an up-and-coming pattern of translational research” — indeed, he adds, “a harbinger of things to come”.

Hobbs and Cohen might not have found their gene if they had not had a hunch about where to look, but improved sequencing technology and decreasing costs now allow genomicists to incorporate the rare variant approach and to mount large-scale sweeps in search of such variants. “Gene sequencing is getting cheap enough that if there’s another gene like PCSK9 out there, you could probably find it genome-wide,” says Jonathan Pritchard, a population biologist at the University of Chicago, Illinois.

“What was amazing to us,” says Hobbs, “was that the genome project was spending all this time, energy, effort sequencing people, and they weren’t phenotyped, so there was no potential for discovery. We didn’t understand, and couldn’t understand, why everybody wasn’t doing what we were doing. Particularly when we started making discoveries.”

Nature

 496,

152–155

(11 April 2013)

doi:10.1038/496152a

References

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  2. Victor, R. G. et al. Am. J. Cardiol. 93, 1473–1480 (2004).

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  3. Cohen, J. C. et al. Science 305, 869–872 (2004).

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  4. Seidah, N. G. et al. Proc. Natl Acad. Sci. USA 100, 928–933 (2003).

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  5. Abifadel, M. et al. Nature Genet. 34, 154–156 (2003).

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  6. Maxwell, K. N., Soccio, R. E., Duncan, E. M., Sehayek, E. & Breslow, J. L. J. Lipid Res. 44,2109–2119 (2003).

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  9. Cohen, J. et al. Nature Genet. 37, 161–165 (2005).

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  10. Cohen, J. C., Boerwinkle, E., Mosley, T. H. Jr & Hobbs, H. H. N. Engl. J. Med. 354, 1264–1272(2006).

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  11. Horton, J. D., Cohen, J. C. & Hobbs, H. H. J. Lipid Res. 50, S172–S177 (2009).

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  12. Roth, E. M., McKenney, J. M., Hanotin, C., Asset, G. & Stein, E. A. N. Engl. J. Med. 367,1891–1900 (2012).

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Cancer Screening Programs at Sourasky Medical Center’s Cancer Prevention Center in Tel-Aviv

Author: Ziv Raviv, PhD

Cancer is one of the leading causes of death in the World. Major efforts are devoted for its eradication. There are several strategies to fighting cancer. Considerable research efforts were allocated over the last 50 years to elucidate the genetic factors causing cancer and the molecular mechanisms governing its biology for the purpose of developing anti-cancer treatments. It is important to note that cancer is a disease that environmental and life style factors play crucial role in its development.

It is accepted in the Medical community that the earlier the cancer has being detected, the greater are the odds for better prognosis and often the attainment of complete remission. Thus, it is important that more efforts should be addressed into prevention and early detection programs. Several medical centers and research institutes have set up prevention programs, among them is the integrated cancer prevention center (ICPC) of Tel-Aviv Sourasky medical center (TASMC) directed by Prof. Nadir Arber. A comprehensive cancer screening is applied by specialist physicians aimed at identification of potential cancer patients. The Screening program is supported by an integrated research laboratory, that develops and implements innovative technologies and approaches for early detection and therapy of cancer.

ICPC program is considered to be unique in the World. The Screening involves a comprehensive examination, on the spot, for the early detection of at least 11 different most common cancers taking advantage of up-to-date contemporary as well as innovative tests, which are carried out under the same roof and require a single visit taking only few hours, where results are given within few weeks. That is instead of doing separate examinations for the detection of each cancer type, a process when performed through the ordinary health care pathway could consume much of the patient time and involves several bureaucratic levels.

The cancers being tested for by the center include among others:

  • Skin
  • Colon
  • Breast
  • Lung
  • Ovarian
  • Prostate

Respectively, the screenings performed include careful body and skin examination, imaging, blood tests for cancer markers accompanied with standard clinical tests, as well as personal interview evaluating the family history and risk factors of the client. However, it is important to note that the ICPC is not restricted only to patients with known family history of cancer incidents and/or with high risk factors, rather, ICPC is providing its services to any person whom would like to be examined if having cancer. The goal of ICPC is indeed to create the atmosphere among the general public to give attitude to this screening as it is a standard process of body checkup that should be performed periodically on a regular basis. The visit at ICPC clinic consumes relatively small effort from the patient in terms of time and costs. In addition, the persons arriving to ICPC are receiving dietary as well as life style counseling. If cancer or a pre-cancerous condition is been discovered, the client is being referred for further evaluation of treatment options. Personalized approach is applied that includes performing a personal questionnaire and interview before screening as mentioned above, as well as ongoing documentation and follow-ups that are initiated after the results are obtained and shared with the patient.

The cost of this sequence of checkups and tests is seemingly expensive, and there is an impression that this is a “rich people only clinic”, too expensive for the average pocket. Yet, when thinking carefully the costs are rather low, only few hundreds of American dollars, a price which is definitely low comparing to the costs of some of these tests, and as Prof. Arber stated: “the cost is not higher than that one pays for his annual car service, so why not giving the same attention to your own body as given to your car.” The fees being paid by the patients for the screening and genetic testing are not covering the costs. However, in the long run, it is believed that this approach is worthwhile if taking in consideration the costs benefits of cancer early detection, of reducing hospitalization days and medicines prescription. Therefore, a governmental intervention should take place in the form of subsidizing the costs of the cancer screening. In addition, the various health care insurance plans should cover at least in part the fees required to be paid by the patient for this screening, thus, making the visit to the cancer prevention center affordable to every citizen.

ICPC reported that, around 10 percent of people following the screening protocol, were found to be carrying premature tumors, emphasizing the importance of the existence of such a preventive center. Now it is remained to evaluate if the program is being accepted broadly by the general public. PR is needed in order to support public awareness to this program. It is important to note that aside from rising public responsiveness for the existence of ICPC, overcoming psychological barriers is another issue that requires attention on as many people do not like to “know what the future holds” especially when it comes to diseases.

ICPC, a cancer prevention center located within a major hospital, integrates specialized medical doctors with state of the art facilities, performing comprehensive tests for cancer detection in an intensive one-day visit, is unique and very important for performing a good cancer prevention program. The ICPC and other similar prevention centers (see references) should give example for other medical centers around the globe willing to adopt the approach of cancer prevention in the ongoing battle against cancer. The more centers as such will exist, the greater are the chances for early Cancer detection and increase the potential of significantly reducing the rate of cancer incidences worldwide.

REFERENCES:

http://www.tasmc.org.il/sites/en/internalmed/ICPC/Pages/ICPC.aspx

MD Anderson Cancer Prevention Center

St. Joseph Hospital cancer programs Related article on this Open Access Online Scientific Journal, include the following:

https://pharmaceuticalintelligence.com/2013/03/07/the-importance-of-cancer-prevention-programs-new-perceptions-for-fighting-cancer/

 

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Reproductive Genetic Testing

Reporter and Curator: Sudipta Saha, Ph.D.

Reproductive genetics, a field of medical genetics integrated with reproductive medicine, assisted reproduction, and developmental genetics, involves a wide array of genetic tests that are conducted with the intent of informing individuals about the possible outcomes of current or future pregnancies. The tests themselves can include the analysis of chromosomes, DNA, RNA, genes, and/or gene products to determine whether an alteration is present that is causing or is likely to cause a specific disease or condition.

Types of Tests

In general, reproductive genetic testing involves the following categories of tests:

Carrier testing is performed to determine whether an individual carries one copy of an altered gene for a particular recessive disease. The term recessive refers to diseases that will occur only if both copies of a gene that an individual receives have a disease-associated mutation; thus, each child born to two carriers of a mutation in the same gene has a 25 percent risk of being affected with the disorder. Examples of carrier tests include those for

Couples are likely to have carrier tests if they are at higher risk of having a child with a specific disorder because of their racial or ethnic heritage or family history. Carrier testing is often done in the context of family planning and reproductive health.

Preimplantation diagnosis is used following in vitro fertilization to diagnose a genetic disease or condition in a preimplantation embryo. Preimplantation genetic diagnosis is essentially an alternative to prenatal diagnosis, as it allows prenatal testing to occur months earlier than conventional tests such as amniocentesis on week 18th of pregnancy, even before a pregnancy begins. Doctors can test a single cell from an eight-cell embryo that is just days old to determine, among other things, whether it is a male or female. This can provide crucial information for genetic diseases that afflict just one sex. Preimplantation genetic diagnosis has been applied to patients carrying chromosomal rearrangements, such as translocations, in which it has been proven to decrease the number of spontaneous abortions and prevent the birth of children affected with chromosome imbalances. Preimplantation genetic diagnosis techniques have also been applied to

  • increase implantation rates,
  • reduce the incidence of spontaneous abortion, and
  • prevent trisomic offspring in women of advanced maternal age undergoing fertility treatment.

A third group of patients receiving preimplantation genetic diagnosis are those at risk of transmitting a single gene disorder to their offspring. The number of monogenic disorders that have been diagnosed in preimplantation embryos has increased each year. So far, at least 700 healthy babies have been born worldwide after undergoing the procedure, and the number is growing rapidly.

Prenatal diagnosis is used to diagnose a genetic disease or condition in a developing fetus.

The techniques currently in use or under investigation for prenatal diagnosis include

  • (1) fetal tissue sampling through amniocentesis, chorionic villi sampling (CVS), percutaneous umbilical blood sampling, percutaneous skin biopsy, and other organ biopsies, including muscle and liver biopsy;
  • (2) fetal visualization through ultrasound, fetal echocardiography, embryoscopy, fetoscopy, magnetic resonance imaging, and radiography;
  • (3) screening for neural tube defects by measuring maternal serum alpha-fetoprotein (MSAFP);
  • (4) screening for fetal Down Syndrome by measuring MSAFP, unconjugated estriol, and human chorionic gonadotropin;
  • (5) separation of fetal cells from the mother’s blood; and
  • (6) preimplantation biopsy of blastocysts obtained by in vitro fertilization.

The more common techniques are amniocentesis, performed at the 14th to 20th week of gestation, and CVS, performed between the 9th and 13th week of gestation. If the fetus is found to be affected with a disorder, the couple can plan for the birth of an affected child or opt for elective abortion.

Newborn screening is performed in newborns on a public health basis by the states to detect certain genetic diseases for which early diagnosis and treatment are available. Newborn screening is one of the largest public health activities in the United States. It is aimed at the early identification of infants who are affected by certain genetic, metabolic or infectious conditions, reaching approximately 4 million children born each year. According to the Centers for Disease Control and Prevention (CDC), approximately 3,000 babies each year in the United States are found to have severe disorders detected through screening. States test blood spots collected from newborns for 2 to over 30 metabolic and genetic diseases, such as

  • phenylketonuria,
  • hypothyroidism,
  • galactosemia,
  • sickle cell disease, and
  • medium chain acyl CoA dehyrogenase deficiency.

The goal of this screening is to identify affected newborns quickly in order to provide treatment that can prevent mental retardation, severe illness or death.

It is possible that somatic cell nuclear transfer (cloning) techniques could eventually be employed for the purposes of reproductive genetic testing. In addition, germline gene transfer is a technique that could be used to test and then alter the genetic makeup of the embryo. To date, however, these techniques have not been used in human studies.

Ethical Issues

Any procedure that provides information that could lead to a decision to terminate a pregnancy is not without controversy. Although prenatal diagnosis has been routine for nearly 20 years, some ethicists remain concerned that the ability to eliminate potential offspring with genetic defects contributes to making society overall less tolerant of disability. Others have argued that prenatal diagnosis is sometimes driven by economic concerns because as a society we have chosen not to provide affordable and accessible health care to everyone. Thus, prenatal diagnosis can save money by preventing the birth of defective and costly children. For reproductive genetic procedures that involve greater risk to the fetus, e.g., preimplantation diagnosis, concerns remain about whether the diseases being averted warrant the risks involved in the procedures themselves. These concerns are likely to escalate should

  • cloning or
  • germline gene transfer

be undertaken as a way to genetically test and select healthy offspring.

SOURCE:

http://www.genome.gov/10004766

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Reporter: Aviva Lev-Ari, PhD, RN

 

Meningitis outbreak: 13,000 got shots of recalled steroid but how many at risk unclear

(Kristin M. Hall/ Associated Press ) – A vial of injectable steroids from the New England Compounding Center is displayed in the Tennessee Department of Health in Nashville, Tenn., on Monday, Oct. 8, 2012. The CDC has said an outbreak of fungal meningitis may have been caused by steroids from the Massachusetts specialty pharmacy.

By Associated Press, Published: October 8

NEW YORK — As many as 13,000 people received steroid shots suspected in a national meningitis outbreak, health officials said Monday. But it’s not clear how many are in danger.Officials don’t how many of the shots may have been contaminated with meningitis-causing fungus. And the figure includes not only those who got them in the back for pain — who are most at risk — but also those who got the shots in other places, like knees and shoulders.

There was no breakdown on the number of back injections, said Curtis Allen, a spokesman for the Centers for Disease Control and Prevention. Those injected in joints are not believed to be at risk for meningitis, he said.The number of people sickened in the outbreak reached 105 on Monday. Deaths rose to eight, with another fatality in Tennessee, the CDC said. Tennessee has the most cases, followed by Michigan, Virginia, Indiana, Florida, Maryland, Minnesota, North Carolina and Ohio.

Investigators suspect a steroid medication made by a specialty pharmacy may be to blame. About 17,700 single-dose vials of the steroid were sent to 23 states. Inspectors found at least one sealed vial contaminated with fungus, and tests were being done on other vials.

The first known case of the rarely seen fungal meningitis was diagnosed last month in Tennessee. The steroid maker, New England Compounding Center of Framingham, Mass., recalled the drug, and over the weekend recalled everything else it makes.

“While there is no indication at this time of any contamination in other NECC products, this recall is being taken as a precautionary measure,” the company said in a statement.

Meningitis is an inflammation of the lining of the brain and spinal cord, and a back injection would put any contaminant in more direct contact with that lining.

Symptoms on meningitis include severe headache, nausea, dizziness and fever. The CDC said many of the cases have been mild and some people had strokes. Symptoms have been appearing between one and four weeks after patients got the shots.

A Michigan man whose wife’s death was linked to the outbreak said Monday that he, too, was treated with steroids from one of the recalled batches.

“Not only have I lost my wife, but I’m watching the clock to see if anything develops,” George Cary said, as friends and family gathered for his wife’s wake in Howell, 60 miles northwest of Detroit.

His wife, Lilian, 67, had been ill since late August, but meningitis wasn’t detected until Sept. 22, her husband said. She died Sept. 30.

Michigan officials have not released the names of two people who have died in the outbreak in that state, but did say one was a 67-year-old woman.

Fungal meningitis is not contagious like the more common forms. The two types of fungus linked so far to the outbreak are all around, but very rarely causes illness. Fungal meningitis is treated with high-dose antifungal medications, usually given intravenously in a hospital.

The steroid is known as preservative-free methylprednisolone acetate, which the compounding pharmacy creates by combining a powder with a liquid.

Doctors should contact any patient who got doses from any of the recalled lots, and should look back at their records as far back as mid-May, CDC officials say.

___

AP writer Ed White in Detroit contributed to this report.

___

Online:

CDC information: http://www.cdc.gov/HAI/outbreaks/meningitis.html

Copyright 2012 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

http://www.washingtonpost.com/national/health-science/cdc-cases-of-a-rare-fungal-meningitis-rise-to-105-outbreak-tied-to-steroid-shots/2012/10/08/15f2468a-116e-11e2-9a39-1f5a7f6fe945_story.html

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

Oral Cephalosporins No Longer a Recommended Treatment for Gonococcal Infections: an update to CDC‘s 2010 STD guidelines.

Gonorrhea is a major cause of serious reproductive complications in women and can facilitate human immunodeficiency virus (HIV) transmission (1). Effective treatment is a cornerstone of U.S. gonorrhea control efforts, but treatment of gonorrhea has been complicated by the ability of Neisseria gonorrhoeae to develop antimicrobial resistance. This report, using data from CDC’s Gonococcal Isolate Surveillance Project (GISP), describes laboratory evidence of declining cefixime susceptibility among urethral N. gonorrhoeae isolates collected in the United States during 2006–2011 and updates CDC’s current recommendations for treatment of gonorrhea (2). Based on GISP data, CDC recommends combination therapy with ceftriaxone 250 mg intramuscularly and either azithromycin 1 g orally as a single dose or doxycycline 100 mg orally twice daily for 7 days as the most reliably effective treatment for uncomplicated gonorrhea. CDC no longer recommends cefixime at any dose as a first-line regimen for treatment of gonococcal infections. If cefixime is used as an alternative agent, then the patient should return in 1 week for a test-of-cure at the site of infection.

Infection with N. gonorrhoeae is a major cause of pelvic inflammatory disease, ectopic pregnancy, and infertility, and can facilitate HIV transmission (1). In the United States, gonorrhea is the second most commonly reported notifiable infection, with >300,000 cases reported during 2011. Gonorrhea treatment has been complicated by the ability of N. gonorrhoeae to develop resistance to antimicrobials used for treatment. During the 1990s and 2000s, fluoroquinolone resistance in N. gonorrhoeae emerged in the United States, becoming prevalent in Hawaii and California and among men who have sex with men (MSM) before spreading throughout the United States. In 2007, emergence of fluoroquinolone-resistant N. gonorrhoeae in the United States prompted CDC to no longer recommend fluoroquinolones for treatment of gonorrhea, leaving cephalosporins as the only remaining recommended antimicrobial class (3). To ensure treatment of co-occurring pathogens (e.g., Chlamydia trachomatis) and reflecting concern about emerging gonococcal resistance, CDC’s 2010 sexually transmitted diseases (STDs) treatment guidelines recommended combination therapy for gonorrhea with a cephalosporin (ceftriaxone 250 mg intramuscularly or cefixime 400 mg orally) plus either azithromycin orally or doxycycline orally, even if nucleic acid amplification testing (NAAT) for C. trachomatis was negative at the time of treatment (2). From 2006 to 2010, the minimum concentrations of cefixime needed to inhibit the growth in vitro of N. gonorrhoeae strains circulating in the United States and many other countries increased, suggesting that the effectiveness of cefixime might be waning (4). Reports from Europe recently have described patients with uncomplicated gonorrhea infection not cured by treatment with cefixime 400 mg orally (5–8).

GISP is a CDC-supported sentinel surveillance system that has monitored N. gonorrhoeae antimicrobial susceptibilities since 1986, and is the only source in the United States of national and regional N. gonorrhoeae antimicrobial susceptibility data. During September–December 2011, CDC and five external GISP principal investigators, each with N. gonorrhoeae–specific expertise in surveillance, antimicrobial resistance, treatment, and antimicrobial susceptibility testing, reviewed antimicrobial susceptibility trends in GISP through August 2011 to determine whether to update CDC’s current recommendations (2) for treatment of uncomplicated gonorrhea. Each month, the first 25 gonococcal urethral isolates collected from men attending participating STD clinics (approximately 6,000 isolates each year) were submitted for antimicrobial susceptibility testing. The minimum inhibitory concentration (MIC), the lowest antimicrobial concentration that inhibits visible bacterial growth in the laboratory, is used to assess antimicrobial susceptibility. Cefixime susceptibilities were not determined during 2007–2008 because cefixime temporarily was unavailable in the United States at that time. Criteria for resistance to cefixime and ceftriaxone have not been defined by the Clinical Laboratory Standards Institute (CLSI). However, CLSI does consider isolates with cefixime or ceftriaxone MICs ≥0.5 µg/mL to have “decreased susceptibility” to these drugs (9). During 2006–2011, 15 (0.1%) isolates had decreased susceptibility to cefixime (all had MICs = 0.5 µg/mL), including nine (0.2%) in 2010 and one (0.03%) during January–August 2011; 12 of 15 were from MSM, and 12 were from the West and three from the Midwest.* No isolates exhibited decreased susceptibility to ceftriaxone. Because increasing MICs can predict the emergence of resistance, lower cephalosporin MIC breakpoints were established by GISP for surveillance purposes to provide greater sensitivity in detecting declining gonococcal susceptibility than breakpoints defined by CLSI. Cefixime MICs ≥0.25 µg/mL and ceftriaxone MICs ≥0.125 µg/mL were defined as “elevated MICs.” CLSI does not define azithromycin resistance criteria; CDC defines decreased azithromycin susceptibility as ≥2.0 µg/mL.

Evidence and Rationale

The percentage of isolates with elevated cefixime MICs (MICs ≥0.25 µg/mL) increased from 0.1% in 2006 to 1.5% during January–August 2011 (Figure). In the West, the percentage increased from 0.2% in 2006 to 3.2% in 2011 (Table). The largest increases were observed in Honolulu, Hawaii (0% in 2006 to 17.0% in 2011); Minneapolis, Minnesota (0% to 6.9%); Portland, Oregon (0% to 6.5%); and San Diego, California (0% to 6.4%). Nationally, among MSM, isolates with elevated MICs to cefixime increased from 0.2% in 2006 to 3.8% in 2011. In 2011, a higher proportion of isolates from MSM had elevated cefixime MICs than isolates from men who have sex exclusively with women (MSW), regardless of region (Table).

The percentage of isolates exhibiting elevated ceftriaxone MICs increased slightly, from 0% in 2006 to 0.4% in 2011 (Figure). The percentage increased from <0.1% in 2006 to 0.8% in 2011 in the West, and did not increase significantly in the Midwest (0% to 0.2%) or the Northeast and South (0.1% in 2006 and 2011). Among MSM, the percentage increased from 0.0% in 2006 to 1.0% in 2011.

The 2010 CDC STD treatment guidelines (2) recommend that azithromycin or doxycycline be administered with a cephalosporin as treatment for gonorrhea. The percentage of isolates exhibiting tetracycline resistance (MIC ≥2.0 µg/mL) was high but remained stable from 2006 (20.6%) to 2011 (21.6%). The percentage exhibiting decreased susceptibility to azithromycin (MIC ≥2.0 µg/mL) remained low (0.2% in 2006 to 0.3% in 2011). Among 180 isolates collected during 2006–2011 that exhibited elevated cefixime MICs, 139 (77.2%) exhibited tetracycline resistance, but only one (0.6%) had decreased susceptibility to azithromycin.

Ceftriaxone as a single intramuscular injection of 250 mg provides high and sustained bactericidal levels in the blood and is highly efficacious at all anatomic sites of infection for treatment of N. gonorrhoeae infections caused by strains currently circulating in the United States (10,11). Clinical data to support use of doses of ceftriaxone >250 mg are not available. A 400-mg oral dose of cefixime does not provide bactericidal levels as high, nor as sustained as does an intramuscular 250-mg dose of ceftriaxone, and demonstrates limited efficacy for treatment of pharyngeal gonorrhea (10,11). The significant increase in the prevalence of U.S. GISP isolates with elevated cefixime MICs, most notably in the West and among MSM, is of particular concern because the emergence of fluoroquinolone-resistant N. gonorrhoeae in the United States during the 1990s also occurred initially in the West and predominantly among MSM before spreading throughout the United States within several years. Thus, observed patterns might indicate early stages of the development of clinically significant gonococcal resistance to cephalosporins. CDC anticipates that rising cefixime MICs soon will result in declining effectiveness of cefixime for the treatment of urogenital gonorrhea. Furthermore, as cefixime becomes less effective, continued use of cefixime might hasten the development of resistance to ceftriaxone, a safe, well-tolerated, injectable cephalosporin and the last antimicrobial that is recommended and known to be highly effective in a single dose for treatment of gonorrhea at all anatomic sites of infection. Maintaining effectiveness of ceftriaxone for as long as possible is critical. Thus, CDC no longer recommends the routine use of cefixime as a first-line regimen for treatment of gonorrhea in the United States.

Based on experience with other microbes that have developed antimicrobial resistance rapidly, a theoretical basis exists for combination therapy using two antimicrobials with different mechanisms of action to improve treatment efficacy and potentially delay emergence and spread of resistance to cephalosporins. Therefore, the use of a second antimicrobial (azithromycin as a single 1-g oral dose or doxycycline 100 mg orally twice daily for 7 days) is recommended for administration with ceftriaxone. The use of azithromycin as the second antimicrobial is preferred to doxycycline because of the convenience and compliance advantages of single-dose therapy and the substantially higher prevalence of gonococcal resistance to tetracycline than to azithromycin among GISP isolates, particularly in strains with elevated cefixime MICs.

Recommendations

For treatment of uncomplicated urogenital, anorectal, and pharyngeal gonorrhea, CDC recommends combination therapy with a single intramuscular dose of ceftriaxone 250 mg plus either a single dose of azithromycin 1 g orally or doxycycline 100 mg orally twice daily for 7 days (Box).

Clinicians who diagnose gonorrhea in a patient with persistent infection after treatment (treatment failure) with the recommended combination therapy regimen should culture relevant clinical specimens and perform antimicrobial susceptibility testing of N. gonorrhoeae isolates. Phenotypic antimicrobial susceptibility testing should be performed using disk diffusion, Etest (BioMérieux, Durham, NC), or agar dilution. Data currently are limited on the use of NAAT-based antimicrobial susceptibility testing for genetic mutations associated with resistance in N. gonorrhoeae. The laboratory should retain the isolate for possible further testing. The treating clinician should consult an infectious disease specialist, an STD/HIV Prevention Training Center (http://www.nnptc.orgExternal Web Site Icon), or CDC (telephone: 404-639-8659) for treatment advice, and report the case to CDC through the local or state health department within 24 hours of diagnosis. A test-of-cure should be conducted 1 week after re-treatment, and clinicians should ensure that the patient’s sex partners from the preceding 60 days are evaluated promptly with culture and treated as indicated.

When ceftriaxone cannot be used for treatment of urogenital or rectal gonorrhea, two alternative options are available: cefixime 400 mg orally plus either azithromycin 1 g orally or doxycycline 100 mg twice daily orally for 7 days if ceftriaxone is not readily available, or azithromycin 2 g orally in a single dose if ceftriaxone cannot be given because of severe allergy. If a patient with gonorrhea is treated with an alternative regimen, the patient should return 1 week after treatment for a test-of-cure at the infected anatomic site. The test-of-cure ideally should be performed with culture or with a NAAT for N. gonorrhoeae if culture is not readily available. If the NAAT is positive, every effort should be made to perform a confirmatory culture. All positive cultures for test-of-cure should undergo phenotypic antimicrobial susceptibility testing. Patients who experience treatment failure after treatment with alternative regimens should be treated with ceftriaxone 250 mg as a single intramuscular dose and azithromycin 2 g orally as a single dose and should receive infectious disease consultation. The case should be reported to CDC through the local or state health department.

For all patients with gonorrhea, every effort should be made to ensure that the patients’ sex partners from the preceding 60 days are evaluated and treated for N. gonorrhoeae with a recommended regimen. If a heterosexual partner of a patient cannot be linked to evaluation and treatment in a timely fashion, then expedited partner therapy should be considered, using oral combination antimicrobial therapy for gonorrhea (cefixime 400 mg and azithromycin 1 g) delivered to the partner by the patient, a disease investigation specialist, or through a collaborating pharmacy.

The capacity of laboratories in the United States to isolate N. gonorrhoeae by culture is declining rapidly because of the widespread use of NAATs for gonorrhea diagnosis, yet it is essential that culture capacity for N. gonorrhoeae be maintained to monitor antimicrobial resistance trends and determine susceptibility to guide treatment following treatment failure. To help control gonorrhea in the United States, health-care providers must maintain the ability to collect specimens for culture and be knowledgeable of laboratories to which they can send specimens for culture. Health-care systems and health departments must support access to culture, and laboratories must maintain culture capacity or develop partnerships with laboratories that can perform culture.

Treatment of patients with gonorrhea with the most effective therapy will limit the transmission of gonorrhea, prevent complications, and likely will slow emergence of resistance. However, resistance to cephalosporins, including ceftriaxone, is expected to emerge. Reinvestment in gonorrhea prevention and control is warranted. New treatment options for gonorrhea are urgently needed.

Reported by

Carlos del Rio, MD, Rollins School of Public Health, Emory Univ, Atlanta, Georgia. Geraldine Hall, PhD, Dept of Clinical Pathology, Cleveland Clinic, Cleveland, Ohio. King Holmes, MD, Olusegun Soge, PhD, Dept of Medicine, Univ of Washington. Edward W. Hook, MD, Div of Infectious Diseases, Univ of Alabama at Birmingham. Robert D. Kirkcaldy, MD, Kimberly A. Workowski, MD, Sarah Kidd, MD, Hillard S. Weinstock, MD, John R. Papp, PhD, David Trees, PhD, Thomas A. Peterman, MD, Gail Bolan, MD, Div of Sexually Transmitted Diseases Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC.Corresponding contributor: Robert D. Kirkcaldy, rkirkcaldy@cdc.gov, 404-639-8659.

Acknowledgments

Collaborating state and local health departments. Baderinwa Offut, Emory Univ, Atlanta, Georgia. Laura Doyle, Cleveland Clinic, Ohio. Connie Lenderman, Paula Dixon, Univ of Alabama at Birmingham. Karen Winterscheid, Univ of Washington, Seattle. Tamara Baldwin, Elizabeth Delamater, Texas Dept of State Health Svcs. Alesia Harvey, Tremeka Sanders, Samera Bowers, Kevin Pettus, Div of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC.

References

  1. Fleming D, Wasserheit J. From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Transm Infect 1999;75:3–17.
  2. CDC. Sexually transmitted diseases treatment guidelines, 2010. MMWR 2010;59(No. RR-12).
  3. CDC. Update to CDC’s sexually transmitted diseases treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR 2007;56:332–6.
  4. CDC. Cephalosporin susceptibility among Neisseria gonorrhoeae isolates—United States, 2000–2010. MMWR 2011;60:873–7.
  5. Unemo M, Golparian D, Syversen G, Vestrheim DF, Moi H. Two cases of verified clinical failures using internationally recommended first-line cefixime for gonorrhea treatment, Norway, 2010. Euro Surveill 2010;15(47):pii:19721.
  6. Ison C, Hussey J, Sankar K, Evans J, Alexander S. Gonorrhea treatment failures to cefixime and azithromycin in England, 2010. Euro Surveill 2011;16(14):pii:19833.
  7. Unemo M, Golparian D, Stary A, Eigentler A. First Neisseria gonorrhoeae strain with resistance to cefixime causing gonorrhea treatment failure in Austria, 2011. Euro Surveill 2011;16(43):pi:19998.
  8. Unemo M, Golparian D, Nicholas R, Ohnishi M, Gallay A, Sednaoui P. High-level cefixime- and ceftriaxone-resistant Neisseria gonorrhoeae in France: novel penA mosaic allele in a successful international clone causes treatment failure. Antimicrob Agents Chemother 2012;56:1273–80.
  9. National Committee for Clinical Laboratory Standards. Approved Standard M100-S20 performance standards for antimicrobial susceptibility testing; twentieth informational supplement. Wayne, PA: Clinical and Laboratory Standards Institute; 2010.
  10. Moran JS, Levine WC. Drugs of choice for the treatment of uncomplicated gonococcal infections. Clin Infect Dis 1995;20(Suppl 1):S47–65.
  11. Handsfield HH, McCormack WM, Hook EW 3rd, et al. A comparison of single-dose cefixime with ceftriaxone as treatment for uncomplicated gonorrhea. The Gonorrhea Treatment Study Group. New Engl J Med 1991;325:1337–41.

* U.S. Census regions. Northeast: Connecticut, Maine, Massachusetts, New Jersey, New Hampshire, New York, Pennsylvania, Rhode Island, and Vermont; Midwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin; South:Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia; West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, New Mexico, Nevada, Oregon, Utah, Washington, and Wyoming.

TABLE. Percentage of urethral Neisseria gonorrhoeae isolates with elevated cefixime MICs (≥0.25 µg/mL), by U.S. Census region and gender of sex partner — Gonococcal Isolate Surveillance Project, United States, 2006–August 2011
Region 2006 2009 2010 2011*
% (95% CI) % (95% CI) % (95% CI) % (95% CI)
West† (total) 0.2 (0.1–0.4) 1.9 (1.4–2.6) 3.3 (2.6–4.0) 3.2 (2.3–4.2)
MSM 0.1 (0.0–0.6) 2.6 (1.7–3.8) 5.0 (3.8–6.5) 4.5 (3.1–6.3)
MSW 0.2 (0.0–0.6) 1.4 (0.7–2.3) 1.3 (0.7–2.2) 1.8 (0.9–3.1)
Midwest§ (total) 0.0 (0.0–0.3) 0.5 (0.2–1.0) 0.5 (0.2–1.1) 0.6 (0.2–1.5)
MSM 0.0 (0.0–2.8) 2.3 (0.6–5.7) 3.4 (1.1–7.7) 4.9 (1.4–12.2)
MSW 0.0 (0.0–0.3) 0.3 (0.1–0.7) 0.1 (0.0–0.6) 0.0 (0.0–0.6)
Northeast and South¶ (total) 0.1 (0.0–0.3) 0.0 (0.0–0.2) 0.1 (0.0–0.4) 0.3 (0.1–0.8)
MSM 0.6 (0.0–3.0) 0.3 (0.0–1.9) 0.9 (0.2–2.5) 1.5 (0.4–3.9)
MSW 0.0 (0.0–0.2) 0.0 (0.0–0.2) 0.0 (0.0–0.2) 0.1 (0.0–0.4)
Abbreviations: CI = confidence interval; MICs = minimum inhibitory concentrations; MSM = men who have sex with men; MSW = men who have sex exclusively with women.

* January–August 2011.

† Includes data from Albuquerque, New Mexico; Denver, Colorado; Honolulu, Hawaii; Las Vegas, Nevada; Los Angeles, California; Orange County, California; Phoenix, Arizona; Portland, Oregon; San Diego, California; San Francisco, California; and Seattle, Washington.

§ Includes data from Chicago, Illinois; Cincinnati, Ohio; Cleveland, Ohio; Detroit, Michigan; Kansas City, Missouri; and Minneapolis, Minnesota.

¶ Includes data from Atlanta, Georgia; Baltimore, Maryland; Birmingham, Alabama; Dallas, Texas; Greensboro, North Carolina; Miami, Florida; New Orleans, Louisiana; New York, New York; Oklahoma City, Oklahoma; Philadelphia, Pennsylvania; and Richmond, Virginia.

FIGURE. Percentage of urethral Neisseria gonorrhoeae isolates (n = 32,794) with elevated cefixime MICs (≥0.25 µg/mL) and ceftriaxone MICs (≥0.125 µg/mL) — Gonococcal Isolate Surveillance Project, United States, 2006–August 2011

The figure shows the percentage of Neisseria gonorrhoeae isolates (n = 32,794) with elevated cefixime MICs (≥0.25 μg/mL) and ceftriaxone MICs (≥0.125 μg/mL) in the United States during 2006-August 2011, according to the Gonococcal Isolate Surveillance Project. The percentage of isolates with elevated cefixime MICs (MICs ≥0.25 μg/mL) increased from 0.1% in 2006 to 1.5% during January-August 2011.

Abbreviation: MICs = minimum inhibitory concentrations.

* Cefixime susceptibility not tested during 2007–2008.

† January–August 2011.

Alternate Text: The figure above shows the percentage of Neisseria gonorrhoeae isolates (n = 32,794) with elevated cefixime MICs (≥0.25 μg/mL) and ceftriaxone MICs (≥0.125 μg/mL) in the United States during 2006-August 2011, according to the Gonococcal Isolate Surveillance Project. The percentage of isolates with elevated cefixime MICs (MICs ≥0.25 μg/mL) increased from 0.1% in 2006 to 1.5% during January-August 2011.

BOX. Updated recommended treatment regimens for gonococcal infections
Uncomplicated gonococcal infections of the cervix, urethra, and rectum

Recommended regimen

Ceftriaxone 250 mg in a single intramuscular dose

PLUS

Azithromycin 1 g orally in a single dose

or doxycycline 100 mg orally twice daily for 7 days*

 

Alternative regimens

If ceftriaxone is not available:

Cefixime 400 mg in a single oral dose

PLUS

Azithromycin 1 g orally in a single dose

or doxycycline 100 mg orally twice daily for 7 days*

PLUS

Test-of-cure in 1 week

 

If the patient has severe cephalosporin allergy:

Azithromycin 2 g in a single oral dose

PLUS

Test-of-cure in 1 week

 

Uncomplicated gonococcal infections of the pharynx

Recommended regimen

Ceftriaxone 250 mg in a single intramuscular dose

PLUS

Azithromycin 1 g orally in a single dose

or doxycycline 100 mg orally twice daily for 7 days*

 

* Because of the high prevalence of tetracycline resistance among Gonococcal Isolate Surveillance Project isolates, particularly those with elevated

 

NOTE: THIS IS FOR YOUR INFORMATION ONLY, BUT “NOT A MEDICAL ADVISE”.

 

source

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6131a3.htm?s_cid=mm6131a3_w

 

 

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Reporter: Prabodh Kandala, PhD

According to a new study, children exposed to high levels of the common air pollutant naphthalene are at increased risk for chromosomal aberrations (CAs), which have been previously associated with cancer. These include chromosomal translocations, a potentially more harmful and long-lasting subtype of CAs.

Researchers from the Columbia Center for Children’s Environmental Health (CCCEH) at the Mailman School of Public Health, Columbia University Medical Center, and the Centers for Disease Control and Prevention (CDC) report the new findings in Cancer, Epidemiology, Biomarkers & Prevention, a journal of the American Association for Cancer Research.

Naphthalene is found in both outdoor and indoor urban air. It is present in automotive exhaust, tobacco smoke, and is the primary component of household mothball fumes. Classified as a possible carcinogen by the International Agency for Cancer Research, naphthalene belongs to a class of air pollutants called polycyclic aromatic hydrocarbons (PAH). Prior research at the CCCEH has established a link between prenatal exposure to PAH and increased risk for childhood obesity, IQ deficits, and CAs. The new study is the first to present evidence in humans of CAs, including translocations, associated with exposure to one specific PAH — naphthalene — during childhood.

The researchers followed 113 children, age 5, who are part of a larger cohort study in New York City. They assessed the children’s exposure to naphthalene; a CDC laboratory measured levels of its metabolites — 1- and 2-naphthol — in urine samples. (Metabolites are products of the body’s metabolism, and can serve as marker for the presence of a chemical.) Researchers also measured CAs in the children’s white blood cells using a technique called fluorescent in situ hybridization. Chromosomal aberrations were present in 30 children; of these, 11 had translocations. With every doubling of levels of 1- and 2-naphthol, translocations were 1.55 and 1.92 times more likely, respectively, to occur.

CAs have been associated with increased cancer risk in adults. Translocations are of special concern as they result in a portion of one chromosome being juxtaposed to a portion of another chromosome, potentially scrambling the genetic script. “Translocations can persist for years after exposure. Some accumulated damage will be repaired, but not everyone’s repair capacity is the same. Previous studies have suggested that chromosomal breaks can double an adult’s lifetime risk for cancer, though implications for children are unknown,” says first author Manuela A. Orjuela, MD, ScM, assistant professor of clinical environmental health sciences and pediatrics (oncology) at Columbia University Medical Center and a pediatric oncologist at NewYork-Presbyterian Morgan Stanley Children’s Hospital.

To obtain a better sense of the long-term consequences of naphthalene exposure, Dr. Orjuela and other CCCEH investigators are following some of the children in the study as they reach fourth grade. While they expect to see further translocations, they do not expect to see any signs of cancer in the white blood cells. “So far, the translocations seem to be random, and there has been no evidence of the specific translocations that are known to be associated with leukemia. This is entirely expected; leukemia is very rare.” Frederica Perera, DrPH, senior author on the paper, adds that “the findings provide yet more evidence of the vulnerability of the young child to carcinogenic air pollutants.”

The researchers hypothesized that naphthalene exposure was primarily from mothballs, which can release high levels of the chemical. Furthermore, according to previous research, some Caribbean immigrant families use mothballs as an air freshener. Other important sources of naphthalene in indoor air are tobacco smoke, paint fumes, cooking, and heating. The new findings have implications beyond the urban environment as elevated levels of naphthalene metabolites have been documented in rural communities using biomass-burning stoves (coal, wood) — another source of PAH exposure.

 Ref:

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