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May 22, 2017Infectious Disease
The fight to contain the 2013-16 Ebola outbreak in West Africa was hampered by the lack of an effective treatment or vaccine. Now, according to an article published in the journal Cell (May 2017), researchers have studied the blood of an Ebola survivor, searching for human antibodies that might effectively treat not only people infected with Ebola virus, but those infected with related viruses as well. Two such antibodies have been identified that hold promise as Ebola treatments.
Previously, researchers had discovered only one antibody -- from a mouse -- capable of protecting mice against multiple different species in the ebolavirus lineage. To find similar broadly protective human antibodies, the authors surveyed 349 human monoclonal antibodies derived from the blood of one survivor of the recent West African Ebola outbreak, which was caused by Zaire ebolavirus. They searched specifically for antibodies that might neutralize all five common ebolavirus species.
The authors mined the human immune response to natural infection by the Ebola virus and found two antibodies, ADI-15878 and ADI-15742, which recognized the GP fusion loop-a section of a protein found on the surface of the Ebola virus. By analyzing the structure of these antibodies and testing their action on the viruses, the researchers determined that when given access to the GP fusion loop, the antibodies could likely block the five related ebolaviruses from entering a host cell. Moreover, when tested with human cells in a laboratory setting, the antibodies protected the cells from becoming infected with several different virulent ebolaviruses.
To further investigate these findings, the authors tested the antibodies in three animal models: wild-type mice, mice genetically altered to be susceptible to Sudan ebolavirus, and ferrets. Treating wild-type mice with the antibodies after exposure to the Zaire ebolavirus appeared to have a protective effect, as did treating the altered mice after exposure to Sudan ebolavirus. The ferrets experienced a protective effect from the antibodies after exposure to Bundibugyo ebolavirus. However, in the ferrets exposed to the Bundibugyo virus and treated with ADI-15742, the virus developed a single mutation that enabled it to escape the antibody's effects. In addition, neither antibody conferred protection against the related Lloviu or Marburg viruses when tested in human cells in the laboratory setting. Still, the researchers suggest that these broadly neutralizing antibodies could provide the basis for a candidate treatment, but further exploration is needed. These findings may help inform the development of therapeutic pan-ebolavirus antibodies, as well as vaccines for potential use in the event of another Ebola outbreak.
May 22, 2017What's New
Last week, Target Health was honored as Dr. Jules Mitchel joined Dr. John Laschinger (FDA), for a Clinical Trials Transformation Initiative (CTTI) Webinar on CTTI's recommendations on how to design and use registries for prospective clinical trials. The Webinar attracted more than 200 participants and the questions from the attendees were all "on target." According to the CTTI website, "CTTI's recommendations for registry assessment and design can assist in making embedded clinical trials suitable for regulatory purposes. By using registries as a reusable platform for evidence generation, we can improve the efficiency of clinical trials and bring new treatments to patients faster."
Holden Beach, NC - Pier, Sunset
Dr. Mitchel is in Israel right now at the Biomed meeting, but had the pleasure of being in North Carolina last Wednesday. Our good friend and colleague James Farley was at the meeting and shared some his great photos, in between an intense day of consulting.
It's been a while, since James, photographer extraordinaire, has sent out any photos as he has recently transitioned all of his landscape, architectural and macro/wildlife photography to Advanced Fine Art. These photos were taken at Holden Beach, NC in mid-April, during Spring Break.
According to James, make sure to zoom-in on the viewer! Even on this resampled version, there is a lot of detail! :-))) Shot on his Canon 5D Mark IV and 17mm Tilt-shift. The photo under the pier was a 4-second exposure.
For more information about Target Health contact Warren Pearlson (212-681-2100 ext. 165). For additional information about software tools for paperless clinical trials, please also feel free to contact Dr. Jules T. Mitchel. The Target Health software tools are designed to partner with both CROs and Sponsors.
Joyce Hays, Founder and Editor in Chief of On Target
Jules Mitchel, Editor
May 22, 2017History of Medicine
Pain has accompanied human beings since the moment this species appeared on Earth. From that moment on, and throughout his long history mankind has tried not only to look for the causes of pain but also to find remedies to relieve pain. The concept of pain has remained a topic of long debate since its emergence in ancient times. The initial ideas of pain were formulated in both the East and the West before 1800. Since 1800, due to the development of experimental sciences, different theories of pain have emerged and become central topics of debate. However, the existing theories of pain may be appropriate for the interpretation of some aspects of pain, but are not yet comprehensive. The history of pain problems is as long as that of human beings; however, the understanding of pain mechanisms is still far from sufficient. Thus, intensive research is required. This historical review mainly focuses on the development of pain theories and the fundamental discoveries in this field. Other historical events associated with pain therapies and remedies are beyond the scope of this review. As long as humans have experienced pain, they have given explanations for its existence and sought soothing agents to dull or cease the painful sensation. Archaeologists have uncovered clay tablets dating back as far as 5,000 BCE which reference the cultivation and use of the opium poppy to bring joy and cease pain. In 800 BCE, the Greek writer Homer wrote in his epic, The Odyssey, of Telemachus, a man who used opium to soothe his pain and forget his worries. While some cultures researched analgesics and allowed or encouraged their use, others perceived pain to be a necessary, integral sensation. Physicians of the 19th century used pain as a diagnostic tool, theorizing that a greater amount of personally perceived pain was correlated to a greater internal vitality, and as a treatment in and of itself, inflicting pain on their patients to rid the patient of evil and unbalanced humors. This article focuses both on the history of how pain has been perceived across time and culture, but also how malleable an individual's perception of pain can be due to factors like situation, their visual perception of the pain, and previous history with pain.
Because of the only relatively recent discovery of neurons and how they conduct and interpret signals, including sensations such as pain, within the body, various theories have been proposed as to the causes of pain and its role or function. Even within seemingly limited groups, such as the ancient Greeks, there were competing theories as to the root cause of pain. Aristotle did not include a sense of pain when he enumerated the five senses; he, like Plato before him, saw pain and pleasure not as sensations but as emotions (passions of the soul). Alternatively, Hippocrates believed that pain was caused by an imbalance in the vital fluids of a human. At this time, neither Aristotle nor Hippocrates believed that the brain had any role to play in pain processing but rather implicated the heart as the central organ for the sensation of pain. In the 11th century, Avicenna theorized that there were a number of feeling senses including touch, pain and titillation.
Even just prior to the scientific Renaissance in Europe, pain was not well understood and it was theorized that pain existed outside of the body, perhaps as a punishment from God, with the only management treatment being prayer. Again, even within the confined group of religious, practicing Christians, more than one theory arose. Alternatively, pain was also theorized to exist as a test or trial on a person. In this case, pain was inflicted by god onto person to reaffirm their faith, or in the example of Jesus, to lend legitimacy and purpose to a trial through suffering. In his 1664 Treatise of Man, Rene Descartes theorized that the body was more similar to a machine, and that pain was a disturbance that passed down along nerve fibers until the disturbance reached the brain. This theory transformed the perception of pain from a spiritual, mystical experience to a physical, mechanical sensation meaning that a cure for such pain could be found by researching and locating pain fibers within the bodies rather than searching for an appeasement for god. This also moved the center of pain sensation and perception from the heart to the brain. Descartes proposed his theory by presenting an image of a man's hand being struck by a hammer. In between the hand and the brain, Descartes described a hollow tube with a cord beginning at the hand and ending at a bell located in the brain. The blow of the hammer would induce pain in the hand, which would pull the cord in the hand and cause the bell located in the brain to ring, indicating that the brain had received the painful message. Researchers began to pursue physical treatments such as cutting specific pain fibers to prevent the painful signal from cascading to the brain.
Scottish anatomist Charles Bell proposed in 1811 that there exist different kinds of sensory receptors, each adapted to respond to only one stimulus type. In 1839 Johannes Muller, having established that a single stimulus type (e.g., a blow, electric current) can produce different sensations depending on the type of nerve stimulated, hypothesized that there is a specific energy, peculiar to each of five nerve types that serve Aristotle's five senses, and that it is the type of energy that determines the type of sensation each nerve produces. He considered feelings such as itching, pleasure, pain, heat, cold and touch to be varieties of the single sense he called feeling and touch. Muller's doctrine killed off the ancient idea that nerves carry actual properties or incorporeal copies of the perceived object, marking the beginning of the modern era of sensory psychology, and prompted others to ask, do the nerves that evoke the different qualities of touch and feeling have specific characteristics?
Filippo Pacini had isolated receptors in the nervous system which detect pressure and vibrations in 1831. Georg Meissner and Rudolf Wagner described receptors sensitive to light touch in 1852; and Wilhelm Krause found a receptor that responds to gentle vibration in 1860. Moritz Schiff was first to definitively formulate the specificity theory of pain when, in 1858, he demonstrated that touch and pain sensations traveled to the brain along separate spinal cord pathways. In 1882 Magnus Blix reported that specific spots on the skin elicit sensations of either cold or heat when stimulated, and proposed that the different sensations of cool and warm are caused by stimulation of different, specific receptors in the skin. Max von Frey found and described these heat and cold receptors and, in 1896, reported finding pain spots on the skin of human subjects. Von Frey proposed there are low threshold cutaneous spots that elicit the feeling of touch, and high threshold spots that elicit pain, and that pain is a distinct cutaneous sensation, independent of touch, heat and cold, and associated with free nerve endings.
In the first volume of his 1794 Zoonomia; or the Laws of Organic Life, Erasmus Darwin supported the idea advanced in Plato's Timaeus, that pain is not a unique sensory modality, but an emotional state produced by stronger than normal stimuli such as intense light, pressure or temperature. Wilhelm Erb, in 1874, also argued that pain can be generated by any sensory stimulus, provided it is intense enough, and his formulation of the hypothesis became known as the intensive theory. Alfred Goldscheider (1884) confirmed the existence of distinct heat and cold sensors, by evoking heat and cold sensations using a fine needle to penetrate to and electrically stimulate different nerve trunks, bypassing their receptors. Though he failed to find specific pain sensitive spots on the skin, Goldscheider concluded in 1895 that the available evidence supported pain specificity, and held the view until a series of experiments were conducted in 1889 by Bernhard Naunyn. Naunyn had rapidly (60-600 times/second) prodded the skin of tabes dorsalis patients, below their touch threshold (e.g., with a hair), and in 6-20 seconds produced unbearable pain. He obtained similar results using other stimuli including electricity to produce rapid, sub-threshold stimulation, and concluded pain is the product of summation. In 1894 Goldscheider extended the intensive theory, proposing that each tactile nerve fiber can evoke three distinct qualities of sensation - tickle, touch and pain - the quality depending on the intensity of stimulation; and extended Naunyn's summation idea, proposing that, over time, activity from peripheral fibers may accumulate in the dorsal horn of the spinal cord, and spill over from the peripheral fiber to a pain-signaling spinal cord fiber once a threshold of activity has been crossed. The British psychologist, Edward Titchener, pronounced in his 1896 textbook, excessive stimulation of any sense organ or direct injury to any sensory nerve occasions the common sensation of pain.
By the mid-1890s, specificity was mainly backed by physiologists (prominently by von Frey) and clinicians; and the intensive theory received most support from psychologists. But after Henry Head in England published a series of clinical observations between 1893 and 1896, and von Frey's experiments between 1894 and 1897, the psychologists migrated to specificity almost en masse, and by century's end, most textbooks on physiology and psychology were presenting pain specificity as fact, with Titchener in 1898 now placing the sensation of pain alongside that of pressure, heat and cold. Though the intensive theory no longer featured prominently in textbooks, Goldscheider's elaboration of it nevertheless stood its ground in opposition to von Frey's specificity at the frontiers of research, and was supported by some influential theorists well into the mid-twentieth century. William Kenneth Livingston advanced a summation theory in 1943, proposing that high intensity signals, arriving at the spinal cord from damage to nerve or tissue, set up a reverberating, self-exciting loop of activity in a pool of interneurons, and once a threshold of activity is crossed, these interneurons then activate transmission cells which carry the signal to the brain's pain mechanism. The reverberating interneuron activity also spreads to other spinal cord cells that trigger a sympathetic nervous system and somatic motor system response; and these responses, as well as fear and other emotions elicited by pain, feed into and perpetuate the reverberating interneuron activity. A similar proposal was made by RW Gerard in 1951, who proposed also that intense peripheral nerve signaling may cause temporary failure of inhibition in spinal cord neurons, allowing them to fire as synchronized pools, with signal volleys strong enough to activate the pain mechanism. Building on John Paul Nafe's 1934 suggestion that different cutaneous qualities are the product of different temporal and spatial patterns of stimulation, and ignoring a large body of strong evidence for receptor fiber specificity, DC Sinclair and G Weddell's 1955 peripheral pattern theory proposed that all skin fiber endings (with the exception of those innervating hair cells) are identical, and that pain is produced by intense stimulation of these fibers. In 1953, Willem Noordenbos had observed that a signal carried from the area of injury along large diameter touch, pressure or vibration fibers may inhibit the signal carried by the thinner pain fibers - the ratio of large fiber signal to thin fiber signal determining pain intensity; hence, we rub a smack. This was taken as a demonstration that pattern of stimulation (of large and thin fibers in this instance) modulates pain intensity.
Ronald Melzack and Patrick Wall introduced their gate control theory of pain in the 1965 Science article Pain Mechanisms: A New Theory. The authors proposed that both thin (pain) and large diameter (touch, pressure, vibration) nerve fibers carry information from the site of injury to two destinations in the dorsal horn of the spinal cord: transmission cells that carry the pain signal up to the brain, and inhibitory interneurons that impede transmission cell activity. Activity in both thin and large diameter fibers excites transmission cells. Thin fiber activity impedes the inhibitory cells (tending to allow the transmission cell to fire) and large diameter fiber activity excites the inhibitory cells (tending to inhibit transmission cell activity). So, the large fiber (touch, pressure, vibration) activity relative to thin fiber activity at the inhibitory cell, the less pain is felt. The authors had drawn a neural circuit diagram to explain why we rub a smack. They pictured not only a signal traveling from the site of injury to the inhibitory and transmission cells and up the spinal cord to the brain, but also a signal traveling from the site of injury directly up the cord to the brain (bypassing the inhibitory and transmission cells) where, depending on the state of the brain, it may trigger a signal back down the spinal cord to modulate inhibitory cell activity (and so pain intensity). The theory offered a physiological explanation for the previously observed effect of psychology on pain perception. In 1975, well after the time of Descartes, the International Association for the Study of Pain sought a consensus definition for pain, finalizing an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage as the final definition. It is clear from this definition that while it is understood that pain is a physical phenomenon, the emotional state of a person, as well as the context or situation associated with the pain also impacts the perception of the nociceptive or noxious event. For example, if a human experiences a painful event associated with any form of trauma (an accident, disease, etc.), a reoccurrence of similar physical pain will not only inflict physical trauma but also the emotional and mental trauma first associated with the painful event. Research has shown that should a similar injury occur to two people, one person who associates large emotional consequence to the pain and the other person who does not, the person who associates a large consequence on the pain event will feel a more intense physical pain that the person who does not associate a large emotional consequence with the pain.
Modern research has gathered considerable amounts of evidence that support the theory that pain is not only a physical phenomenon but rather a biopsychosocial phenomenon, encompassing culture, nociceptive stimuli, and the environment in the experience and perception of pain. For example, the Sun Dance is a ritual performed by traditional groups of Native Americans. In this ritual, cuts are made into the chest of a young man. Strips of leather are slipped through the cuts, and poles are tied to the leather. This ritual lasts for hours and undoubtedly generates large amounts of nociceptive signaling, however the pain may not be perceived as noxious or even perceived at all. The ritual is designed around overcoming and transcending the effects of pain, where pain is either welcomed or simply not perceived. Additional research has shown that the experience of pain is shaped by a plethora of contextual factors, including vision. Researchers have found that when a subject views the area of their body that is being stimulated, the subject will report a lowered amount of perceived pain. For example, one research study used a heat stimulation on their subjects' hands. When the subject was directed to look at their hand when the painful heat stimulus was applied, the subject experienced an analgesic effect and reported a higher temperature pain threshold. Additionally, when the view of their hand was increased, the analgesic effect also increased and vice versa. This research demonstrated how the perception of pain relies on visual input. The use of fMRI to study brain activity confirms the link between visual perception and pain perception. It has been found that the brain regions that convey the perception of pain are the same regions that encode the size of visual inputs. One specific area, the magnitude-related insula of the insular cortex, functions to perceive the size of a visual stimulation and integrate the concept of that size across various sensory systems, including the perception of pain. This area also overlaps with the nociceptive-specific insula, part of the insula that selectively processes nociception, leading to the conclusion that there is an interaction and interface between the two areas. This interaction tells the individual how much relative pain they are experiencing, leading to the subjective perception of pain based on the current visual stimulus.
Humans have always sought to understand why they experience pain and how that pain comes about. While pain was previously thought to be the work of evil spirits, it is now understood to be a neurological signal. However, the perception of pain is not absolute and can be impacted by various factors in including the context surrounding the painful stimulus, the visual perception of the stimulus, and an individual's personal history with pain.
May 22, 2017Target Healthy Eating
2/3 cup pine nuts, toasted, plus extra (toasted) for garnish
1 pound fresh, (organic) locally grown fat asparagus, rinsed
1 lemon, halved
1.5 Tablespoons fresh lemon juice
Zest of 1/2 lemon
Lemon circles, for garnish
2.5 Tablespoons extra virgin olive oil
1 or 2 fresh garlic clove, juiced (squeezed)
1 Tablespoon fresh chives, minced
Pinch turmeric (that comes with black pepper, already mixed in)
Pinch black mustard seeds, toasted
Pinch chili flakes
Pinch, black pepper
1 cup freshly grated Parmesan
1. Rinse the chives, then chop and set aside.
2. Toast the pine nuts and the black mustard seeds together. Keep your eye on them and stir constantly so they don't burn. You'll have to do them over if they burn. Set aside
3. Rinse the asparagus, then make the asparagus ribbons
4. To shave the asparagus lay a stalk flat on a cutting board, holding it at the base. Usually, with asparagus recipes, you snap off the tough bottom, that are too tough to eat. In this recipe, don't snap them off, so you have something to hold onto when you make the asparagus ribbons.
5. Gripping the base, at about where the pale base turns green, use a vegetable peeler to shave the stalk in long, even strips all the way through the tip. Be sure to peel the asparagus ribbon, all the way to the end of the tip. Some of your ribbons will have part or all of the tip and others won't. That's okay. The end result will be a lovely variety of ribbons.
6. The best peeler to use, is the Y-shape one. Peel again until you're about half way through the stalk, then turn over and peel the other side. When you reach the point that the peeler will no longer shave the spear, rest the spear on top of a wooden spoon (or wooden spatula) with a flat handle, to elevate the spear and take the last two or three strips. Peel all of the asparagus spears, like this.
7. Combine asparagus shavings, toasted pine nuts and toasted black mustard seeds, in a large salad (serving) bowl, and toss gently. Save some of the nuts for garnish.
8. In a small bowl, place the minced chives and the garlic juice in the bottom of the bowl and cover with olive oil. Add lemon juice, zest, turmeric and pinch chili flakes, and whisk until smooth.
9. Pour this dressing over the asparagus mixture and toss gently with salad servers, to lightly coat all of the asparagus ribbons. Toss gently. Taste and adjust seasoning, if needed.
10. Finally, sprinkle the salad with the freshly grated parmesan, a few extra (toasted) pine nuts and toss. Place the lemon circles around the bowl for decoration, or on individual plates. Serve immediately.
Two of the seven theater clubs we support (RoundAbout Theater and Manhattan Theater Club), started years ago with very little financing. They struggled on, in various off Broadway locations, for many years, until today each owns several Broadway theaters and, each has been nominated for many Tony Awards. Last week, at RoundAbout's American Airlines Theater, we saw some great theater in Arthur Miller's, The Price. The surprise of the year, is the emergence of Danny DeVito, giving a great memorable performance, not to be missed. His beautifully created character will knock your socks off. Although, he's made a name for himself on the screen and in other entertainment ventures, he belongs on the stage in live theater. He is a gem! Run to see this show before it closes. It has a limited engagement.
Photo credit: Gage Skidmore [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons - File:Danny DeVito by Gage Skidmore 3.jpg, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=50628181
From Our Table to Yours
May 22, 2017Regulatory
Cystic fibrosis is a rare disease that affects about 30,000 people in the United States and affects the cells that produce mucus, sweat and digestive juices. These secreted fluids are normally thin and slippery due to the movement of sufficient ions (chloride) and water in and out of the cells. People with the progressive disease have a defective cystic fibrosis transmembrane conductance regulator (CFTR) gene that can't regulate the movement of ions and water, causing the secretions to become sticky and thick. The secretions build up in the lungs, digestive tract and other parts of the body leading to severe respiratory and digestive problems, as well as other complications such as infections and diabetes.
The FDA has expanded the approved use of Kalydeco (ivacaftor) for treating cystic fibrosis. The approval triples the number of rare gene mutations that the drug can now treat, expanding the indication from the treatment of 10 mutations, to 33. The agency based its decision, in part, on the results of laboratory testing, which it used in conjunction with evidence from earlier human clinical trials. The approach provides a pathway for adding additional, rare mutations of the disease, based on laboratory data.
Results from an in vitro cell-based model system have been shown to reasonably predict clinical response to Kalydeco. When additional mutations responded to Kalydeco in the laboratory test, researchers were thus able to extrapolate clinical benefit demonstrated in earlier clinical trials of other mutations. This resulted in the addition of gene mutations for which the drug is now indicated. Kalydeco, available as tablets or oral granules taken two times a day with fat-containing food, helps the protein made by the CFTR gene, function better and as a result, improves lung function and other aspects of cystic fibrosis, including weight gain. If the patient's genotype is unknown, an FDA-cleared cystic fibrosis mutation test should be used to detect the presence of a CFTR mutation followed by verification with bi-directional sequencing when recommended by the mutation test instructions for use.
Kalydeco is indicated for patients aged 2 and older who have one mutation in the CFTR gene that is responsive to drug treatment based on clinical and/or in vitro (laboratory) data. The expanded indication will affect another 3 percent of the cystic fibrosis population, impacting approximately 900 patients. Kalydeco serves as an example of how successful patient-focused drug development can provide greater understanding about a disease. For example, the Cystic Fibrosis Foundation maintains a 28,000-patient registry, including genetic data, which it makes available for research.
Common side effects of Kalydeco include headache; upper respiratory tract infection (common cold) including sore throat, nasal or sinus congestion, or runny nose; stomach (abdominal) pain; diarrhea; rash; nausea; and dizziness. Kalydeco is associated with risks including elevated transaminases (various enzymes produced by the liver) and pediatric cataracts. Co-administration with strong CYP3A inducers (e.g., rifampin, St. John's wort) substantially decreases exposure of Kalydeco, which may diminish effectiveness, and is therefore not recommended.
Kalydeco is manufactured for Boston-based Vertex Pharmaceuticals Inc.
May 22, 2017Epidemiology
Despite cross-sectional evidence linking racial residential segregation to hypertension prevalence among non-Hispanic blacks, it remains unclear how changes in exposure to neighborhood segregation may be associated with changes in blood pressure. As a result, a study published on line (15 May 2017) in JAMA Internal Medicine, was performed to examine the association of changes in neighborhood-level racial residential segregation with changes in systolic and diastolic blood pressure over a 25-year period.
This observational study examined longitudinal data of 2,280 black participants of the Coronary Artery Risk Development in Young Adults (CARDIA) study, a prospective investigation of adults aged 18 to 30 years who underwent baseline examinations in field centers in 4 US locations from March 25, 1985, to June 7, 1986, and then were re-examined for the next 25 years. Racial residential segregation was assessed using the Getis-Ord Gi statistic, a measure of SD between the neighborhood's racial composition (i.e., percentage of black residents) and the surrounding area's racial composition. Segregation was categorized as high (Gi* >1.96), medium (Gi* 0-1.96), and low (Gi* <0). Fixed-effects linear regression modeling was used to estimate the associations of within-person change in exposure to segregation and within-person change in blood pressure while tightly controlling for time-invariant confounders. Data analyses were performed between August 4, 2016, and February 9, 2017. The main outcome measures were within-person changes in systolic and diastolic blood pressure across 6 examinations over 25 years.
Results showed that of the 2,280 participants at baseline, 974 (42.7%) were men and 1306 (57.3%) were women. Of these, 1861 (81.6%) were living in a high-segregation neighborhood; 278 (12.2%), a medium-segregation neighborhood; and 141 (6.2%), a low-segregation neighborhood. Systolic blood pressure increased by a mean of 0.16 (95% CI, 0.06-0.26) mm Hg with each 1-SD increase in segregation score after adjusting for interactions of time with age, gender, and field center. Of the 1,861 participants (81.6%) who lived in high-segregation neighborhoods at baseline, reductions in exposure to segregation were associated with reductions in systolic blood pressure. Mean differences in systolic blood pressure were -1.33 (95% CI, -2.26 to -0.40) mm Hg when comparing high-segregation with medium-segregation neighborhoods and -1.19 (95% CI, -2.08 to -0.31) mm Hg when comparing high-segregation with low-segregation neighborhoods after adjustment for time and interactions of time with baseline age, sex, and field center. Changes in segregation were not associated with changes in diastolic blood pressure.
According to the authors, decreases in exposure to racial residential segregation are associated with reductions in systolic blood pressure, and that this study adds to the small but growing body of evidence that policies that reduce segregation may have meaningful health benefits. Living in racially segregated neighborhoods is associated with a rise in the blood pressure of black adults, while moving away from segregated areas is associated with a decrease - and significant enough to lead to reductions in heart attacks and strokes, a National Institutes of Health-funded study has found. The findings offer further evidence that policies to reduce residential racial segregation may have meaningful health benefits, especially for African-Americans, who suffer the highest rates of hypertension of any group in the United States.
Residential segregation, the separation of groups into different neighborhoods by race, has long been identified as a major cause of health disparities between blacks and whites. This is the first study to explore whether increases or decreases in residential segregation specifically affect blood pressure.
May 22, 2017Quiz
Chronic pain is any pain that lasts for more than three 1) ___. The pain can become progressively worse and reoccur intermittently, outlasting the usual healing process. After injured tissue heals, pain is expected to stop once the underlying cause is treated, according to conventional ideas of pain. Chronic pain afflicts over 100 million people across the United States. It diminishes their productivity and their quality of 2) ___ and costs hundreds of billions of dollars each year to medically manage. It shatters people's emotional wellbeing, tears apart families and claims lives through suicides and accidental drug overdoses. But now researchers at the University of Arizona have found promise in a novel, non-pharmacological approach to managing chronic 3) ___ -- treating it with green light-emitting diodes (LED). Results of the study appear in the February 2017 issue of the journal Pain.
In the study, rats with neuropathic pain that were bathed in green LED showed more tolerance for thermal and tactile stimulus than rats that were not bathed in 4) ___ LED. In both cases, and of note, no side effects from the therapy were observed, nor was motor or visual performance impaired. The beneficial effects lasted for four days after the rats' last exposure to the green 5) ___. In addition, no tolerance to the therapy was noted. Chronic pain is a serious issue afflicting millions of people of all ages, says Mohab Ibrahim, UA assistant professor of Anesthesiology and Pharmacology and lead author of the study. Pain physicians are trained to manage chronic pain in several ways including medication and interventional procedures in a multimodal approach. Opioids, while having many benefits for managing pain, come with serious side 6) ___. We need safer, effective and affordable approaches, used in conjunction with our current tools, to manage chronic pain. While the results of the green LED are still preliminary, it holds significant promise to manage some types of chronic pain.
To receive the green LED exposure, one group of rats were placed in clear plastic containers that were affixed with green LED strips, allowing them to be bathed in green light. Another group of rats was exposed to room light and fitted with contact lenses that allowed the green spectrum wavelength to pass through. Both groups benefitted from the green LED exposure. However, another group of rats was fitted with opaque contact lenses, which blocked the green light from entering their 7) ___ system. These rats did not benefit from the green LED exposure. "While the pain-relieving qualities of green LED are clear, exactly how it works remains a puzzle," says Rajesh Khanna, UA associate professor of Pharmacology and senior author of the study. "Early studies show that green light is increasing the levels of circulating endogenous opioids, which may explain the pain-relieving effects. Whether this will be observed in 8) ___ is not yet known and needs further work." Todd Vanderah, professor and chair of Pharmacology and co-author of the study stated that novel non-pharmacological methods are desperately needed to help the millions of individuals suffering from 9) ___ pain. The initial results hint of green LED altering the levels of endogenous substances that may inhibit pain and possibly decrease inflammation of the nervous system is a great breakthrough, he says. Such therapy is inexpensive and can easily be used worldwide.
The researchers are now conducting a clinical trial using green LED therapy in people with fibromyalgia, a common source of chronic pain. The hope is that green LED light therapy will alleviate the participants' pain when used alone or in combination with other treatments including physical 10) ___ or low-dose analgesics.
Sources: University of Arizona. "Promise in light therapy to treat chronic pain." (February 28, 2017); Mohab M. Ibrahim, Amol Patwardhan, Kerry B. Gilbraith, Aubin Moutal, Xiaofang Yang, Lindsey A. Chew, Tally Largent-Milnes, T. Philip Malan, Todd W. Vanderah, Frank Porreca, Rajesh Khanna. Long-lasting antinociceptive effects of green light in acute and chronic pain in rats. PAIN, 2017; 158 (2): 347
ANSWERS: 1) months; 2) life; 3) pain; 4) green; 5) LED; 6) effects; 7) visual; 8) humans; 9) chronic; 10) therapy
May 15, 2017Ophthalmology
Uveitis is an inflammatory disease of the eye and the fifth leading cause of vision loss in the United States. Concerns about potential adverse effects of systemic corticosteroid and immunosuppressive therapy drove the development of an intraocular implant to treat uveitis locally. The fluocinolone intraocular implant, developed by Bausch & Lomb, was approved by the FDA in 2005. Early data suggested the implant was effective at controlling inflammation but had local ocular side effects. The Multicenter Uveitis Steroid Treatment Trial (MUST) was undertaken to evaluate whether the implant treatment was an improvement over systemic therapy for management of uveitis.
According to an article published online in JAMA (6 May 2017), after seven years, an NIH-funded clinical trial found that systemic therapy consisting of corticosteroids and immunosuppressants preserved vision of uveitis patients better -- and had fewer adverse outcomes -- than a long-lasting corticosteroid intraocular implant. Visual acuity, on average, remained stable among participants on systemic therapy but declined by an average of six letters (about one line on an eye chart) among participants who had the implant.
The study recruited 255 uveitis patients at 23 sites (21 in the U.S., one in the U.K., and one in Australia) and randomly assigned them to receive the fluocinolone implant or systemic treatment with corticosteroids (prednisone) and immunosuppressants (such as methotrexate or mycophenolate mofetil). While systemic corticosteroids, which are FDA-approved for treatment of uveitis, reduce acute inflammation effectively, they have potential systemic adverse effects when used at a high dose for a long time. The immunosuppressants, which are not FDA-approved for uveitis, inhibit pathological immune responses, thus reducing the amount of corticosteroids needed over the long-term, mitigating such side effects.
Through the first two years, the visual acuity remained about the same in the two groups (results published in 2011). However, at the end of the study, visual acuity on average remained stable in the systemic group but declined about six letters in the implant group. The authors found that implant-treated eyes also had reactivations of uveitis after about five years, which coincided with a decline in visual acuity. The loss of vision in the implant group appears to have been due to increased damage in the retina and choroid (a tissue rich in blood vessels lying underneath the retina).
With respect to side effects, patients in the implant group were more likely to develop ocular side effects like cataracts, intraocular pressure elevation that required treatment with medicine and often surgery, and glaucoma. Patients receiving systemic therapy had increased risk of needing treatment with antibiotics, possibly due to immunosuppression, but otherwise did not have large increases in the risk of adverse effects typically associated with systemic corticosteroids such as high blood pressure or diabetes.
May 15, 2017What's New
1 cup almond flour
8 dates (pits removed)
1/4 tsp. vanilla extract
1. Do any chopping, slivering, cutting, toasting, you need to do.
2. Put parchment paper on a cookie sheet
3. Preheat oven to 350 degrees
4. Place all ingredients in a high speed blender, or food processor and blend until a dough like consistency is formed. If the dough is not sticky enough, keep blending until it sticks together.
5. With a spatula, remove all the dough and put into a bowl. Now is the time to add your choice of a fourth ingredient, if you want. White chocolate chips are better added now, so they don't get ground down too much. You control the size of the fourth ingredient, like walnuts and coconut, much better, if it's added after the first three ingredients are pulsed in the food processor, and scraped in a mixing bowl. Feel free to experiment with that fourth ingredient. I tried banana but it didn't work out too well.
6. Divide the dough into six pieces. Squeeze each portion in your hand, and roll into a ball.
7. In your hands, flatten each ball into a cookie shape and smooth the outer rim, as well.
8. Place cookies on the baking sheet, with parchment, and bake for 10 minutes, for a warm, just out of the oven cookie.
Hope everyone had a special Mother's Day. It's been a (welcome) cool Spring, here in the Big Apple.
From Our Table to Yours
May 15, 2017Quiz
Researchers at the University of Washington-Madison were able to grow skin, brain, bone marrow and blood 1) ___ on plants using a highly-specialized, natural scaffolding from plants like parsley. The researchers collaborated with the Olbrich Botanical Gardens to identify plant species that show scaffolding potential, which in turn could be turned into structures for biomedical purposes. The researchers observed that certain plant species possess strength, rigidity and porosity as well as low mass and surface area, and that these characteristics make for a structurally-efficient 2) ___. The researchers also noted that plants have really high surface area to volume ratio, while their porous structure facilitates fluid transport, and that 3D printed stem cell scaffold helped support, feed and organize the cells. John Wirth, Olbrich's conservatory curator, said the idea was a good way to use the living plant material to develop 3) ___ tissue. Parsley, orchid, and vanilla were among the plant species chosen for the study. Bamboo, wasabi, and elephant ear plant were also among the plants where cellulose was derived since plants have a huge capacity to grow 4) ___ populations According Bill Murphy, co-director of the UW-Madison Stem Cell and Regenerative Medicine Center, plants can deliver fluids very efficiently to their leaves and at the microscale, they're very well organized. Murphy added that the vast diversity in the plant kingdom provides virtually any size and shape of interest, and that plants are extraordinarily good at cultivating new tissues and 5) ___. Plants, therefore, represent a tremendous feedstock of new materials for tissue engineering applications.
Study details: Cellulose and 3D scaffolding techniques
The researchers decellularized the plant materials leaving only cellulose, the basic components of a plant's cell walls. The team then added peptides to serve as biological fasteners since human cells have no affinity to cellulose. Advanced technologies such as 3D printing and injection molding were used to create the three-dimensional scaffolds. It was found that eliminating all the other cells that make up the plant and retaining only the 6) ___ husks encouraged human stem cells such as fibroblasts to attach to the scaffold and develop miniature structures. Fibroblasts are common connective tissue cells that result from stem cell cultivation. Stem cells seeded into the scaffold also appeared to align themselves along its structure. This mechanism indicates a potential to use the materials in order to regulate the structure and alignment of developing human tissues, which may prove crucial for nerve and muscle tissues that need alignment and patterning. The plant scaffolds proved to be pliable, inexpensive, renewable and can be easily mass-7) ___, Murphy said. The researchers plan to conduct the efficacy of plant scaffolds in animal studies. While plant toxicity is highly unlikely, it could trigger immune responses when the plant scaffolds were implanted to mammals. However, significant immune response may not be apparent in their prospective study as plant cells were already taken out of the scaffolds. According to the researchers, the results suggest that plants may serve as an alternative to artificial scaffolds used in growing stem cells. Growing clusters of human stem cells that mimic organs in the laboratory may also be used on tissue implants in the near future. The findings were published in the journal Advanced Healthcare Materials.
Short History of Parsley
Apiole is a phenylpropene, also known as apiol, parsley apiol or parsley camphor. Its chemical name is 1-allyl-2,5-dimethoxy-3,4-methylenedioxybenzene. It is found in the essential oils of celery leaf and all parts of 8) ____. Heinrich Christoph Link, an apothecary in Leipzig, discovered the substance in 1715 as greenish crystals reduced by steam from oil of parsley. In 1855 Joret and Homolle discovered that apiol was an effective treatment of amenorrea or lack of menstruation. Parsley has been used In medicine as essential oil or in purified form, for the treatment of menstrual disorders and as an abortifacient. It is an irritant and, in high doses, it can cause liver and kidney 9) ___. Cases of death due to attempted abortion using apiol have been reported. Hippocrates wrote about parsley as a herb to cause an abortion. Plants containing apiole were used by women in the Middle Ages to terminate pregnancies. Now that safer methods of 10) ___ are available, apiol is almost forgotten.
Apiole (always with the final 'e') is the correct spelling of the trivial name for 1-allyl-2,5-dimethoxy-3,4-methylenedioxybenzene. Apiol, also known as 'liquid apiol' or 'green oil of parsley' is the extracted oleoresin of parsley, rather than the distilled oil. Its use was widespread in the USA, often as ergoapiol or apergol, until a highly toxic adulterated product containing apiol and tri-ortho-cresyl phosphate (also famous as the adulterant added to Jamaican ginger) was introduced on the American market. 1'-sulfoxy metabolite formation for apiole (3,4-OMe-safrole) is about 1/3 as active as safrole. No carcinogenicity was detected with parsley apiol or dill apiol in mice.
ANSWERS: 1) vessels; 2) scaffold; 3) human; 4) cell; 5) organs; 6) cellulose; 7) produced; 8) parsley; 9) damaged; 10) abortion