Monthly Archives: February 2013

An epigenetic cure for cancer?

A review article by researchers at the Boston University School of Medicine suggests that subtle changes in DNA expression patterns could be targeted to treat cancer, reducing the risk of cancer relapse. The authors, led by Sibaji Sarkar, PhD, propose that chemical modification of DNA and the negatively charged proteins it binds to – ultimately resulting in changes in gene expression and cell phenotype – plays a role in driving cancer stem cell formation. Whilst our current understanding of these “epigenetic” changes remains sketchy, the hypothesis developed by Sarkar and colleagues may represent an important leap forward in the field of cancer research.

One in three people in the UK will develop cancer in their lifetime. Cancer exists in several forms, but broadly consists of a complex disease characterised by unchecked cell proliferation and tissue invasion. Many scientists believe that cancer develops from perverted immortal progenitor cells. The immortality of these “cancer stem cells” is believed to underlie both tumours’ resistance to chemotherapy and their relapse.

Sarkar and colleagues propose that gene silencing by DNA methylation – in conjunction with other genetic and environmental events – could trigger cancer stem cell formation. Over-expression of the enzyme responsible for DNA methylation in cancer cells is believed to silence genes that promote cell death and prevent tumour growth. On the contrary, oncogenes – genes with the potential to cause cancer – are highly expressed in cancer cells. The authors hypothesise that this bizarre mis-match is the result of concurrently active DNA methylating and demethylating enzymes found only in cancer cells. Current epigenetic drug treatments are believed to facilitate gene demethylation, increasing the expression of anti-growth genes.

At present, the role of epigenetic changes in cancer development is poorly understood. Despite this, it is clear that epigenetic drugs could eliminate cancer stem cells and generate vast improvements in patient outcomes and relapse rates.

http://www.bangscience.org/2013/02/an-epigenetic-cure-for-cancer/

 *Courtesy of Boston University School of Medicine

 

2013 Grasberger Research Symposium

The Grasberger Research Symposium is an annual research event that provides an opportunity for the surgical residents, faculty and staff to present original basic and clinical research. The symposium was established in 1990 in memory of Robert Grasberger MD.  Yesterday, we welcomed Michael W. Mulholland, MD, PhD, Frederick A. Coller Distinguished Professor of Surgery and Chair, Department of Surgery at the University of Michigan as this year’s visiting Grasberger Professor. In addition to giving morning Grand Rounds, Dr. Mulholland delivered the keynote lecture: “Metagenomics, New Diseases and Surgery – Some Things to Think About”. Residents and faculty presented posters and research presentations throughout the day.

Mahoney_and_mulholland

Trauma & Acute Care Surgeon Dr. Eric Mahoney shares his research with this year’s visiting Grasberger Professor, Dr. Michael Mullholland.

Mulholland_and_doherty

BMC’s Chief of Surgery, Dr. Gerald Doherty welcomes Dr. Michael Mullholland.

Boston Medical Center Offering New Procedure for GERD

Boston – Feb. 20, 2013 – Physicians at Boston Medical Center (BMC) are among the first in the city to offer a new treatment option for gastroesophageal reflux disease (GERD), in which a small implanted device is placed around the esophagus to help support a weak lower esophageal sphincter (LES). BMC is one of only two hospitals in New England currently offering the procedure using the LINX® Reflux Management System, which is available in less than 20 hospitals across the country.


    Dr. Hiran Fernando

GERD is a chronic, often progressive disease resulting from a weak LES. The LES is a muscle at the junction of the esophagus and stomach that functions like a valve allowing food and liquid to pass through to the stomach. A weak LES allows acid and bile to reflux from the stomach into the esophagus. Aditionally, as many as 10 percent of GERD patients go on to develop Barrett’s esophagus, a precancerous condition of the esophagus.

The LINX system comprises a small band of interlinked titanium beads with magnetic cores. This system creates a dynaminic spincter in the lower esophagus, that mimicks the true spincter action of the LES. The system is placed around the esophagus just above the stomach using a minimally invasive laparoscopic procedure. The magnetic attraction between the beads will resist opening of the LES to mild elevations in gastric pressures, preventing reflux from the stomach into the esophagus.

“On the other hand the LINX system is designed so that when exposed to the normal forces generated during swallowing, the magnetic bonds will temporarily break, allowing food and liquid to pass in the usual manner from the esophagus into the stomach,” explained Hiran Fernando, MD, Chief, Division of Thoracic Surgery and Director, Center for Minimally Invasive Esophageal Surgery at BMC. “The magnetic attraction of the device will then close the LES immediately after swallowing, restoring the body’s natural barrier to reflux,” he added.

According to Fernando, a major advantage of this procedure is the elimination of the symptoms of gas bloat, or difficulty with burping. These symptoms are often seen among patients undergoing the more traditional (fundoplication surgery) surgery for GERD. “However, because of the ability of the magnetic ring to open and close with the LINX system, this problem is eliminated in 99 percent of cases,” said Fernando.

Patients undergoing this one-hour procedure normally go home one day after surgery and can resume a normal diet. 

 

Massachusetts ED docs reporting impaired drivers to the state

SCOTTSDALE, ARIZ. – Boston emergency department physicians are now reporting impaired motorists for possible driver’s license revocation.

Over a 16-month period, 31% of admitted drivers were impaired. Of these, 17 were considered medically unqualified to drive, and 86 needed further medical evaluation.

“The vast majority of patients believe they’ll be reported [to authorities] if they arrive at the hospital impaired or under the influence, but that is not the case in Massachusetts, or in most other states from what we’ve found,” according to trauma surgeon Eric Mahoney, who helped develop the reporting protocol.

Many health care personnel resist such reporting because they fear a lawsuit or retaliation. The Massachusetts Safe Driving Law of 2010 has changed the landscape by expanding the ability of health care providers and law enforcement to report drivers whom the health care providers believe are unfit to drive because of cognitive or functional impairment. The reports are sent to the Registry of Motor Vehicles (RMV), not the police.

“This has never been meant to be punitive,” noted Dr. Mahoney of the department of trauma and emergency services at Boston Medical Center.

The intent has always been to get impaired drivers to visit their physicians to adjust their medication if needed, reevaluate their medical condition, or, if impairment results from substance abuse, counsel them. It’s been shown that the more contact patients have with health care, the more successful they will be at managing their health problems, he said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma (EAST).

The protocol may also reduce motor vehicle crashes by having recidivists held accountable for their actions.

“In our state, the acquittal rate is close to 90% for first-time DUI offenders, so we know the current system in place really isn’t working,” according to study coauthor Lisa Allee, Boston Medical Center’s injury prevention coordinator. “So our goal is to reduce recidivism and get people the help they need,” she said.

Dr. Mahoney and his colleagues used the Massachusetts RMV definition of impaired driving and vetted HIPPA compliance through the hospital’s legal department. A physician can request that the RMV medical advisory board seek medical evaluation of a driver when the physician has a good faith belief of impairment based on personal observation, physical examinations, or laboratory studies. The request cannot be based on driver age or previous diagnosis.

When the accident involves substance abuse, reporting is limited to instances of a “violent/high risk” to the public such as driving in the wrong direction of traffic, speed exceeding 55 mph, having a child or loaded firearm in the car, or fleeing from police

In the 16-month study period, 363 motor vehicle-crash drivers were admitted to the ED, of which 114 (31%) were impaired and 90% met the “dangerousness” requirement, Dr. Mahoney reported. Their average age was 42 years, 60% were white, 23% were black, 8% were Hispanic, and 41% had private commercial insurance.

Of those reported as being impaired, 18% were incapacitated by a medical condition, 78% were impaired because of substance use, and 3% were incapacitated by both.

Syncope and seizure were the most common medical conditions causing impairment (50% and 25%), followed by about 5% each of narcolepsy, brain lesion, respiratory failure, dizziness, dementia, normal pressure hydrocephalus, and cerebrovascular accident.

Alcohol was the most common substance causing impairment, present in more than 80% of cases, followed by a benzodiazepine, cocaine, and other prescriptions, he said.

“Impairment is common in drivers admitted to the trauma center, and 90% are violent, dangerous to the public,” Dr. Mahoney said. “We need to encourage and empower others to report.”

The topic of impaired drivers was on the radar of other EAST investigators. Dr. Felicia Ivascu of the Beaumont Health System in Royal Oak, Mich., reported that 11% of the 541 crash victims treated from 2008 to 2010 at their level I trauma center were legally intoxicated. Moreover, data available on 52 of these drivers revealed these patients cost the hospital $5.2 million in total charges, which accounts for 12% of all charges for drivers.

Michigan is one of 12 states to have no-fault automobile insurance, and the only one that provides unlimited medical benefits. Because of the high costs, House Bill 5588 was recently introduced to remove no-fault benefits if a person is found driving while intoxicated or impaired at the time of the accident, regardless of responsibility.

The dilemma, however, is that passage of the bill would reduce net revenue, and “this will lead to a large financial burden for hospitals that treat intoxicated drivers, requiring them to either absorb this cost or pass it on to Medicaid,” the authors wrote.

Dr. Mahoney, Dr. Ivascu, and their coauthors reported no relevant financial disclosures.

BY PATRICE WENDLING
IMNG Medical News
http://www.imng.com

Courtesy of: http://www.acep.org/Content.aspx?id=90214

 

Brain Injury: My Road To Recovery – ‘Time Is Of The Essence’

By Mary Blake, WBZ NewsRadio 1030

Mary Blake with John Pliakas, critical care transport nurse at Boston MedFlight.BOSTON (CBS) – If you were to ask 10 people on the street what TBI is, you’d be hard pressed to find even one person who knows the answer.

TBI stands for traumatic brain injury.

I’ve been recovering from one for the past six months.

Last July, I tumbled from my very old, somewhat rusty, yet trusty bicycle. It was the first day of my two-week summer vacation on Nantucket.

I remember nothing of that day, or the 8 days in the hospital that followed. However, one of the first responders to the scene, Nantucket police officer Keith Mansfield, later filled me in on some of it.

“You were on the ground, very injured and definitely not with it, and pretty much what we’re trained is, if it’s an issue like that, time is of the essence,” Mansfield said.

Dr. Tim Lepore, general surgeon at Nantucket Cottage Hospital, deals with the so-called ‘golden hour of trauma’ too. He recalled the first time he saw me.

“When I first met you, you were not particularly talkative,” Lepore joked.

“I had heard there was a very bad bike accident, and since my office is about 50 feet from the emergency room, and my home is about 75 yards from the emergency room, I’m always here. When you came in, the EMT’s had done a tremendous job in protecting your neck and immobilizing you, but once we saw the CAT scans and saw the number of problems that you had, we felt it was very necessary to get you to a higher level of care.”

Boston MedFlight was instrumental in getting me to that higher level of care.

Now in its 27th year, Boston Medflight is not-for-profit, and works with all of the major medical adacemic centers in Boston.

“I fondly, often say that we’re the only successful co-operative venture between them,” said Suzanne Wedel, Chief Executive Officer-Medical Director of Boston MedFlight.

“Our mission is to take the sickest patients and link them with the resources they need.” She added, “I often say one thing all of our patients have in common is that when they woke up in the morning they never knew they were going to need our services.”

She is so right about that.

Boston Medflight took me by helicopter to Boston Medical Center in record time.

Dr. Lepore notes, “When it works right, it’s sweet.” He says on proverbial dark and stormy nights, he’s had to take out the seats of a Cessna 402 for patient transport, or wait for Coast Guard assistance.

Fortunately, I had favorable conditions and a ‘flying ICU’ with John Pliakas on board.

I met him last October and it was an emotional greeting for me. I asked him if he was the one responsible for keeping me stable. “More or less,” Pliakas joked. ” I was the one keeping you out of trouble.”

Pliakas, my critical care transport nurse, escorted me on an extensive tour of Boston MedFlight’s Bedford operation that October day.

The Bedford facility is one of their three bases. CEO Suzanne Wedel explained Boston MedFlight provides not only helicopter service to patients who require transport, but they have jet and ground capabilities too.

“You hold the life versus death, sort of in the palm of your hand, and the choices that we make is the difference between life and death and good outcome and bad outcome, so attention to detail, attention to safety and attention to doing everything right to give you the best chance is what we bring to the table,” she said.

I confess tears welled in my eyes upon hearing that.

Another emotional meeting took place earlier in my recovery, when I met Dr. Eric Mahoney, trauma acute care surgeon at Boston Medical Center.

I don’t know how, but I recognized him, even though I have no memory at all of my hospital stay.

“During your evaluation, what you may not know is we actually had some signs and symptoms that there actually may be pressure developing inside your skull that was causing pressure on your brain that could be emergently life-threatening,” Dr. Mahoney explained.

“So we did give you medication to help prevent some of the swelling of your brain, that if left unchecked, could actually go on and be immediately life-threatening. “

Simply put, Dr. Mahoney and the BMC team saved my life, something Dr. Mahoney wouldn’t hear of.

“Thank you, but you did all the hard work,” he said.

While I survived the critical early phase of traumatic brain injury, I slowly became aware of the other stages that follow.

Dr. Jim Hosapple is chief of Neurosurgery at Boston Medical Center.

” Now you’re grappling with the fact that your integrated circuits, so to speak, have been damaged,” he said. “We don’t have tools at the moment to either replace those components or encourage them to function again normally. We are very much in the dark on this.”

However, there are rehabilitative and support services available.

Details of my rehab therapy, how a bike helmet might have made a tremendous difference and fellow TBI patients’ recovery stories are coming up all this week.

Courtesy of: http://boston.cbslocal.com/2013/02/18/brain-injury-my-road-to-recovery-time-i…

Click the above link to listen to Mary’s story: My Road to Recovery

A Hospital Offers a Grisly Lesson on Gun Violence

At Temple University Hospital, Scott Charles, trauma outreach coordinator, left, and Dr. Amy Goldberg, chief of trauma and surgical care, held students’ attention.

PHILADELPHIA — In a darkened classroom, 15 eighth graders gasped as a photograph appeared on the screen in front of them. It showed a dead man whose jaw had been destroyed by a shotgun blast, leaving the lower half of his face a shapeless, bloody mess.

Students listed people who would miss them if they were killed.
Next came a picture of the bullet-perforated legs of someone who had been shot with an AK-47 assault rifle, and then one of the bloated abdomen of a gunshot victim with internal injuries so grievous that the patient had to be fitted with a colostomy bag to replace intestines that can no longer function normally.

These are among about 500 gunshot victims who are treated each year at Temple University Hospital, an institution in the heart of impoverished, crime-ridden North Philadelphia. While President Obama and Congressional leaders debate legislation intended to prevent mass killings like the elementary school shooting in Newtown, Conn., the hospital is trying to slow the rate of street killings by helping teenagers understand the realities of gun violence.
The hospital program includes listening to tapes of victims’ families.

The unusual program, called Cradle to Grave, brings in youths from across Philadelphia in the hope that an unflinching look at the effects that guns have in their community will deter young people from reaching for a gun to settle personal scores, and will help them recognize that gun violence is not the glamorous business sometimes depicted in television shows and rap music.

The program is open to all schools in the city, but about two-thirds of the participants were referred by officials from the juvenile justice system. Children younger than 13 are not normally admitted. So far, about 7,000 teenagers have participated since it began in 2006, and despite the graphic content, no parent has ever complained, said Scott P. Charles, the hospital’s trauma outreach coordinator.
A demonstration of gunshot wounds.

“In seven and a half years, I have never had a parent say, ‘I can’t believe what you just showed my child,’ ” Mr. Charles said.

On a recent day the eighth graders, students from nearby Kenderton School, gathered around Mr. Charles at the start of a two-hour visit. Most said they knew someone who had been shot.

“Our goal here isn’t to scare you straight,” Mr. Charles told them. “We’re just trying to give you an education.”
The program also teaches morgue terminology.

According to police statistics, 331 people were killed in the city in 2012, equaling the highest total since 2008, and the fourth consecutive year of increase. Eighty-six percent of them were killed by firearms, the police say.

Still, the number of killings in the city of about 1.5 million residents has dropped from a high of 406 in 2006, when national news media started calling the city Killadelphia.

In a 2010 paper published in the medical journal Injury, Dr. Amy J. Goldberg, the hospital’s chief of trauma and surgical critical care, and others cited data showing that students’ inclination toward violence decreased after participating in the Cradle to Grave program, especially among those classified as having an “aggressive response to shame.”

“These results suggest that hospitals offer a unique opportunity to address the public health crisis posed by inner-city firearm violence,” the study said.
Students listed people who would miss them if they were killed.

The program starts with a visit to the hospital’s trauma bay, the first stop for gunshot victims — half of them under 25 — who are brought to the hospital from North Philadelphia’s streets at an average rate of more than one a day.

As the 13- and 14-year-olds gathered around a gurney on a recent visit, Mr. Charles told the story of Lamont Adams, 16, who died at the hospital after being shot 14 times by another boy who believed Lamont had snitched about a street dice game that was broken up by police officers.

Lamont arrived in the trauma bay with 24 gunshot wounds, 10 more than the 14 rounds that had been emptied into him, because some of the shots had also exited his body, in some cases leaving indentations in the sidewalk, Mr. Charles told the students.

In case his verbal description was not sufficiently vivid, Mr. Charles asked Justin Robinson, 13, to play the part of Lamont. The boy lay down on an empty body bag. Mr. Charles attached 24 circular red stickers to Justin’s clothing to represent the wounds in Lamont’s body.

Mr. Charles told the students that the wounds he finds most moving were those in the boy’s hands. “He holds up his hands and begs the boy to stop shooting,” Mr. Charles said. “He had not prepared himself for how terrible this would be.”

The narrative was then taken up by Dr. Goldberg, who told the children that by the time Lamont arrived in the trauma bay, he was not breathing, so surgeons — without the use of anesthetics — quickly inserted a breathing tube into his windpipe.

Neither did he have a pulse but that did not stop the doctors from inserting a tube into his groin to replace the blood he was losing, and then to open his chest in the hope of restarting his heart — which turned out to have three or four holes in it, Dr. Goldberg said. She held up a stainless steel rib-spreader.

As the details of Lamont’s story unfolded, one girl struggled to keep her composure. Another hid her face in her friend’s shoulder. Lamont died about 15 minutes after arriving at the hospital, underscoring that prevention of gun violence is a lot better than trying to cure its effects, Dr. Goldberg concluded.

“Who do you think has the best chance of saving your life?” she asked the students. “You do.”

Despite the grisly images, most of the students said afterward that people should still be allowed to own guns for self-defense, although not assault weapons. Mahogany Johnson, 14, said she is in favor of a street ban on semiautomatic weapons like AK-47 assault rifles, which she said should be used “only in the woods.” Jabriel Steward, 14, said, “Everybody should be allowed to have one gun for protection, for self-defense.”

But Feliciana Asada, 14, said more students should be given the opportunity to participate in Cradle to Grave. “Programs like this need to be installed in schools,” she said.

*Courtesy of the New York Times

Parenting Starts Here: Booster Seats Save Lives

“It seems like we just transitioned my daughter into a booster seat from her forward-facing car seat; but it’s been two years. She’s now six years old, in kindergarten, and rides the bus to school. About once a week she asks me if I’m sure she still needs to sit in her booster seat. The question usually arises on the days I pick her up at school or if she is having a friend over. She told me one day, as I was buckling her in, “Mom, some parents don’t worry as much as you do about being safe. Do you know that?” I asked her what she meant and she gave me a list of names of kids in her class who apparently do not use booster seats. I’ve seen these kids – they’re not taller than my daughter – and they should be in a booster.

Did you know that current MA law states: “A passenger in a motor vehicle on any way who is under the age of 8 shall be fastened and secured by a child passenger restraint, unless such passenger measures more than 57 inches in height. The child passenger restraint shall be properly fastened and secured according to the manufacturer’s instructions.”

What this means is that once your child has outgrown their forward-facing convertible (usually around age 4 or 5, but do utilize that car seat as long as you can – until your child reaches the height and weight limit) when they are 4’9’’, they should be in a booster seat. Yes, 4’9”! Most kids reach this height somewhere between the ages of 8 and 12 years old. Another way to remember this is with this simple rule: if when they are sitting in the car, their feet can’t touch the floor, they are much safer in a booster seat.

The height requirement is to ensure that the vehicle’s lap-and-shoulder seat belts fit properly so that in the event of an accident, your child will be restrained. If the seat belt doesn’t fit tight enough, a child can be thrown from the seat (or even worse, from the car) during a collision. This is important information, because sadly motor vehicle injuries are a leading cause of death among 4-8 year-olds and we know that booster seat use lowers the risk of injury to children in crashes by about half. We also know, unfortunately, that about half the children who should be in booster seats aren’t (according to a 2009 National Survey of the Use of Booster Seats).

Last month I attended a meeting for the Massachusetts Prevents Injuries Now Network (MassPinn), at which Dr. Lois Lee from Boston Children’s Hospital shared her findings from a recent study. She and her fellow researchers examined the different booster seat laws in the 50 states and in D.C. from 1999-2009. They found that in States where booster seat laws were implemented, there was a drop in serious injuries from motor vehicle crashes among children ages 4 to 8. There are three states without booster seat laws (Florida, Arizona and South Dakota) and those states unfortunately did not see a change. In the other 47 states and in DC, although less children were injured through motor vehicle accidents, there is a discrepancy based on age and this is because in some states booster seats are required only until age 5. What Dr. Lee et al, found is that only 35% of 6-7 year olds are using booster seats. I am proud to say that my daughter is part of that 35%!

But what about the other 65%? Do you know someone who doesn’t use a booster seat for his child and should? Unfortunately, I do. We have a relative who not only doesn’t have her 7- year old ride in a booster seat, but she also lets her ride in the front seat. It makes me cringe every time I see it happening. This relative has told me that she thinks booster seats are a waste of money. My daughter had a play-date with a friend a few weeks ago and I picked both of them up at school. When I was making the arrangements with her mother, I told her I have an extra booster seat that her daughter could use in my car. The mother’s response was, “Oh, don’t worry about that! She doesn’t sit in a booster seat anymore.” (She DID when she was in my car!) A study published in 2012 looked at carpooling and it shows that booster-seat usage in this situation is inconsistent and needs improvement.

I’ve heard from some parents they didn’t want to buy yet another seat, so after their child outgrew the car seat they decided it was okay to use just the seat belt. I’ve learned from local Child Passenger Safety Technicians that even when boosters are used, they’re often used incorrectly. So there is a lot of work for those of us in the world of Safety to do around booster seat education.

It’s likely that for many of you reading this, your little one is still in his infant-seat. It can feel as if the topic of booster seats is one you don’t need to consider quite yet. But if you’re thinking about buying the next car seat, a convertible, I recommend getting one that can eventually convert into a booster seat as well. There are many great options; but my personal favorite is the line of Diono Radians, which depending on the model, supports up to 100-120 lbs, making it the only seat you’ll need to buy to safely keep your child restrained from infancy until he reaches that height requirement of 4’9”.

Booster seats save lives. So when my daughter asks me if I am sure she still needs to sit in a booster seat, I don’t hesitate with my response: yes, I am sure!”

Teresa Stewart, MS, MPH
Program Manager: Safety and Wellness

About Teresa Stewart MS MPH

 

Teresa Stewart is the Safety & Wellness Program Manager at Isis Parenting and has been a proud member of the Isis team for the past five years. She holds a MS in Child Development from Wheelock College and an MPH in Maternal and Child Health from Boston University School of Public Health. She is certified by the American Heart Association as a CPR and First Aid instructor. Teresa is a member of the Safe Kids Boston Coalition and MassPinn (Massachusetts Prevents Injuries Now Network). She combines those areas of expertise to help parents understand why our children do the mysterious things they do and how to keep them healthy and safe.
Teresa also supports parents around sleep through her work as an Isis Sleep Consultant. Teresa is the mother of a daughter and toddler son and understands the joys and challenges of parenting.

*Courtesy of http://www.parentingstartshere.com/index.php/2013/01/24/booster-seats-save-li…