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February 2009 News Archives
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February 2: New Oral Cancer Tests: Crucial or Wasteful?, The New York Times
By LAURIE TARKAN
Though relatively rare, it is one of the easiest cancers to spot and diagnose. And if treated early, it is usually curable. So why do experts find oral cancer so vexing?
Despite the many advances against cancer in recent decades, the statistics on this form of it remain discouraging: more than 60 percent of cases are diagnosed in the late stages, and the five-year survival rate is a disappointing 59 percent. Moreover, oral cancer is increasing in people traditionally at low risk, a phenomenon partly attributed to the rise of the cancer-causing human papillomavirus, or HPV, which can be transmitted through oral sex.
Now some dentists — whose visual examinations have long been a first line of defense against oral cancer — are using screening devices that they say may help identify cancers and premalignant lesions.
But these new tests have set off a debate over cost and effectiveness. Experts are divided on whether they will reduce mortality from oral cancer or simply lead to a wave of expensive and unnecessary biopsies.
An estimated 35,300 Americans learned they had oral cancer last year, and about 7,600 died from the disease. For survivors, oral cancer can be painful and disfiguring, and can destroy the ability to taste and enjoy food. Smokers and heavy drinkers are considered at highest risk for the disease, but 25 percent of those who receive a diagnosis are neither. Still, the lifetime risk of oral cancer — about 1 in 99 — is very low compared with breast and prostate cancer.
Because the disease is often diagnosed late, many experts believe that screening can reduce mortality. This has not been proved, partly because there is a dearth of research on oral cancer.
Indeed, no one knows for sure whether even a visual examination in the dentist’s office saves lives, though most oral cancer experts believe it does. That hypothesis is based on the proven benefits of early detection of other cancers and the better survival rates in cases that are detected early — about 80 percent five years after diagnosis.
“We know in every cancer where we’ve seen a reduction in the death rate — cervical, skin, breast — that what has brought the death rate down is early detection,” said Brian Hill, an oral cancer survivor from Laguna Niguel, Calif., and a founder of the Oral Cancer Foundation, a nonprofit group.
One large study from India, where oral cancer rates are much higher than in the United States, found that when high-risk subjects had a visual exam, it reduced the mortality rate by 34 percent compared with control subjects who were not screened. But some experts say this research cannot be applied to the general population or to Americans.
The American Cancer Society and the American Dental Association recommend a regular visual exam. But even though it is generally covered by insurance, not all dentists perform it.
“Studies show that most dentists don’t leave dental school feeling comfortable doing it,” said Dr. Michael A. Siegel, a professor and the chairman of diagnostic sciences at Nova Southeastern University College of Dental Medicine in Fort Lauderdale, Fla.
Now medical companies are marketing several new screening tests and devices to dentists, saying they will vastly improve early detection of oral cancer. The devices, which can cost several thousand dollars, use rinses, dyes and different types of lights to detect abnormal cells.
Some experts say the new technology will lead to earlier detection, if only by encouraging dentists to do a screening exam. “The tests change the paradigm by which they practice,” Dr. Siegel said. “Simply because it’s new, they say, ‘I’m going to use it.’ ”
They can also charge for the test, and some insurers have started covering it.
“We’re advocates of using these devices because there are some things your eye might miss,” Mr. Hill said.
Yet no extensive studies of the general population show that these devices are any better than the naked eye for screening, and they have not been shown to reduce mortality.
“There’s no evidence for their use by front-line screeners, no evidence,” said Dr. A. Ross Kerr, an assistant professor at the New York University College of Dentistry.
In small studies, the devices successfully detected potentially malignant lesions that experienced specialists missed with the naked eye. For example, in one group of subjects a scanning system called the VELscope identified all of the cases of moderate to severe dysplasia, or potentially precancerous cells, compared with just 68 percent for a visual exam, said the study’s author, Dr. Edmond Truelove, a professor and the chairman of oral medicine at the University of Washington. (Dr. Truelove does not receive financing from LED Dental, the company in British Columbia that makes the VELscope.)
Another study of 688 high-risk patients examined by experienced specialists found that when only a visual exam was performed, the specialist requested a biopsy of 12 of the 30 lesions that turned out to be cancerous. Of those who also used toluidine blue, a dye that is a component of a test called ViziLite Plus, 29 of the 30 lesions would have been biopsied, said the study’s author, Dr. Joel Epstein, a professor of oral medicine at the University of Illinois, Chicago.
But he added, “What we don’t know is what happens if we use the same technique in a low-risk population by people with less experience.” (Dr. Epstein said that in the past he had received compensation from Zila Pharmaceuticals, which makes ViziLite, and is currently receiving financing from the company for a small study.)
The screening tests can cost the patient $35 to $65, though some dentists do not charge extra for it. And the tests have a high false-positive rate that may lead to unnecessary biopsies. If a suspicious lesion is detected, dentists typically ask the patient to return in two weeks to see if it has improved. If not, the patient may be given a biopsy or referred to a specialist.
Some dentists are telling their patients that because of the rise of oral cancers linked to HPV, every adult, not just the traditionally high-risk groups, should be screened with these devices.
Yet oral cancers associated with the papillomavirus are still rare, and they typically occur near the base of the tonsils and the back of the tongue, where they are very difficult to see at the earliest stages, even with the use of these devices, said Dr. Maura L. Gillison, a professor of medicine at Ohio State who is a leading expert on oral HPV.
Dr. Mark Lingen, an associate professor of pathology at the University of Chicago Medical Center, agreed. “If you can’t get back there to see it,” he asked, “how is that device going to help you?”
But Dr. Epstein says the devices may help. “If you’re someone with a high risk of HPV exposure, meaning that you’ve had oral sex with multiple partners, you need to be examined carefully,” he said. “Higher-risk people could maybe benefit from some of these adjuncts.”
Dr. Truelove, who did the VELscope study, said he would not recommend expensive screening for normal individuals, but he added, “On the other hand, a low-cost test, say $5, that enhances a clinician’s ability to detect something they might otherwise miss is potentially useful, particularly in people who have some increased risk of the disorder.”
Researchers are working on the holy grail of oral cancer screening: a test that can analyze saliva for early gene changes that could lead to the disease.
Most experts agree that everyone should have an annual visual exam and that it should be thorough. A dentist or trained hygienist should examine the cheeks, the gums, the floor of the mouth, the area behind the teeth, the palate and the tonsil area, pulling the tongue forward — often to the point of gagging. The dentist should also feel the lymph nodes of the neck, sometimes the first visible sign of oral cancer.
“The emphasis should also be placed on educating physicians about oral cancer,” said Dr. Kerr, of N.Y.U. Only 60 percent of adults see a dentist at least once a year, he continued, adding, “The 40 percent who never go to the dentist are likely to have the highest risk factors.
“When I teach my students,” he said, “I say at the end of the day, all you need is to have one patient with an early cancer that you picked up and you will do this for the rest of your career.”
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February 2: Best Treatment for TMJ May Be Nothing, The New York Times
By JANE E. BRODY
One person gets migraine headaches, another ringing in the ears, a third clicking and locking of the jaw, a fourth pain on the sides and back of the head and neck. All are suspected of having a temporomandibular disorder.
Up to three-fourths of Americans have one or more signs of a temporomandibular problem, most of which come and go and finally disappear on their own. Specialists from Boston estimate that only 5 percent to 10 percent of people with symptoms need treatment.
Popularly called TMJ, for the joint where the upper and lower jaws meet, temporomandibular disorders actually represent a wider class of head pain problems that can involve this pesky joint, the muscles involved in chewing, and related head and neck muscles and bones.
But too often, experts say, patients fail to have the problem examined in a comprehensive way and undergo costly and sometimes irreversible therapies that may do little or nothing to relieve their symptoms. As scientists at the National Institute of Dental and Craniofacial Research wrote recently, “Less is often best in treating TMJ disorders.”
A New Understanding
The TMJ is a complicated joint that connects the lower jaw to the temporal bone at the side of the head. It has both a hinge and a sliding motion. When the mouth is opening, the rounded ends, or condyles, of the lower jaw glide along the sockets of the temporal bones. Muscles are connected to both the jaw and the temporal bones, and a soft disc between them absorbs shocks to the jaw from chewing and other jaw movements.
TMJ problems were originally thought to stem from dental malocclusion — upper and lower teeth misalignment — and improper jaw position. That prompted a focus on replacing missing teeth and fitting patients with braces to realign their teeth and change how the jaws come together.
But later studies revealed that malocclusion itself was an infrequent cause of facial pain and other temporomandibular symptoms. Rather, as the Boston specialists wrote recently in The New England Journal of Medicine “the cause is now considered multifactorial, with biologic, behavioral, environmental, social, emotional and cognitive factors, alone or in combination, contributing to the development of signs and symptoms of temporomandibular disorders.”
According to the American Academy of Orofacial Pain, the disorder “usually involves more than one symptom and rarely has a single cause.”
Among the “mechanical” causes that are now recognized as distorting the function of the TMJ are congenital or developmental abnormalities of the jaw; displacement of the disc between the jaw bones; inflammation or arthritis that causes the joint to degenerate; traumatic injury to the joint (sometimes just from opening the mouth too wide); tumors; infection; and excessive laxity or tightness of the joint.
But the most common TMJ problem is known as myofacial pain disorder, a neuromuscular problem of the chewing muscles characterized by a dull, aching pain in and around the ear that may radiate to the side or back of the head or down the neck. Someone with this disorder may have tender jaw muscles, hear clicking or popping noises in the jaw, or have difficulty opening or closing the mouth. Simple acts like chewing, talking excessively or yawning can make the symptoms worse.
Jaw-irritating habits, like clenching the teeth or jaw, tooth grinding at night, biting the lips or fingernails, chewing gum or chewing on a pencil, can make the problem worse or longer lasting. Psychological factors also often play a role, especially depression, anxiety or stress.
Proper Assessment
The overwhelming majority of people with TMJ symptoms are women. Women represent up to 90 percent of patients who seek treatment, Dr. Leonard B. Kaban, chief of oral and maxillofacial surgery at the Massachusetts General Hospital in Boston, said in an interview. Most patients are middle-age adults, he and two dental specialists, Dr. Steven J. Scrivani and Dr. David A. Keith, wrote in the journal article.
Dr. Kaban urged patients to obtain a thorough assessment of the problem before choosing therapy, especially if they have symptoms like tinnitus (ringing in the ears) and migraine headaches.
He said doctors and dentists should “start with a thorough history — you can get 80 to 90 percent of the needed information just from talking to the patient about their habits.” This should be followed by a physical examination, checking for signs like muscle tenderness and pain in the jaw, limited jaw opening and noises.
“Among the biggest advances in diagnosis has been imaging studies, especially by M.R.I. and occasionally by CT scan with a cone-beam image,” Dr. Kaban said.
For those with complicated problems, he suggested visiting a multidisciplinary temporomandibular clinic, found at many leading hospitals and dental schools.
Therapy Options
Resting the jaw is the most important therapy. Stop harmful chewing and biting habits, avoid opening your mouth wide while yawning or laughing (holding a fist under the chin helps), and temporarily eat only soft foods like yogurt, soup, fish, cottage cheese and well-cooked, mashed or pureed vegetables and fruit. It also helps to apply heat to the side of the face and to take a nonsteroidal anti-inflammatory medication, for up to two weeks.
Other self-care measures suggested by the orofacial academy include not leaning on or sleeping on the jaw and not playing wind, brass or string instruments that stress, strain or thrust back the jaw.
Physical therapy to retrain positioning of the spine, head, jaw and tongue can be helpful, as can heat treatments with ultrasound and short-wave diathermy.
Some patients are helped by a low-dose tricyclic antidepressant taken at bedtime, or antianxiety medication. Stress management and relaxation techniques like massage, yoga, biofeedback, cognitive therapy and counseling to achieve a less frenetic work pace are also helpful, according to the findings of a national conference on pain management.
If you clench or grind your teeth, you can be fitted with a mouth guard that is inserted like a retainer or removable denture, especially at night, to prevent this joint-damaging behavior.
But Dr. Kaban cautioned against embarking on “any expensive, irreversible treatment” before a thorough diagnosis is completed and simple, reversible therapies have been tried and found wanting.
As with other joints, he said, surgery is a treatment of last resort, when medical management has proved ineffective. As he and his colleagues wrote, surgery is primarily for patients who are born with or develop jaw malformations and patients with arthritis who have loose fragments of bone or require condyle reshaping.
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February 6: Obstructive Sleep Apnea - Losing Weight Helps Obese Patients, Scientific Blogging
Losing weight is good for all overweight people but for sufferers of obstructive sleep apnea (OSA), a new study shows that losing weight is perhaps the single most effective way to reduce OSA symptoms and associated disorders. The study is in the American Journal of Respiratory and Critical Care Medicine.
Weight loss may not be a new miracle pill or a fancy high-tech treatment, but it is an exciting therapy for sufferers of OSA both because of its short- and long-term effectiveness and for its relatively modest price tag. Surgery doesn't last, continuous positive airway pressure (CPAP) machines are only as effective as the patient's adherence, and most other devices have had disappointing outcomes, in addition to being expensive, unwieldy and having poor patient compliance. Furthermore, OSA is generally only treated when it has progressed to a moderate to severe state.
"Very low calorie diet (VLCD) combined with active lifestyle counseling resulting in marked weight reduction is a feasible and effective treatment for the majority of patients with mild OSA, and the achieved beneficial outcomes are maintained at 1-year follow-up," wrote Henri P.I. Tuomilehto, M.D., Ph.D., of the department of Otorhinolaryngology at the Kuopio University Hospital in Finland.
The prospective, randomized trial found that, in 81 patients with mild OSA, the 40 patients who were in the intervention arm underwent a diet that strictly limited caloric intake combined with lifestyle counseling lost more than 20 pounds on average in a year—and kept it off, resulting in markedly lower symptoms of OSA. The 41 patients in the control arm, who only received lifestyle counseling and lost on average less than 6 pounds, and were much less likely to see improvements in their OSA.
And not only does sustained weight loss improve OSA, it also improves the many other independently linked co-morbidities such as hypertension, high cholesterol, and diabetes.
"This is emphasized by our findings that, in conjunction with the improvement in AHI, significant improvements were also found in symptoms related to OSA, insulin resistance, lipids, and cardiorespiratory variables, such as arterial oxygen saturation, in patients belonging to the intervention group," wrote Dr. Tuomilehto.
Furthermore, Dr. Tuomilehto observed, "The greater the change in body weight or waist circumference, the greater was the improvement in OSA." In fact, mild OSA was objectively cured in 88 percent of the patients who lost more than 33 pounds, a statistic that declined with the amount of weight lost. Only in 62 percent of those who lost between 11 and 33 pounds were objectively cured of their OSA, as were 38 percent of those who lost between zero and 11 pounds, and only 11 percent of those who had not lost weight or who had gained weight.
"Witnessed apneas," i.e., those loud or disturbing enough to have wakened the bedfellows of study participants, "totally vanished" in 26 percent of those patients, but in only three percent of the control group.
"This appears to be a fairly straightforward relationship, and while we would not necessarily recommend the severe caloric restriction used in our study to every patient, one of the first treatment for OSA that should be considered in the overweight patient is clearly weight loss," said Dr. Tuomilehto.
"A more aggressive treatment of obesity in patients with OSA is well-founded. Lifestyle intervention with an early VLCD is a feasible, low-cost, and curative treatment for the vast majority of patients with mild OSA and it can be implemented in a primary care setting after diagnosis of OSA. Weight reduction also results in an improvement of obesity-related risk factors for cardiovascular diseases."
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February 16: Many children with hearing loss also have eye disorders, USA Today
About one-fifth of children with hearing loss also have eye disorders, according to new research.
In the study, which appears in this month's Archives of Otolaryngology–Head & Neck Surgery, the authors report that children with hearing impairment are already dependent on other means of information acquisition, and if they are having unrecognized vision problems, further detrimental effects on their development may be occurring.
“Especially early in life, sensorineural hearing loss is associated with delays in language, speech, cognitive and social development,” write the authors, scientists from Children's Hospital of Pittsburgh.
An estimated one to three out of every 1,000 children have some hearing loss as a result of damage to the nerves of the inner ear -- half the cases are related to environmental issues and half are genetically-linked.
The researchers reviewed ophthalmologic findings in 226 patients with sensorineural hearing loss who were seen at a children’s hospital between 2000 and 2007. Of these, 49 (21.7%) had an eye abnormality, including 23 (10.2%) with refractive errors, such as nearsightedness, farsightedness and astigmatism. Twenty-nine (12.8%) had non-refractive errors.
The authors conclude that it is important to evaluate children with hearing loss for eye problems as well, to ensure that their medical, educational, and social needs are addressed.
--By Mary Brophy Marcus, USA TODAY
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February 20: Anatomy May Help Identify Sleep Apnea, HealthDay News
People with the condition appear to have longer soft palates, research shows
(HealthDay News) -- People with the breathing disturbance known as obstructive sleep apnea
have soft palates that are more elongated and angled than those of people without the condition, researchers report.
The soft palate is the tissue at the back of the roof of the mouth.
A team at the Seoul National University College of Medicine, in South Korea, used sleep videofluoroscopy -- which combines X-ray images with video recording -- to evaluate 53 patients with obstructive sleep apnea and 10 patients who were diagnosed as "simple snorers."
Among those with obstructive sleep apnea, the length and angle of the soft palate increased while they were awake and when they experienced "desaturation sleep events" -- a drop in blood oxygen levels of 4 percent or more caused by interrupted breathing. These soft palate changes did not occur in the simple snorers.
"Sleep videofluoroscopy quantitatively showed that the soft palate was considerably elongated and angulated in patients with obstructive sleep apnea even in an awake state," wrote Dr. Chul Hee Lee and colleagues in a news release. "It is an easy way to measure the soft palate changes and may be a useful technique to differentiate obstructive sleep apnea from simple snoring with short examination time."
The researchers noted that "identification of the obstruction site of upper airway in patients with obstructive sleep apnea is essential in choosing the appropriate treatment, especially surgical intervention."
The study appears in the February issue of the journal Archives of Otolaryngology -- Head & Neck Surgery.
More information - The U.S. National Heart, Lung, and Blood Institute has more about sleep apnea.
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February 22: Antibodies Offer a New Path for Fighting Flu, The New York Times
By DONALD G. McNEIL Jr.
In a discovery that could radically change how the world fights influenza, researchers have engineered antibodies that protect against many strains of the virus, including even the 1918 Spanish flu and the H5N1 bird flu.
The discovery, experts said, could lead to the development of a flu vaccine that would not have to be changed yearly. And the antibodies already developed can be injected as a treatment, going after the virus in ways that drugs like Tamiflu do not.
Clinical trials to prove that the antibodies are safe in humans could begin within three years, a researcher estimated.
“This is a really good study,” said Dr. Anthony S. Fauci, the director of the National Institute of Allergy and Infectious Diseases, who was not part of the study. “It’s not yet at the point of practicality, but the concept is really quite interesting.”
The work is so promising that Dr. Fauci’s institute will offer the researchers grants and access to its ferrets, which can catch human flu.
The study, done by researchers from Harvard Medical School, the Centers for Disease Control and Prevention and the Burnham Institute for Medical Research, was published Sunday in the journal Nature Structural & Molecular Biology.
In an accompanying editorial, Dr. Peter Palese, a leading flu researcher from Mount Sinai Medical School, said the researchers had apparently found “a viral Achilles’ heel.”
Dr. Anne Moscona, a flu specialist at Cornell University’s medical school, called it “a big advance in itself and one that shows what’s possible for other rapidly evolving pathogens.”
But Henry L. Niman, a biochemist who tracks flu mutations, was skeptical, arguing that human immune systems would have long ago eliminated flu were the virus as vulnerable in one spot as this discovery suggested. Also, he noted, protecting the mice in the study took huge doses of antibodies, which are expensive and cumbersome to infuse.
One team leader, Dr. Wayne A. Marasco of Harvard, said it began by screening a library of 27 billion antibodies he had created, looking for ones that take aim at the hemagglutinin “spikes” on the shells of flu viruses.
Antibodies are proteins normally produced by white blood cells that attach to invaders, either neutralizing them by clumping on or tagging them so that white cells can find and engulf them. They can be built in the laboratory and then “farmed” in plants, driving prices down, Dr. Marasco said.
The flu virus uses the lollipop-shaped hemagglutinin spike to invade nose and lung cells. There are 16 known types of spikes, H1 through H16.
The spike’s tip mutates constantly, which is why flu shots have to be reformulated each year. But the team found a way to expose the spike’s neck, which apparently does not mutate, and picked antibodies that clamped onto it. Once its neck is clamped, a spike can still penetrate a human cell, but it cannot unfold to inject the genetic instructions that take over the cell’s machinery to make more virus.
The team then turned the antibodies into full-length immunoglobulins and tested them in mice.
Immunoglobulin — antibodies derived from the blood of survivors of an infection — has a long history in medicine. As early as the 1890s, doctors injected blood from sheep that had survived diphtheria to save a girl dying of it. But there can be dangerous side effects, including severe immune reactions or accidental infection with other viruses.
The mice in the antibody experiments were injected before and after receiving doses of H5N1. In 80 percent of cases, they were protected. The team then showed that their new antibodies could protect against both H1 and H5 viruses. Most of the flu this season is H1, and experts still fear that the lethal H5N1 bird flu may start a human pandemic.
However, the other seasonal flu outbreaks each year are usually caused by H3 or B strains, so flu shots must also contain those. But there is always at least a partial mismatch because vaccine makers must pick from among strains circulating in February since it takes months to make supplies. By the time the flu returns in November, its “lollipop heads” have often mutated.
Therefore, other antibodies that clamp onto and disable H3 and B will have to be found before doctors even think of designing a once-a-lifetime flu shot. It is also unclear how long an antibody-producing vaccine will offer protection; new antibodies themselves fade out of the blood after about three weeks.
Dr. Marasco said that his team had already found a stable neck in the H3 and that they were “going after that one too.” They have not tried with B strains yet.
To make a vaccine work, researchers also need a way to teach the immune system to expose the spike’s neck for attack. It is hidden by the fat lollipop head, whose rapid mutations may act as a decoy, attracting the immune system.
As a treatment for people already infected with flu, Dr. Marasco said, the antibodies are “ready to go, no additional engineering needed.”
They will, of course, need the safety testing required by the Food and Drug Administration.
Antiflu drugs like Tamiflu, Relenza and rimantadine do not go after the hemagglutinin spike.
Tamiflu and Relenza inhibit neuraminidase (the “N” in flu names like H5N1), which has been described as a helicopter blade on the outside of the virus that chops up the receptors on the outside of the infected cell so the new virus being made inside can escape. Rimantidine is believed to attack a layer of the virus’s shell.
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February 24: New Report Paints Stark Picture Of Medical Costs, kwtx.com
A new government report on medical costs paints a stark picture for President Barack Obama, who's expected to call for a health care overhaul in his speech Tuesday night to Congress.
The Department of Health and Human Services says healthcare costs will top $8,000 per person this year, consuming an ever-bigger slice of a shrinking economic pie.
The report says as the recession cuts into tax receipts, Medicare's hospital trust fund could become insolvent as early as 2016.
At the same time, the government's already large share of the nation's health care bill will keep growing.
Programs such as Medicaid are expanding to take up some of the slack as more people lose job-based coverage, and baby boomers will soon start reaching 65 and signing up for Medicare.
Those trends together mean that taxpayers will be responsible for more than half of the nation's health care bill by 2016, just seven years from now.
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