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Genetic engineering & mosquito bites

As spring approaches, we can expect a new onslaught of pollen, bugs, and mud puddles. Mosquito eggs will hatch in stagnant water, and a new generation of hungry little disease vectors will be lurking in wooded areas, awaiting their first meal.

Luckily for those of us who live in North America, those annoying mosquito bites are unlikely to infect us with malaria.

A team of scientists committed to eradicating malaria (one of my personal favorite parasites) has taken a new approach to reducing transmission rates: creating a strain of malaria-immune mosquitoes.

I had been under the mistaken impression that mosquitoes lived in perfect harmony with malaria parasites, but apparently the organisms can make them quite ill as well. Not ill enough to die immediately (hence their ability to spread the disease) but ill enough to die prematurely.

So if we could create a malaria immune mosquito, we could give them a survival advantage over their peers, thus slowly influencing the mosquito population in favor of the new strain. This could result in a new population of mosquitoes who could not harbor malaria.

In humans, malaria parasites have learned how to attach themselves to red blood cell proteins and incubate inside the cells. In mosquitoes, the parasites latch on to a protein (called SM1) on the surface of epithelial cells of their gut lining. Through the miracle of genetic engineering, we’ve managed to alter the SM1 proteins in certain mosquitoes, making them immune to invasion by parasites they ingest through infected blood.

Although the immune mosquitoes are not ready for prime time release in malaria endemic countries (the research only showed that the scientists could genetically engineer resistance to one strain of malaria), it sure would be interesting to see if we could use mosquitoes themselves to fight a disease that claims the lives of over one million people per year.

This is a rare case of a problem becoming the solution!

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

What the heck is a "rehab doc?" Part 1

One medical specialty has managed to avoid (nearly completely) the public eye: Physical Medicine & Rehabilitation (or PM&R). Physicians who choose this specialty are referred to as “physiatrists” or “rehabilitation medicine specialists” or “rehab docs.” But the truth is that very few people understand what they do, and unfortunately the rehab docs haven’t made much of an effort to explain themselves to their peers or the world at large.

A dear friend and mentor once asked me, “why did you choose such an odd ball specialty?” This rather direct question forced me to ponder my career decision, and to determine how it came to pass that PM&R was given the unhappy reputation of “odd ball specialty.” I’ll begin with a little background about the specialty and then explain why I chose to devote my life to it.

The history of PM&R

PM&R really traces its roots back to the American Civil War (1861-1865). This gruesome battle resulted in over 620,000 casualties and over 60,000 limb amputations. The modern specialty of general surgery developed through life saving trial and error on the battlefield. Massachusetts General Hospital, for example, was performing an average of 39 surgeries/year before the civil war, and this increased to 2,427 in the late 1800’s.

But physicians and surgeons were not prepared for the aftermath of war – tens of thousands of maimed and partially limbless now trying to live out their careers in a disabled condition. One confederate soldier, James E. Hanger, lost a leg in the war, and subsequently created America’s first prosthetics company, still in operation today. Unfortunately for the disabled, though, there was no guarantee that appropriate accommodations would be made for them to be fully reintegrated into society.

With the rise of surgery came a major realization: patients did not do well after surgery if they remained in bed. Conventional medical wisdom suggested that bed rest and inactivity were the most effective way to recuperate, but now with thousands of post-operative patients in full view, it became painfully clear that the patients who did the best were the ones that got up and returned to regular physical activity as quickly as possible.

Following this realization, the University of Pennsylvania created (in the late 1800’s) an orthopedic gymnasium for “the development of muscular power with apparatus for both mechanical and hot air massage, gymnastics and Swedish movement.”

A young Canadian gymnast trained in Orthopedic Surgery, Dr. Robert Tait McKenzie, was recruited to U. Penn to develop a new field in medicine: “Physical Training.” Dr. McKenzie created a medical specialty called “Physical Therapy” and he was the first self-proclaimed “Physical Therapist.” He wrote a seminal book on the subject called “Reclaiming the Maimed” (1918) and continued to practice orthopedic surgery until his death in 1938.

Other major medical institutions followed U. Penn’s lead, creating “Medicomechanical Departments” at Mass General and the Mayo Clinic. Technicians were trained to assist in helping post-operative patients to become active and reclaim their range of motion – these technicians were known as “physiotherapists” and formed the first physiotherapy training program at the Mayo Clinic in 1918.

World War I (1914-1918) resulted in millions of additional amputations, thus flooding the health system with disabled veterans. In response, the army created two medical divisions: The division of orthopedic surgery and the division of physical reconstruction. By 1919, 45 hospitals had physiotherapy facilities, treating hundreds of thousands of war veterans.

And then there was polio. Suddenly a viral illness created a whole new wave of disabled individuals, further stimulating the need for orthotics (leg braces and such) and rehabilitative programs.

World War II (1940-1945) resulted in yet another influx of disabled veterans. All the while the medical community was developing innovative programs to maximize veterans’ functionality and integration into society and the work place through the burgeoning field of Physical Medicine & Rehabiltiation.

Key players in the development of the specialty:

Dr. Frank Krusen developed the first physical medicine training program at the Mayo Clinic in 1935 and the “Society of Physical Therapy Physicians” (now the American Academy of Physical Medicine & Rehabilitation) in 1938. He coined the term “physiatrist” to describe the physicians who specialized in physical modalities for rehabilitating patients.

Dr. Howard Rusk founded the Institute for Physical Medicine & Rehabilitation in 1950 at NYU.  Excellent research in the field ensued.

Dr. Henry Kessler founded the Kessler Institute for Rehabilitation, in New Jersey, 1949.  More medical research was developed.

Mary E. Switzer successfully lobbied for the enactment of Public Law 565 which mandated that government funds be channeled towards rehabilitation facilities and programs for the disabled.

What’s in a name?

So as you can see, there is some good reason to be confused about the modern specialty of PM&R. It has undergone several name changes, molded by historical circumstance. Today, physiotherapists (they still go by that name in Canada) or physical therapy technicians have become a well known and respected profession: Physical Therapy.

Physicians who specialize in Physical Medicine & Rehabilitation are called rehabilitation medicine specialists or “rehab docs” or “physiatrists.”

-See Next Post for the rest of the story –
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Can the Internet save primary care?

I’ve been thinking a lot lately about the plight of family physicians – reimbursal for their services continues to decline, overhead steadily increases, and pressure to see a minimum of 30 patients a day can drive them to near despair. Family physicians want to provide quality care for their patients, but are exhausted by volume demands and paperwork.

If you missed this article about the primary care crisis in America in the New England Journal of Medicine, it’s an excellent read. Here are some excerpts:

Excessive demands contribute to long waiting times and inadequate quality of care for patients. A growing proportion of patients report that they cannot schedule timely appointments with their physician. Emergency departments are overflowing with patients who do not have access to primary care. The majority of patients with diabetes, hypertension, and other chronic conditions do not receive adequate clinical care, partly because half of all patients leave their office visits without having understood what the physician said.

These problems are exacerbated by the system of physician payment. Thirty minutes spent performing a diagnostic, surgical, or imaging procedure often pays three times as much as a 30-minute visit with a patient with diabetes, heart failure, headache, and depression…

These factors add up to an unsurprising result: fewer U.S. medical students are choosing careers in primary care. Between 1997 and 2005, the number of U.S. graduates entering family practice residencies dropped by 50 percent…

Who might support a national policy to rescue primary care? Employers and insurers, public and private, may reap a return on investment by fostering a more effective primary care sector that will reduce health care costs… Whoever takes up the cause of primary care, one thing is clear: action is needed to calm the brewing storm before the levees break.

A recent article in the Wall Street Journal sent ripples through the blogosphere. It was about how a few family physicians found a way to drastically reduce overhead – by being a solo practitioner and using technology to replace office staff and automate billing as much as possible.

Drs. Charlie Smith and Joe Scherger are family physicians here at Revolution Health who are leading the charge towards high tech solutions for family physicians. Charlie explains his philosophy in his recent blog post:

Having practiced primary care for over 30 years, I’m convinced the model of receiving in office care for every problem is not working well. I really like the ideas espoused by Don Berwick in changing the model of care in the doctor’s office to that of seeing patients in groups, treating them by phone or by e mail, rather than in the office. Using phone calls or e mails to sort through the patient issues, the doctor can decide to see the ones who really need to come into the office and the others can be taken care of without an office visit. This is a MUCH more efficient method, allows you to take care of many more people that need care, and gets people the care when they need it, rather than forcing them to wait until they can fit into a slot in your office.

The ideal way to partner with your doctor to use the health care system in the most effective way possible is to call or e mail him whenever possible, use the internet to research all of your health conditions, and only go into the office when you require in office care, such as exams, procedures, lab tests or x rays. Become an e patient!

I personally believe that Revolution Health can substantially improve the life of family physicians through innovative technologies designed to automate their practices as much as possible (thus reducing overhead and time spent on paperwork), as well as educating patients about the management of their diseases and conditions, (thus improving outcomes and increasing pay for performance bonuses), and triaging low acuity issues through online physician emailing services and retail clinics (thus helping patients receive the care they need without excessive use of office time).

Who will take up the cause of primary care (asks the NEJM)? Revolution Health will. Let’s work together to improve the quality of life for physicians and patients alike.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Circumcision reduces HIV transmission in Africa

Recent research suggested that circumcision may reduce the rate of HIV transmission by 50% (foreskin cells are particularly vulnerable to infection with the virus). In response to this news, adult men in Uganda and Kenya have been undergoing the procedure in the hope of reducing their risk of HIV infection.

Some young boys in Kenya were actually expelled from school for not being circumcised. Their parents were asked to bring them back to school once the deed was done.

HIV rates have decreased in Uganda from 15% to 5% after aggressive public health initiatives raised awareness of the importance of safe sexual practices. This is an incredibly positive achievement.

One would hope, however, that circumcision in infancy would become the preferred target age for future procedures.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Can we cure malaria with blood pressure medicine?

Malaria is caused by a crafty little parasite that has become resistant to many medicines. But now researchers at Northwestern University have discovered a chink in its armor – a blood pressure medicine called propranolol. Who knew that a common beta-blocker used to treat hypertension might provide the death blow to such a scourge?

Usually, malarial parasites infect their host’s blood stream through a mosquito bite, and then congregate in the liver and pounce on red blood cells as they pass by. They have a way of adhering to the red blood cells via certain surface receptors (beta 2 adrenergic receptors linked to Gs proteins). They latch on to the red cells and then burrow into the cell and hijack it in order to reproduce inside it. Then, like the horror movie Alien, once they’re fully grown (into “schizonts”) they burst out of the cells and roam free to repeat the process all over again.

Now propranolol happens to block the Gs proteins, which effectively makes it impossible for the parasites to attach themselves to the red blood cells (which they need to use to reproduce themselves).

So what’s the caveat to of all this? Well, folks don’t know they have been infected with malaria until they have symptoms, and the symptoms include high fevers and low blood pressure… so giving someone a medicine that lowers their blood pressure even further might not be a good idea.

The other caveat is that propranolol works like a charm in the test tube, and in mice, but we haven’t yet tried it out in humans who have malaria.

Still, it seems to me that a little bit of propranolol might go a long way to preventing malarial infections in at risk populations. I’ll be interested to see what further studies show!

And if you’re interested, I’ll create a few more blog posts about parasites and other creepy crawly human invaders… Just let me know if you can handle more of this!

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

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