Americans spend more than $300 billion a year on prescription drugs. How we use these drugs, and how effective they are, have become important subjects for public health researchers. A leader in this area is Dr. Jerry Avorn, chief of the Division of Pharmacoepidemiology and Pharmacoeconomics at Brigham and Women’s Hospital in Boston and professor of medicine at Harvard Medical School. Avorn is the author of numerous articles and the book Powerful Medicines.

Dr. Jerry Avorn

For an article in the Harvard Health Letter, editor Peter Wehrwein spoke with Avorn about generic drugs, the pharmaceutical industry, the high cost of cancer drugs, and more. Here’s an excerpt from their conversation.

PW: We get a lot of questions from readers about generic drugs and whether they really are just as good as brand-name drugs. Are they?

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JA: Yes they are. Generics are often made by the same companies that make the branded products. And if they aren’t, they are usually made by equally large companies that the FDA subjects to the same degree of quality control as brand-name manufacturers. We are collectively wasting billions of dollars on brand-name drugs when we can buy generics that are just as safe and effective, for as little as $4 a month.

PW: We also get questions about the side effects of statins. Do you think they have been downplayed?

JA: Statins have prevented enormous amounts of sickness and death from heart disease; they are fantastic drugs. But it’s also probably fair to say that we are not as good as we should be about studying side effects that don’t land people in the hospital—or kill them. I think we have a good handle on statins and rhabdomyolysis, the muscle breakdown that can be fatal. But I don’t think we have studied as carefully as we should have the extent to which statins sometimes make people ache. And making tens of millions of people ache — that’s not nothing.

PW: Are you optimistic or pessimistic about the future of medications and their regulation?

JA: I am optimistic. The examples of what happened with Vioxx and several other problematic drugs have had a bracing effect on how we understand and study medications that is analogous to the bracing effect that thalidomide had on drug regulation in the 1960s. The other thing that gives me hope is that we have begun to pay more attention to the way existing drugs are used — and not used. The next big dent in heart disease, diabetes, and hypertension may come not from a new blockbuster drug but from understanding better how we can get people to take their medications and help them afford them.

There is no such thing as a small stroke…

Strokes are the fifth leading cause of death in the United States and a significant cause of disability. Learn from Harvard Medical School experts how to understand your odds for having a stroke, evidence-based steps that can lower your risk, how to recognize the early signs of a stroke, and what to do to get rapid, brain-saving treatment.

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The Harvard Health Letter is a general interest health and medical newsletter published monthly by Harvard Medical School.

My fingers hate diabetes. Several times a day they get poked with a sharp, needle-like lancet. The drops of blood they give up tell me how my blood sugar roller coaster is doing. That’s really important information I need to determine whether to eat, exercise, or give myself some insulin.

It would be such a treat to check my blood sugar (glucose) without pricking a finger, squeezing out a drop of blood, and placing it on a small test strip attached to a meter. Help may be on the way—though I’m not expecting any big breakthroughs for another few years—as researchers across the country explore prick-free ways to measure blood sugar.

Here are three interesting approaches.

An implantable sensor. University of California, San Diego researchers have developed a titanium sensor the diameter of a quarter that is implanted under the skin. “It takes about a minute to place the sensor in the abdomen or under the collarbone,” says lead developer David A. Gough. It continuously measures blood glucose and wirelessly sends the information to a data receiver worn on a belt or carried in a pocket. In tests in pigs, the sensor worked for more than a year. The technology is now being tested in a small clinical trial in humans. If it turns out to be safe, a larger trial will test if it’s an effective alternative to current blood-sugar monitors.

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A glucose-sensing tattoo. Ultra-tiny beads originally designed to detect glucose in cell cultures could someday do the same thing in humans. Heather A. Clark and her colleagues at Northeastern University are experimenting with injecting glucose-detecting nanosensors under the skin. Shining light of a particular wavelength on this functional tattoo makes it light up. The amount of light the tattoo gives off corresponds to the amount of glucose in the fluid surrounding the sensors. The group has already developed a light and optical filter that work with an iPhone, and are in the process of creating a data-processing app that would turn an iPhone into a blood sugar meter. MIT researchers are working on a similar type of tattoo using tiny tubes of carbon wrapped around a glucose-sensitive material.

Testing tears. The eyes, the say, are windows to the soul. If Arizona State University researchers successfully develop their TOUCH Tears device, the eyes will also be windows to blood sugar. The device has a wick made of highly absorbent gel that you touch to the white of an eye for a second. It captures a small amount of tear fluid and routes it to a sensor that measures the concentration of glucose. Lead researcher Jeffrey T. LaBelle and his colleagues have teamed up with the Mayo Clinic to develop and test tear glucose monitoring technology. University of Michigan researchers are also working on ways to detect glucose in tears.

For many people with diabetes, especially those who take insulin, accurate blood sugar readings are absolutely essential to safely controlling the disease. Any new methods must be at least as precise and reliable as measuring glucose in a drop of blood. All of the researchers I talked with cautioned that it will take several years of development and testing for their approaches to hit that standard. I’m keeping my fingers crossed that one or all of them succeed.

About the Author

Patrick J. Skerrett, Former Executive Editor, Harvard Health Publishing

Pat Skerrett is the editor of STAT’s First Opinion and host of the First Opinion podcast. He is the former editor of the Harvard Health Blog and former Executive Editor of Harvard Health Publishing. Before that, he was editor of … See Full Bio

View all posts by Patrick J. Skerrett

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No content on this site, regardless of date, should ever be used as a substitute for direct medical advice from your doctor or other qualified clinician.

Today is the 13^th annual World AIDS Day, and it has been 30 years since that first ominous report of five cases of Pneumocystis carinii pneumonia among previously healthy young men in Los Angeles.

Health officials estimate that about 60 million people worldwide have been infected with the HIV virus and that about half of them have died. In the United States, just over a million people have been diagnosed with AIDS since the epidemic began in 1981 and almost 600,000 have died.

HIV infections, which suppress the immune system so opportunistic infections can take hold, are responsible for the resurgence of tuberculosis, especially in Africa.

And there’s still no HIV/AIDS vaccine, despite all the research into HIV and over two dozen ongoing trials of candidate agents.

These aren’t the kind of facts and figures that engender a lot of hope or give cause for celebration.

Reasons for optimism

Yet there’s actually more reason now to be optimistic—cautiously optimistic, ever so cautiously, and with caveats—about the course of the HIV/AIDS epidemic than there has been in years.

Here’s why:

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• The epidemic seems to have peaked (for now). Many of the important indices of the epidemic—new HIV infections, new AIDS diagnoses, AIDS-related deaths—have peaked and trend lines have a downward slope. UNAIDS, the special international agency created to deal with the epidemic, estimates there were 2.7 million new HIV infections worldwide in 2010, which is 21% fewer than the peak of 3.2 million in 1997. AIDS-related deaths fell to 1.8 million last year, according to the agency, down from a peak of 2.2 million during the mid-2000s. In the United States, the number of newly diagnosed cases of AIDS peaked in 1993, and the number of AIDS-related deaths has been decreasing since 1995.
• Drug therapy has turned HIV/AIDS into a manageable chronic disease. The antiretroviral (ARV) drugs that were first introduced in 1996 have changed HIV/AIDS from being a veritable death sentence into a chronic infection that can be hemmed in and managed for decades. Danish researchers have calculated that HIV-infected men in developed countries with access to ARV drugs and health care now have a life expectancy of about 75 years, provided they start treatment when their immune systems are relatively intact. That’s about seven fewer years of life expectancy than among those who aren’t infected, so there’s still a morbidity and mortality price to be paid. But it’s a lot less than it was before today’s sophisticated ARV drug regimens became available.
• Drug therapy prevents transmission of the virus. By reducing the amount of virus in an HIV-infected person’s body (“lowering the viral load”), ARV drugs also reduce transmission of the virus. “Treatment is prevention,” Dr. Thomas Frieden, director of the federal Centers for Disease Control and Prevention (CDC), said emphatically during a press conference this week. For anyone familiar with the old treatment vs. prevention dichotomy in HIV/AIDS, it was stunning to hear them equated—and by the director of the CDC, no less. But it makes sense. Early on, studies showed that treating HIV-infected mothers with ARV drugs dramatically reduced transmission of the virus to their newborn children. Now studies are showing that the drugs can prevent adult-to-adult transmission. In May of this year, results of a major international study of “serodiscordant” couples, nearly all of whom were heterosexual, were made public. The HPTN 052 study, as it is called, showed that if a person who is HIV positive starts taking antiretroviral drugs when his or her immune system is still strong, it reduces the chances of that person transmitting the virus to an uninfected partner by a stunning 96%. Another approach that uses drug therapy for prevention has been dubbed pre-exposure prophylaxis (PrEP): people take ARV medications on a preventive basis before they are infected so if they are exposed to HIV, the chances of becoming infected with the virus are reduced. CDC-sponsored studies have shown that PrEP works to substantially lower infection rates among gay and bisexual men in the United States and among heterosexual men and women in Africa.
• HIV cures are under investigation. ARV drugs corral HIV, but even if virus levels get very low, some HIV continues to hide out in the body. An HIV cure would get rid of the virus altogether—or, more plausibly, drive it down to such low, weakened levels that the immune system could control it on its own. Hope that a cure is feasible has been kindled by the case of Timothy Brown, a leukemia patient whose HIV infection seems to have been cured (he stopped taking ARV drugs and tests can’t find the virus in his body) by the bone marrow transplants he received from a donor with a genetic mutation. This mutation is known to protect people from HIV infection by altering a protein on immune cells so they can resist the virus. Bone marrow transplants aren’t the answer, but researchers are investigating whether gene therapy might be used to modify the immune cells of HIV-infected individuals so they gain the resistance that some people have naturally. Other curative strategies under investigation involve early, aggressive treatment of HIV with ARV drugs in combination with other agents, with the goal of flushing the virus from its hiding spots in the body.

Protect yourself from the damage of chronic inflammation.

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Mission not accomplished

Optimism is one thing. Foolish optimism is another.

The AIDS epidemic is far from over, and the downward slope of those trend lines could plateau or head up if prevention and treatment efforts slack off. The overalI trends don’t apply to everybody. In this country, new HIV infections are still increasing among young black men, both gay and bisexual, and the CDC launched the Testing Makes Us Stronger campaign this week in response.

And now the flip sides

Moreover, every bit of good news about HIV/AIDS has a problem- and question-filled flip side.

• If drug therapy has turned HIV/AIDS into a chronic condition, then what kind of side effects are HIV-infected people going to experience in their fourth, fifth, or even sixth decades of treatment?
• If treatment is the new prevention, will people have access to it? The price of ARV drugs has dropped, and the number of people in sub-Saharan Africa who are taking them has climbed in recent years. Still, only about half of the approximately 15 million people worldwide who might benefit from ARV drugs (for both treatment and preventive purposes) are receiving them. The CDC estimates that only 336,000 (28%) of the 1.2 million Americans who are HIV-positive are getting the kind of care that keeps viral loads low.
• Even if scientists were to find ways to cure people of HIV infections, will the cures be practical and affordable?

The list goes on.

About the Author

Peter Wehrwein, Contributor, Harvard Health

Peter Wehrwein was the editor of the Harvard Health Letter from 1999 to May 2012. He is currently a freelance writer and editor, and contributes to the Harvard Health blog and HarvardProstateKnowledge.org. Before editing the Health Letter, … See Full Bio

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We are fast entering the era of the electronic health record, when it will be possible to call up our medical records on our computers and mobile devices. Medication lists, lab results, appointment schedules—they’ll all be available with clicks of your mouse or taps on the screen of your smartphone or tablet.

But one question that’s far from settled is whether the electronic health record should include the notes that doctors make about them. A doctor’s notes can be straightforward, such as a reminder that an additional test might be needed. But they can also include somewhat speculative observations and hunches about a patient and his or her medical conditions. The Open Notes project is a research program designed to test the consequences of giving patients access to doctors’ notes. Harvard-affiliated Beth Israel Deaconess Medical Center is one of the test sites.

The Open Notes project is far from finished. But results of a survey of the expectations that doctors and patients have for note sharing are being reported in today’s Annals of Internal Medicine.

I don’t think there are any great surprises here.  More than half of the primary care physicians participating in the project thought sharing their notes would result in greater worry among patients, and a sizable percentage (36% to 50%) anticipated more patient questions. Yet a large majority (74% to 92%) was optimistic it would improve patient communication and education.

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View Protect yourself from the damage of chronic inflammation.

Some doctors at the test sites who elected not to participate in the Open Notes project were also surveyed, and, not unexpectedly, they’re less enthusiastic about giving patients access to note than the participating doctors.

The patients who filled out the survey thought seeing their doctor’s notes would have a variety of good effects, like a clearer understanding of their medical condition, improved self-care, a greater sense of control, and so on.

I contacted two members of the Harvard Health Letter editorial board, Drs. Nancy Keating and Suzanne Salamon, and asked them what they thought about giving patients access to doctors’ notes. They’re on different sides of the issue.

“I’m in the camp that thinks the benefits will probably outweigh the downsides,” said Dr. Nancy Keating, an associate professor of medicine and health care policy at Harvard Medical School and an associate physician at Brigham and Women’s Hospital.

Dr. Keating continued: “There may be some patients where there are complex issues that could be challenging (like patients with drug seeking behavior), but for the vast majority of patients, I think this is no big deal, and likely very helpful.”

There is no such thing as a small stroke…

Strokes are the fifth leading cause of death in the United States and a significant cause of disability. Learn from Harvard Medical School experts how to understand your odds for having a stroke, evidence-based steps that can lower your risk, how to recognize the early signs of a stroke, and what to do to get rapid, brain-saving treatment.

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View There is no such thing as a small stroke…

“Personally, I don’t like the idea of Open Notes,” said Dr. Suzanne Salamon, who is associate chief for clinical geriatrics at Beth Israel Deaconess Medical Center. “I think that doctors will have to spend a lot of time explaining to patients what they meant if a patient misinterprets. For example, a doctor may see a patient as ‘anxious’ or ‘depressed’ or ‘obese’ or ‘alcohol dependent’ or ‘drug dependant’ and the patient may object, perhaps because they don’t see themselves that way, or perhaps because they don’t want this description in the notes.”

Dr. Salamon said doctors may alter what they say in their notes so as not to upset patients, and important pieces of information may be lost as a result.

“I believe that a good doctor-patient relationship should be based on honesty regarding diagnosis and treatment options,” Dr. Salamon said. “However, the medical record and notes are a place where doctors should be able to describe uncertainties, subtle observations, and speculations while an evaluation is being undertaken without having to worry about needlessly upsetting patients who may not have the medical background to interpret the process.”

So what do you think? Would you like to see your doctor’s notes? For what purpose? Is there a danger that they will be misinterpreted?

ARCHIVED CONTENT: As a service to our readers, Harvard Health Publishing provides access to our library of archived content. Please note the date each article was posted or last reviewed. No content on this site, regardless of date, should ever be used as a substitute for direct medical advice from your doctor or other qualified clinician. 

An epileptic seizure is a frightening thing to experience, and almost as frightening to watch. The person loses consciousness and falls to the ground. His or her muscles contract in spasms, causing uncontrollable jerks and twitches. Spasms of the jaw muscles can cause the person to bite his or her tongue. Breathing becomes difficult, and may even stop briefly. Seizures cause some people to lose control of their bladder or bowels.

Fortunately, most seizures stop on their own after a couple minutes. Any that last longer than five to 10 minutes (doctors call such long-lasting seizures status epilepticus) are a medical emergency and must be halted with medication administered intravenously by a doctor or emergency medical technician. More than 50,000 people in the United States die from prolonged seizures every year, either from brain damage due to the seizure itself or from accidents related to passing out mid-attack.

A study published last week in the New England Journal of Medicine indicates that a hand-held auto-injector—much like the epi pens used by people with life-threatening allergies—could be used to treat seizures that don’t stop on their own. This could pave the way for home treatment of epileptic seizures.

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Muscle trumps vein

For the trial, more than 4,000 emergency medical technicians were trained to administer seizure-stopping drugs called benzodiazepines two ways: through an intravenous line inserted into a vein in the arm (the current standard treatment), and with a device that automatically injects the drug into the thigh. Intravenous administration works faster, but it can be hard to put an intravenous line into the arm of someone having a seizure. Injection into the thigh takes effect a bit more slowly, but is far easier to do.

Over an 18-month period, emergency medical crews responded to 893 long-lasting seizures. Half of the people in status epilepticus received a benzodiazepine intravenously, the other half by thigh injection. The muscle injection worked faster and better. It stopped the seizure in 73% of the people before they arrived at the hospital. The intravenous route stopped the seizure in 63%.

Protect yourself from the damage of chronic inflammation.

Science has proven that chronic, low-grade inflammation can turn into a silent killer that contributes to cardiovas­cular disease, cancer, type 2 diabetes and other conditions. Get simple tips to fight inflammation and stay healthy — from Harvard Medical School experts.

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View Protect yourself from the damage of chronic inflammation.

Minutes matter

Seizures that end quickly don’t damage the brain. Those that last longer than five minutes can cause permanent brain damage and disability. The longer a seizure goes on past 10 minutes, the harder it is to stop it with medication. And up to one in five people die from a long-lasting seizure. So the sooner an anti-seizure medication can reach the brain, the better.

If you ever witness a seizure, stay calm and do your best to keep everyone else calm. Here are some steps you can take:

Call 911, or have someone else do it.

Time the seizure. This information will be helpful when the emergency medical crew arrives. Try to remember as many details as you can to tell the paramedics and doctor later.

Provide support. Don’t try to hold the person down or force anything into his or her mouth, even if the tongue is bleeding. To prevent head injury, gently position a soft, flat object like a jacket under the head. Remove any hard or sharp objects that are near the person.

When the jerking stops, gently roll the person onto his or her side. When the person wakes up, be reassuring and provide transportation or other help that may be needed.

Looking ahead

This one study isn’t the green light for doctors to give auto-injectors filled with anti-seizure medication to all of their patients who have seizures. With further testing for safety, though, that is likely to happen. This could spare these people and their families the agonizing wait for an ambulance to arrive in order to halt the seizure. Proper education on the use of these injectors will also be important.

In addition to auto-injectors, researchers are also testing a nasal spray containing a benzodiazepine. This could deliver the medication to the brain even faster than an auto-injector.

By Patrick J. Skerrett, Former Executive Editor, Harvard Health Publishing

Games are meant to be fun and exciting. Some involve the body, some the mind. Others do both. Because of this engagement, games can also be powerful medicine for an ailing mind or body.

Virtual reality

Early efforts to use games for healing focused on virtual reality—a computer-simulated environment that a person can interact with as if he or she was in the “real” world. A virtual reality approach to fear of flying, for example, would create the feeling of being in an airplane, taking off, cruising, and landing.

According to PubMed, an extraordinary database provided by the U.S. National Library of Medicine, researchers are testing virtual reality to help people with a wide range of mental and physical problems. Here’s a partial list:

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• post-traumatic stress disorder
• stroke rehabilitation
• drug and alcohol abuse
• smoking cessation
• autism
• eating disorders and obesity
• stuttering
• phobias like fear of speaking in public or fear of open spaces
• pain relief among burn victims

A presentation at this week’s annual meeting of the Healthcare Information and Management Systems Society described various ways that virtual reality can be used in hospitals, doctors’ offices, and other clinical settings. MedPageToday reports on the session and offers a video discussion about the use of virtual reality with Dr. Ivana Steigman, chief medical officer for Thrive Research, a company that develops online behavioral health programs.

Protect yourself from the damage of chronic inflammation.

Science has proven that chronic, low-grade inflammation can turn into a silent killer that contributes to cardiovas­cular disease, cancer, type 2 diabetes and other conditions. Get simple tips to fight inflammation and stay healthy — from Harvard Medical School experts.

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View Protect yourself from the damage of chronic inflammation.

Exergames

Games may also help people become more physically active. As reported in the March 2012 issue of the Harvard Heart Letter, researchers are taking a close look at games such as Nintendo’s Wii Fitness and Xbox’s Kinect Sports to get couch potatoes moving. The American Heart Association, for example, convened a summit of researchers, clinicians, and game makers to explore the influence that exergames (also called active-play video games) might have on “improving health-related skills, enhancing self-esteem and self-efficacy, promoting social support, and ultimately motivating positive changes in health behaviors.” (You can read the full report here.)

Have you ever tried an exergame or virtual reality therapy? Did it help?

About the Author

Patrick J. Skerrett, Former Executive Editor, Harvard Health Publishing

Pat Skerrett is the editor of STAT’s First Opinion and host of the First Opinion podcast. He is the former editor of the Harvard Health Blog and former Executive Editor of Harvard Health Publishing. Before that, he was editor of … See Full Bio

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The term “personalized medicine” is still something of an abstract idea. In an audacious experiment, Stanford molecular geneticist Michael Snyder gave it a face—his own—and showed what it can do.

Snyder and a large team of colleagues first sequenced his DNA, revealing his complete genetic library. This information showed that Snyder was at increased risk for high cholesterol, coronary artery disease, basal cell carcinoma (a type of skin cancer), and type 2 diabetes. Next, they measured thousands of biological markers in Snyder’s blood every few weeks for two years.

During the average checkup or workup for an illness, a doctor will look at maybe 20 chemical or biological markers. This simple snapshot can be helpful. What Snyder and his colleagues did was akin to taking a 3-D movie of his inner workings on a molecular level to observe how genes, the molecules that read and decode them (RNA), the proteins they make, and other substances work together during health and how they respond to illness.

The team saw how Snyder’s body responded to a cold at the very beginning of the study. Midway through, they watched as molecular changes wrought by a respiratory infection tipped him into full-blown diabetes. The work was published in the journal Cell.

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Protect yourself from the damage of chronic inflammation.

Science has proven that chronic, low-grade inflammation can turn into a silent killer that contributes to cardiovas­cular disease, cancer, type 2 diabetes and other conditions. Get simple tips to fight inflammation and stay healthy — from Harvard Medical School experts.

LEARN MORE

View Protect yourself from the damage of chronic inflammation.

This intensive approach to health monitoring isn’t coming to your doctor’s office any time soon. It’s an expensive process that takes a lot of time and technology, and the information it generates would overwhelm most people and their doctors. But it offers new ways to identify diseases and their triggers early, and offers a peek at how personalized medicine might someday work.

Diabetes connection

The study’s eyewitness account of the development of diabetes really caught my attention. Just before the study’s midpoint, Snyder was infected by the respiratory syncytial virus, which affects the lungs. About two weeks later, measures of his blood sugar regulation stopped looking normal. Then his blood sugar level began increasing. Three months later, Snyder was diagnosed with type 2 diabetes.

The lung infection prompted Snyder’s body to make various antibodies. That’s a healthy response to an infection. But it also made autoantibodies—antibodies that attacked his own proteins. One of the autoantibodies targeted a receptor on the surface of cells that latches onto insulin, a hormone that’s needed to usher glucose (blood sugar) into cells. Interfering with that receptor makes it hard for cells to absorb sugar from the bloodstream, a hallmark of diabetes.

I was diagnosed with diabetes six years ago, right after having a severe and persistent infection. The news was an absolute shock—I’m thin, active, eat a pretty healthy diet, and there isn’t any diabetes in my family.

I’ve long thought that the infection caused, or at least triggered, my diabetes. There hasn’t been much in the medical literature—until now—to back up my suspicion. The work by Michael Snyder and his colleagues won’t do anything to help me control my blood sugar, but it does help take some of the mystery out of why I’m living with this condition.

About the Author

Patrick J. Skerrett, Former Executive Editor, Harvard Health Publishing

Pat Skerrett is the editor of STAT’s First Opinion and host of the First Opinion podcast. He is the former editor of the Harvard Health Blog and former Executive Editor of Harvard Health Publishing. Before that, he was editor of … See Full Bio

View all posts by Patrick J. Skerrett

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Disclaimer:

As a service to our readers, Harvard Health Publishing provides access to our library of archived content. Please note the date of last review or update on all articles.

No content on this site, regardless of date, should ever be used as a substitute for direct medical advice from your doctor or other qualified clinician.

For many people, the most unpleasant part of having a colonoscopy is the aggressive bowel-cleansing prep the day before. In tomorrow’s Annals of Internal Medicine, Harvard researchers report a laxative-free version of “virtual colonoscopy,” an established procedure that uses a CT scan instead of a ‘scope to check the colon for cancers and precancerous polyps.

At present, virtual colonoscopy requires a full bowel prep to make the colon wall visible to the CT scan. But a new, experimental version does it digitally. The team, led by Dr. Michael Zalis of Harvard-affiliated Massachusetts General Hospital (MGH), used sophisticated computer software to make stool in the colon disappear — akin to Photoshopping blemishes from still photos.

Reluctance to undergo the bowel prep hinders more widespread testing for cancer and precancerous polyps. According to the American Cancer Society, colorectal cancer screening rates hover around 50% in some states. Virtual colonoscopy without a day-long bowel prep beforehand could help remedy the problem.

“Laxative-free CT colonography has the potential to reach some of the unscreened population and save lives,” says Dr. Zalis, an associate professor of radiology at MGH and director of CT colonography at MGH Imaging.

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Aversion to colon prep

Public health guidelines urge people 50 or older to be checked for colon cancer and polyps. There are several options, including a simple stool test. But the gold standard is colonoscopy using a flexible, lighted instrument called a colonoscope. A doctor looks through the colonoscope and inspects the colon. If he or she finds a pre-cancerous polyp, a device on the end of the colonoscope is used to remove it from the colon wall. Removing precancerous growths helps prevent cancer, and research strongly suggests it prevents premature deaths from colon cancer—a critical test for any screening method to pass.

Colonoscopy’s ability to both find and remove polyps is an advantage over other screening options. “The trouble is a lot of the people at risk of colorectal cancer have a strong aversion to the laxative prep that is required for colonoscopy,” Dr. Zalis told me.

Enter laxative-free virtual colonoscopy, known in the medical world as CT colonography or CTC.

An experimental version of the virtual colonoscope digitally removes stool from the colon, allowing doctors to see polyps and other abnormalities. (Photo courtesy Dr. Michael Zalis.)

Protect yourself from the damage of chronic inflammation.

Science has proven that chronic, low-grade inflammation can turn into a silent killer that contributes to cardiovas­cular disease, cancer, type 2 diabetes and other conditions. Get simple tips to fight inflammation and stay healthy — from Harvard Medical School experts.

LEARN MORE

View Protect yourself from the damage of chronic inflammation.

Colon photoshopping

In the study, Zalis and his colleagues recruited 605 volunteers at four medical centers, including MGH and nearby Brigham and Women’s Hospital. For two days before the their scans, the volunteers drank small amounts of a contrast agent with meals. This chemically “tagged” the stool, allowing software to detect it and subtract it from the CT scan. What remained was a 3D image of the colon wall that radiologists then searched for polyps, as shown in the image to the right.

The laxative-free method identified 91% of the people with precancerous polyps that were 1 centimeter or larger, which is about as accurate as conventional colonoscopy. Zalis says that more than 90% of polyps that develop into cancer are 1 centimeter or larger.

Two factors that limit virtual colonoscopy’s wider adoption today are that it still requires a colon prep and, if polyps are discovered, you still need to have a full colonoscopy. Laxative-free CTC removes one of those limits.

Larger studies are needed to fully understand the potential of laxative-free CTC, but the latest research is an important step toward expanding colorectal cancer screening to people who would otherwise put it off or avoid it entirely—and put themselves at higher risk of developing colon cancer or dying prematurely. “The study opens the door to a laxative-free and more patient-friendly version of colon cancer screening,” Dr. Zalis says.

For several years I’ve been preaching in the pages of the Harvard Heart Letter about the importance of taking part in clinical trials. Why? Because I believe they improve medical care, telling us what works and what doesn’t. Figuring it was time to put up or shut up, I volunteered for a clinical trial. I’m glad I did—I learned a lot, received excellent care, and saw first-hand the effort it takes.

The trial was called Targeting Inflammation Using Salsalate in Type 2 Diabetes, or TINSAL-T2D for short. It was being conducted at 16 centers, including the Joslin Diabetes Center in Boston, a short walk from my office. Its aim was to see if an old drug called salsalate (a cousin of aspirin) could arrest low-grade inflammation that may—emphasis on may—make muscles resistant to the effects of insulin and eventually tip the body into type 2 diabetes.

I responded to an ad for TINSAL-T2D and, after undergoing a few preliminary tests, was accepted to take part in it. I was given a bottle of blue pills and asked to take several of them every day. No one—not lead investigator Dr. Allison Goldfine, not study nurse Kathleen Foster, and certainly not me—knew if the pills were the real thing or a placebo. I was also asked to check my blood sugar every morning, and to show up monthly for blood tests and questions galore.

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I just finished my year-long stint, still not knowing whether I was taking salsalate or a placebo. I really don’t care, though I’m keen to know if salsalate worked as hoped, something I’ll learn when the results are published.

Why bother?

For people with cancer or other potentially deadly conditions, joining a clinical trial might give them access to new drugs or procedures that may work better than existing ones. For the rest of us, taking part in a clinical trial may have more subtle benefits:

• the possibility of better medical care and monitoring than you currently receive
• learning more about your condition and how to manage it
• feeling good that you are improving care for others by helping answer important medical or scientific questions

There are downsides, too. You don’t get to choose whether you get the “new thing” or the placebo, which can be difficult for folks who don’t like uncertainty.  The new drug or procedure may have unwanted or unexpected side effects. And volunteering for a clinical trials takes time—over the course of a year I spent about 20 hours at the Joslin, and twice wore a portable blood pressure monitor for 24 hours.

Protect yourself from the damage of chronic inflammation.

Science has proven that chronic, low-grade inflammation can turn into a silent killer that contributes to cardiovas­cular disease, cancer, type 2 diabetes and other conditions. Get simple tips to fight inflammation and stay healthy — from Harvard Medical School experts.

LEARN MORE

View Protect yourself from the damage of chronic inflammation.

Still, I’d do it again. And I hope you will think about taking part in a clinical trial. I had such a good experience with the TINSAL staff that I’d like to plug a second trial they are running, called TINSAL-CVD, that’s looking for volunteers. (You can check it out on Facebook.) It is testing whether salsalate lowers the risk of heart disease which, like diabetes, may be an inflammation-related condition. To see the wealth of clinical trials that are currently looking for volunteers, explore ClinicalTrials.gov, the National Institutes of Health’s up-to-date listing of the 18,000 clinical trials now underway in the U.S.

A heart attack in progress is a medical emergency. Blood flow must be restored to a blocked coronary artery, or one so narrowed by fatty deposits that it triggers intense chest pain and other symptoms at rest. Every minute the heart is starved of oxygen means more damage. “It’s time for quick action, because that could help save more heart muscle,” says Dr. Deepak Bhatt, a cardiologist at Brigham and Women’s Hospital and professor of medicine at Harvard Medical School.

The leading way to nip a heart attack in the bud is artery-opening angioplasty. But not all angioplasties are 911s. About one-third are done to lessen chest pain that appears with physical activity or stress. This is the chest pain known as stable angina. Sometimes the prospective patient has no symptoms at all — just test results that indicate one or more clogged arteries.

Cardiologists continuously debate when it’s appropriate to do non-emergency angioplasty. This week, two studies in JAMA Internal Medicine add some provocative new information: that incomplete or even misleading advice from doctors contributes to unnecessary angioplasties. And that’s a problem because angioplasty can harm as well as help.

Overselling angioplasty?

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Everybody with cholesterol-clogged arteries, a condition formally known as coronary artery disease, can lower their risk of having a heart attack by making healthier lifestyle choices and taking medications when necessary. Does angioplasty add anything extra? In people with stable angina, the best clinical trials to date say that opening narrowed arteries with angioplasty on top of risk-lowering care does not prevent heart attacks or death in people with stable angina, and it eases chest pain only temporarily. Based on a strict reading of current guidelines, the benefit of angioplasty ranges from “none” to “uncertain” in nearly half of people with stable angina.

And that potential lack of benefit must be balanced by the potential harms of angioplasty. These include bleeding at the puncture site, a small tear in the lining of the coronary artery, heart attack, and even death.

So why do people with stable angina get angioplasties anyway? The JAMA studies suggest that imperfect medical advice is an important contributing factor.

In one study, researchers scrutinized recorded conversations between cardiologists and their patients as they decided whether to proceed with angioplasty. Few of the doctors explained the uncertain scientific evidence for angioplasty in people with stable angina. Also, the researchers said, some doctors “implicitly or explicitly overstated the benefits,” while underselling medication and lifestyle change. In some encounters, the doctors dominated the conversation, leaving the patient with little opportunity to raise concerns, or used technical jargon that most people don’t understand.

The second study found that additional information can counter unrealistic assumptions about angioplasty. Researchers administered a short survey to about 2,000 people with stable angina. When provided with an explanation that angioplasty may not prevent heart attacks, the participants were less likely to want the procedure.

“These trials emphasize the importance of patient education as to what an angioplasty can or can’t do, what causes a heart attack, and how to best prevent a heart attack,” says Dr. James Kirshenbaum, a cardiologist at Brigham and Women’s Hospital and associate professor of medicine at Harvard Medical School.

Protect yourself from the damage of chronic inflammation.

Science has proven that chronic, low-grade inflammation can turn into a silent killer that contributes to cardiovas­cular disease, cancer, type 2 diabetes and other conditions. Get simple tips to fight inflammation and stay healthy — from Harvard Medical School experts.

LEARN MORE

View Protect yourself from the damage of chronic inflammation.

Mistaken faith

Quality counseling before angioplasty is especially important given the widespread belief that all blocked coronary arteries are ticking time bombs. “A lot of times when a patient has a diagnosis of significant coronary artery disease, they think it’s a heart attack waiting to happen,” Dr. Bhatt says. “It’s not necessarily the case.”

In the JAMA survey study, about 70% of participants incorrectly believed that angioplasty would lower their chance of having a heart attack. After receiving more information, the number of people with that false belief dropped by half.

At the core of the exaggerated faith in angioplasty is the notion that simply unblocking arteries “fixes” coronary artery disease. “People need to be disabused of the plumbing analogy,” Dr. Kirshenbaum says. “Angioplasty does not eliminate the need to take medication and make lifestyle changes.”