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ON TARGET is the newsletter of Target Health Inc., a NYC-based contract research organization (CRO), providing strategic planning, regulatory affairs, clinical research, data management, biostatistics, medical writing and software services, including the paperless clinical trial, to the pharmaceutical and device industries.
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Make the Diagnosis
1. Sore Feet in Barbados
Case Findings: A 28-year-old man returned from a fun vacation in Barbados where he spent time surfing, walking on the beach, and eating a lot of local food. While he was happy with his tan, he was a bit concerned with a rash that he noticed on his foot the week after he returned. The cream for athlete’s foot he had at home was not helping.
Which disease do you diagnose this patient with?
2) Swimmer’s itch
3) Portuguese man of war sting
4) Cutaneous larva migrans
For the correct answer, go to the end of this Quiz section
2. Iraq War Vet’s Rash
Case Findings: A 28-year-old soldier just returned from active duty in Iraq. He said the rash started several weeks ago. It is somewhat pruritic, but otherwise he feels well. He was given doxycycline, but it did not resolve.
Which disease do you diagnose this patient with?
1) Lyme disease
3) erythema annulare centrifugum
4) granuloma annulare
For the correct answer, go to the end of this Quiz section
The correct diagnosis to quiz question one is number 4.
Cutaneous larva migrans is also known as creeping eruption, creeping verminous dermatitis, sandworm eruption, plumber’s itch, ground itch, and duck hunter’s itch. It is a parasitic infestation of a hookworm. It can be acquired from contact with soil or sand contaminated with dog or cat feces. It may not show up for weeks to months after exposure to sand or soil. The eruption is characterized by local itching. Four days after entry, the migration of the larvae begins and then progresses horizontally about 2 cm daily. Larvae may lie dormant in the skin in colder temperatures and become active again when the seasons change.
What To Look For:
1. pruritic, raised, red, serpiginous (snake-like), curvilinear trails with or without papules and/or vesicles
2. lesions most commonly found on ankles and feet
3. lesions occasionally found on buttocks, genitals, hands (or any area that had direct contact with sand or soil)
The correct diagnosis to quiz question two is number 3 .
Erythema annulare centrifugum (EAC) is a figurate erythema possibly related to hypersensitivity. The etiology of EAC has been postulated to be secondary to infection, inhalants, drugs, and malignancy, but in most cases, an etiologic agent is not identified. Most cases of EAC are idiopathic, but a number of agents have been reported to cause EAC-like lesions including piroxicam, penicillins, and others.
What To Look For:
1. single or multiple erythematous papules (may also appear urticarial) that advance peripherally by millimeters per day
2. erythematous papules eventually form large rings with central clearing and faint brownish pigmentation
3. the ring may have a trailing scale behind the advancing edge
4. lesions are slow moving and usually either arcuate or annular
Frederick Sanger (1918-2013) Genetics Pioneer, Two-Time Winner of Nobel Prize
Nobel prize-winning scientist Frederick Sanger pictured at home in 1993 at age 75.
Photograph: David Levenson/Getty Images
<<I heard a story that when Fred Sanger was working on dideoxy sequencing he didn’t publish a paper for 7 years. He got flak from his head of department for his lack of productivity only to respond by publishing his method, changing molecular biology forever and winning a second Nobel Prize.>> Comment from a Guardian reader, November 2013
Colin Blakemore, professor of neuroscience and philosophy at the School of Advanced Study in London and former chief executive of the Medical Research Council, said: The death of a great person usually provokes hyperbole, but it is impossible to exaggerate the impact of Fred Sanger’s work on modern biomedical science. His invention of the two critical technical advances – for sequencing proteins and nucleic acids – opened up the fields of molecular biology, genetics and genomics. He remains the only person to have won two Nobel prizes in chemistry – recognizing his unique contribution to the modern world.
Sanger was awarded a share of the Nobel prize for chemistry in 1980 for his work on sequencing DNA. It was his second Nobel prize, having also won the chemistry award in 1958 for his pioneering work on the structure of the protein insulin. He is one of only four people to have won two Nobel prizes – the highest honors in science – and the only person to have won two Nobel prizes in chemistry.
Compared with his contemporaries, the discoverers of the structure of DNA, James Watson and Francis Crick, Sanger was a relatively unknown figure outside science. He never courted fame (describing himself as a chap who messed about in his lab) and retired at the age of 65 to devote time to his garden. He even rejected a knighthood because, he told a journalist in 2000, he did not care to be called Sir. He was awarded the Order of Merit by the Queen in 1986.
Reading the DNA letters that make up genes of living organisms is done routinely in modern laboratories, and understanding how particular sequences influence a person’s susceptibility to diseases such as cancer and heart disease is a major focus of medical research. Though Watson and Crick had worked out the structure of DNA’s double helix in the early 1950s, and revealed that it held a linear code of base pairs (C, G, T and A), it took Sanger and his team at Cambridge to work out a way to read the DNA sequence. In the 1960s and 70s, Sanger developed techniques to clone the DNA of the genes under investigation and then add chemicals to break it into short pieces. Sanger’s group were the first to produce a whole genome sequence – 5,000 letters long of the virus phiX174 – and they also sequenced the first bit of human genetic material, the 16,000-letter sequence of DNA in a mitochondrion, the batteries inside biological cells.
In 1962, he moved to the new Medical Research Council Laboratory of Molecular Biology along with leading scientists including Nobel laureates Max Perutz and Francis Crick and began working on the problem of sequencing DNA. His technique – dideoxy or Sanger sequencing – is still in use today to read DNA code, including the 3bn base pairs of the first ever complete human genome sequence published in 2003.
Sanger was the fourth person to have been awarded two Nobel Prizes, either individually or in tandem with others.
When Sanger was around five years old the family moved to the small village of Tanworth-in-Arden in Warwickshire. The family were reasonably wealthy and employed a governess to teach the children. In 1927, at the age of nine, he was sent to the Downs School, a residential preparatory school run by Quakers near Malvern. His brother Theo was a year ahead of him at the same school. In 1932, at the age of 14, he was sent to the recently established Bryanston School in Dorset. This used the Dalton system and had a more liberal regime which Sanger much preferred. At the school he liked his teachers and particularly enjoyed scientific subjects.
He achieved good results in the School Certificate examinations and in 1936 moved as an undergraduate to St John’s College, Cambridge to study natural sciences. His father had attended the same college. For Part I of his Tripos (The University of Cambridge, divides the different kinds of honors bachelor’s degree by Tripos, plural Triposes) he took courses in physics, chemistry, biochemistry and mathematics but struggled with physics and mathematics. Many of the other students had studied more mathematics at school. In his second year he replaced physics with physiology. He took three years to obtain his Part I. For his Part II he studied biochemistry. It was a relatively new department founded by Gowland Hopkins with enthusiastic lecturers who included Malcolm Dixon, Joseph Needham and Ernest Baldwin.
Sanger began studying for a PhD in October 1940 under N.W. Bill Pirie. His project was to investigate whether edible protein could be obtained from grass. After little more than a month Pirie left the department and Albert Neuberger became his adviser. Sanger changed his research project to study the metabolism of lysine and a more practical problem concerning the nitrogen of potatoes. His thesis had the title, The metabolism of the amino acid lysine in the animal body. He was examined by Charles Harington and Albert Charles Chibnall and awarded his doctorate in 1943.
Neuberger moved to the National Institute for Medical Research in London, but Sanger stayed in Cambridge and in 1943 joined the group of Charles Chibnall, a protein chemist who had recently taken up the chair in the Department of Biochemistry. Chibnall had already done some work on the amino acid composition of bovine insulin and suggested that Sanger look at the amino groups in the protein. Insulin could be purchased from Boots (Boots UK Limited, formerly Boots the Chemist is a pharmacy chain in the United Kingdom) and was one of the very few proteins that were available in a pure form. Up to this time Sanger had been funding himself. In Chibnall’s group he was initially supported by the Medical Research Council and then from 1944 until 1951 by a Beit Memorial Fellowship for Medical Research.
Sanger’s first triumph was to determine the complete amino acid sequence of the two polypeptide chains of bovine insulin, A and B, in 1952 and 1951, respectively. Prior to this it was widely assumed that proteins were somewhat amorphous. In determining these sequences, Sanger proved that proteins have a defined chemical composition. For this purpose he used the Sanger Reagent, fluorodinitrobenzene (FDNB), to react with the exposed amino groups in the protein and in particular with the N-terminal amino group at one end of the polypeptide chain. He then partially hydrolyzed the insulin into short peptides, either with hydrochloric acid or using an enzyme such as trypsin. The mixture of peptides was fractionated in two dimensions on a sheet of filter paper, first by electrophoresis in one dimension and then, perpendicular to that, by chromatography in the other. The different peptide fragments of insulin, detected with ninhydrin, moved to different positions on the paper, creating a distinct pattern that Sanger called fingerprints. The peptide from the N-terminus could be recognized by the yellow color imparted by the FDNB label and the identity of the labeled amino acid at the end of the peptide determined by complete acid hydrolysis and discovering which dinitrophenyl-amino acid was there. By repeating this type of procedure Sanger was able to determine the sequences of the many peptides generated using different methods for the initial partial hydrolysis. These could then be assembled into the longer sequences to deduce the complete structure of insulin. Finally, because the A and B chains are physiologically inactive without the three linking disulfide bonds (two interchain, one intrachain on A), Sanger and coworkers determined their assignments in 1955. Sanger’s principal conclusion was that the two polypeptide chains of the protein insulin had precise amino acid sequences and, by extension, that every protein had a unique sequence. It was this achievement that earned him his first Nobel prize in Chemistry in 1958. This discovery was crucial for the later sequence hypothesis of Crick for developing ideas of how DNA codes for proteins.
From 1951 Sanger was a member of the external staff of the Medical Research Council and when they opened the Laboratory of Molecular Biology in 1962, he moved from his laboratories in the Biochemistry Department of the university to the top floor of the new building. He became head of the Protein Chemistry division. Soon after his move he started looking at the possibility of sequencing RNA molecules and began developing methods for separating ribonucleotide fragments generated with specific nucleases. One of the problems was to obtain a pure piece of RNA to sequence. In the course of this he discovered in 1964, with Kjeld Marcker, the formylmethionine tRNA which initiates protein synthesis in bacteria. He was beaten in the race to be the first to sequence a tRNA molecule by a group led by Robert Holley from Cornell University, who published the sequence of the 77 ribonucleotides of alanine tRNA from Saccharomyces cerevisiae in 1965. By 1967 Sanger’s group had determined the nucleotide sequence of the 5S ribosomal RNA from Escherichia coli, a small RNA of 120 nucleotides.
He then turned to sequencing DNA, which would require an entirely different approach. He looked at different ways of using DNA polymerase I from E. coli to copy single stranded DNA. In 1975 together with Alan Coulson he published a sequencing procedure using DNA polymerase with radio labeled nucleotides that he called the Plus and Minus technique. This involved two closely related methods that generated short oligonucleotides with defined 3′ termini. These could be fractionated by electrophoresis on a polyacrylamide gel and visualized using autoradiography. The procedure could sequence up to 80 nucleotides in one go and was a big improvement on what had gone before, but was still very laborious. Nevertheless, his group were able to sequence most of the 5,386 nucleotides of the single-stranded bacteriophage phagX174. This was the first fully sequenced DNA-based genome. To their surprise they discovered that the coding regions of some of the genes overlapped with one another.
In 1977 Sanger and colleagues introduced the dideoxy chain-termination method for sequencing DNA molecules, also known as the Sanger method. This was a major breakthrough and allowed long stretches of DNA to be rapidly and accurately sequenced. It earned him his second Nobel prize in Chemistry in 1980, which he shared with Walter Gilbert and Paul Berg. The new method was used by Sanger and colleagues to sequence human mitochondrial DNA (16,569 base pairs) and bacteriophage ? (48,502 base pairs). The dideoxy method was eventually used to sequence the entire human genome.
As of 2013, he is the only person to have been awarded the Nobel Prize in Chemistry twice, and one of only four two-time Nobel laureates: The other three were Marie Curie (Physics, 1903 and Chemistry, 1911), Linus Pauling (Chemistry, 1954 and Peace, 1962) and John Bardeen (twice Physics, 1956 and 1972).
Sanger married Margaret Joan Howe in 1940. They had three children ? Robin, born in 1943, Peter born in 1946 and Sally Joan born in 1960. He said that his wife had contributed more to his work than anyone else by providing a peaceful and happy home.
The Sanger Institute
Sanger retired in 1983 to his home, Far Leys, in Swaffham Bulbeck outside Cambridge and next to Sanger Wood. In 1992, the Wellcome Trust and the Medical Research Council founded the Sanger Centre (now the Sanger Institute), named after him. The Institute is located on the Wellcome Trust Genome Campus near Hinxton, only a few miles from Sanger’s home. He agreed to having the Centre named after him when asked by John Sulston, the founding director, but warned, It had better be good. It was opened by Sanger in person on 4 October 1993, with a staff of fewer than 50 people, and went on to take a leading role in the sequencing of the human genome. The Institute now has over 900 people and is one of the world’s largest genomic research centers.
He declined the offer of a knighthood, as he did not wish to be addressed as Sir. He is quoted as saying, A knighthood makes you different, doesn’t it, and I don’t want to be different. In 1986, he accepted the award of an Order of Merit, which can have only 24 living members.
In 2007 the British Biochemical Society was given a grant by the Wellcome Trust to catalogue and preserve the 35 laboratory notebooks in which Sanger recorded his remarkable research from 1944 to 1983. In reporting this matter, Science noted that Sanger, the most self-effacing person you could hope to meet, was now spending his time gardening at his Cambridgeshire home.
In 2008, and with his express consent, NHS Gloucestershire Primary Care Trust named their newly built HQ building Sanger House in recognition of his pre-eminent work and as a citizen of the county.
Sanger died on 19 November 2013. As The Times noted in his obituary, he had described himself as just a chap who messed about in a lab.
Keystone/Hulton Archive, via Getty Images. Dr. Sanger in 1958 at his home in Cambridge, England.
Sources: The New York Times, by Denise Gellene; Daniel E. Slotnik contributed reporting, Wikipedia, The Guardian, The Sanger Institute
Exercise as Potent Medicine
Johner Images/Getty Images
According to an article which was published in October in the British Medical Journal, exercise can be as effective as many frequently prescribed drugs in treating some of the leading causes of death. The study raises important questions about whether our health care system focuses too much on medications and too little on activity and preventative medicine to combat physical ailments.
Comparative effectiveness studies are a staple of science, of course, especially in pharmaceutical research. Scientists often track how well one drug treats a condition compared with the outcome if they use a different drug. But few studies have directly compared drugs with exercise, and even fewer have compared outcomes in terms of mortality or whether the intervention significantly lessens the chance that someone with a disease will die from it, despite treatment.
So Huseyin Naci, a graduate student at the London School of Economics and Political Science, and Dr. John Ioannidis, the director of the Stanford Prevention Research Center at the Stanford University School of Medicine, decided to create a comprehensive comparison of the effectiveness of drugs and exercise in lessening mortality among people who had been diagnosed with one of four diseases: heart disease, chronic heart failure, stroke or diabetes. They chose these particular conditions because those were the only ones for which they could find studies that had examined whether exercise lessened the risk of death among patients with that disease.
For the study, the authors compared how well various drugs and exercise succeed in reducing deaths among people who had been diagnosed with several common and serious conditions, including heart disease and diabetes. The authors gathered all of the recent randomized controlled trials, as well as previous reviews and meta-analyses of older experiments relating to mortality among patients with those diseases, whether they had been treated with drugs or exercise. They ended up with data covering 305 past experiments that, collectively, involved almost 340,000 participants, which is an impressive total. But most of the volunteers had received drugs. Only 57 of the experiments, involving 14,716 volunteers, had examined the impact of exercise as a treatment.
Still, the numbers were large enough that Mr. Naci and Dr. Ioannidis could create an elaborate network of cross-references, comparing the outcomes when people received certain drugs, followed exercise regimens or, occasionally, both. The exercise routines, typically part of rehabilitation programs, usually involved walking or other aerobic routines but sometimes consisted of weight training or other exercises.
The researchers compared mortality risks for people following any of the treatment options.
The results consistently showed that drugs and exercise produced almost exactly the same results. People with heart disease, for instance, who exercised but did not use commonly prescribed medications, including statins, angiotensin-converting-enzyme inhibitors or antiplatelet drugs, had the same risk of dying from – or surviving – heart disease as patients taking those drugs. Similarly, people with diabetes who exercised had the same relative risk of dying from the condition as those taking the most commonly prescribed drugs.
On the other hand, people who once had suffered a stroke had significantly less risk of dying from that condition if they exercised than if they used medications – although the authors noted that stroke patients who can exercise may have been unusually healthy to start with. Only in chronic heart failure were drugs noticeably more effective than exercise. Diuretics staved off mortality better than did exercise.
Over all, Dr. Ioannidis said, our results suggest that exercise can be quite potent in treating heart disease and the other conditions, equaling the lifesaving benefits available from most of the commonly prescribed drugs, including statins. Statins are at the center of a debate about new treatment guidelines that could vastly expand the number of people taking the drugs.
The results also underscore how infrequently exercise is considered or studied as a medical intervention, Dr. Ioannidis said. Only 5% of the available and relevant experiments in his new analysis involved exercise. We need far more information about how exercise compares, head to head, with drugs in the treatment of many conditions, he said, as well as what types and amounts of exercise confer the most benefit and whether there are side effects, such as injuries. Ideally, he said, pharmaceutical companies would set aside a tiny fraction of their profits for such studies.
For now, Mr. Naci said, he hopes that this new study will prompt smaller-scale negotiations. We are not suggesting that anyone stop taking their medications, he said. But maybe people could think long and hard about their lifestyles and talk to their doctors about whether exercise could and should be incorporated into their care. Source: The New York Times, by Gretchen Reynolds, December 11, 2013
Fertility Treatments and Multiple Births in the United States
The advent of fertility treatments has led to an increase in the rate of multiple births in the United States. However, the trends in and magnitude of the contribution of fertility treatments to the increase are uncertain. As a result, a study published in the New England Journal of Medicine (2013;369:2218-2225), and funded by the CDC, derived the rates of multiple births after natural conception from data on distributions of all births from 1962 through 1966 (before fertility treatments were available). Publicly available data on births from 1971 through 2011 were used to determine national multiple birth rates, and data on in vitro fertilization (IVF) from 1997 through 2011 were used to estimate the annual proportion of multiple births that were attributable to IVF and to non-IVF fertility treatments, after adjustment for maternal age. Trends in multiple births were examined starting from 1998, the year when clinical practice guidelines for IVF were developed with an aim toward reducing the incidence of multiple births.
Results showed that by 2011, a total of 36% of twin births and 77% of triplet and higher-order births resulted from conception assisted by fertility treatments. The observed incidence of twin births increased by a factor of 1.9 from 1971 to 2009. The incidence of triplet and higher-order births increased by a factor of 6.7 from 1971 to 1998 and decreased by 29% from 1998 to 2011. This decrease coincided with a 70% reduction in the transfer of three or more embryos during IVF (P<0.001) and a 33% decrease in the proportion of triplet and higher-order births attributable to IVF (P<0.001).
According to the authors, over the past four decades, the increased use of fertility treatments in the United States has been associated with a substantial rise in the rate of multiple births, but that the rate of triplet and higher-order births has declined over the past decade in the context of a reduction in the transfer of three or more embryos during IVF.
TARGET HEALTH excels in Regulatory Affairs. Each week we highlight new information in this challenging area.
FDA Takes Significant Steps to Address Antimicrobial Resistance
Certain antimicrobials have historically been used in the feed or drinking water of cattle, poultry, hogs, and other food animals for production purposes such as using less food to gain weight. Some of these antimicrobials are important drugs used to treat human infection, prompting concerns about the contribution of this practice to increasing the ability of bacteria and other microbes to resist the effects of a drug. Once antimicrobial resistance occurs, a drug may no longer be as effective in treating various illnesses or infections.
The FDA is implementing a plan to help phase out the use of medically important antimicrobials in food animals for food production purposes, such as to enhance growth or improve feed efficiency. The plan would also phase in veterinary oversight of the remaining appropriate therapeutic uses of such drugs.
Because antimicrobial drug use in both humans and animals can contribute to the development of antimicrobial resistance, it is important to use these drugs only when medically necessary. The plan announced today focuses on those antimicrobial drugs that are considered medically important (i.e., are important for treating human infection) and which are approved for use in feed and water of food animals.
In a final guidance issued last week, the FDA lays out a road map for animal pharmaceutical companies to voluntarily revise the FDA-approved use conditions on the labels of these products to remove production indications. The plan also calls for changing the current over-the-counter (OTC) status to bring the remaining appropriate therapeutic uses under veterinary oversight. Once a manufacturer voluntarily makes these changes, its medically important antimicrobial drugs can no longer be used for production purposes, and their use to treat, control, or prevent disease in animals will require veterinary oversight.
The FDA is asking animal pharmaceutical companies to notify the agency of their intent to sign on to the strategy within the next three months. These companies would then have a three-year transition process.
In order to help phase in veterinary oversight of those drugs covered by the guidance that are intended for medically appropriate uses in feed, the FDA also has issued a proposed rule to update the existing regulations relating to Veterinary Feed Directive (VFD) drugs. The use of VFD drugs requires specific authorization by a licensed veterinarian using a process outlined in the agency’s VFD regulations. The VFD proposed rule is intended to update the existing VFD process and facilitate expanded veterinary oversight by clarifying and increasing the flexibility of the administrative requirements for the distribution and use of VFD drugs. Such updates to the VFD process will assist in the transition of OTC products to their new VFD status.
The guidance for animal pharmaceutical companies is now in final form, and the proposed VFD rule is open for public comment for 90 days starting on Dec. 12, 2013. To electronically submit comments on the proposed VFD rule, go towww.regulations.gov and insert docket FDA-2010-N-0155. Send written comments to the Division of Dockets Management, Food and Drug Administration, Room 1061, 5630 Fishers Lane, Rockville, MD 20852.
The Best Green Bean Salad You’ve Ever Tasted
Green Bean Salad, Photo ©Joyce Hays, Target Health Inc.
1.5 pounds green beans
5 Tablespoons extra virgin olive oil (use your best), + 1 teaspoon
2 teaspoons chicken stock
4 Tablespoons balsamic vinegar (use your best)
1/2 cup capers
1 cup fresh basil, chopped
1 cup pine nuts, toasted
1 cup red seedless grapes, cut in half
1 garlic clove, juiced (use 2 if you like garlic)
Toast the pine nuts in a fry pan, with 1 teaspoon olive oil, and 1-2 teaspoons chicken stock, stirring constantly for about 3 minutes. Then set aside on paper towel to drain any excess liquid from the nuts.
Steam the green beans, until slightly cooked, al dente, you do not want mushy. Rinse under cold water to stop them from cooking (and enhance the beautiful green color) and dry with paper towel. Depending on the length of the beans, cut them in half or in thirds.
In a small bowl, mix the Olive oil with the balsamic vinegar, garlic juice, pinch salt, pinch black pepper.
Into your salad bowl, add the green beans, basil and capers. Toss gently. Then, add the grapes. Slowly pour the dressing over the salad. Use a spatula to get every drop of the dressing poured over the salad. Toss. Finally, add the pine nuts, toss gently once more and serve.
You are in for a treat with this delicious salad.
Something wonderful happens when sweet grapes and sour capers combine, along with crunchy green beans, and toasted pine nuts. Basil adds a mysterious depth. Of course, gourmet olive oil and balsamic vinegar add their magic too. It’s rare to get such a delicious result from so few ingredients, and so little work. It’s taken me a long time, of trial and error, to get the exact delicious flavor mix, of this particular green bean salad.
Although, this salad would go with poultry, the best entre to serve would be fish or seafood. This salad could be served as a first course, then the fish with rice or polenta, and a cauliflower casserole or ratatouille or whatever veggie casserole you like. We had a selection of warm breads, chilled Sauvignon Blanc and a fruit and cheese platter.
Life is good!