Breaking: Prominent Holistic Doctor and Entire Family Found Shot Dead in AZ Home


Another holistic doctor tragically killed.

Holistic Dr. Annie Fairbanks was tragically killed along with her two small children in a shooting believed to have been by Dr. Fairbanks’ husband, Jason.

The Scottsdale Police Department released the names of the family members who were killed in this awful way on the morning of November 11th.Annie’s death is another in a trend of holistic doctors being murdered or taking their own lives in tragic circumstances.

Annie and her 9-month-old son 

Annie was killed along with her 3-year-old daughter and 9-month-old son.

Jason’s sister Laura Fairbanks spoke about the tragic end that befell her brother, saying: 

“I just wished he had asked for help. Jason could make people laugh in ways you never thought you could. He was an extraordinary big brother.”

Annie (left) and Jason Fairbanks are pictured.

Az Central have reported: 

“…The two-story stucco home is in a quiet upper-middle-class neighborhood. Homemade art adorned one of the family’s windows.

When Jason did not show up to work, a co-worker went to the home and discovered the bodies, Hoster said.

Hoster said the couple had been experiencing financial struggles. The two owned a Scottsdale business, Macrotherapy, specializing in physical therapy and rehabilitation.

According to an event page, Annie Fairbanks was a Master CHEK Practitioner and a doctor of holistic nutrition. Efforts by The Arizona Republic to reach Annie Fairbanks’ family were unsuccessful.”

Laura Fairbanks also described her sister-in-law, saying: 

“When you were around her, she just made you feel all right. It was just her presence.”

 Az Central also touched upon possible marital problems within the couple, saying: 

“She said he worked seven days a week to provide for his family. However, she knew that funds were not coming in like Jason needed them to.”

It is thought that many holistic doctors feel pressure to bow to the status quo, and find it hard being a holistic practitioner in a world full of pharmaceuticals.

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FDA safety alert on unanticipated deaths with intragastric balloons


FDA is issuing an update to alert health care providers of five reports of unanticipated deaths that occurred from 2016 to present in patients with liquid-filled intragastric balloon systems used to treat obesity. Four reports involve the Orbera Intragastric Balloon System, manufactured by Apollo Endo Surgery, and one report involves the ReShape Integrated Dual Balloon System, manufactured by ReShape Medical Inc. All five reports indicate that patient deaths occurred within a month or less of b…

Read more at Medical Dialogues: FDA safety alert on unanticipated deaths with intragastric balloons http://speciality.medicaldialogues.in/fda-safety-alert-on-unanticipated-deaths-with-intragastric-balloons/

Gaps in Gender Equality May Fuel Disparities in Cognitive Achievement


Slight gender variations in attention scores have been well documented, but a new study from Harvard Medical School suggests that these minor gaps widen significantly in places with lower gender equality.

The findings, published Nov. 1 in PLOS One, reveal that gender variations in performance of tasks that require participants to exercise sustained attention control are closely tied to gender equality by country. The observation, the research team said, suggests that attention, along with other cognitive functions, is not hardwired but amenable to sociocultural modulation.

Sustained attention control—the ability to focus on a task for a prolonged period of time while resisting distractions—is critical in all spheres of life, including learning and academic achievement, career success, social interactions and interpersonal relationships.

Past research has shown gender variations in cognitive patterns of attention—for example, men are generally more vigilant about spotting certain signals while women have better inhibitory control, an ability to override a natural urge to respond. The findings of the HMS-led study, however, suggest such propensities may be modified by environmental, social and cultural factors, the team said. Understanding the modifiable factors that contribute to gender disparities in sustained attention tasks—and by extension cognitive development—is critical to identifying and removing barriers to gender parity, the researchers added.

“At its core, it’s a provocative idea that social and cultural conditions can either interfere with or improve cognition,” said study lead investigator Lissa Riley, a research fellow in psychiatry at HMS. “In this case, we are seeing that gender equality, or lack thereof, might influence one’s ability to focus and maintain attention.”

Results of the research, which involved more than 16,000 men and women, ages 10 through 70, from 41 countries, revealed greater differences in attention scores between men and women from countries with less gender equality.

Not surprisingly, the researchers said, men and women performed slightly differently overall. However, when investigators analyzed performance variations by country, a striking trend emerged.

Participants from countries with greater gender equality showed minimal differences by gender, while countries with lower gender equality showed much greater variations in scores. Beyond gender, men and women from countries with high gender equality had better overall performance.

In the experiment, participants were shown a series of gradually transitioning landscapes—predominantly city images, interspersed with mountain terrains. They were asked to push a button every time a cityscape flashed across the screen but refrain from pushing the button whenever a mountain appeared.

To examine the interplay between men’s and women’s scores and a country’s gender equality index, the researchers used several country-specific indicators, including female-to-male ratio in the labor force, poverty rate, a human development index—which, among other things, factors in life expectancy, education and per-capita income—and the Social Institutions and Gender Index, a cross-country measure of discrimination against women in social institutions through formal and informal laws or social practices.

As expected based on previous research, women refrained from responding to the correct image more often, while men tended to overcall, or wrongly identify, images they were supposed to ignore. Overall these differences were minor in highly developed countries with greater gender equality, but twice as pronounced in countries that scored lower on human development and gender equality indicators.

Individually and taken together, all factors except poverty were linked to gender differences in performance, the researchers found. Women in countries that scored lower on these measures were more likely to miss out on identifying the correct image, but they were also more likely to refrain from erroneously identifying the incorrect image when it flashed on screen. In countries with greater gender inequality women, but not men, made more mistakes.

Researchers estimated that up to 2.5 percent of errors in performance could be attributed to gender inequality.

As gender equality increased, the gap largely vanished, becoming virtually non-existent in countries with the highest indicators of gender equality, such as Finland and New Zealand.

The investigators said their findings require further study to tease out the dynamics behind such differences. However, one possible explanation, the researchers said, is that in countries with less gender equality, women made fewer errors of overcall and more errors of omission, both of which may stem from social norms that discourage speaking up and taking risks. In other words, women in such settings may be less likely to take chances for fear of making a mistake, a reluctance that may have propelled them to refrain from correctly responding to an image.

“Attention is a gatekeeping cognitive faculty that plays a critical role in everyday activities,” says study senior investigator Joseph DeGutis, assistant professor of psychiatry at HMS. “If our observations are true for sustained attention scores, they may also be true for other cognitive tasks. It’s important to consider the notion that social equality results in better cognition.”

Other investigators involved in the research included Hidefusa Okabe, Laura Germine, Jeremy Wilmer and Michael Esterman.

BioMarin to Begin Phase 3 Gene Therapy Trials for Hemophilia A


BioMarin announced the results from their ongoing Phase 1/2 gene therapy studies evaluating  BMN 270 for patients with hemophilia A. Based on encouraging data, Phase 3 studies are being planned to start later this year.

Hemophilia A is a chronic, genetic disorder that results in impaired clotting mechanisms due to missing or reduced levels of Factor VIII. People with this rare disorder experience recurrent painful bleeding episodes, some of which can be life-threatening. Numerous orphan drugs have been approved and are available to treat the bleeding episodes and 2 orphan drugs – Advate and Kogenate – are approved for prophylactic use in patients with hemophilia A.

BMN 270 is an AAV 5 factor VIII vector designed to restore factor VIII plasma concentrations to levels that would essentially cure the person of the disorder.

In the Phase 1/2 study, patients with severe hemophilia A were given doses of BMN 270, 4e13 vg/kg or 6e13 vg/kg.

In the 6 patients given the 4e13 vg/kg dose, each has shown increased plasma levels of Factor VII and has experienced a dramatic reduction in bleeding episodes.  Three of the patients have been monitored for 32 weeks and 3 others monitored for 20 weeks. Results from those patients are shown in the table below.

Table 1:  Factor VIII Levels (%) of 4e13 vg/kg Dose Patients 

Week Mean Factor VII Levels (%) (mean) Range (low, high)
          4 (n=6)
 8
12
16
20
5
13
19
26
31
2, 10
3, 21
6, 32
5, 38
7, 45
          24 (n=3)
28
32
32
39
51
24, 42
32, 44
48, 54

Table 2:  Mean Annualized Bleeding Rate (ABR) and FVIII Infusions of 4e13 vg/kg Dose Patients Previously on Prophylaxis (N=6) up to 32 Weeks

Before BMN 270 Infusion** After BMN 270 
Infusion***
Annualized Bleeding Rate* (mean) 12.2 1.0
Annualized FVIII Infusions* (mean) 144.2 4.8

* Post infusion data were based on data after Factor VIII levels were above 5%
**Obtained from medical records.
***5 of 6 patients had 0 bleeds requiring Factor VIII infusions after Factor VIII levels were above 5%.

Similar trends were observed in the 7 patients receiving the higher dose (6e13 vg/kg). Those patients have been monitored for 52 weeks, the mean Factor VIII levels continue to be above 50%.

Based on the results, BioMarin plans to initiate 2 separate Phase 3 studies; a study with the 4e13 vg/kg dose and another with the 6e13 vg/kg dose. They are expected to start in the 4th quarter of 2017 and will enroll about 100 patients.

Hank Fuchs, M.D., President, Worldwide Research and Development at BioMarin said. “Given the low level of pre-existing immunity to AAV5, we expect that approximately 90 percent of patients would be treatment candidates for BMN 270 based on this criteria.”

BMN 270 was well-tolerated and no patients withdrew from the study. The most common adverse events across all dose cohorts were alanine aminotransferase (ALT) elevation in 11 patients; arthralgia, aspartate aminotransferase elevation, and headache in 7 patients each, and; back pain and fatigue in 5 patients each. One patient developed Grade 2 pyrexia with myalgia and headache within 24 hours of receiving BMN 270. The event resolved within 48 hours but was determined to be related to BMN 270.

Genetic Testing for the Healthy. 


Randomized trial examines genome sequencing in healthy patients

However, the use of genome sequencing in healthy individuals is controversial because no one fully understands how many patients carry variants that put them at risk for rare genetic conditions and how they and their doctors will respond to learning about these risks.

In a new paper published June 26 in the Annals of Internal Medicine by investigators at Harvard Medical School and Brigham and Women’s Hospital, along with collaborators at Baylor College of Medicine, report the results of the four-year, NIH-funded MedSeq Project, the first-ever randomized trial conducted to examine the impact of whole genome sequencing in healthy primary care patients.

In the MedSeq Project, 100 healthy individuals and their primary care physicians were enrolled and randomized so that half of the patients received whole genome sequencing and half did not.

Nearly 5,000 genes associated with rare genetic conditions were expertly analyzed in each sequenced patient, and co-investigators from many different disciplines, including clinical genetics, molecular genetics, primary care, ethics and law, were involved in analyzing the results.

Researchers found that among the 50 healthy primary care patients who were randomized to receive genome sequencing, 11 (22 percent) carried genetic variants predicted to cause previously undiagnosed rare disease.

Two of these patients were then noted to have signs or symptoms of the underlying conditions, including one patient who had variants causing an eye disease called fundus albipunctatus, which impairs night vision.

This patient knew he had difficulty seeing in low-light conditions but had not considered the possibility that his visual problems had a genetic cause.

Another patient was found to have a genetic variant associated with variegate porphyria, which finally explained the patient’s and family members’ mysterious rashes and sun sensitivity.

The other nine participants had no evidence of the genetic diseases for which they were predicted to be at risk. For example, two patients had variants that have been associated with heart rhythm abnormalities, but their cardiology workups were normal. It is possible, but not at all certain, that they could develop heart problems in the future.

“Sequencing healthy individuals will inevitably reveal new findings for that individual, only some of which will have actual health implications,” said lead author Jason Vassy, an HMS assistant professor of medicine at Brigham and Women’s and primary care physician at the VA Boston Healthcare System.

“This study provides some reassuring evidence that primary care providers can be trained to manage their patients’ sequencing results appropriately, and that patients who receive their results are not likely to experience anxiety connected to those results. Continued research on the outcomes of sequencing will be needed before the routine use of genome sequencing in the primary care of generally healthy adults can be medically justified,” Vassy said.

Primary care physicians received six hours of training at the beginning of the study regarding how to interpret a specially designed, one-page genome testing report summarizing the laboratory analysis.

Consultation with genetic specialists was available, but not required. Primary care physicians then used their own judgment about what to do with the information, and researchers monitored the interactions for safety and tracked medical, behavioral and economic outcomes.

The researchers noted that they analyzed variants from nearly 5,000 genes associated with rare genetic diseases. These included single genes causing a significantly higher risk for rare disorders than the low-risk variants for common disorders reported by direct-to-consumer genetic testing companies. No prior study has ever examined healthy individuals for pathogenic (high-risk) variants in so many rare disease genes.

“We were surprised to see how many ostensibly healthy individuals are carrying a risk variant for a rare genetic disease,” said Heidi Rehm, HMS associate professor of pathology at Brigham and Women’s and director of the Laboratory for Molecular Medicine at Brigham and Women’s.

“We found that about one-fifth of this sample population carried pathogenic variants, and this suggests that the potential burden of rare disease risk throughout our general population could be far higher than previously suspected,” said Rehm, a co-investigator on the study who directed the genome analysis. “However, the penetrance, or likelihood that persons carrying one of these variants will eventually develop the disease, is not fully known.”

Additionally, investigators compared the two arms of the study and found that patients who received genome sequencing results did not show higher levels of anxiety. They did, however, undergo a greater number of medical tests and incurred an average of $350 more in health care expenses in the six months following disclosure of their results. The economic differences were not statistically significant with the small sample size in this study.

“Because participants in the MedSeq Project were randomized, we could carefully examine levels of anxiety or distress in those who received genetic risk information and compare it to those who did not,” said Amy McGuire, director of the Center for Medical Ethics and Health Policy at Baylor College of Medicine.

“While many patients chose not to participate in the study out of concerns about what they might learn, or with fears of future insurance discrimination, those who did participate evinced no increase in distress, even when they learned they were carrying risk variants for untreatable conditions,” said McGuire, who supervised the ethical and legal components of the MedSeq Project.

There has also been great concern in the medical community about whether primary care physicians can appropriately manage these complicated findings. But when a panel of expert geneticists reviewed how well the primary care physicians managed the patients with possible genetic risk variants, the experts determined that only two of the 11 cases were managed inappropriately and that no harm had come to these patients.

MedSeq Project investigators note that the study’s findings should be interpreted with caution because of the small sample size and because the study was conducted at an academic medical center where neither the patients nor the primary care physicians are representative of the general population. They also stressed that carrying a genetic risk marker does not mean that patients have or will definitely get the disease in question. Critical questions remain about whether discovering such risk markers in healthy individuals will actually provide health benefits, or will generate unnecessary testing and subsequent procedures that could do more harm than good.

“Integrating genome sequencing and other -omics technologies into the day-to-day practice of medicine is an extraordinarily exciting prospect with the potential to anticipate and prevent diseases throughout an individual’s lifetime,” said senior author Robert C. Green, HMS professor of medicine at Brigham and Women’s Hospital, associate member of the Broad Institute of Harvard and MIT and leader of the MedSeq Project. “But we will need additional rigorously designed and well-controlled outcomes studies like the MedSeq Project with larger sample sizes and with outcomes collected over longer periods of time to demonstrate the full potential of genomic medicine.”

The MedSeq Project is one of the sites in the Clinical Sequencing Exploratory Research Consortium and was funded by the National Human Genome Research Institute, part of the National Institutes of Health.

The Genomes2People Research Program at Brigham and Women’s Hospital, the Broad Institute and Harvard Medical School conducts empirical research in translational genomics and health outcomes. NIH-funded research within G2P seeks to understand the medical, behavioral and economic impact of using genetic risk information to inform future standards. The REVEAL Study has conducted several randomized clinical trials examining the impact of disclosing genetic risk for a frightening disease. The Impact of Personal Genomics (PGen) Study examined the impact of direct-to-consumer genetic testing on over 1,000 consumers of two different companies. The MedSeq Project has conducted the first randomized clinical trial to measure the impact of whole genome sequencing on the practice of medicine. The BabySeq Project is recruiting families of both healthy and sick newborns into a randomized clinical trial where half will have their baby’s genome sequenced. Green directs the Program.

Singapore scientists uncover how neural stem cells are activated intrinsically by spindle matrix proteins


Neural progenitor cells (green) in the rat olfactory bulb 

Neural stem cells (NSCs) are self-renewing and multipotent cells that give rise to the neurons and glia of the nervous system during an animal’s embryonic development. In a mammalian brain, only a small fraction of the adult NSCs are proliferative and a majority are in a nondividing state, also known as quiescence.

The balance between NSC proliferation and quiescence is essential for brain development and emerging evidence suggests that its imbalance is linked to neurodevelopmental disorders, such as microcephaly. On the other side, the population of quiescent NSCs in the brain increases with ageing, which is associated with declining brain function.

Understanding how endogenous NSCs can be activated has huge potential in regenerative medicine. However, it is poorly understood as to how NSCs switch between proliferation and quiescence in vivo.

A multicentre research team led by Duke-NUS Medical School (Duke-NUS)’s Neuroscience and Behavioural Disorders Programme has uncovered that spindle matrix proteins can play an intrinsic role in regulating neural stem cell (NSC) reactivation and proliferation.

This discovery is an early important step towards opening up avenues for further research that could lead to potential stem cell-based therapies for neurodevelopmental and neurodegenerative disorders such as microcephaly and Alzheimer’s disease.

Study

The study, published in Nature Communicationsis a first of its kind conducted on fruit flies (Drosophila melanogaster) that demonstrates a critical role of the spindle matrix complex containing chromator (Chro) functioning as an essential nuclear factor for controlling gene expression during NSC reactivation. The study suggests that Chro plays an important role in maintaining the balance between NSC proliferation and quiescence, as it is not only critical for NSC reactivation (exit from quiescence) but also essential for preventing re-entry into inactivation.

“In this study, we have uncovered that spindle matrix proteins play a novel role in regulating reactivation of neural stem cells. It may be in its early stage, but this should help to open up avenues for further research and the development of potent therapies for neurodevelopmental disorders in the future,” said lead author Hongyan Wang, an Associate Professor and Deputy Director of Duke-NUS’ Neuroscience and Behavioural Disorders Programme.

Chromator is required for activation of neural stem cells (NSCs). Upper panels show wild-type control Drosophila larval brains with proliferating NSCs (EdU+; in red). Lower panels show NSCs from chromator- mutant brains stay in a quiescent stage (EdU-). Note that cellular extension, a hallmark of quiescent NSCs, is indicated by a yellow arrowhead. NSCs are marked by nuclear Dpn (in blue) and cortical Mira (in green).

The team employed the state-of-art genomic technique for transcriptome analysis in vivo and identified binding-sites of Chro in NSCs. The main findings from these experiments suggest that Chro is a master nuclear factor that reactivates NSCs through regulating gene expression of key transcription factors that either promote or repress the proliferation of NSCs. The study also suggests that Chro functions downstream of Insulin/PI3k pathway, which is known to promote NSC reactivation and mutations of which are found in microcephalic patients.

“Our study demonstrates that some of the players such as transcription factors Grainy Head and Prospero act downstream of Chro and identifies the likely pathway by which NSCs are activated,” added Professor Wing-Kin Sung, who is from the National University of Singapore (NUS) School of Computing and a Senior Group Leader at A*STAR’s Genome Institute of Singapore (GIS).

First U.S. Human Embryo Gene Editing Experiment Successfully “Corrects” a Heart Condition


IN BRIEF

A study published today in the journal Nature confirms earlier reports of the first-ever successful gene-editing of embryos in the U.S. Though controversial, the treatment could one day be used to address any of the 10,000 disorders linked to just a single genetic error.

CORRECTING MUTANT GENES

Last week, reports circulated  that doctors had successfully edited a gene in a human embryo — the first time such a thing had been done in the United States. The remarkable achievement confirmed the powerful potential of CRISPR, the world’s most efficient and effective gene-editing tool. Now, details of the research have been published in Nature.

The procedure involved “correcting” the DNA of one-cell embryos using CRISPR to remove the MYBPC3 gene. That gene is known to cause hypertrophic cardiomyopathy (HCM), a heart disease that affects 1 out of 500 people. HCM has no known cure or treatment as its symptoms don’t manifest until the disease causes sudden death through cardiac arrest.

How CRISPR Works: The Future of Genetic Engineering and Designer Humans
Click to View Full Infographic

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The researchers started with human embryos created from 12 healthy female donors and sperm from a male volunteer who carried the MYBOC3 gene. The defective gene was cut out using CRISPR around the time the sperm was injected into the eggs.

 As a result, as the embryos divided and grew, many repaired themselves using the non-edited genes from the genetic materials of the female donors, and in total, 72 percent of the cells that formed appeared to be corrected. The researchers didn’t notice any “off-target” effects on the DNA, either.

The researchers told The Washington Post that their work was fairly basic. “Really, we didn’t edit anything, neither did we modify anything,” explained Shoukhrat Mitalipov, lead author and a researcher at the Oregon Health and Science University. “Our program is toward correcting mutant genes.”

A [CONTROVERSIAL] NEW ERA?

Basic or not, the development is remarkable.“By using this technique, it’s possible to reduce the burden of this heritable disease on the family and eventually the human population,” Mitalipov said in an OHSU press release.

However, gene editing is a controversial area of study, and the researchers’ work included changes to the germ line, meaning the changes could be passed down to future generations. To be clear, though, the embryos were allowed to grow for only a few days and none were implanted into a womb (nor was that ever the researchers’ intention).

In fact, current legislation in the U.S. prohibits the implantation of edited embryos. The work conducted by these researchers was well within the guidelines set by the National Academies of Sciences, Engineering, and Medicine on the use of CRISPR to edit human genes.

University of Wisconsin-Madison bioethicist Alta Charo thinks that the benefits of this potential treatment outweigh all concerns. “What this represents is a fascinating, important, and rather impressive incremental step toward learning how to edit embryos safely and precisely,” she told The Washington Post. “[N]o matter what anybody says, this is not the dawn of the era of the designer baby.”

Before the technique could be truly beneficial, regulations must be developed that provide clearer guidelines, according to Mitalipov. If not, “this technology will be shifted to unregulated areas, which shouldn’t be happening,” he explained.

More than 10,000 disorders have been linked to just a single genetic error, and as the researchers continue with their work, their next target is BRCA, a gene associated with breast cancer growth.

Mitalipov hopes that their technique could one day be used to treat a wide-range of genetic diseases and save the lives of millions of people. After all, treating a single gene at the embryonic stage is far more efficient that changing a host of them in adults.

Largely Ceded to GI Physicians, Surgeons Urged to Reclaim Endoscopy


Experts Describe Advantages of Developing Endoscopic Techniques for Practice

 

image

New York—What do colonoscopy, polypectomy and endobiliary stenting all have in common? They are all endoscopic techniques first described by surgeons, along with control of hemorrhage, endoscopic retrograde cholangiopancreatography, percutaneous endoscopic gastrostomy/jejunostomy and control of variceal bleeding.

“It’s an old adage that general surgeons started endoscopy and gave it up to the gastroenterologists,” said Paresh C. Shah, MD, professor of surgery at NYU Langone School of Medicine, in New York City. “Unfortunately, that’s true, but we’re changing that and we need to be aggressive about it.”

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The American Board of Surgery has acknowledged the importance of surgical endoscopy through changes in residency training requirements for board eligibility. Starting in 2018, surgical residents will have to complete a flexible endoscopy curriculum and pass the Fundamentals of Endoscopic Surgery (FES) examination assessing their cognitive and technical skills. The FES program was developed by the Society of American Gastrointestinal and Endoscopic Surgeons.

But surgical endoscopy can expand and enhance practice for surgeons at any stage in their career, Dr. Shah explained at the 2016 Controversies, Problems & Techniques in Surgery annual meeting, noting that it was general surgeons again who played a role in promoting some of the more advanced endoscopic interventions, such as EndoCinch suturing, Stretta, anastomotic plication and peroral endoscopic myotomy (POEM).

“If we think of ourselves as gastrointestinal surgeons, we’re really obligated to look at the spectrum of what GI surgery is. Advanced endoscopy, therapeutic endoscopy, is nothing more than another form of GI surgery; it’s just one that happens within the lumen rather than outside.”

In the world of diagnostic endoscopy, some of the newer tools that surgeons have include microendoscopy and narrow-band imaging. “For those of you who do diagnostic upper and lower endoscopy, these are critical to have at your disposal,” Dr. Shah said. “They’ve impacted adenoma detection rate, early cancer detection, and clearly, postsurgical anatomy.”

As Jose Martinez, MD, pointed out, nobody understands postsurgical anatomy better than the surgeon who made it. “We do a lot of replumbing in the human body, and we know the plumbing doesn’t always work. We can end up with strictures or worse—a leak, fistula or perforations,” said Dr. Martinez, associate professor of surgery and chief of laparoendoscopic surgery at the University of Miami Miller School of Medicine.

Basic tools for interventional endoscopy include balloon dilation, bleeding control and feeding tubes. More advanced interventions—to manage complications that surgeons themselves may have created—include stents, clips, fibrin glue and endoscopic suturing.

Injection is an important skill to develop. “It allows you to do a lot of things in the GI tract, whether you’re injecting saline to lift the mucosa, tattoo to mark a lesion or epinephrine to control bleeding,” Dr. Shah said.

The application of clips, which have improved dramatically in recent years, also has myriad uses. “Closing small holes, mucosal defects; I use clips after endoscopic submucosal dissection (ESD) resections and peroral endoscopic myotomy, and they’re good for bleeding control,” Dr. Shah said.

When it comes to dealing with strictures, surgeons again have a number of tools at their disposal: stents, energy sources, balloons and dilators. “Many of these things were created for one purpose, but we’re using them in different ways to figure out how to best accomplish treatment for our patient,” Dr. Martinez said.

And then there are the very advanced endoscopic interventions: POEM, gastric POEM (G-POEM), ESD and endoscopic full-thickness resection (EFTR). “G-POEM changed our practice—I don’t do pyloroplasties anymore; and ESD and EFTR are now the avant- garde of what we can do endoluminally,” Dr. Shah said.

Incorporating Endoluminal Techniques

Jeffrey Marks, MD, long a promoter of flexible endoscopy, acknowledged that while the younger generation of surgeons might be more comfortable with it—especially the residents who will have to pass the FES and complete the flexible endoscopy curriculum in 2018 before sitting for their boards—more established surgeons can be a tougher sell.

“The hardest person to impress is the person outside fellowship and residency, someone in practice already. If they’re not doing flexible endoscopy, it’s hard to get them started,” said Dr. Marks, professor of surgery and director of surgical endoscopy at Case Western/University Hospitals, Cleveland Medical Center, in Ohio.

Drs. Marks and Shah recommend surgeons start with intraoperative assessment. “For one thing, the GI doctors aren’t going to want to come in to assess every anastomosis or bariatric bypass; also, the patient being asleep makes it easier—you don’t have to worry about them being uncomfortable—so it’s a great way to gain skills.”

Dr. Shah suggests having an endoscope involved in every case. “There is no downside to you doing your own intraoperative endoscopy, whether it’s foregut or colon.”

Once a surgeon has gained some comfort, some formal training can advance his or her competence. “Both the American College of Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons have hands-on courses for surgeons who have a basic skill set in flexible endoscopy to learn how to do more advanced therapies,” Dr. Marks said.

Dr. Shah also recommends working with GI colleagues to build one’s skill set for more advanced endoscopic procedures. “Most of them have more experience than you with the more advanced procedures,” he said.

This can be difficult politically in situations where gastroenterologists sense a turf war and resist sharing what they know, but the reality, according to Dr. Shah, is that most gastroenterologists are more than willing to turn over the more challenging and relatively less remunerative advanced endoscopic procedures. “It does not pay for them to do a two-hour procedure when they can do six screening colonoscopies in the same time. The reimbursement isn’t there for them, the interest isn’t there for them, and they don’t want to be responsible for potential complications.

“If you have a therapeutic or developmental endoscopist in your area or practice, partner with them,” he said. They’ll love to have that work with you. And if you don’t have a therapeutic endoscopist, there’s a very good opportunity for you to become that person for your GI community. They’ll be happy to do your pre-ops, screenings and post-ops, and to call on you when they need one of these more advanced therapeutic endoscopic procedures.”

U.S. Laws On Human Embryo Gene Editing Are Unexpectedly Lax


A team of scientists in Oregon successfully used the powerful genetic re-writing technique known as CRISPR to edit human embryos, the MIT Technology Review reported on Wednesday. While CRISPR-mediated gene editing has been ongoing for several years now, the scientific community has been generally leery of applying it to humans because of the implications it might have for our evolution.

human embryo

Still, it wasn’t the first the first time someone had used CRISPR on human embryos. A team in China had done so previously in 2015, but with limited success. The edits were imperfect and only altered some of the cells in the embryos, resulting in chimeral embryos with multiple genomes. The Oregon embryo edit was reportedly much more successful, creating alterations that — were those embryos implanted and allowed to grow to term into a human being that then had kids — could reliably be passed down through the generations. That’s what’s called a germline edit.

It might seem surprising to learn that this is legal at all in the United States, which has had long, drawn-out political battles in recent decades over even stem cell research. And there are serious unresolved concerns around profiteering on the creation of “designer babies.”

But as it turns out, gene editing in humans is not a problem — not a legal one, anyway. As STAT reported earlier this year, the closest we have to a law forbidding it is one that prevents the Food and Drug Administration from reviewing “research in which a human embryo is intentionally created or modified to include a heritable genetic modification.”

But the FDA’s approval is only necessary for medical treatments that are used on actual human beings. Simple laboratory research on embryos that will never be implanted isn’t covered — and there’s no law directly preventing gene-editing them.

So even if the techniques for germ-line editing have been developed, no actual germ-line editing has been done, and the coast remains clear.

Scientists, legal scholars, and bioethicists differ among themselves in just how worried they are about the moral and legal questions CRISPR has raised. But the most up-to-date guidance on CRISPR assumes that sooner or later, the germ-line editing train will pull out the station.

Depression doubles risk of early death in heart patients


Heart disease patients are twice as likely to suffer an early death if they suffer depression, warns a study. Researchers tracked more than 24,000 patients for 10 years and found that post-coronary artery disease depression was the single biggest predictor of death. Lead author Dr Heidi May said that no matter how long or how short it was, patients were found to have twice the risk of dying compared to those who did not have a follow-up diagnosis of depression. May stated that depression was …

To detect subsequent depression, the researchers used standardised diagnostic coding system. The patients with depression were placed into subcategories based on how long after their heart disease diagnosis the depression was identified. In all, 15 percent, or 2,646 patients, were diagnosed with depression at some point during follow-up. Of those, most of them (37 percent) were diagnosed with depression for more than five years after their first heart event, but the two diagnosis were linked….

Source: European Heart Journal

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