Alzheimer’s one day may be predicted during eye exam

Greg Van Stavern, MD, (seated) and Rajendra Apte, MD, PhD, examine Kathleen Eisterhold’s eyes, using technology that one day may make it possible to screen patients for Alzheimer’s disease during an eye exam. In a small study, the eye test was able to detect the presence of Alzheimer’s damage in older patients with no symptoms of the disease.

Credit: Matt Miller

It may be possible in the future to screen patients for Alzheimer’s disease using an eye exam.

Using technology similar to what is found in many eye doctors’ offices, researchers at Washington University School of Medicine in St. Louis have detected evidence suggesting Alzheimer’s in older patients who had no symptoms of the disease.

Their study, involving 30 patients, is published Aug. 23 in the journal JAMA Ophthalmology.

“This technique has great potential to become a screening tool that helps decide who should undergo more expensive and invasive testing for Alzheimer’s disease prior to the appearance of clinical symptoms,” said the study’s first author, Bliss E. O’Bryhim, MD, PhD, a resident physician in the Department of Ophthalmology & Visual Sciences. “Our hope is to use this technique to understand who is accumulating abnormal proteins in the brain that may lead them to develop Alzheimer’s.”

Significant brain damage from Alzheimer’s disease can occur years before any symptoms such as memory loss and cognitive decline appear. Scientists estimate that Alzheimer’s-related plaques can build up in the brain two decades before the onset of symptoms, so researchers have been looking for ways to detect the disease sooner.

Physicians now use PET scans and lumbar punctures to help diagnose Alzheimer’s, but they are expensive and invasive.

In previous studies, researchers examining the eyes of people who had died from Alzheimer’s have reported that the eyes of such patients showed signs of thinning in the center of the retina and degradation of the optic nerve.

In the new study, the researchers used a noninvasive technique — called optical coherence tomography angiography — to examine the retinas in eyes of 30 study participants with an average age in the mid 70s, none of whom exhibited clinical symptoms of Alzheimer’s.

Those participants were patients in The Memory and Aging Project at Washington University’s Knight Alzheimer’s Disease Research Center. About half of those in the study had elevated levels of the Alzheimer’s proteins amyloid or tau as revealed by PET scans or cerebrospinal fluid, suggesting that although they didn’t have symptoms, they likely would develop Alzheimer’s. In the other subjects, PET scans and cerebrospinal fluid analyses were normal.

“In the patients with elevated levels of amyloid or tau, we detected significant thinning in the center of the retina,” said co-principal investigator Rajendra S. Apte, MD, PhD, the Paul A. Cibis Distinguished Professor of Ophthalmology and Visual Sciences. “All of us have a small area devoid of blood vessels in the center of our retinas that is responsible for our most precise vision. We found that this zone lacking blood vessels was significantly enlarged in people with preclinical Alzheimer’s disease.”

The eye test used in the study shines light into the eye, allowing a doctor to measure retinal thickness, as well as the thickness of fibers in the optic nerve. A form of that test often is available in ophthalmologist’s offices.

For this study, however, the researchers added a new component to the more common test: angiography, which allows doctors to distinguish red blood cells from other tissue in the retina.

“The angiography component allows us to look at blood-flow patterns,” said the other co-principal investigator, Gregory P. Van Stavern, MD, a professor of ophthalmology and visual sciences. “In the patients whose PET scans and cerebrospinal fluid showed preclinical Alzheimer’s, the area at the center of the retina without blood vessels was significantly larger, suggesting less blood flow.”

Added Apte: “The retina and central nervous system are so interconnected that changes in the brain could be reflected in cells in the retina.”

Of the patients studied, 17 had abnormal PET scans and/or lumbar punctures, and all of them also had retinal thinning and significant areas without blood vessels in the centers of their retinas. The retinas appeared normal in the patients whose PET scans and lumbar punctures were within the typical range.

More studies in patients are needed to replicate the findings, Van Stavern said, but he noted that if changes detected with this eye test can be used as markers for Alzheimer’s risk, it may be possible one day to screen people as young as their 40s or 50s to see whether they are at risk for the disease.

“We know the pathology of Alzheimer’s disease starts to develop years before symptoms appear, but if we could use this eye test to notice when the pathology is beginning, it may be possible one day to start treatments sooner to delay further damage,” he said.

O’Bryhim BE, Apte RS, Kung N, Coble D, Van Stavern GP. Optical coherence tomography angiography findings in pre-clinical Alzheimer’s disease. JAMA Ophthalmology, Aug. 23, 2018.

This work was supported by Research to Prevent Blindness and by a grant from Optovue Inc.

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Story Source:

Materials provided by Washington University School of Medicine. Original written by Jim Dryden. Note: Content may be edited for style and length.

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Journal Reference:

1. O’Bryhim BE, Apte RS, Kung N, Coble D, Van Stavern GP. Optical coherence tomography angiography findings in pre-clinical Alzheimer’s disease. JAMA Ophthalmology, 2018; DOI: 10.1001/jamaophthalmol.2018.3556

https://bit.ly/2o91CKj

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Other Amazon Effect : How Prices Became Less Insulated From Supply Shocks

Increased online competition has made retailers faster to adjust prices and more likely to hold prices constant across geographic locations, according to new research presented here.

This could make retail prices more sensitive to shocks from tariffs or oil prices than they were in past periods, according to a paper released Saturday at the Kansas City Fed’s annual symposium.

The popular press has focused on the disinflationary forces of online retailers, or the so-called Amazon effect, that has led to declines in consumer goods prices. Harvard Business School’s Alberto Cavallo took a different tack in his paper examining pricing behaviors in the Amazon era. After all, the disinflationary effects of online retailing could eventually run their course because markups can only fall so far, he wrote.

Meantime, these other changes in pricing, where retailers have grown both more flexible and their prices have grown more uniform across locations, could prove longer-lasting.

Mr. Cavallo found the frequency of price changes in multichannel retailers — those that sell online and in bricks-and-mortar stores — has increased over the past decade. The average duration of regular price changes that exclude temporary discounts and sales has fallen from 6.7 months in 2008 to 2010 to 3.7 months in 2014 to 2017.

The increased frequency of pricing changes, moreover, is particularly pronounced in sectors where online retailers have a stronger presence, such as electronics and household goods.

Mr. Cavallo also examined how several large retailers — Amazon, Walmart, Best Buy and Safeway — set prices across different sales locations. Because Amazon is primarily an online retailer, its prices are the most uniform. But he found the degree to which the other retailers with predominantly bricks-and-mortar operations maintained uniform pricing was nearly as high as Amazon. Food and beverage sales, he found, are the one area in which prices are more geographically dispersed.

“The transparency of the web imposes a constraint on brick-and-mortar retailers’ ability to price discriminate across locations,” wrote Mr. Cavallo.

The upshot for policy makers, including central bankers that are on watch for higher inflation, suggests that retailers that are both faster to adjust prices and more likely to charge the same prices across locations will react faster to shocks, such as higher import tariffs or changing oil prices.

“These results suggest that retail prices are less insulated from this type of aggregate shock than in the past,” wrote Mr. Cavallo.

https://bit.ly/2P3lxWE

Are Physicians Ready for Medical Marijuana?

Do you feel comfortable with authorizing medical cannabis for patients?

TOPPING	SLICES
No	26
Yes	21

• No – 55%
• Yes – 45%

(Total Votes: 47)

08.24.2018

— Dr Dave (H+N Surgical Oncology)

Yes and have for some time BUT I prefer the CBD component only
My concern is the THC component still is a wild card. We don’t know if the THC is anything more then the high psychoactive component or if it is a key to actually giving results.
We have recommended CBD oils for several YEARS now as it is and has been legal in all 50 states and the Fed for years and years so it poses no discussion about incinerated compounds psychoactive side effects or legal concerns
It tastes like crap but it works GREAT at reducing the need for opioids and anti-nausea on oncology patients
For those who want medical MJ that is fine as well. Cheaper but more hassle factor
Dr. Dave

https://bit.ly/2MNgXy6

Electronic Medical Records: Holy Grail for Blockchain

Over the past decades, politicians and entrepreneurs alike have tried and failed to solve the problem of healthcare interoperability, leaving patients increasingly frustrated at the lack of control over personal medical records.

Now, industry leaders are hoping that blockchain technology might be the answer. Though blockchain is typically associated with cryptocurrencies like Bitcoin, it is now being explored as a way to create shared networks of healthcare data.

According to experts gathered at last week’s Blockchain Healthcare Summit here, blockchain is a dramatically better way to store, share, and protect sensitive data among disparate groups.

“If you were to do something from scratch, you would do it on blockchain,” said Ben Jessel of Kadena, a recent spinoff from JP Morgan Chase. Blockchain has a real shot at untangling the mess of electronic health records because, for the first time, it’s encouraging all the major healthcare stakeholders to come together, Jessel said.

Countries like Estonia and Australia are already using blockchain to manage health data and broker transactions among patients, healthcare providers, and federal insurance programs.

According to self-described “blockchain evangelists,” many of whom spoke at last week’s conference, blockchain will soon usher in a utopian future in which each patient has control of his or her entire medical record, easily accessible through an app-like interface.

In this vision, patients are the touchstone of their own medical records, licensing data out to payors and providers only as needed.

But according to Jim Nasr of Certara’s Synchrogenix unit, “right now, it’s just largely science fiction — at least here in the U.S.”

“Everyone’s favorite use case is medical records on the blockchain,” said John Bass, founder and CEO of Hashed Health. “I love that use case as well, but I just think it’s going to take a while to get there.”

Despite the $5.6 billion projected market for blockchain in healthcare by 2025, most blockchain applications thus far have focused on lower-hanging fruit, like supply chain logistics or physician credentialing.

That’s because protected health information — which includes names and identifying information defined by the Health Insurance Portability and Accountability Act (HIPAA) — is considered “toxic” data, says Bass.

Despite the regulatory and governance obstacles surrounding protected health information, there are about a half dozen companies trying to create blockchain based personal health and electronic health records, says Heather Flannery, co-founder of Blockchain in Healthcare Global.

Those include startups such as MintHealthand Medicalchain, which have both have launched blockchain applications to manage electronic medical records.

“Their work is important and valuable, but it’s stuck,” said Flannery, noting that some tech companies are skipping the U.S. healthcare market entirely and instead deploying their blockchain solutions in the developing world.

Blockchain in Healthcare Global is a trade organization whose aim is to reduce deeply entrenched governance and regulatory barriers that are stifling blockchain innovation.

Healthcare providers in the U.S. have “zero risk tolerance” when it comes to managing electronic medical records, said Flannery.

“The only way this is going to happen — and this is my opinion — is if our government partners with the providers and [becomes] part of the initiative directly,” Flannery said. That way, “providers do not have to worry about the reaction the government may have about the potentially hundreds of micro-policy decisions that have to be made to move something like this forward.”

Despite the regulatory challenges of dealing with patient data, blockchain’s ability to manage data that’s both tamper proof and anonymous makes it the best solutions to fix healthcare’s interoperability problems, according to Shada Alsalamah, a visiting scholar in MIT’s Media Lab.

“Different technologies have been tried over the years, but there are a lot of security problems, and a lot of privacy problems,” she said. If deployed correctly, blockchain can “help give patients better quality of life by connecting their electronic medical records to allow seamless sharing of medical record across healthcare providers.”

This is the fourth in a MedPage Today series about uses of blockchain technology in health care. Earlier installments included:

Blockchain: The Future for Research Data Integrity?

Blockchain Holds Promise for Thwarting Drug Counterfeiters

Vetting Physician Credentials: Tech to the Rescue?

https://bit.ly/2BYwAif

Early Hip Fracture Surgery Reduces Mortality

A new study in CMAJ reports that seniors are more likely to survive a hip fracture if the surgery is done as soon as they’re admitted to the hospital — suggesting that hospitals should expedite operating room access for patients whose surgery has already been delayed for nonmedical reasons.

An international team of researchers estimated that 16.5% of in-hospital deaths after a hip fracture could have been avoided if patients had received surgery within 48 hours of checking into the hospital, according to the study.

A claims database study in Canada studied the outcomes of 139,119 medically stable patients over 65 years old who sustained a hip fracture according to the delay in hip surgery: day of admission, inpatient day 2, day 3, and after day 3.

The 30-day in-hospital mortality was 4.9% among patients who were surgically treated on admission day, but increased to 6.9% for surgery done after day 3. The researchers calculated an additional 10.9 deaths per 1,000 surgeries if all surgeries were done after inpatient day 3 instead of on the day of admission. The attributable proportion of deaths for delays beyond inpatient day 2 was 16.5% (95% CI 12.0%-21.0%).

Jack Cush, MD, is the director of clinical rheumatology at the Baylor Research Institute and a professor of medicine and rheumatology at Baylor University Medical Center in Dallas. He is the executive editor of RheumNow.com. A version of this article first appeared on RheumNow, a news, information, and commentary site dedicated to the field of rheumatology. Register to receive their free rheumatology newsletter.

• Primary Source

  Canadian Medical Association Journal

  Source Reference: Sobolev B, et al “Mortality effects of timing alternatives for hip fracture surgery” CMAJ 2018; doi: 10.1503/cmaj.171512.

https://bit.ly/2NkNtVg

Tele-Monitoring of Heart Failure Cuts Admissions, Mortality

Telemedicine monitoring in heart failure patients seemed to reduce the percentage of days lost due to unplanned cardiovascular hospital admissions and all-cause mortality, researchers reported here.

Patients assigned to remote management lost a mean of 17.8 days per year due to unplanned hospitalization compared with 24.2 days per year lost by patients assigned to usual care, for a relative risk reduction of 20% (P=0.046), according to Friedrich Koehler, MD, of the Center for Cardiovascular Telemedicine at Charite-Universitätsmedizin in Berlin, and colleagues.

In addition, the all-cause death rate was 11.34 per 100 patient-years versus 7.86 per 100 patient-years among the telemedicine patients (P=0.028), they stated in a presentation at the European Society of Cardiology annual meeting and in the Lancet.

However, cardiovascular mortality was not significantly different between the two groups (HR 0.671, 95% CI 0.45-1.01, P=0.0560), the authors noted.

“The Telemedical Interventional Management in Heart Failure II (TIM-HF2) trial suggests that a structured remote patient management intervention, when used in a well-defined heart failure population, could reduce the percentage of days lost due to unplanned cardiovascular hospital admissions and all-cause mortality,” Koehler’s group wrote. “To the best of our knowledge, this is the first randomized clinical trial to use a structured remote patient management intervention that was designed to be a true holistic approach for the management of patients with heart failure, involving cardiologists, general practitioners, nurses, other health-care providers, and the patient.”

From Aug. 13, 2013 to May 12, 2017, 1,571 patients were randomly assigned to remote patient management (n=796) or usual care (n=775). Of these, 765 in the remote patient management group and 773 in the usual care group started their assigned care, and were included in the full analysis set, the authors noted.

Eligible patients had heart failure, were New York Heart Association class II or III, and had a left ventricular ejection fraction (LVEF) of ≤45%. They also had to have been admitted to hospital for heart failure within 12 months before randomization. Patients with an LVEF >45% had to be on prescribed oral diuretics.

Patients were randomly assigned (1:1) with a secure web-based system to either remote patient management plus usual care or to usual care only. They were followed up for a maximum of 393 days. The primary outcome was percentage of days lost due to unplanned cardiovascular hospital admissions or all-cause death, while key secondary outcomes were all-cause and cardiovascular mortality.

The authors pointed out that “data transmitted to the telemedical center was not just monitored; the Fontane system (telemedical analysis software) enabled the telemedical center staff to provide tailored patient support and management using predefined algorithms and biomarker values obtained during follow-up visits. This approach enabled a risk profile to be defined for each patient and the subsequent individual patient care was tailored around this risk profile accordingly.”

They noted that the telemedical center care concept did require the involvement of physicians and heart failure nurses. Ideally, such a service runs for 24 hours a day, 7 days a week, and has a “modern information technology infrastructure, including a self-adapting software algorithm with prioritization rules, to enable the tailored management of a large number of patients.”

These elements set the TIM-HF2 trial apart from other telemedicine studies, said Mary Norine Walsh, MD, of St. Vincent’s Hospital in Indianapolis.

“Telemedicine has a checkered past. Previous studies have left decision-making up to a doctor who was given reports and he or she decided what to do. This system recommends action be taken — with the whole team on site day or night,” Walsh, who is a a spokesperson for the American College of Cardiology, told MedPage Today.

But she pointed out that the system was set up under a German government grant. “Before I would advocate for such a system here, I would like to see a thorough cost analysis,” she cautioned.

In an accompanying comment, John F. G. Cleland, MD, of the University of Glasgow, and colleague, noted that the result from TIM­-HF2 was similar to that of the TEN­-HMS trial, in which the proportion of days lost due to death or hospital admission >450 days with usual care was 37% versus 22.6% with remote management, for a difference between means of -65 days (95% CI -4 to -125).

“Neither study on its own has sufficient statistical power to be completely convincing but, despite much clinical skepticism and feeble support from most guidelines, in our view the growing weight of evidence suggests that home telemonitoring does reduce mortality for patients with heart failure, this effect might be substantial,” they wrote.

They pointed out that some of the “key issues” with telemonitoring that need to be resolved are the development of sustainable business models, integration into existing health services, and overcoming the skepticism of health­care professionals who have no telemonitoring experience.

But they also stressed that “Home telemonitoring puts the patient back in the centre of healthcare, ensuring that they know what the health professional is trying to achieve and that they agree with those aims.”

The trial was funded by the German Federal Ministry of Education and Research.

Koehler disclosed relevant relationships with NexGen-Next Generation of Body Monitoring, Novartis, Abbott, and Medtronic International.

Walsh disclosed no relevant relationships with industry.

Cleland disclosed relevant relationships with AstraZeneca, GlaxoSmithKline, Johnson & Johnson, MyoKardia, Sanofi, Servier, Amgen, Bayer, Bristol-Myers Squibb, Philips, Stealth Biopharmaceuticals, Torrent Pharmaceuticals, Medtronic, Novartis Vifor, Pharmacosmos, and Pharma Nord.

LAST UPDATED 08.25.2018

• Primary Source

  The Lancet

  Source Reference: Koehler F, et al “Efficacy of telemedical interventional management in patients with heart failure (TIM-HF2): a randomised, controlled, parallel-group, unmasked trial” Lancet 2018; DOI: 10.1016/S0140-6736(18)31880-4.

• Secondary Source

  The Lancet

  Source Reference: Cleland JFG and Clark RA “Telehealth: delivering high-quality care for heart failure” Lancet 2018; DOI: 10.1016/S0140­6736(18)31995­0.

https://bit.ly/2o7alga

Lupin gets tentative FDA OK for generic contraceptive

Lupin announced that it has received tentative approval for its Nudovra (Estradiol Valerate Tablets, 3 mg and 1 mg and Estradiol Valerate and Dienogest Tablets, 2 mg/2 mg and 2 mg/3 mg) Tablets from the United States Food and Drug Administration (FDA) to market a generic version of Bayer HealthCare Pharmaceuticals Inc.’s Natazia Tablets.

Lupin’s Nudovra (Estradiol Valerate Tablets, 3 mg and 1 mg and Estradiol Valerate and Dienogest Tablets, 2 mg/2 mg and 2 mg/3 mg) Tablets is the generic version of Bayer HealthCare Pharmaceuticals Inc.’s Natazia Tablets. It is an estrogen/progestin combined oral contraceptive (COC), indicated for use by women to prevent pregnancy.

Clobetasol Propionate Cream USP 0.05% had annual sales of approximately USD 108.6 million in the US (IQVIA MAT June 2018).

Nudovra Tablets had annual sales of approximately USD 31.4 million in the US (IQVIA MAT June 2018).

https://bit.ly/2BME082