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To Operate or Not: The Dilemma of Preventative Cardiac Surgery

by Shaffin Siddiqui

While it may be considered a platitude, the objective of medicine – in addition to actually administering hands-on care – is to pursue the path of treatment that minimizes long-term harm. Hence, the role of the doctor is not to simply slice and dice, but also to advise a patient whether to undergo the risky route of an invasive operation in the first place. Should one undergo the arduously invasive procedure of receiving a pacemaker for a heart chronically prone to arrythmia or settle for the less onerous alternative, albeit less bulletproof, alternative of oral treatment? The dilemma is often times acute, yet how often is it that this gradient of risk is assessed with the scruple it deserves…?

This past summer I had the privilege of conducting clinical research in the field of cardiology with Dr. William Roberts M.D[DS1] . at Baylor Scott and White in Dallas, Texas. With his guidance, I investigated replacement of the aorta in patients with congenitally abnormal aortic valves. Most individuals are born with normal three-leaflet (tricuspid) aortic valves which are located at the juncture of the left ventricle and aorta, from which oxygenated blood flows to the rest of the body. However, 1% of the American population is born with two-leaflet (bicuspid) aortic valves. In early cardiology, being born with these valves was strongly associated with aortic dilation (also given the scarier and more provocative label of “aortic aneurysm”) during one’s adult life. While bicuspid patients tend to see highest incidences of aortic dilation, many with normal valves experience idiopathic (i.e. random) dilation as well. Researchers[DS2]  and doctors believed that the more dilated an aorta from its normal size, the more likely it was to crack open (i.e. dissect) or even rupture fully – incidents, both of which, are acutely painful and potentially fatal.

If aortic dilation is detected even in mild amounts, especially in patients with bicuspid aortic valves, surgeons insist that patients preemptively opt for an elective surgery to replace their dilated aorta in order to prevent the incidence of dissection/rupture in the future should it dilate even more. The thought of an aorta slowly expanding and popping, like a balloon, is terrifying to both physician and patient. Even if a surgeon happened to be performing cardiac surgery for another “neighboring” issue and incidentally noticed the patient had aortic dilation, many would subsequently replace the aorta in addition to the initial operation intended.

However, recent clinical data (~2007 onwards) has contested the need to categorically replace dilated aortas. Some aortas are so enlarged that it goes without saying that they deserve the title of aneurysm and need to be replaced. But, even then, rates of aortic dissection across the most frequently occurring sizes of dilation were shown to be exceedingly low. As well, rates of aortic expansion (i.e. how fast an aorta dilates) were shown to be quite low – if not, negligible – reducing the need to panic to preempt disaster. Even more strikingly, patients with bicuspid aortic valves were shown to be equally at risk for dissection/rupture as those with normal valves if given the same degree of dilation. Bicuspid patients, who had their aortas replaced the most frequently, had nothing to fear more than a patient with ordinary valves.

Given the data, one would think surgeons would be more deliberate in their decision to remove dilated aortas, especially with the operational risk associated cardiac surgery and specifically aortic replacement. Yet, my time at Baylor with Dr. Roberts, a cardiac pathologist – who looked at excised cardiac tissue post-operationally – showed me something quite different: countless pieces of functional heart tissue that were excised seemingly needlessly, and the most frequent organ amongst them: mildly dilated aortas. Indeed, the majority of the time the tissue was macroscopically and microscopically normal! As someone who has personally suffered from the tragedy of superfluous invasive operation, I was appalled. What could be behind this? For one, some CT surgeons are just not up to date on the data, and, to their credit, these studies are fairly new. Nonetheless, surgical practices should be in tune with changes in literature, especially when there is so much at stake, as with cardiac surgery.  The bigger catalysts, however, seem to be more pecuniary: cardio-thoracic surgeons are paid by the operation, not by a fixed salary. As such, like it or not, there are incentives to operate on pathologies, even if they are likely benign for the patient. These operations are often elective, meaning the patient can opt out. When physicians, however, throw words like “aneurysm” onto the table, patients have a proclivity to panic. As such, combatting the tendency to needlessly operate requires a fundamental shift in health policy. While fixed salaries may be a somewhat tenable solution, this is an issue in health care that requires more awareness and the serious thought of health-care officials.

The views expressed in this article are mine alone, and do not express the opinion of the Princeton Public Health Review.


Dementia: A Forgotten Crisis

By Chino Kieran Eke

In the United States, there are approximately 5.8 millions Americans living with Alzheimer’s disease. This disease causes the slow loss of mental faculties, including memory, critical thinking, and the ability to carry out simple tasks. While the disease principally affects individuals in their mid-60s, it is projected to impact the lives of 13.8 million Americans by 2050 despite medical advances that have improved the overall quality of life of afflicted patients.

While the treatment for Alzheimer’s disease is largely ineffective in the pharmaceutical realm, complementary therapies have proven to help maintain or improve the quality of life of a person with Alzheimer’s. For example, music therapy has proven to treat the behavioral and psychological symptoms of dementia. It enables people with Alzheimer’s to form meaningful human interactions with the therapist. Although music therapy and other complementary therapies do not provide a cure for the disease, they improve the quality of life for those with Alzheimer’s.

Alzheimer’s is believed to be caused by the buildup tau proteins which form plaques that effectively block the spread of information between neurons. As more plaques form, the information flow between neurons becomes more restricted, impairing a neuron’s ability to function properly. These plaques eventually cause neuronal death which leads to the shrinkage of the brain and the loss of memory, control over reasoning, language and thinking. Ultimately, this disease has devastating effects on those it affects and their loved ones. 

In 1980, a Congressional Hearing was held on the impact of Alzheimer’s disease on America’s elderly in order to help establish public funding for citizens with the disease. During this hearing, Alzheimer’s patients without proper care were described as suffering an “unbearable loss of dignity and self-respect” which undeniably has had a “crushing impact upon their spouses.” This hearing, ultimately, lead to the establishment of public funding for hospice and long-term care through Medicaid which cost the government an approximate “$290 billion for Alzheimer’s or other dementias” in 2019. With a growing number of Americans expected to have Alzheimer’s by 2050, the annual spending is projected to increase to 1.1 trillion. The near quadrupling of the current cost demonstrates how Alzheimer’s and other dementias present a daunting crisis for society. 

Currently, pharmaceuticals such as “cholinesterase inhibitors and memantine only treat the cognitive symptoms of Alzheimer’s disease,” but no medications exist that directly treats or prevents the buildup of tau plaques in the brain. There have been a number of studies performed in the last decade that have led to major advancements in the understanding of the disease, but they have all been quite limited in scope. This is primarily due to “low recruitment and high attrition rates” of research subjects with Alzhermier’s disease or related dementias. The best solution to this research impediment is increasing awareness surrounding the importance of this type of research; perhaps, then, rates of public participation might actually rise and a pharmaceutical treatment that slows or prevents the progression of plaque buildup may become a reality. 

Image was found on https://www.getdoc.com/mental-exercise-dementia/

The First Cancer Vaccine: Design, Barriers, and Importance

By Zsombor Gal

In 2018, the World Health Organization counted nearly 570,000 new cases of cervical cancer in addition to 310,000 deaths worldwide. Roughly 90% of these deaths occurred in low- and middle-income countries, where screening and treatment programs are not as readily available as in developed nations. Though it may be surprising, prevention of cervical cancer through vaccination has only recently been viewed as a comprehensive solution to this global health crisis.

21st century innovation provided the first vaccine specifically approved for the prevention of cancer. In 2006, the U.S. Food and Drug Administration approved a vaccine developed by Merck & Co. to prevent human papillomavirus (HPV) infection. The tetravalent vaccine, known as Gardasil, protects against four HPV strains known to cause cervical, anal, vulvar, vaginal, and penile cancers. More recently, Gardasil 9 was approved to protect against five additional HPV strains associated with cervical cancer. These vaccines contain virus-like particles, which consist of self-assembled HPV capsid proteins, but lack the viral DNA. Thus, the vaccine enables the recipient to produce antibodies against HPV virions while preventing the production of harmful viral proteins that are responsible for disease. HPV is an example of a transforming virus, in that it encodes proteins that inactivate tumor suppressor proteins within human cells. This causes the rapid proliferation of cells, leading to tumor formation. Hence, as HPV is the most common sexually transmitted infection, not only in the United States but globally, it represents a serious threat to human health.

Not everyone infected with HPV will develop cancer. In fact, HPV is typically cleared by the immune system or simply causes precancerous lesions such as skin warts. However, exposure to high-risk HPV strains or long-lasting infectious greatly increases the risk for cancers caused by HPV. Because the risk of death due to these cancers is exceptionally high, it is important that all children and adolescents receive the vaccine prior to becoming sexually active.

However, this has unfortunately not been the case. In 2017, the Centers for Disease Control and Prevention reported that only 49 percent of adolescents in the United States are up to date on HPV vaccination. Many developing nations fall short of this statistic or have only recently introduced countrywide vaccination programs. The reasons for low vaccination rates encompass a variety of factors, including awareness, healthcare accessibility, cost, and misguided parental decisions.

Cancer-causing viruses are not a recent discovery, but public awareness of genital and oropharyngeal cancers caused by HPV is strikingly low. Additionally, because HPV is typically diagnosed in sexually active adults, many pediatricians are either unaware of the cancer risk or unwilling to discuss sex with the parents of younger children. The HPV vaccine may be suffering from an “image problem,” as it is often portrayed as a sexually transmitted disease vaccine, not as a cancer prevention vaccine. This contributes to parental anxieties that receiving the vaccine may encourage sexual promiscuity at a young age.

Poor access to healthcare and infrequent medical check-ups also contribute to low vaccination rates. Citizens of developing nations and minority populations face difficulties in obtaining regular care by a physician at all and thus have lower vaccination rates overall. Further complicating the matter is the fact that the HPV vaccine is rather expensive. Those without health insurance can expect to pay $250 dollars per dose for Gardasil in the United States, which consists of three doses!

The HPV vaccine clearly needs a rebranding. As the world’s first vaccine against cancer, and perhaps the simplest form of cancer prevention aside from lifestyle change, it seems illogical that parents should reject vaccination for their children. Initiatives must be put into place to serve populations without reliable and inexpensive access to healthcare, as well as in developing nations with high incidences of HPV infection. There is hope: leaders in these countries may choose to follow the example of Rwanda, a sub-Saharan nation that has achieved 93% vaccination coverage. Rwandan leaders combined the expertise and influence of state agencies, infectious disease entities, and international vaccine providers to reach a substantial portion of the population within a short period of time. The elimination of preventable cancers such as HPV would be a major milestone in the history of medicine.

Our Unexpected Ally in the Fight against Zika: Mosquitoes

By: Nicholas Persaud

 

Zika is my no means a novel development. In fact, the virus that causes Zika was first identified in a monkey living in the Zika forest in 1947. One year later a specific species of mosquito called Aedes africanus was determined to be the mosquito that carries the virus. The first time a human contracted the Zika virus was actually in 1952, but it was not until 2007 that the first major outbreak occurred. The symptoms of the Zika virus, while potentially serious, are by no means out-of-the-ordinary and include pain in various parts of the body, rashes, and fever.

However, one of the main reasons why Zika has gained so much attention is because of the negative health effects it has on newborns. Zika has been shown to cause microcephaly in infants, a devastating condition that leads to abnormal brain development. Because it’s spread by mosquitoes, often an unavoidable reality in tropical regions, it has become of the most frightening health crises in our modern world.

The Zika virus has been spreading across the globe and has managed to find its way to the United States. In order to combat the rapid growth of Zika researchers have been desperately searching for a method to combat Zika. It just so happens that the people of Florida are considering fighting fire with fire. A British biotech company called Oxitec has genetically modified the Aedes aegypti mosquito in order to prevent the spread of Zika. The scientists of Oxitec have modified the mosquitoes so that they will not be able to produce viable offspring upon mating. Essentially, the purpose of these mosquitoes is to significantly reduce mosquito populations by being sterile.

Oxitec released their genetically modified mosquitoes in other countries and the results were favorable. The next place that Oxitec wants to release its mosquitoes in is Florida. Florida has had multiple reported cases of Zika and Oxitec believes that its mosquitoes will offer a solution. The FDA has approved the the genetically modified mosquitoes and deem it safe to be tested in Florida. However, before releasing the mosquitoes government officials want the consent of the residents and not everyone is willing to give it.

Many residents in Florida are against the release of the mosquitoes because they fear that it will have drastic effects on the environment. Oxitec attempted to alleviate the fears of the residents by making a statement that the mosquitoes will “not have a significant impact on the environment”. Despite this, people are still against the idea of releasing the mosquitoes in Florida. Government officials are asking residents to vote in order to express their opinion on the matter. While the vote will reflect the public opinion it may have little impact on the decision to release the mosquitoes because the officials can choose to ignore the results. The majority of government officials say that they will take into account the results of the election when making the final decision. The vote will take place on November 8, which coincidentally is the same day America makes its decision on who the next president will be. Even with the negative feedback from the public the possibility that the mosquitoes will be released is very high, marking a potential first step in the fight against a dangerous contagion. 

Is Acupuncture a Placebo?

By: Barbara Gruszka

You may have seen the Grey’s Anatomy episode where Dr. Meredith Grey ruins Dr. Dereck Shepard’s Alzheimer disease trial with the placebo drugs by interfering with the randomization of the placebo and the experimental drugs.[1] These “placebo trials” are not at all a Hollywood dramatization of the real world- the placebo effect is used to test various kinds of medications and surgical operations to see how patients react psychologically to the treatment.

What is the Placebo Effect?

A placebo is an inactive treatment, much like a “sugar pill”, that does not contain any active substance or ingredient.[2] In simpler terms, a placebo is not a medication. A placebo can be administered in many forms: pill, injection, or surgical procedure.

The placebo effect, on the other hand, is the psychological belief that the “treatment” administered is working for the greater good of the patient. The subject of the treatment feels that the placebo is working, and the medical condition is resolved even upon application of an inactive, or fake, treatment. Some medical studies require a double-blind control placebo, where the patient does not know whether they are receiving an active or inactive treatment, and the doctor does not know which is administered. This way, the results are reported without any bias and the full effect of the placebo versus that of the drug being tested can be measured.

As always, there may be a negative result that can be experienced even when receiving the inactive treatment. In this case, the placebo is a nocebo, and the patient experiences negative symptoms.[3]

Acupuncture and Theoretical Placebo

Acupuncture is a traditional Chinese practice of inserting needles in specific points around the body called “acupoints”.[4] These points are believed to influence certain parts of the body through a natural flow of energy, known as chi.[5]

While there have been many studies conducted to test the effectiveness of acupuncture, there have been no real conclusive results. In fact, some studies run by Harvard professor Ted Kaptchuk have examined the placebo effect in the context of acupuncture, where retractable needles are “inserted” into the test subject and the patient is observed for any medical changes or symptoms.[6] Ironically enough, the test subjects of the placebo experiment noted negative results after the placebo acupuncture.

With this in mind, could the idea of receiving  acupuncture treatment trick the mind into believing that certain parts of the body are healing? “Tricking” the mind through acupuncture, to many a well-accepted medical practice, could deliver an effect similar to a placebo treatment and lead one to believe that he or she is healed. Researchers looking to find more about the placebo effect, like Ted Kaptchuk, look to find how the stimulation of placebo treatments affects the brain and how the brain can control our body’s mechanisms, as if to allow the brain to function as its own treatment. [7] Scientists like Kaptchuk hope to uncover the specific neural pathways and encoding that produce the placebo effect: in other words, is “feeling better” after a treatment linked with specific activity in a brain region?

[1] “Grey’s Anatomy” (April 28, 2011). ABC Episode: “It’s a Long Way Back”

[2] http://www.cancer.org/treatment/treatmentsandsideeffects/treatmenttypes/placebo-effect

[3] http://www.smithsonianmag.com/science-nature/what-is-the-nocebo-effect-5451823/?no-ist

[4] www.evidencebasedacupuncutre.org

[5] http://www.mayoclinic.org/tests-procedures/acupuncture/basics/definition/prc-20020778

[6] http://harvardmagazine.com/2013/01/the-placebo-phenomenon

[7] http://harvardmagazine.com/2013/01/the-placebo-phenomenon