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“Personalized genetic” vs. “the” patch ?

July 14, 2007 by dendrite

A 21 mg patch applied to the left arm
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Uhl and colleagues present a genome-wide search for SNPs that distinguish smokers (nicotine dependence) – and perhaps more importantly – successful smoking quitters, in their recent article in the free and open-access journal BioMed Central. As pointed out in the article, this work is a step closer to personalized “efforts to match vulnerable individuals with the prevention and treatment strategies most likely to work for them.” A set of genetic variants that distinguish nicotine dependence from a control population with no personal history of smoking or substance abuse was identified and a novel set of variants that distinguish folks who’ve had success after using the patch and other self-help methods are exciting new tools that were produced by the study.

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GINA and the death of health insurance ?

July 7, 2007 by dendrite

Health care for all protest outside health ins...
Image by Steve Rhodes via Flickr

I much enjoyed the recent article, “Do Not Ask or Do Not Answer” in the August 25th Economist. As genetic data begins to trickle into the hands of consumers, the debate on genetic privacy grows more intense. On the one hand, the article notes that the SRY gene has long been used to price insurance (its the gene that determines the male vs. female pathway during embryonic development – sorry males) and that a look at one’s parents and siblings gives a fairly decent sense of one’s genetic liabilities. On the other hand, the article notes a study showing that folks who find they carry a potent Alzheimer’s risk gene are more likely to purchase extra health insurance – thus out-gaming the insurance industry to their discontent. Both hands having acknowledged the disconnect, the article turns to the search for new financial strategies for the future when consumers possess detailed knowledge of their own genomes (speaking of which, take a moment to browse Jim Watson’s genome). Some of the solutions noted were a form of compulsory universal coverage where neither side can outgame the other, HSA’s where out-of-pocket expenses are paid from individual tax free investment account and other new business models such as provided by RedBrick Health where benefits are maximized by optimizing participants behavior. The science is moving fast. Will the health insurance markets keep up?

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Glimpse into the personal genetics near future

June 28, 2007 by dendrite

Navigenics
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I’m not sure how they will compete with the open community effort of the Personal Genome Project, but they do have a very slick commercial. Check out Navigenics and you’ll feel your saliva start to flow !

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Interview central for discussions on healthcare economics

June 21, 2007 by dendrite

If I may shill for the corporate medical industrial complex for a moment … I much enjoyed the video interviews found at the Corporate Research Group. Regina Herzlinger predicts universal coverage, but not a single-payer system – rather a system where consumers have choices. How to decide which plan to chose ???

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Where’s the alpha in healthcare?

June 14, 2007 by dendrite

Its hard not to gawk at the sub-prime mortgage spectacle these days … seems like there are limits to borrowing – who’d a thunk? I was struck reading the news of one fund, Global Alpha, a quantitative strategy fund run by the elite Goldman Sachs firm. Wow, if the brightest of the bright can stumble, I suppose no one will escape unscathed. In any case, the name of the fund ‘alpha‘ – refers to an aspect of the capital asset pricing model (the y intercept) that accounts for endogenous, organic growth of an asset, instead of growth driven by an overall rising marketplace (this type of illusory growth is denoted by beta). I’m not a successful investor, but the ability to identify sources of alpha seems like an important skill.

Which eventually got me wondering … where is the alpha in healthcare? What drives organic growth of the for-profit sector of the healthcare industrial complex? Creativity? New technology? Efficient use of technology? Demographic shifts? Cost-cutting and adverse selection (think Sicko by Michael Moore)? I suppose all of the above.

But, in some ways, the concept of alpha as embodied in the CAPM doesn’t seem to apply quite right … I mean, if we’re doing a great job helping folks stay healthy, shouldn’t that reduce the demand for services? Where’s the growth (alpha) in that?

What business model generates a common benefit such as health and the type of financial alpha needed to attract investors?

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Sobering article on economics of preventative care

June 7, 2007 by dendrite

David Leonhardt’s recent New York Times article “Free Lunch on Health? Think Again” on the economics of preventative medicine suggests the cost of preventative care for the vast majority of healthy individuals does not save money in the long run. The argument seems to go something like … most of the cost of healthcare goes toward a small percent of very sick people and that spending on preventative care does not do much to reduce the size of this already small group. It seems that spending a ‘little on a lot’ of healthy people is equivalent to spending a ‘lot on a little’ group of people.

This seems to me to be one of the big challenges for personalized medicine. How will bio-marker and IT-technologies be deployed to save money? Perhaps when it is cheap, reliable, trustworthy, consumer-friendly and useful enough to encourage individuals to get involved (ie. rewards consumers for paying out of their own pockets) ? Hmmm.

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Genetics and emotional memory – a view from Rawanda

June 2, 2007 by dendrite

Map showing principal routes in RwandaImage via Wikipedia

Dominique JF de Quervain and colleagues provide an elegant example of how genetic differences can relate to complex traits such as the ability to recall emotionally laden experiences. In their recent Nature Neuroscience paper, they looked at a deletion of 3 glutamic acid residues (301–303) in the third intracellular loop of the alpha-2-adrenergic receptor and its relation to emotional memory. Since emotion-laden experience (fight-or-flight) is often accompanied by surges in noradrenaline, it makes sense that adrenergic receptors might facilitate such memories. In this case, the deletion genetic variant encodes a slightly less effective receptor whose carriers show enhanced recall of positive and negatively charged images – a memory effect that is similarly achieved when the receptor is blocked using the antagonist yohimbine.

Such genetic findings can lend themselves quickly to practical applications. One first step to begin to understand how the ADRA2B genetic influence might be used to help alleviate the sometimes debilitating effects of persistent emotional memory was an examination of individuals who fled from the Rwandan civil war and were living in the Nakivale refugee camp in Uganda at the time of investigation. Individuals who carry the deletion genetic variant were more likely to re-experience symptoms of traumatic events although, this particular variant is present at relatively low frequencies (about 1 in 8 individuals are carriers).

Readers may wish to learn more about the Rawandan Civi War and explore channels for aid including Rawanda-Aid and Genocide Intervention.

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Hot soup – no doctor necessary

May 24, 2007 by dendrite

A statue of Asclepius. The Glypotek, Copenhagen.
Image via Wikipedia

My wife was recently unfortunate to spill hot soup on her hand and ended up with a pretty uncomfortable set of 2nd degree burns. At our fingertips (mine anyway) we had easy online access to guidelines for pain management and infection prevention. The next day at work, she was able to see a company-sponsored nurse practitioner who cleaned, redressed and provided a prescription for burn cream. Only after the smoke cleared (or soup as it were) did we realize she was going to be OK and that we had paid $0 so far with a $10 co-pay coming for the burn cream. At dinner that night (we stuck with cold chicken salad) we each wondered uneasily whether we should have, or should think of, going to see a doctor. “Wouldn’t that be best?” “But you seem to have gotten such good care already.” The conundrum reminded me of Andy Kessler‘s book, The End of Medicine, where he becomes a human guinea pig and explores all sorts of medical diagnostics technology and also wonders how much longer people will really need doctors. We’re not as brave as Mr. Kessler, but are certainly wondering how far the consumer revolution can go in healthcare. For the time being, no more soup.

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Brain based algorithms and personalized medicine

May 16, 2007 by dendrite

An image of a 1901 examination in the faculty ...
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I much enjoyed Helen Mayberg’s October 13th podcast, “Paths to Recovery in Major Depression: Insights from Functional Neuroimaging” hosted by Science & the City, the webzine of the NY Academy of Science. One comment that stuck with me was her mention of ‘brain-based algorithms’ for the diagnosis and treatment of mental illness. Indeed, from her talk, there are many brain regions involved in the regulation of mood and that individuals who experience depression may show poor activity in any or all of these brain regions. Also, Dr. Mayberg shows that these various brain regions may be more or less responsive to drug- vs. talk-based therapies. This seems like a major step forward in personalized medicine in psychiatry and perhaps might be augmented by other biomarkers. Presently, scanning is somewhat cumbersome relative to current drug-trial-and-error regimens, but the benefits of recovery far, far outweigh the costs of a lifetime of chronic illness.

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Xeno-phenocopy or true mouse model ?

May 8, 2007 by dendrite

The DISC1 mouse is a major step forward in a translational research path towards understanding how genes contribute to the risk of complex mental disorders such as schizophrenia. The latest mouse (see PNAS – Dominant-negative DISC1 transgenic mice display schizophrenia-associated phenotypes detected by measures translatable to humans by Hikida et al.) attempts to replace the normal mouse gene with a human mutation. The deficits parallel human abnormalities in a remarkable way. Note, however, that Joseph Gogos and colleagues (including my one-time boss Maria Karayiorgou) have shown (see PNAS -Disc1 is mutated in the 129S6/SvEv strain and modulates working memory in mice by Hiroko et al.) that an ostensibly normal mouse inbred strain (normal, that is, if you’re inbred for one, and a mouse, for another) carries a truncated form of DISC1. Both of these mouse models show deficits in frontal cortex dependent behaviors but, together, they also demonstrate how the many interacting genes in the background can modify and ameliorate the effects of a single mutation. Do the genes that modify DISC1 in mice modify risk in humans?

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The new financial order – for healthcare?

April 30, 2007 by dendrite

In, The New Financial Order, professor Robert Shiller offers an in-depth analysis of how finance can and should be used to improve the human condition. By appropriately adapting financial instruments with risk, the consequences of many of life’s sudden shocks (natural disaster, loss of job, health crisis etc.) are readily ameliorated. Although he does not cover health insurance directly, his suggestions on how to better manage other types of risk point to an alternative viewpoint … away from the polarized “universal coverage” vs. “consumer-driven private coverage” debate. New bioinformatic strategies for managing health risk could readily be linked to financial instruments that more efficiently provide buffering to the economic consequences of illness.

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Happenings at Harvard Partners

April 22, 2007 by dendrite

Harvard University
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Christopher Rowland gives a great perspective on the new venture fund at the Harvard Partners Healthcare system. If you want a peek at the future of personalized medicine, check out the Partners Center for Genetics and Genomics – where basic research is seamlessly integrated with clinical care. I attended their first annual meeting in 2005 and took home a lot to think about. This year’s meeting features Regina Herzlinger, who will discuss economic framework issues. I wonder if the Partners system is adopting or experimenting with new payor models … certainly the new venture fund will support research, but what about everyday clinical care?

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Spontaneous mutations and genetic risk

April 16, 2007 by dendrite

Mike Wigler’s team at Cold Spring Harbor Labs finds that spontaneous mutations are more prevalent in patients with autism than in patients with a first-degree relative also with autism. Perhaps the comparative genomic hybridization methods applied in this case will prove useful in sifting our spontaneous vs. ancestral forms of genetic variation in other diseases and mental disorders. Will males be assessed for rates of spontaneous mutation someday?

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James R. Knickman’s views on making an impact in healthcare

April 14, 2007 by dendrite

I much enjoyed listening to the remarks of James R. Knickman, President and Chief Executive Officer, New York State Health Foundation. He reviewed some highlights of his career and the inner thoughts processes of non-profit foundations taking on complex problems. One particular topic he emphasized is the interest that foundations have in better understanding how new technology will alter the healthcare landscape.

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