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Missouri State Medical Association (MSMA) 159th Annual Convention Wrap-Up

At the end of March, David Young, SPHR, Regional Director and I (Lisa Thomas, MD, Director of Psychiatry and Telepsychiatry) attended the Missouri State Medical Association (MSMA) 159th Annual Convention which was held at the Sheraton Kansas City Hotel at Crown Center. It ran from March 31 through April 2 and there were 231 MSMA physicians who were present among the 508 total registrants.

The Exhibit Hall included 30 vendors (counting PSN). The event was very productive as a lot of people stopped by the PSN booth expressing interest in learning more about opportunities to affiliate with us.

Many talked about the frustrations of their current clinical situations and eagerly embraced how the PSN model could reinvigorate enthusiasm for, as well as enjoyment of, practicing medicine. I also met and spoke with a variety of practitioners as I attended lectures, other programming, and the Council as well as House of Delegates in my other roles as general conference attendee, vice-Councilor for District 5, and Delegate from District 5.

David Young and I are following up on the leads generated at the MSMA convention which include a wide range of physicians from Family Practice, to General Surgery, Psychiatry, Ophthalmology, and Oncology.

Reaching Patients Who Lack Access to Care

Across the country, more rheumatology practices are employing telemedicine to treat patients, particularly physicians at academic medicine centers that have the resources to launch comprehensive units.

The technology is a way to bridge the shortage of rheumatologists in rural areas and reach patients who cannot access specialty care for rheumatic conditions, proponents say.

A 2013 study in Arthritis & Rheumatism found that many towns and small cities with populations up to 50,000 have no practicing rheumatologists, with some patients having to travel more than 200 miles to get specialty care.

Telemedicine is growing by leaps and bounds, and rheumatology is a key specialty in which to use the technology, said Jonathan Linkous, chief executive officer for the American Telemedicine Association.
“Telemedicine is expanding both in terms of the number of consultations and the breadth of services involved,” he said. “Tele-rheumatology was certainly not a big area to be looked at in years past, but it’s one more area that is starting to expand.”

For most of doctors and patients involved in the study, tele-rheumatology visits were positive and aided patient access.

Tele-rheumatology: Is it effective?

Research is lacking regarding how prevalent tele-rheumatology has become in the United States and whether it’s as effective as face-to-face visits.

In a recent analysis of 1,468 potentially eligible tele-rheumatology studies and literature, only 20 addressed direct provider to patient contact that influenced or had the potential to influence clinical care, according to a November 2016 review in Arthritis Care & Research.

Of the 20 studies, the majority of articles involved tele-rheumatology use in Europe or Great Britain, said study author John Allen McDougall, MD, a postdoctoral fellow at Yale University, New Haven, Conn.

“The first major finding was that there’s really not much out there as far as high quality research that supports or contradicts the use of tele-rheumatology in wide distribution,” Dr. McDougall said. However, “in general, the conclusion of the authors was a qualified, ‘Yes,’ that [tele-rheumatology] has potential and should go forward.”

According to the literature, the most common condition treated through telemedicine was rheumatoid arthritis. Little information existed on telemedicine use for gout or the treatment of connective tissue diseases, Dr. McDougall said.

Best uses of technology for Tele-rheumatology

In order for more practices to consider tele-rheumatology, more research about cost-effectiveness and best uses of the technology use would be useful, Dr. McDougall said.

“The main question that policy makers are going to want to answer is, ‘What’s the return on investment? Does this make sense for my practice?’ ” he said. “The methods reporting in tele-rheumatologist [literature] is lacking.” But regardless of barriers, telemedicine experts say the technology will likely continue to expand and transform the way rheumatologists are practicing and patients are receiving care.

“Tele-rheumatology will never replace an in-person exam,” Dr. Ferucci said.

“But my vision is that it will be able to improve the quality of care for patients living in rural and remote locations, by allowing for more frequent visits and adjustment of medications, which are necessary to achieve the goal of treat-to-target for RA and other rheumatologic conditions.”

The Rheumatologist has an excellent article online that compliments this story.

Memphis Community Pharmacy Now Open at Scotland County Hospital

Memphis Community Pharmacy Now Open at Scotland County Hospital

Scotland County Hospital and adjoining Memphis Medical Services are pleased to announce the opening of a new community retail pharmacy located in the lobby of Memphis Medical Services. Memphis Community Pharmacy is a full-service retail pharmacy giving hospital & clinic patients direct access to their prescriptions, right in the clinic lobby.

The new pharmacy is open Monday – Friday 8:30 am – 5:30 pm. Patients can have their clinician in any clinic, anywhere, phone in or e-scribe to the Memphis Community Pharmacy. The new pharmacy will offer a free mail-delivery service and a free home delivery service in the near future. The phone number to the pharmacy is 660-465-8568.

Nick Herrmann, PharmD, is the new clinical pharmacist that will manage the Memphis Community Pharmacy at Memphis Medical Services. Nick is a native of Hinckley, Illinois, a small, rural town in North Central Illinois with a population very similar to Memphis. Nick is a 2010 graduate of the St. Louis College of Pharmacy and has been a pharmacist with the Shop ‘n Save grocery retailer in the St. Louis area for the last seven years. Nick and his wife, India, a native of Kirksville and also a pharmacist now employed at Rider Drug in Kirksville, have relocated to northeast Missouri along with their two small children, son Aiden-age 3 1/2 and daughter, Charlotte-age 18 months. Outside of work, Nick enjoys spending time with his wife & kids and he enjoys following most professional sports. Since moving to the area, he says he’s enjoyed fishing with his son.

Assisting Nick as the Pharmacy Technician is an Adair County native. Josh Small is a 2001 graduate from Kirksville High School. He received his Pharmacy Technician License with Walgreens in the Kansas City area in 2007 and earned a Pharmacy Technician Certificate through Walgreens in 2016. Josh has been an assistant store manager with Walgreens in the Kansas City area for the last 10 years. Prior to his career with Walgreens, Josh attended Indian Hills Community College in Ottumwa and earned an associate degree in Applied Science. Josh has relocated to the area. Many may know Josh’s family from the area. His mother, Donna Small, LPN, has been employed at Scotland County Hospital for 18 years.

“We are constantly looking for ways to improve our patients’ experience,” said Randy Tobler, MD, FACOG, CEO of Scotland County Hospital. “With this new service, we hope to make filling prescriptions even more convenient, and in some cases more affordable, so our patients can get home quickly and the healing process can begin. You’ll want to stop by and meet Nick & Josh and have a cup of coffee from our new complimentary coffee service in the lobby of the new pharmacy.”

The new community pharmacy, which is located where International Eyecare Center (IEC) used to be located at Memphis Medical Services, is bringing an additional service to the patients of the area. The hospital has contracted with the new pharmacy for the 340B discount drug program. There is currently not a 340B contracted pharmacy in Memphis. The hospital’s closest 340B discount drug program partners are in Kirksville (Rider Drug) and Edina (Knox County Pharmacy). IEC expanded and moved to the Hospital’s Annex Building, once occupied by the Health Department.

The 340B discount drug program is a hospital program, not a pharmacy program, governed by the Health Resources & Services Administration (HRSA). To comply with the program, a hospital (340B applies only to safety net facilities like Scotland County Hospital) buys the drugs from a third party vendor that buys the drugs at a greatly reduced rate from drug manufacturers that are required to make the rate similar to what is sold to the Veterans Administration. The hospital contracts with a pharmacy (or multiple pharmacies) to dispense the drugs for a mutually agreed upon dispensing fee, which the pharmacy retains.
Scotland County Hospital and clinic patients at all 3 locations (Memphis Medical Services-MMS, Lancaster Medical Services-LMS, and Wyaconda Medical Services-WMS) will have the same choice they have always had to choose any pharmacy they prefer to fill their prescriptions. Should they choose any of the hospital’s contracted 340B pharmacies (Memphis Community Pharmacy, Rider Drug or Knox County Pharmacy), their choice helps support the Hospital’s many medical services and mission to serve the community’s health needs. In fact, often the 340B program can provide lower out of pocket costs for expensive medications for our patients.

In addition to serving patients from MMS, LMS, WMS & Scotland County Hospital as well as patients from any other clinics in the area, the new pharmacy provides a prescription delivery service to hospital patients right before discharge and ER patients prior to discharge, during pharmacy operating hours. For MMS clinic patients, it’s similarly convenient since they can now stop at the pharmacy, located in the clinic lobby, to fill prescriptions before they leave the clinic.

“The Board, Administration and entire patient care team at the Hospital and Clinics are excited to have this new venture that brings patient care and service to the next level,” said Randy Tobler, MD. “Many patients leaving the clinic, hospital or emergency room often have prescriptions to fill. By having a retail pharmacy on site, we can offer a convenient and very accessible option for patients, visitors and even our staff. Previous experience indicates that on site pharmacies result in patients taking their meds more reliably, and that means a healthier patient and community.”

Memphis Community Pharmacy is open Monday through Friday from 8:30 am until 5:30 pm. Nick reports that most major insurance plans are accepted at the pharmacy, as they would be at any other pharmacy. He said that patients who want to use Memphis Community Pharmacy can simply direct their prescribing clinician, from any clinic in the area or even outside the area, to use the hospital’s pharmacy. Prescriptions are electronically sent there as they would be to any other pharmacy in the area.

Multi-Language service comes to the Heartland

MILAN, Mo. — A diverse northeast Missouri community now getting big help from a doctor who speaks their native language.

Francisco J. Garriga, M.D. is a rheumatologist from St. Louis whom speaks a variety of languages including English, Spanish and French.

He’ll soon be coming to Milan Family Practice, a campus of Sullivan County Memorial Hospital, to treat patients.

It’s all part of the Premier Specialty Network, which allows doctors from major cities to come to rural areas across the state of Missouri.

“This is something that is surely needed. There’s a big void right now and the ability to serve the community of such a diverse demographic. He is excited because he’s going to be able to serve a population that he can relate to and and it’s an under served area. So it’s a meeting of two very important needs, to be a provider of medicine and be there for people who are looking for somebody who can relate to them on a personal level while also having their needs met,” said Premier Specialty Network Regional Director David Young.

Garriga starts his job next Wednesday, August 17. You can now call (660) 265-4456 to schedule an appointment.

He’ll be making visits to the clinic in Milan on the second Wednesday for a few months before seeing patients on the first and second Wednesday of every month.

The doctor will also be seeing patients at Scotland County Hospital in Memphis on the first and second Tuesday of each month.

Source>> KTVO

Critical Access Status With Surgical Outcomes

According to a study by Dr. Ibrahim and colleagues on critical access status, Medicare beneficiaries undergoing common surgical procedures, patients admitted to critical access hospitals compared with non–critical access hospitals had no significant difference in 30-day mortality rates, decreased risk-adjusted serious complication rates, and lower-adjusted Medicare expenditures.


Critical access hospitals are a predominant source of care for many rural populations. Previous reports suggest these centers provide lower quality of care for common medical admissions. Little is known about the outcomes and costs of patients admitted for surgical procedures.


To compare the surgical outcomes and associated Medicare payments at critical access hospitals vs non-critical access hospitals.


Cross-sectional retrospective review of 1,631,904 Medicare beneficiary admissions to critical access hospitals (n = 828) and non-critical access hospitals (n = 3676) for 1 of 4 common types of surgical procedures-appendectomy, 3467 for critical access and 151,867 for non-critical access; cholecystectomy, 10,556 for critical access and 573,435 for non-critical access; colectomy, 10,198 for critical access and 577,680 for non-critical access; hernia repair, 4291 for critical access and 300,410 for non-critical access-between 2009 and 2013. We compared risk-adjusted outcomes using a multivariable logistical regression that adjusted for patient factors (age, sex, race, Elixhauser comorbidities), admission type (elective, urgent, emergency), and type of operation.


Undergoing surgical procedures at critical access vs non-critical access hospitals.


Thirty-day mortality, postoperative serious complications (eg, myocardial infarction, pneumonia, or acute renal failure and a length of stay >75th percentile). Hospital costs were assessed using price-standardized Medicare payments during hospitalization.


Patients (mean age, 76.5 years; 56.2% women) undergoing surgery at critical access hospitals were less likely to have chronic medical problems, and they had lower rates of heart failure (7.7% vs 10.7%, P < .0001), diabetes (20.2% vs 21.7%, P < .001), obesity (6.5% vs 10.6%, P < .001), or multiple comorbid diseases (% of patients with ≥2 comorbidities; 60.4% vs 70.2%, P < .001). After adjustment for patient factors, critical access and non-critical access hospitals had no statistically significant differences in 30-day mortality rates (5.4% vs 5.6%; adjusted odds ratio [OR], 0.96; 95% confidence interval [CI], 0.89-1.03; P = .28). However, critical access vs non-critical access hospitals had significantly lower rates of serious complications (6.4% vs 13.9%; OR, 0.35; 95% CI, 0.32-0.39; P < .001). Medicare expenditures adjusted for patient factors and procedure type were lower at critical access hospitals than non-critical access hospitals ($14,450 vs $15,845; difference, -$1395, P < .001).


Among Medicare beneficiaries undergoing common surgical procedures, patients admitted to critical access hospitals compared with non-critical access hospitals had no significant difference in 30-day mortality rates, decreased risk-adjusted serious complication rates, and lower-adjusted Medicare expenditures, but were less medically complex.

Andrew M. Ibrahim, MD; Tyler G. Hughes, MD,  Jyothi R. Thumma, MPH; Justin B. Dimick, MD, MPH

Budget Savings Should Offset the Cost of Expanding Medicaid

The 31 states and District of Columbia that have expanded Medicaid are saving millions — and in some cases, tens of millions — compared to states that have not adopted the federal program, according to a report released Tuesday by the Robert Wood Johnson Foundation.

The report was prepared by Manatt Health, a consulting firm with the law offices of Manatt, Phelps & Phillips in Washington, D.C.

In January, Manatt Attorney Cindy Mann said hospitals in expansion states fare better financially than providers in states without the Affordable Care Act initiative. Specifically, hospitals in expansion states have less uncompensated care due to a rise in the number of patients covered, said Mann, who formerly directed the Medicaid program for the Centers for Medicare and Medicaid Services.

The newly-released report confirmed that hospitals’ uncompensated care costs are estimated to have been $7.4 billion, or 21 percent less in 2014 than they would have been in the absence of Medicaid expansion.

In 2014, expansion states saw a reduction in uncompensated care costs of 26 percent, compared to a 16 percent reduction in non-expansion states, the report said.

As of September 2015, the percentage of rural hospitals at risk of closure is about twice as high in non-expansion states in comparison to expansion states, it said.

The report identifies several sources of savings and new revenue for expansion states: less state spending on programs for the uninsured; more federal dollars coming to the state for newly eligible Medicaid enrollees — including funds to cover typically expensive beneficiaries such as pregnant women and high-need populations; and increased revenue from existing insurer and provider taxes.

Most of the 19 states that have not expanded Medicaid have Republican governors or legislatures controlled by the GOP. Some policymakers in those states have said they don’t want taxpayers to foot the 10 percent of the cost after federal funds for expansion are reduced to 90 percent.

Report researchers, however, said budget savings should offset the cost of expanding Medicaid through 2021.

“As some states continue to debate whether or not to expand, they need only look as far as their neighbors for evidence of the economic benefits that result,” “said John Lumpkin, MD, senior vice president at the Robert Wood Johnson Foundation.

States that have expanded Medicaid generate savings and revenue which can be used to finance other state spending priorities or offset much, if not all, of the state costs of expansion, according to the report.

For instance, the report said: California saved $250 million in spending on its low income health program in 2015; Colorado saved $96 million in spending in 2015 on childless adults newly eligible for Medicaid; Kentucky saved $21 million on mental health services in 2015; Maryland saved nearly $14 million on uncompensated hospital care in 2015; Michigan saved $19 million on prison health services in 2015; and Pennsylvania saved nearly $108 million in state spending in 2015 because of expansion.

Between 2014 and 2015, Medicaid spending in expansion states grew by half as much as spending in non-expansion states, 3.4 percent compared to 6.9 percent, the report said.

The report is an update to an April 2015 Robert Wood Johnson Foundation State Health Reform Assistance Network issue brief on the impact of Medicaid expansion, examining the budget effects of expansion in a sample of 11 states from all regions of the country, as well as in the District of Columbia.

SOURCE: Healthcare IT News

Alzheimer’s Researchers Cast a Broader Net to Find a Cure

With the demographic shift toward an increasingly elderly population, it has been predicted that the number of people afflicted with dementia will triple by 2050, with the cost to the healthcare system estimated to be $1.1 trillion.

The complex neuropathology underlying Alzheimer’s disease (AD) is only beginning to be understood, and we have only scratched the surface in investigating the role that each underlying biology plays in propagating disease.

This complexity can be used as a weapon against disease by combining drugs of different biologies with the hope that a multipronged therapeutic attack will add up to a cure.

To consider the players in such combinations, let us review what we know today.

When Alois Alzheimer first described amyloid plaques and neurofibrillary tangles as cardinal features of the disease, it brought about a revolution in perception; dementia went from being a social stigma or sign of weak character to a physical disease of the brain that might someday be cured through development of new medicines.

It took nearly 80 years for scientists to “take apart” amyloid plaques and neurofibrillary tangles and discover compositions principally of beta-amyloid peptide (βAP or Aβ) and the microtubule-associated protein tau, respectively.

Coincident with these key discoveries, a curious schism emerged: The research community began dividing into camps that favored βAP or tau as principal causal agents in AD.

This schism became so pronounced in the 1990s that it was whimsically dubbed the “βAPtist/Tauist war.”

While science thrives on the pursuit of competing hypotheses, the βAPtist/Tauist war had an unfortunate consequence: Research seeking a more integrated understanding of AD pathophysiology was discouraged, and clinical approaches to treatment became narrowly focused.

Large-effect genes focused attention on βAP

The proponents of βAP hypothesized that a generation of βAP from a longer protein called the amyloid precursor protein (APP) is a seminal event in the development of AD.

This view was strongly boosted by the discovery that a sizable number of genetic mutations in APP and in γ-secretase – one of the enzymes that liberates βAP from APP – invariably led to an early-onset form of AD.

Enthusiasm built for the idea that slowing the rate at which βAP was liberated from APP or preventing βAP from forming aggregates believed to be toxic in the brain would prevent or delay AD from developing, and likely mitigate symptoms in AD patients.

The “amyloid hypothesis” has now been pursued in the clinic over the past 2 decades through the design of inhibitors for the APP cleaving enzymes β-secretase and γ-secretase, which are responsible for βAP generation.

Another therapeutic approach has been to design antibodies that bind to βAP or aggregates of βAP to accelerate their removal from the brain or decrease their toxicity.

The clinical trial results to date for treatments aimed at the amyloid hypothesis are disappointing at best.

First generation γ-secretase inhibitors were amenable to design, but they were plagued by safety issues. Centrally penetrant β-secretase inhibitors have been much more difficult to design and are only now entering advanced clinical trials.

Multiple antibodies against βAP have failed to meet their primary clinical endpoints. Whether they were tested too late in the disease or they just didn’t work is not clear.

So while it is premature to write an epitaph for the “amyloid hypothesis,” the clinical record to date suggests we need to be casting a wider net in the battle against AD.

Smaller-effect genes reveal the complexity of Alzheimer’s

Genes affecting the generation of βAP from APP are rare, but they increase one’s chances of getting early-onset AD to near certainty.

Over the years, other genes and gene families impacting the risk of AD have emerged. These gene variants tend to have a much broader distribution in the general population, but their impact on increasing one’s lifetime risk of developing AD is lower than for the so-called familial genes.

Consequently, it has often been necessary to study large populations – as opposed to individual families – to identify these genetic risk factors.

The oldest and best known of these “smaller-effect” genes is a specific variant of apolipoprotein E, known as ApoE4. Possessing a single ApoE4 gene increases one’s lifetime risk of developing AD by three-fold in Caucasians.

While apoE studies by AD researchers have focused on its potential role as a βAP transport protein, this emphasis likely reflects the “βAPtist bias.”

ApoE has been studied more broadly for its causal role in vascular/metabolic disease. Viewed from this perspective, one needs to look no further than the APP gene that sparked the βAPtist movement to find AD’s vascular connections: Mutations within βAP lead to vascular diseases of the brain, and the best established function for one variant of APP is as a regulator of the blood coagulation cascade.

These and other findings in recent years have led AD to be viewed as a vascular/metabolic disease, even prompting AD to be referred to as “type 3 diabetes.”

The role of innate immune system genes in AD

Genome-wide association studies approach the genetics of AD from the opposite end of the spectrum as single family studies. These studies explore the full genome of very large numbers of individuals to look for genes contributing to risk of disease.

Such studies have identified novel genes and gene families that underlie the pathophysiology of AD. Among the more prominent of these players are genes of the innate immune system.

Studies that explore changes in transcriptional activity across the entire genome also implicate the innate immune system in AD.

One interesting example of note is TREM2, an innate immune gene that – similar to ApoE4 – increases lifetime risk of developing AD by three-fold in certain populations. TREM2 genetics extend the curious vascular connection of AD in a way similar to APP: While certain mutations increase risk of AD, other mutations lead to Nasu-Hakola disease – a vascular dementia.

Circling back to tau, there is still no identified tau genetic mutation leading to AD. While this fact has given tau a decided disadvantage in the βAPtist/Tauist war, other properties of tau pathology clearly implicate tau in dementia.

First, there are genetic mutations in tau known to lead to non-AD dementia. As we’ve seen with the TREM2 and APP examples, such mutations offer important clues about AD biology even if they do not specifically lead to AD.

Second, pathologic changes in tau are associated with a wide variety of central nervous system(CNS) disorders, collectively called tauopathies.

Third, the appearance of tau-related pathology in AD correlates much better with the onset of dementia than does the appearance of amyloid plaques (which can precede clinical AD by decades). Thus, the absence of a direct genetic link between tau and AD is a poor argument for de-emphasizing the potential role of tau in the pathogenesis of AD.

An integrated approach to AD is emerging

The recent string of clinical trial failures in AD will teach us little if they are used only to resurrect old βAPtist/Tauist rivalries. Rather, the emerging science reminds us that AD is a complicated disease with multiple stages of development.

Researchers are likely to learn much more about the biology of AD by investigating the common links among pathologies implicated in AD rather than studying those pathologies in isolation.

Four biologies ripe for investigating these common links in AD are βAP/amyloid pathology, tau/neurofibrillary tangle pathology, vascular/metabolic dysregulation, and innate immune dysregulation/neuroinflammation. Just a few of the many known intersection points for these biologies are mentioned here.

Putting all the biological puzzle pieces together will take time. Unfortunately, the AD epidemic facing the aging baby boomer generation is fast approaching with no time to spare.

In the absence of an integrated understanding of how AD develops and what treatments may work best at different disease stages, it is important, like in other complex diseases, to consider strategies such as combination therapy sooner than we might traditionally pursue these.

Apart from the many βAP-focused treatments in later stage clinical development for AD, TRx-0237 is a tau-focused compound in development.

A large number of tau-directed monoclonal antibodies are also in preclinical development. Agents having a vascular/metabolic disease focus include intranasal insulin, the PPARγ agonist pioglitazone, and the calcium channel blocker nilvadipine.

Treatments targeting the immune system include intravenous immunoglobulin and the RAGE antagonist TTP-488.

These agents and others that are more comprehensively reviewed elsewhere, together with symptomatic approaches such as the 5HT6 antagonist idalopirdine – an investigational compound designed to improve neurocognitive function – are possible contenders for combinations.

To make combination therapy in AD a reality, it will – to borrow a phrase – “take a village” to make it happen.

Leaders from industry, the Food and Drug Administration (FDA), the National Institutes of Health (NIH), academia, and patient groups will need to come together to enable funding, trial design, and solve a host of complex issues associated with delivering combination therapy.

But there is hope. Such public-private partnerships like the Global Alzheimer’s Platform and others have already begun to take up this important challenge.

Skin Bacteria Do Not Change Much, Despite Regular Washing

New research now shows that despite regular cleaning and contact with microbe-contaminated objects, our personal skin microbiome remains surprisingly stable over time.

Our skin is home to huge numbers of bacteria, fungi, and viruses, and each of us has a unique fingerprint of our particular mix of microbial communities that is defined by its genetic makeup or microbiome.

Writing in the journal Cell, researchers from the National Human Genome Research Institute (NHGRI) and the National Cancer Institute (NCI) – both in Bethesda, MD – suggest their findings should help us better understand how skin diseases develop.

While most of the microbes that live on our skin are friendly and cause no harm, some have been linked to skin disorders, such as acneeczema, and psoriasis.

Studies of the more harmful skin microbes have helped us understand, for example, why eczema tends to affect moist areas such as skin in the bends of the arms and legs, while psoriasis tends to appear on the outside, more exposed parts of elbows and knees.

In previous work, the researchers had already established that microbial communities not only have a strong preference for particular sites, but that each person has a unique genetic fingerprint of the range of microbes on their skin.

Within-person stability greater than between persons

For the new study, the researchers wanted to explore a less well-studied area, and that is how the microbial communities on our skin change over time and whether these fluctuations have a role in health and disease.

They found to their surprise that skin microbial communities remain remarkably stable over time, despite coming into regular and frequent contact with other sources of bacteria, fungi, and viruses, including other people, clothing, surfaces, and bacteria-laden objects.

The researchers analyzed the genetic makeup of microbes in skin samples taken from 12 healthy volunteers at three successive intervals, ranging from 1 month to 2 years apart. The samples came from 17 sites on the body. For the analysis, they used an approach called “metagenomic shotgun sequencing.”

In their paper, senior study authors Dr. Julie Segre, of the NHGRI, and Dr. Heidi Kong, of the NCI, and colleagues note how they found “an individual’s short- and long-term community similarity significantly exceeded similarity between individuals,” and that these findings are similar to “observations in gut and other communities.”

However, they also found that the stability of the microbial communities varied from person to person, and to different extents with different strains.

For example, oily sites – such as on the back and in the tube that runs from the outer ear to the middle ear – showed the least variation over time, as did highly exposed and dry sites, such as the palms.

But on skin areas with a much larger range of different microbes, such as the feet and moist sites, the researchers found the microbial fingerprint was much less stable over time. They suggest this could be because of the influence of personal hygiene or because the sites are exposed to more variable environments.

Because they only studied a small number of healthy adults, the researchers now plan to widen their investigations to include patients with eczema and skin disorders that arise because part of the body’s immune system is missing.

Future studies can use the knowledge of the relative stability of the skin microbial communities in healthy adults to understand how various exposures or disease state may alter these skin microbes.”
Dr. Julie Segre

For example, researchers could study acne patients to find out if specific strains of skin microbes flourish during flare-ups or change when patients take antibiotics.

What is Pain and How Do You Treat It?

Pain is an unpleasant sensation and emotional experience linked to tissue damage. Its purpose is to allow the body to react and prevent further tissue damage.

We feel pain when a signal is sent through nerve fibers to the brain for interpretation.

The experience of pain is different for everyone, and there are different ways of feeling and describing pain. This can makes it difficult to define and treat.

Pain can be short-term or long-term, it can stay in one place, or it can spread around the body.

Fast facts on pain:

  • Here are some key points about pain. More detail is in the main article.
  • Pain results from tissue damage.
  • It is a part of the body’s defense mechanism. It warns us to take action to prevent further tissue damage.
  • People experience and describe pain differently, and this makes it hard to diagnose.
  • A range of medications and other treatments can help relieve pain, depending on the cause.


  • Pain chronic acute
  • Pain can be chronic or acute and take a variety of forms and severities.
  • Pain is felt when special nerves that detect tissue damage send signals to transmit information about the damage along the spinal cord to the brain. These nerves are known as nociceptors.

The brain then decides what to do about the pain.

For example, if you touch a hot surface, a message will travel through a reflex arc in the spinal cord and cause an immediate contraction of the muscles. This contraction will pull your hand away from the hot surface.

This happens so fast that the message doesn’t even reach the brain. However, the pain message will continue to the brain. Once there, it will cause an unpleasant sensation of pain to be felt.

The brain may also release feel-good chemicals such as dopamine to counter the unpleasant effects of the pain.

Researchers estimate that pain costs the United States (U.S.) between $560 billion and $635 billion each year in treatment costs, lost wages, and missed days of work.


Pain can be acute or chronic.

Acute pain is generally intense and short-lived. It is the body’s way of alerting a person to an injury or localized tissue damage. Treating the underlying injury normally resolves this type of pain.

The body’s “fight-or-flight” mechanism is triggered by acute pain, often resulting in faster heartbeats and breathing rates.

There are different types of acute pain:

  • Somatic pain is superficial pain that is felt on the skin or soft tissues just below the skin.
  • Visceral pain originates in the internal organs and the linings of cavities in the body.
  • Referred pain is felt at a location different to the source of tissue damage, such the shoulder pain felt during a heart attack.

Chronic pain lasts far longer than acute pain. It often cannot be resolved. It can be mild or severe, it can be continuous, as in arthritis, or it can be intermittent, as in migraines. Intermittent pain occurs on repeated occasions but stops in between.

The “fight-or-flight” reactions eventually stop in cases of chronic pain, as the sympathetic nervous system that triggers these reactions adapts to the pain stimulus.

If enough cases of acute pain occur, they can create a buildup of electrical signals in the central nervous system (CNS) that can overstimulate the nerve fibers.

This is known as “windup,” a term that compares the accumulation of these electrical signals to a windup toy. Winding a toy with more intensity leads the toy to run faster for longer. Chronic pain works in the same way. This is why pain may be felt long after the pain-causing event.

Describing pain

There are other, more specialized ways of describing pain.

These include:

Neuropathic pain: This follows injury to the peripheral nerves that connect the brain and spinal cord to the rest of the body. It can take the form of electric shock-like pain, tenderness, numbness, tingling, and discomfort.

Phantom pain: occurs after the amputation of a limb and refers to painful sensations given out by the missing limb. It affects some 70 percent of amputees.

Central pain: is often caused by infarction, abscess, tumors, degeneration, or hemorrhage in the brain and spinal cord. Central pain is ongoing and can range from mild to extremely painful. Patients report burning, aching, and pressing sensations.

Knowing how to describe pain can help a person get a more specific diagnosis.


Diagnosis depends on an individual’s subjective description of the pain. There is no objective scale for identifying the type of pain, so the doctor will take a pain history.

The patient will be able to describe:

  • the character of all pains felt by the patient, such as burning, stinging, or stabbing
  • the site, quality, and radiation of pain, or where the pain is felt, what it feels like, and how far it feels like it spreads
  • what factors aggravate and relieve the pain
  • when the pain occurs throughout the day
  • the impact on the person’s daily function and mood
  • the person’s understanding of their pain

A number of systems can identify and grade pain, but the most important factor in getting an accurate diagnosis is for the patient and doctor to communicate as clearly as possible.

Measuring pain

Some of the pain measures used are:

  • Numerical rating scales: These measure pain on a scale of 0 to 10, where 0 means no pain at all and 10 means the worst pain imaginable. It is useful for gauging changing pain levels in response to treatment or a deteriorating condition.
  • Verbal descriptor scale: This may be used to measure cognitively impaired children, seniors, or people with autism or dyslexia. Instead of numbers, different descriptive questions are asked to narrow down the type of pain the patient is feeling.
  • Faces scale: A series of faces is shown to the person in pain, ranging from distressed to happy. This is mainly used with children and has also shown effective responses in people with autism.
  • Brief pain inventory: This is a more detailed written questionnaire gauging the effect of pain on mood, activity, sleep patterns, and how the pain may have affected the patient’s interpersonal relationships. It also charts the timeline of the pain to detect any patterns.
  • McGill Pain Questionnaire: This encourages people to choose words from 20 word groups to get an in-depth understanding of how the pain is felt. Group 6, for example, is “tugging, pulling, wrenching” and group 9 is “dull, sore, hurting, aching, heavy.”

Other indicators of pain

When people with cognitive impairments cannot accurately describe their pain, there can be clear indicators as to the presence of pain. These include:

  • restlessness
  • crying
  • moaning and groaning
  • grimacing
  • resistance to care
  • reduced social interactions
  • increased wandering
  • not eating
  • sleeping problems

If treatable, the doctor will either treat the underlying, pain-causing problem or prescribe painkilling treatment, such as medicine, to manage the pain.

Different types of pain will be treated in different ways. A treatment that is effective against one type of pain may not relieve another.

Acute pain treatment

Treating acute pain often involves taking medicines.

Non-steroidal anti-inflammatories (NSAIDs) are a type of analgesic, or painkiller, that can reduce pain and help the person regain daily function. They are available over-the-counter (OTC) or on prescription at a range of strengths. They are suitable for minor acute pains such as headaches, light sprains, and backaches.

NSAIDs can relieve localized inflammation and pain due to swelling. They can have side effects in the digestive system, including bleeding. A doctor will monitor higher dosages.

Always read the packaging to find out what’s in an analgesic before use and to check the maximum dosage. Never exceed the recommended dose.

Opioids are prescribed for the most extreme acute pains, such as following surgery, burns, cancer, and bone fractures. Opioids are highly addictive, cause withdrawal symptoms, and lose effectiveness over time. They need a prescription.

In severe trauma and pain situations, the doctor will carefully manage and administer the dose, gradually reducing the dosage to minimize withdrawal symptoms.

Discuss all medication options carefully with a doctor, and disclose any conditions and current medications. COPD, kidney disease, liver problems, previous drug addictions, and dementia can all be seriously affected by opioids.

Often, a doctor can identify and treat an underlying disorder. If an infection, for example, is causing a sore throatantibiotics will remove the infection, and the pain will disappear.

Alternatives to medication

A range of non-drug therapies can help relieve pain.

These include:

  • Acupuncture: The use of needles at certain pressure points can provide an analgesic effect.
  • Nerve blocks: These injections can numb a group of nerves acting as a source of pain for a specific limb or body part.
  • Psychotherapy: This can help with the emotional side of ongoing pain. Chronic pain can often affect the enjoyment of everyday activities and can lead to not being able to work. A psychotherapist can help to enhance understanding and put in place lifestyle changes to enable these parts of life.
  • Transcutaneous electrical nerves stimulation (TENS): TENS aims to stimulate the brain’s opioid and pain gate systems to provide relief.
  • Surgery: Various surgeries of the nerves, brain, and spine are possible to relieve chronic pain. These include rhizotomy, decompression, and electrical deep brain and spinal cord stimulation procedures.
  • Biofeedback: This is a mind-body technique. Through biofeedback, people can learn to better control their organs and automatic processes, such as their heart rate, with their thoughts.
  • Relaxation therapies: This covers a wide range of controlled relaxation techniques and exercises, mostly in the realm of alternative and complementary medicine. This can include hypnosis, yoga, meditation, massage therapy, distraction techniques, and tai chi.
  • Physical manipulation: a physiotherapist or chiropractor can sometimes help relieve pain by manipulating the tension from a person’s back.
  • Heat and cold: Using hot and cold packs can help. These can be alternated or selected according to the type of injury or pain. Some medications have a warming effect when applied topically to the affected part.
  • Rest: If the pain is due to an injury or a repetitive action, rest may be the best option.

Cancer Risk Falls with Higher Levels of Vitamin D

In the journal PLOS One, researchers from the University of California-San Diego (UCSD) School of Medicine report how they analyzed the link between vitamin D and cancer to determine what blood level of vitamin D was required to effectively reduce cancer risk. The study included all invasive cancers, excluding skin cancer.

One of the authors, Cedric Garland, adjunct professor in the UCSD School of Medicine Department of Family Medicine and Public Health, says their study is the first to put numbers on this relationship, as he explains:

“We have quantitated the ability of adequate amounts of vitamin D to prevent all types of invasive cancer combined, which had been terra incognita until publication of this paper.”

Vitamin D, which is produced by the body through exposure to sunshine, helps the body control calcium and phosphate levels. It was Prof. Garland and his late brother Frank who first linked low vitamin D with cancer in the 1980s. They found people who lived at higher latitudes and thus had less access to sunlight had lower levels of vitamin D and were more likely to develop bowel cancer.

Since then, further studies by the Garland brothers and others have found links between low vitamin D and other cancers, including cancers of the breast, lung and bladder.

Much debate about recommended level of vitamin D

The only accurate way to measure vitamin D in the body is to measure the level of 25-hydroxyvitamin D in the blood. The kidneys convert 25-hydroxyvitamin D into the active form that helps control calcium and phosphate levels.

There has been much debate in recent years about what the recommended blood levels of vitamin D should be. In 2010, the Institute of Medicine (IOM) recommended a target of 20 ng/ml for bone health, which could be met in most healthy adults (aged 19-70), with the equivalent of 600 IU of vitamin D each day. Since then, other groups have argued that the target level should be higher, at 50 ng/ml or more.

In the new study, Prof. Garland and colleagues wanted to find out what blood level of vitamin D effectively reduces cancer risk.

They took an approach that is not normally used. They used the results from two different types of study: one a clinical trial of 1,169 women and the other a prospective study of 1,135 women. For some of their analysis, they kept the two data sets separate and compared them, and in another part, they pooled the data to create a larger sample.

Vitamin D level of 40 ng/ml or higher tied to 67% lower cancer risk

The median blood level of 25-hydroxyvitamin D in the participants in the clinical trial was 30 ng/ml, and in the participants in the prospective study, it was 48 ng/ml.

The researchers found that the rate of cancer incidence in the clinical study group (that had the lower median vitamin D level) was higher than in the prospective study group. The figures were 1,020 cases per 100,000 person-years and 722 per 100,000 person-years, respectively.

They also found that cancer rates went down as 25-hydroxyvitamin D levels rose; women whose vitamin D level was 40 ng/ml or higher had a 67% lower risk of developing cancer than women whose vitamin D level was 20 ng/ml or lower.

The researchers did not say what the optimum intake level of vitamin D should be – or how it should be generated, whether by greater exposure to sunlight, dietary changes or supplements.

Prof. Garland says their findings simply show that it is possible to see reduced cancer risk when blood levels of vitamin D reach 40 ng/ml, and that higher than this, the risk drops even further. He and his colleagues conclude:

Primary prevention of cancer, rather than expanding early detection or improving treatment, will be essential to reversing the current upward trend of cancer incidence worldwide. This analysis suggests that improving vitamin D status is a key prevention tool.”