Lab Soft News

Blogs as an Alternative to Academic Publications for Circulating New Ideas

In a recent note on a public health course on blogging, I referred to the need for more bloggers in academic medicine (see: Public Health Graduate Students Offered Practical Course in Social Media). At the end of the piece, I cited the blogging efforts of academic economists Tyler Cower and Alex Tabarrok in Marginal Revolution. It's one of my favorites. At any rate, noted economist Paul Romer refers to this blog in terms of the competition for ideas and the need for alternatives in the academic journals (see: Science on the Internet). Here is an excerpt from his note:

Marginal Revolution, Tyler’s blog with Alex Tabarrok, is a new alternative to the traditional gatekeepers in economics — the journal editors or the program leaders at the NBER [National Bureau of Economic Research].  Tyler and Alex earned this position simply by being good at what they do.  Adding sites like this may do more to increase competition in the space of ideas than traditional strategies such as creating new journals.  A mention from a site like MR [Marginal Revolution] is now an alternative way for new ideas to get attention, one that can parallel the traditional mechanisms.

In my view, blogs can offer a fresh view and solutions that are not always available in academic journals. One example in the world of pathology has been the recent activities by the FDA regarding digital pathology. Keith Kaplan, who posts over at Digital Pathology Blog, wrote about the current situation in an incisive and humorous way (see: Regulators regulating digital scanners). I quoted some of Keith's comments in my note and then added some on my own ideas in a follow-up note (see: Digital Pathology and the FDA; WSI Systems Called Class III Devices). By the way, much of this commentary was stimulated by an article in CAP Today, a monthly tabloid published by the CAP (see: Regulators scanning the digital scanners). I doubt that there will be even a hint of this interaction in any articles about the evolution of digital pathology in the pathology journals if and when they appear.

Gardasil Viewed by AAP as an Anti-Cancer Vaccine

I have posted a few notes in the past about Gardasil, a vaccine against HPV, and the rise of oral cancers as a result of HPV infection. Here are a couple of representative ones (see: Some Key Questions in Cytopathology That Require Immediate Answers; An estimated 7% of Population Carry Oral HPV; Oral Cancer Incidence to Rise Sharply). A recent article about the Gardasil vaccine did catch my attention in a particular way, however (see: 11-year-old boys should get HPV shot, docs say). Here is a an excerpt from it:

Boys 11 years and up should get Merck & Co's Gardasil vaccine to protect them against HPV infections, which can cause genital warts as well as oral, penile and anal cancers, the nation's largest group of pediatricians said Monday. "What we are hoping will come out of this is that we can push this as a cancer vaccine," said Dr. Michael Brady of the American Academy of Pediatrics (AAP). "We now have the ability to interrupt the transmission and the development of cancer." The new statement leans on recommendations released last year by U.S. vaccine advisers and updates the previous stance of the AAP, which until now had only backed routine vaccination for girls....It's estimated that HPV types 16 and 18 are responsible for 7,000 cases of cancer in men every year in the U.S. and 15,000 cases in women, most of them cervical cancers. Clinical studies show HPV vaccines shield boys against genital warts and anal cancer, although the protection isn't complete. Vaccinating boys is also likely to protect women indirectly by preventing them from catching the viruses in the first place, the AAP says.

I never conceptualized Gardasil as a vaccine against cancer although it clearly can function in this way. Perhaps my problem was that I was having trouble making the leap from a vaccine that prevents a viral infection and the virus acting as the etiologic agent that causes the cancer. Just out of curiosity, I googled the term cancer vaccine and turned up a fact sheet from the National Cancer Institute (see: Cancer Vaccines). Here are two key quote from it:

The U.S. Food and Drug Administration (FDA) has approved two types of vaccines to prevent cancer: vaccines against the hepatitis B virus, which can cause liver cancer, and vaccines against human papillomavirus types 16 and 18, which are responsible for about 70 percent of cervical cancer cases. The FDA has approved one cancer treatment vaccine for certain men with metastatic prostate cancer.

[and]

Cancer vaccines are medicines that belong to a class of substances known as biological response modifiers. Biological response modifiers work by stimulating or restoring the immune system’s ability to fight infections and disease. There are two broad types of cancer vaccines:

• Preventive (or prophylactic) which are intended to prevent cancer from developing in healthy people; and
• Treatment (or therapeutic) which are intended to treat an existing cancer by strengthening the body’s natural defenses against the cancer.

So now we all have an understanding of the difference between a prophylactic and a therapeutic vaccine. Gardasil falls into the former category. I certainly have learned something from this exercise. 

 

 

One Tumor Biopsy May Be Insufficient to Reveal Genetic Landscape

We are about to undergo a major change in tumor genotyping for cancer patients, possibly even before the basic protocol is broadly adopted. Not only will the genotype of a tumor be required to initially determine appropriate chemotherapy (see: Identifying Therapeutically Relevant Genetic Abnormalities in Cancer Patients) but the process may need to be repeated multiple times subsequently (see: One Biopsy Not Enough to Reveal Genetic Landscape of a Tumor). Below is an excerpt an article that addresses this topic:

A small study that shows a surprising complexity of genetic changes within a single tumor has far-reaching implications for the march toward personalized cancer therapy....A single biopsy from a tumor might not be sufficient to give a full picture of its genetic landscape [according to a recent study]. When the researchers examined 10 biopsies taken from a single kidney cancer, they found "an extraordinary amount of diversity" in the genetic changes that had taken place in different parts of the tumor....The [research] team also found differences in genetic changes between the primary tumor and metastases that developed both locally and at a distant site (in the chest wall). Similar findings have been documented by other research groups, but it is the extent of intratumoral heterogeneity that is surprising....The findings have far-reaching implications for the efforts currently being directed toward personalized cancer therapy, in which therapy is targeted at genetic changes identified in tumor tissue. An example of this is the SnaPshot broad genetic screen program being used in routine clinical practice at the Massachusetts General Hospital in Boston. 

Here's more about the SnaPshot program (see: Screening: Smile, they're taking a SNaPshot of your cancer-causing genes):

Personalized cancer treatment is just around the corner, suggests a new study. Using SNaPshot, a “multiplexed, robust, highly sensitive and quick clinical test,” [researchers] at Massachusetts General Hospital have screened patients with non-small-cell lung cancer (NSCLC) for multiple cancer-causing gene mutations and demonstrated that implementing broad genotyping in routine clinical practice can identify the right type of treatment for the right patients.

In this emerging era of personalized medicine and the need to match patient chemotherapy to the genomic profile of a tumor, we are now coming to better understand the genetic intratumoral heterogeneity, to quote a phrase from this article. Cellular genetic characteristics appear to change over time and a single, initial biopsy of a tumor may provide insufficient information to guide treatment long-term because of this heterogeneity. 

My first thought about how to address this problem was to examine circulating tumor cells (CTCs) (see: Circulating Tumor Cells for Assessing Survival in Pancreatic Cancer Patients). However, this approach will probably not suffice, even if this technology were sufficiently mature. I suspect that the metastasizing, circulating cells are genetically different than their parent cells. In fact, it may be these genetic differences that determine these cells' ability to circulate and implant in distant organs. The only "practical" solution that I can conjure up in the long run is for continuous genetic monitoring of a tumor using molecular imaging. I say "practical" here because this technology is still largely confined to research labs.

In the short-term, we will need to be satisfied with periodic sampling of tumor tissue using standard biopsy techniques combined with genetic analysis to determine which chemotherapeutic agents will be most effective. Recall, however, that there is some morbidity associated with obtaining a tumor biopsy, even with fine needle aspiration (FNA). However, it must also be stated that two of the most common types of tumors (GI and breast) are accessible via endoscope or percutaneously (see: Assessment of morbidity and mortality associated with EUS-guided FNA: a systematic review).

Roche Moves Entire Global Workforce to Google Apps

I have been using Google Apps for about six years and have been totally satisfied with this cloud-based email and calendar system. The University of Michigan is now switching most of its work force to the same product. Here's an excerpt from a recent article that indicates that Roche is also going in the same direction for its 90,000 workers on a global basis (see: Roche getting entire workforce to use Google Apps). Below is an excerpt from the article:

Swiss drug giant Roche...has generated buzz in the tech press for deciding to adopt Google Apps for its more than 90,000 workers, using the cloud-based software as a way to connect its global workforce without the IT headaches of managing email and calendar software in its own data centers. Roche CIO and financial chief Alan Hippe wrote last week that the company went through a couple of email and calendaring platforms over the past two and a half years that stymied collaboration....Roche, the world's largest maker of cancer drugs, and other large biopharma companies have looked at cloud-based software systems as a way to reduce the strain on their IT support groups, as such applications have been known to require significantly less internal management than local software that lives in the companies' own data centers. Eli Lilly, ..., for instance, tapped Amazon's cloud platform several years ago over expanding its own IT infrastructure. For Roche's part, the company decided to use Google Apps after a review of cloud-based systems. With workers in 140 countries, Hippe wrote, the company expects that the social aspects of Google's...apps will help bring those workers closer together amid efforts to develop products for patients. Employees will also be able to access the Google software with any web-connected device.

This all makes perfect sense to me, particularly for a global company that operates in 140 countries and is seeking to reduce its IT costs as well as make document sharing easier. At first, I was a little confused about CIO Alan Hippe's reference to the "social aspects of Google apps" and then I realized that he must be referring to Google's SMS and interactive chat features. For me, email has always been a much less formal and more efficient means of communication than snail mail. However and for younger generations, email to far too formal -- they much prefer texting for most interactions. I can see why a company such as Roche would prefer an integrated and standardized communication cloud-based system combined with word processing and spreadsheet applications. 

Public Health Graduate Students Offered Practical Course in Social Media

Some interesting things are happening at the University of Michigan regarding the use and teaching of social media. I reported recently about the hiring of a social media director for the institution (see: The University of Michigan Hires Social Media Director at $100,000 Per Year). Now comes news of a graduate course in the School of Public Health on communicating with science blogs (see: SPH students creating science blogs in social media course). Below is an excerpt from the article:

It's not enough for new public health professionals to know the science that drives the field. To make a difference, they need to talk to the public and policy makers in clear, jargon-free language. That notion is behind the inaugural graduate course Communicating Science through Social Media [at the University of Michigan School of Public Health (SPH)]. It was created by Andrew Maynard,..., professor of environmental health sciences at the School of Public Health and director of the Risk Science Center. "There is an increasing hunger amongst public health students to be taught how to communicate and express themselves effectively," Maynard says. Public health practitioners and leaders must be more adept at conveying complex ideas to non-experts, he says, whether they are managers, CEOs, partners, politicians or from the public. To that end, the 10 students in Maynard's class each are required to write 10 blog posts for the website Mind the Science Gap, which has received media coverage in The New York Times, Scientific American and other journals. Students have been inspired to write on subjects including struggles faced by the late singer Whitney Houston and how stress has been identified as a particular trigger in substance abuse among women, to research that finds urban sprawl and car dependence are leading factors for chronic diseases. Nearly 50 mentors recruited by Maynard, and the general public, comment on the posts. Since launching, the blog has averaged 4,500 page views per week, with more than 1,100 comments on posts....Maynard, himself a veteran science blogger, says the best indicator of success in communication is when there is evidence of a connection between the blogger and the audience. "This is part of the power of social media: that rapid and often candid feedback. 

I very much like the quote from the article above that "health practitioners and leaders must be more adept at conveying complex ideas to non-experts." And what better a way for students to become adept at science and health blogging than writing notes for Mind the Science Gap? By publishing their ideas in a real and prestigious blog, there is also an opportunity for the blog readers to "vote" on the quality of the writing -- the number of blog hits can easily be measured.

Given that we are now teaching our graduate students about effective communication through blogging, perhaps we can also adopt the idea that blogging is a suitable academic pursuit for their professors (see: Professional Blogs as Publication Vehicles for Physicians in Academic Clinical Tracks). Here's a quote from the note. By "professional blogs" I am referring to blogs written by content experts about their area of expertise such as physicians writing about various aspect of healthcare delivery.

In general, tenured-track slots in medical school are now reserved for bench researchers with grant support. Physicians engaged in the delivery of clinical care in academic teaching hospitals are also responsible for the training of medical students, house officers, and fellows. They are required to publish articles in their specialty areas. I believe that launching professional blogs would be a very suitable way for such faculty to both develop a regional/national reputation, a requirement for promotion. as well as provide useful information for colleagues and healthcare consumers seeking high quality medical advice.

It's taken more time than I originally anticipated but it seems to me that, at least at the University of Michigan, social media are now getting some well-deserved respect. There is at least one field, economics, where it is almost mandatory for the most eminent scholars to communicate via blogs. Examples include Greg Mankiw (see: GREG MANKIW'S BLOG), Paul Krugman (see: The Conscience of a Liberal), and Tyler Cowen (see: Marginal Revolution). I highly recommend this last blog, which I never miss and which covers an extremely broad spectrum of topics due to Cowen's high degree of intellectual curiosity.

Selecting the "Best" EMR; Problems with the "Greatest Good" Doctrine

Here's an interesting excerpt from a note posted on Hospital EMR and EHR regarding the selection of an EMR (see: Stalking the “Perfect” EMR). It quotes the noted hospital CIO, Dr. John Halamka.

...[I]f you let every department and clinical constituency pick what they want to include in their EMR, you end up with “an unintegrated melange of different products that make care standardization impossible,”  Dr. [John] Halamka suggests. As nice as it would be to satisfy everyone, there’s really only one approach that works, Dr. Halamka says. IT leaders need to pick an EMR for their enterprise that meets the enterprises overall strategic goals, one “providing the greatest good for the greatest number.”  Then, follow up with substantial training, education, collaboration, user engagement support and healthcare information exchange, he says. No matter what your EMR turns out to be, it’s going to fix some workflow and process issues while creating others, he suggests. The best thing healthcare CIOs can do is simply go with smart enterprise-wide technology and help providers user it effectively.

Here's the first comment reacting to this post from a reader named Brian:

The HIS is unlikely to satisfy the unique workflow needs of every department. Other industries such as banking have firmly settled on a best-of-breed model. Improved interoperability standards will probably lead to more BoB over time, not less.

I, like Brian, am a best-of-breed (BOB) advocate for most hospital departmental systems and particularly for LISs. Here are some links to some of my prior notes about this topic, a couple of them dating back to 2006 (see: Defining a "Best-of-Breed" LIS; Best-of-Breed Lab Software Vs. Integrated Clinical Systems; Are You an Enterprise or Best-of-Breed CIO? Access to Cash May Make the Difference). In my opinion, it's impossible for a vendor selling an "enterprise wide solution" (EWS) to provide all of the requisite functionality for key hospital units like surgical pathology and clinical pathology. However, if I were a CIO like Dr. Halamka, I would probably also promote a "greatest good" doctrine for EMR selection. Such an approach makes his job easier in that most of the integration comes shrink-wrapped from the vendor. However, it can also be seriously detrimental to the career of a lab director to hold this same opinion and can impair lab functionality.

The directors of surgical pathology and the clinical labs in a hospital, in the final analysis, will be judged by hospital executives on the cost-per-test generated in the labs. Lab tests are relatively inexpensive because of the high degree of lab automation that has been achieved over the years. A highly functional LIS is a critical component of this scenario. A lab director may be required these days to choose between a BOB LIS plus often some additional software to fill in the gaps or an EWS lab solution like Beaker (see: Here Comes Epic's Beaker LIS -- Ready or Not; More Information about Epic's Beaker LIS and Its Sibling; A Pathologist Describes His Firsthand Experience with a Demo of Epic's Beaker LIS). This latter LIS seems to have good core functionality but also large amounts of "white space," which is to say functionality gaps (see: Details about Epic's Beaker LIS, Supplied by the Company). Beaker is thus not free nor does it provide an escape route from Dr. Halamka dreaded "unintegrated melange of different products that make care standardization impossible." In fact, picking an LIS like Beaker exacerbates the lab software integration problem because there may be more software products to be interfaced to the EMR in association with it than if a BOB LIS had been chosen or retained in the first place.

The University of Michigan Hires Social Media Director at $100,000 Per Year

If you had any doubts whether the various types of social media (e.g., Twitter, Facebook) were here to stay, take a look at a recent news article concerning a new hire the University of Michigan (see: University of Michigan social media director hired at $100K per year):

When Global Communications Director Lisa Rudgers announced the University of Michigan was hiring its first social media director, dozens of applications began pouring in....Jordan Miller...was hired at a $100,000 yearly salary....Among her top priorities, she said, are creating a unique "voice and personality" for the Michigan brand on social media, putting together a seminar on social media strategies for university leaders and making the school's various Twitter and Facebook handles more cohesive. Most important, she said, is creating a "conversation" on social media outlets where followers comment to U-M postings and U-M circles back with a response. That's different than the "loudspeaker" approach the university, for the most part, currently uses, Miller said. "Giving people information on what’s going on is a good thing," Miller offered. "But right now the conversation is very one way and frankly that’s been a resource issue." Resources won't be a problem for long, Miller predicts. She'll begin her post at U-M as a one-woman show but hopes to eventually have a team of people working on U-M's social media message and community engagement.

Although this article is short, it hits all of the high notes about the value of social media. Let me tease out four of them that stood out for me:

• The salary of this new employee is impressive and provides some inkling of the earning power and competition for people working professionally on social media.
• Next, the main stated goal for the new individual will be to create "a unique, integrated voice and personality" for the U of M brand across all social media.
• This goal is differentiated from the prior "loudspeaker" approach at the University because it involves an ongoing "conversation" with the friends of the institution.
• Finally, she will be developing a "seminar" for "university leaders" to explain what she is doing, why she is doing it, and (my addition) why she is worth $100K per year for doing it.

Not to put too sharp a point on this, what we see here is a newly hired individual with a new job function. She will serve as the interface and spokesperson to thousands of current UM students and alumni. In my mind, her stated goal of eventually having "a [larger] team of people working on U-M's social media" will soon be realized. The Twitter stream for the UM will be closely monitored, I am sure, to gauge the ideas and sentiments of U of M alums regarding all of the diverse activities and goals of the University. An ongoing conversation with "friends of the University" via social media will trump a "loudspeaker" approach any day of the week.