Stem Cells, Health, Technology

Texas ranked third in the United States for the number of residents moving out of state (467,338) in 2017. The most popular out-of-state relocation destination for Texans was California (40,999). Let’s put this exodus from Texas into perspective vis-a-vis California.

Texas had a population in 2017 of 28.32 million. On a per capita basis then, the percent of people leaving Texas was 0.016. California lost just over 661,000 people to domestic migration in the 12 months ended in July 2017. Given California’s population in 2017 of 39.4 million, the per capita basis of people leaving California was 0.016, approximately the same rate as in Texas.

The reasons people leave California have received considerable national attention, and the cost of living coupled with our progressive environment are two key reasons why low income, conservative people without college degrees are moving to Texas. On the other hand, high income, educated Texans move to California where they will enjoy the opportunity to prosper in the fastest growing economy in the USA, where most innovation in the US occurs, and where culture and beauty abound.

Simple cost of living averages do not address the quality of life, and the quality of the goods or services available, and Texas does not offer anything close to what California offers. Consider, the average lifespan in TX- 78.5; average income in TX – $59,206; 18.5 percent of Texas residents, aged over 25 years, held a Bachelor’s degree; and the suicide rate was 13.0 per 100,000 in Texas. Whereas in California, average lifespan in CA – 80.9; average income in CA – $71,805; 21.3 percent of Californian residents, aged over 25 years, held a Bachelor’s degree; and the suicide rate was 11.1 per 100,000 in California. Moreover, California is the world’s fifth largest economy, surpassing many countries with much larger populations. Texas has the 10th largest economy in the world. Whereas California leads innovation in the world, economically and socially, Texas is known for oil and finance, stultifying old industries, and is socially regressive led by Republican politicians like Rafael Cruz. California per-capita GDP was $58,619 in 2016, whereas per capita income for Texas was $29,525 in 2017. But those are numbers, and we must also consider quality from a cognitive point of view.

Drive through Houston, TX, the state’s largest city, and you’ll be aghast by the foul smells in the air, tacky neighborhoods where strip clubs stand next to churches, the lack of city planning, an overabundance of superfund clean-up sites, and the general ugliness of the area. Many other cities are worse, and once beautiful Austin now suffers from a lack of strong zoning rules that means tall, ugly skyscrapers now tower over the University of Texas campus. Drive through the state, and most of what you see is dull and banal, and often ugly.

Now drive through California. That drive can include sights of the world’s tallest trees, Redwoods, the largest alpine lake in all of North America, Lake Tahoe, and the world’s most innovative university, UC Berkeley, that is surrounded by mountains and trees, and not skyscrapers, except of course the university’s beautiful Campanile. The drive can continue across the Golden Gate Bridge, into the most beautiful large city in the US, San Francisco, and then onto the largest trees in world, the giant Sequoias in the beautiful Sierra Nevada Mountains close to the highest mountain in the continental USA, Mt. Whitney. Head down south along the dramatic Big Sur coastline to Santa Barbara and enjoy California wine in America’s Riviera, and then continue south to Los Angeles, where the world’s best symphony performs in the world’s best concert hall. A drive into the mountains surrounding Los Angeles brings us upon Mt Wilson where anyone can peer though the giant 100 inch telescope where Nobel Laureate, Dr. James Hubble, Ph.D., discovered the expanding universe. Finish the trip in San Diego for relaxation, surfing, and fish tacos in a beautiful city nestled on the Pacific with the best weather in the USA and a history that dates back to 1769.

These are just a few of the reasons why Texans are fleeing their state and moving to California. All are welcome in California.

NAD (nicotinamide adenine dinucleotide) is a molecule that supports basic cellular function and metabolism in a number of important ways, including protecting our DNA (Sambeat et al, 2019), converting food into usable energy and regulating our sleep-wake cycles. NAD decreases as we age, and low levels of NAD are associated with increased risk of heart disease, Type 2 diabetes, Alzheimer’s disease, and accelerated aging. Decreased NAD levels in our bodies can result from 1. the body making less NAD as we age, 2. more NAD being used in the body as we age because of aged related stress and damage, including oxidative damage, and 3. poor diet, including increased alcohol consumption as we age. Some excellent work has found that SIRT, a molecule dependent on NAD to be synthesized in our bodies, is involved in preventing stem cell aging that even prevents a pro-inflammatory state of the macrophages in our innate immune system (Luo et al, 2019), and also prevents aging-associated inflammation and insulin resistance (He et al, 2020).

There are two forms of vitamin B3, nicotinamide riboside (NR) and nicotinamide mononucleotide (NMN), receiving attention for their ability to increase NAD levels. In mice studies, NR and NMN increase NAD levels, while some newer, small studies suggest the same is found in humans. Sounds great, right? NAD is important to a number of normal cellular functions and keeps some of our cell types young, so taking “NAD supplements” must be healthy and will slow the aging process. Where can I buy this stuff?

If you’ve read my book, “Thinking And Eating For Two: The Science of Using Systems 1 and 2 Thinking to Nourish Self and Symbionts,” you’ll know to ask a few important questions before running off to the store to buy this supplement. And, after having asked those few questions, you’ll know the NAD supplement offered at your local store or online is a waste of money and potentially dangerous.

First, assuming that what you buy is actually the NAD supplement, and that is a big “if” given the supplement industry is rife with fraud, the increase in the concentration of NAD in blood cells shows that NR works to raise the concentration of NAD, but it is not evidence that having more NAD will increase life span or health span in humans, or even improve cellular function of any particular group of cells. We also don’t know how much NAD was getting into and affecting muscles or other organs, and that is difficult to measure. One study, sponsored by one of the NAD supplement companies,  found no correlation between the age of subjects and the level of NAD in their muscle and brain tissue (Elhassan et al, 2019). Therefore blood may not be an indicator for NAD throughout the body; not serving as a biomarker for the therapeutic effects in other tissues. The same study by Elhassen et al found that the supplement didn’t help improve the subject’s grip strength, muscle blood flow and metabolism, but concerningly increased a protein thought to be increased in type 2 diabetes and insulin resistance.

We also need to understand what levels of NAD are healthy. Is too much NDA dangerous? Some studies found that it is.  Deterioration of metabolic health, and dysfunction in fat cells along with an induction of glucose intolerance were found in those mice fed a large quantity of NAD supplements (Shi et al, 2019). Other studies in mice report similar results (Kourtzidis et al, 2018). Pools of increased NAD may also be a risk factor for cancer (Hong et al, 2019). And all NAD supplements are not the same in their actions, and supplements don’t act the same way as do the natural, endogenous precursors to NAD (Sambeat et al, 2019).

Again, if you’ve read my book, you know to ask the question, “compared to what?” If you go to Clinicaltrials.gov to see the basic study design of the trials testing NAD supplements, you’ll discover a level of stupidity in trial design that boggles the imagination. What is the NAD supplement being compared to? In none of the studies is diet being controlled for. And we know diet is very important for the levels of NAD in the body. For example, vegetables such as broccoli and cabbage contain 0.25–1.12 and 0.0–0.90 mg NMN/100 gm, fruits like avocado, tomato contain 0.36–1.60 and 0.26–0.30 mg NMN/100 gm, whereas raw beef has 0.06–0.42 mg NMN/100 gm. So if people are eating a poor diet, like most Americans, their natural supplementation of NMN will be low and easily raised by a NAD supplement. Further, without controlling diet in the NAD supplement group versus placebo group, especially in trials with small numbers of subjects, diet can easily confound the data. Moreover, in at least some of the studies, the placebo group was taking a sugar pill. Sugar has numerous deleterious effects within our different organs and microbiome, all of which can impact the clinical trials. The important clinical trial would be to compare the NAD supplement group with a group eating a whole food plant based diet. But given you can’t patent a whole food plant based diet, the monetary incentives are not in place to perform such a study. The mentality of all such gimmicks is to find that one “magic pill” to make me healthy and young, a reductionist strategy appealing to the lazy consumer, and to companies and providers who make a lot of money selling quackery. I have more to say about NAD and other supplements in my book. Hope springs eternal, but so do stupidity and greed.

References

Elhassan YS et al (2019) Nicotinamide riboside augments the human skeletal muscle NAD⁺ metabolome and induces transcriptomic and anti-inflammatory signatures in aged subjects: a placebo-controlled, randomized trial. BioRxiv, doi: https://doi.org/10.1101/680462

He M et al (2020) An Acetylation Switch of the NLRP3 Inflammasome Regulates Aging-Associated Chronic Inflammation and Insulin Resistance. Cell Metabolism, DOI:https://doi.org/10.1016/j.cmet.2020.01.009.

Hong SM et al (2019) Increased nicotinamide adenine dinucleotide pool promotes colon cancer progression by suppressing reactive oxygen species level. Cancer Sci. 2019 Feb; 110(2): 629–638

Kourtzidis I.A., Dolopikou C.F., Tsiftsis A.N., Margaritelis N.V., Theodorou A.A., Zervos I.A., Tsantarliotou M.P., Veskoukis A.S., Vrabas I.S., Paschalis V., et al.  (2018) Nicotinamide riboside supplementation dysregulates redox and energy metabolism in rats: Implications for exercise performance. Exp. Physiol. 103:1357–1366. doi: 10.1113/EP086964.

Luo H et al (2019) Mitochondrial Stress-Initiated Aberrant Activation of the NLRP3 Inflammasome Regulates the Functional Deterioration of Hematopoietic Stem Cell Aging. Cell Rep. 26(4):945-954.e4.

Sambeat A et al (2019) Endogenous nicotinamide riboside metabolism protects against diet-induced liver damage. Nature Communications volume 10, Article number: 4291

Shi W et al (2019) High Dose of Dietary Nicotinamide Riboside Induces Glucose Intolerance and White Adipose Tissue Dysfunction in Mice Fed a Mildly Obesogenic Diet.  Nutrients. 11(10).

Contrary to a belief by many because of a false narrative often propagated by venture capitalists, the first biotech company was Cetus Corporation of Berkeley, CA, not Genentech of South San Francisco, CA. Cetus was co-founded by UC Berkeley faculty member, Dr. Donald Glaser, Ph.D., a Nobel Prize awardee. Amongst other accomplishments, Cetus developed Betaseron and Proleukin, and the PCR methodology that it out-licensed. Cetus was formed in 1971, five years before the inception of Genetech in 1976. Venture capitalists had no significant involvement in Cetus. Kary Mullis, who attained his Ph.D. at Berkeley, developed PCR while at Cetus, and is the only biotech employee to have been awarded the Nobel Prize. Imagine the world without PCR. Without PCR we wouldn’t have : DNA cloning for sequencing, gene cloning and manipulation, gene mutagenesis; construction of DNA-based phylogenies, or functional analysis of genes; diagnosis and monitoring of hereditary diseases; amplification of ancient DNA;analysis of genetic fingerprints for DNA profiling (for example, in forensic science and parentage testing); and detection of pathogens in nucleic acid tests for the diagnosis of infectious diseases (Kaunitz, 2015).

Although PCR has transformed the world, the technology does have inherent errors that constrain the interpretation of any analysis using the methodology. And with healthcare driven by profit motive, the use of PCR by commercial interests in the healthcare space is rife with fraud and incompetence, often making the use of this technology a detriment to health. I detail many of the problems with PCR based diagnostics in my new book, Thinking And Eating For Two: The Science of Using Systems 1 and 2 Thinking to Nourish Self and Symbionts(Maguire, 2020).

References

Bains W (2020) Genentech was not the first biotech company. Nature, doi: 10.1038/d41586-020-00187-1

Kaunitz JD (2015) The Discovery of PCR: ProCuRement of Divine Power. Dig Dis Sci. 2015 Aug; 60(8): 2230–2231.

Maguire G (2020) Thinking And Eating For Two: The Science of Using Systems 1 and 2 Thinking to Nourish Self and Symbionts. Smashwords, Los Gatos, CA.

You can think of the USA as having five principle institutions to govern us: 1. The Presidency, 2. The House, 3. The Senate, 4. The Judiciary, and 5. The Free Press. Unfortunately, none of these are democratic institutions. The least democratic of the five is the Judiciary. Judges are nominated by the President, who is voted-in by the undemocratic Electoral College, and approved by the Senate, an institution that represents land and not the people. For example, California has nearly 40 million people and two senators, whereas Montana has about 577,000 people and two senators. That’s one senator per 288,000 people in Montana, and one senator per 20,000,000 people in California. The House is more representative of the people than is the Senate. California has 53 representatives in the House, one representative for every 754,000 Californians, whereas Montana has one representative in the House, one representative for every 577,000 Montanans. Considering the Press, much of it is owned by the rich, particularly billionaires (Vinton, 2016). Even PBS is often a shill for the wealthy given it is a private corporation funded by billionaires (Hiltzik, 2014). If people are billionaires, what do you think they’re most interested in? Answer – money, of course. Plutocrats living in a society of trickle down economics is destructive and was brought to us in its current form by Ronald Reagan and his revolution for the rich (Hiltzik, 2019). The continued deregulation of the rich means that they own and control almost everything, including some public universities such as Florida State University (Strauss, 2011).

The privatization and deregulation of our food supplies, drug companies, physicians, and hospitals is literally killing us. And the press, being largely controlled by the wealthy, doesn’t care, or can’t say much about it, as long as their billionaire owners are making money. Even the so-called non-profit “patient advocacy” groups are paid for and controlled by the billionaires, working for the rich so that you’ll take more drugs that don’t work (Kopp et al, 2018). This is all detailed in my new book, “Thinking And Eating For Two: The Science of Using Systems 1 and 2 Thinking to Nourish Self and Symbionts,” where I include well over 2,000 references that give the details of the lack of health and “healthcare” in American society. If you want to learn why about 90% of American are sicker than they should be, why most of us will die young, and what you can do about it, read my new book.

References

Hilzik M (2014) How PBS sold its soul to a billionaire donor. LA Times, Feb. 17, 2014.

Hiltzik M (2019) Column: America is falling out of love with billionaires, and it’s about time. LA Times, Feb. 1, 2019.

Kopp et al (2018) KHN launches “Pre$cription for Power,” a groundbreaking database to expose Big Pharma’s ties to patient groups. Kaiser Health News, April 6, 2018.

Maguire G (2020) Thinking And Eating For Two: The Science of Using Systems 1 and 2 Thinking to Nourish Self and Symbionts. Smashwords, Los Gatos, CA.

Strauss V (2011) Did FSU let billionaire buy professorships? May 16, 2011.

Vinton (2016) These 15 Billionaires Own America’s News Media Companies. Forbes, June 1, 2016.

Physicians use bone marrow stem cells from a donor, transplanted into a recipient, to treat patients with certain cancers or blood disorders. The donors for these procedures, whose blood or bone marrow is used for the procedures, are typically young, to optimize the quality of the donor stem cells.

Previous studies have found that error-corrected sequencing (ECS) of human blood samples, with a limit of detection of ≥0.0001, that nearly every healthy individual >50 years old harbors rare hematopoietic clones, i.e. genetically distinct subpopulations of blood cells caused by genetic mutations. Clonal hematopoiesis of indeterminate potential, or CHIP, is characterized by the presence of mutant hematopoietic stem cell clones in the bone marrow without overt signs of disease. However, emerging evidence suggests that this condition, which is more common in older patients, may not be as innocuous as previously thought, with recent studies connecting CHIP to a variety of medical problems (Xie et al, 2014). These mutations are below the detection limit of standard high-throughput sequencing used for screening. Screening procedures for bone marrow stem cells used for stem cell transplants are critical because even cancer cells have been transplanted from donor to recipient when standard screening procedures are used at hospitals (Maguire, 2019; Maguire, 2019A).

A new study by Wong et al (2020)has raised the possibility that young donors are also passing along mutations in stem cells that could lead to health problems for recipients. The study found that 44% of younger donors had mutations in the transplanted bone marrow stem cells that could raise the risk of conditions that are sometimes seen in recipients, a higher rate than previously suspected. The scientific team also reported that some of these mutations persisted and proliferated in the recipients’ bone marrow for at least a year.  Specifically, Wong et al (2020) performed ECS on 125 blood and marrow samples from 25 matched unrelated donors and recipients. Clonal mutations, with a median variant allele frequency of 0.00247, were found in 11 donors (44%; median, 36 years old). Of the mutated clones, 84.2% of mutations were predicted to be molecularly pathogenic and 100% engrafted in recipients. That is, in all of the patients who were recipients of the bone marrow stem cells (BMSCs), the BMSCs engrafted into the patient and remain alive. Further, 84% of the live BMSCs in the recipient were found to harbor possible pathogenic mutations.

Many questions remain, for example, are these  mutations present in the donor before the BMSCs are taken from the donor, or do the mutations occur during the BMSC collection process? If the mutations are present in the donor before the procedure begins, are the mutations causing problems in the 44% of donors with the CHIP? Because BMSC transplants can lead to many health issues in the recipients (Maguire, 2019A), understanding these mutations and their pathogenicity in both donor and recipient is important. Because BMSC transplants lead to implantation of the donor cells in a manner that is not consistent with a normal niche, that is, the extracellular matrix (ECM) and microenvironment of the implanted stem cells may be abnormal (Wood et al, 2016; Maguire, 2019A), implanted cells with mutations surviving in an abnormal ECM/microenvironment may lead to reprogramming of the implanted cells to a cancerous state (Bhat and Bissell, 2014). The combination of mutations along with an abnormal ECM/microenviornment is what is critical to the reprogramming, not one or the other alone.

References

Bhat R and Bissell MJ (2014) Of plasticity and specificity: dialectics of the microenvironment and macroenvironment and the organ phenotype. Wiley Interdiscip Rev Dev Biol. 3(2):147-63. doi: 10.1002/wdev.130. Epub 2013 Nov 18.

Maguire G. (2019) Transplanted stem cells survive a long time: do they make you sick? J R Soc Med. 2019 Oct;112(10):412-414.

Headlines today are reading, “A study found a drug used to treat ovarian cancer doubled the lifespans of pancreatic cancer patients” (Guzman, 2020). Sounds great, right? A new drug study reports that a new drug called Lynparza from AstraZeneca, based in the UK, “nearly doubled the time patients lived without disease progression” (AstraZeneca website). Let’s look at what this actually means by analyzing the study (Golan et al, 2019) that led to the FDA approving the drug for pancreatic cancer. First, let’s assume the paper is a valid study, and all of the 19 physician-authors were actually involved in the study and acted without fraud. Those are big assumptions though, given that ghostwriting, i.e. someone other than the physician does the research and writes the medical paper, is rampant in medical centers where physicians are on the byline of a medical paper (Lacasse and Leo, 2010). Fraud among physicians on the byline of medical research papers is rampant too (Relman, 1983), and has been described by the former editor of the New England Journal of Medicine, Arnold Relman, M.D., as part of the “medical professionalism in the United States is facing a crisis” (Relman, 2007). Dr. Relman’s sentiment has been echoed by many others, including another former editor of the New England Journal of Medicine, Marcia Angel, M.D., who has written, “It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor of The New England Journal of Medicine” (Angell, 2009).

Now, assuming no fraud in the Golan et al (2019) paper, what are the results? The drug increased the length of life by 3.6 months compared to a placebo: “The median progression-free survival was significantly longer in the olaparib group than in the placebo group (7.4 months vs. 3.8 months; hazard ratio for disease progression or death).” That is about a 50% increase in survival. For the gain in 3 months survivability, one must consider the possible negative side effects: The most common side effects with Lynparza (which may affect more than 1 in 10 people) are tiredness, nausea (feeling sick), vomiting, diarrhea, dyspepsia (heartburn), cough, headache, dysgeusia (taste disturbances), decreased appetite, dizziness, upper abdominal pain (stomach ache), dyspnoea (difficulty breathing), anemia (low red blood cell counts), leucopenia (low white blood cell counts), neutropenia (low levels of neutrophils, a type of white blood cell that fights infection) and thrombocytopenia (low blood platelet counts) according to the European Medicines Agency. Further, given that this drug was just approved in December 2019, and that many drugs are not fully understood until used by a large number of people 4-7 years following approval and used in the market by a diverse group of patients, the negative side effects are likely not well understood (Downing et al, 2017).

Because pancreatic cancer involves the immune system, and those who live the longest with this cancer may have elevated T-cell activity in the tumor and in their blood (Balachandron et al, 2017), if the patient does things to better activate T cell function, such as eating fiber (Trompette et al, 2018), survivability may be improved. I have more to say about this in my new book: “Thinking and Eating for Two: The Science of Using Systems 1 and 2 Thinking to Nourish Self and Symbionts.”

References

Angell M (2009) Drug Companies & Doctors: A Story of Corruption. The New York Review of Books, Jan. 15, 2009.

Balachandron et al (2017) Identification of unique neoantigen qualities in long-term survivors of pancreatic cancer. Nature, 551: 512–516.

Downing NS et al (2017) Postmarket Safety Events Among Novel Therapeutics Approved by the US Food and Drug Administration Between 2001 and 2010. JAMA. 317(18):1854-1863

Golan T et al (2019) Maintenance Olaparib for Germline BRCA-Mutated Metastatic Pancreatic Cancer. N Engl J Med, 381:317-327

Guzman J (2020) FDA green-lights promising new pancreatic cancer drug treatment. A study found a drug used to treat ovarian cancer doubled the lifespans of pancreatic cancer patients. The Hill, Jan. 17, 2020.

Lacasse JR, Leo J (2010) Ghostwriting at Elite Academic Medical Centers in the United States. PLoS Med 7(2): e1000230. https://doi.org/10.1371/journal.pmed.1000230.

Relman AS (1983) Lessons from the Darsee Affair. N Engl J Med 1983; 308:1415-1417.

Relman AS (2007) Medical professionalism in a commercialized healthcare market. JAMA. 298(22):2668-2670. doi:10.1001/jama.298.22.2668.

Trompette A et al (2018) Dietary Fiber Confers Protection against Flu by Shaping Ly6c– Patrolling Monocyte Hematopoiesis and CD8+ T Cell Metabolism. Immunity. 48(5):992-1005.e8.

Beginning in the 1980s during the Reagan administration, the approval and regulation processes for therapeutics have been deregulated and evolved into an increasingly complex and poorly working system with rampant fraud. Irrespective of the many other failures of the system, the use of surrogate measures has been encouraged and found to be of questionable value (Darrow et al, 2020). The use of surrogate measures means that a drug is not being tested for efficacy in treating the disease, rather the drug is being tested to modulate some measure that is associated with disease. For example, if a patient has gout, a disease with symptoms of inflammation, severe pain, redness, and swelling in joints, then a surrogate endpoint of serum uric acid (associated with the disease) can be used to determine efficacy of a drug instead of the disease itself. Remember, patients with gout don’t go to see their physician complaining of high serum uric acid levels. The FDA has increasingly accepted less data and more surrogate measures, and has shortened the review times for drug approvals. In our pro-business, deregulated environment, the process has become so corrupt that one drug was approved, despite the scientist at FDA who evaluated the drug disapproving the drug (Lowe, 2016), because the physician, Janet Woodcock, M.D., in charge of the review process, didn’t want the company to go out of business because the company’s drug wasn’t approved (Harper, 2016). I’ll repeat that: a drug was approved by a physician at the FDA for reasons of profit, even though the scientists evaluating the drug said the drug shouldn’t be approved. While increasing numbers of drug candidates are failing (DiMasi et al, 2016), and those approved and on the market are increasingly causing adverse events and deaths (Chen, 2018), the regulatory deregulation and short-cuts have not led to an increase in new drug approvals or to reduced total development times (Darrow et al, 2020). More than half of our drugs don’t work (Smith, 2003). For example, the FDA’s approval of bevacizumab for progressive glioblastoma, an aggressive brain cancer, “the confirmatory trial, with more than 400 patients, reported no improvement in terms of overall survival, quality-of-life end points, or neurocognitive functioning.” Furthermore, almost two-thirds of the patients on bevacizumab had severe to life-threatening side effects (DiMagno et al, 2019). Unfortunately, the only thing working in the drug development process is that the rich are becoming richer – Physicians are highly paid by pharma companies to put their names on ghostwritten medical journal publications (Wilson and Singer, 2009) or just steal the work of their Ph.D. colleagues and add their name (McCook, 2018), and billions are made by the drug companies (Herman, 2019), of which ownership is mostly by the wealthy (Cohen, 2018). When it comes to taking prescription drugs, do as Nancy Reagan told us about those other kinds of drugs: “just say no.” All of this is explained in greater detail, along with alternatives to prescription drugs in my upcoming book, “Thinking and Eating For Two: The Science of Using Systems 1 and 2 Thinking to Nourish Self and Symbionts”(Maguire, 2020).

 

References

Chen C (2018) FDA Repays Industry by Rushing Risky Drugs to Market. ProPublica, June 26, 2018.

Cohen P (2018) We All Have a Stake in the Stock Market, Right? Guess Again. NY Times, Feb. 8, 2018.

Darrow JD et al (2020) FDA Approval and Regulation of Pharmaceuticals, 1983-2018. Journal of the American Medical Association, 323(2):164-176. doi:10.1001/jama.2019.20288.

DiMagno S et al (2019) Accelerated Approval of Cancer Drugs—Righting the Ship of the US Food and Drug Administration. JAMA Intern Med. 179(7):922-923.

DiMasi JA et al (2016) Innovation in the pharmaceutical industry: New estimates of R&D costs. J. Health Econ., 47:20-33.

Harper M (2016) Approving A Muscular Dystrophy Drug Ignites A Civil War At The FDA. Forbes, Sept. 20, 2016.

Herman B (2019) Axios analysis: Drugmakers getting richer. May 13, 2019.

Lowe D (2016) Sarepta Gets An Approval – Unfortunately. Science Translational Medicine, Sept. 20, 2016.

Maguire G (2020) Thinking and Eating For Two: The Science of Using Systems 1 and 2 Thinking to Nourish Self and Symbionts. Smashwords, Los Gatos, CA.

McCook A (2018) Prominent health policy researcher plagiarized colleagues’ work, Dartmouth investigation finds. STAT, August 20, 2018.

Smith R (2003) The drugs don’t work. BMJ. 327(7428): 0.

Wilson D, Singer N. (2009) Ghostwriting is called rife in medical journals. New York Times. 2009 September 11; B5.

The premise of using Executive Health Programs with their associated cardiovascular diagnostic tests is that the results may help reduce mortality from cardiovascular disease through earlier disease detection, more precise risk assessment, and therefore better treatment. As is often the case in medicine, physicians have beliefs about what works despite the evidence against their cherished, money-making beliefs. Screening tests in general have not been found to reduce mortality in asymptomatic individuals (Sussman and Beyth, 2015; Smetana et al, 2016). Nevertheless, many physicians have an enduring belief in the benefit of using diagnostic tests to discover cardiovascular disease in its earliest stages. In a highly deregulated, capitalistic medical system here in the US where physicians and hospitals are incented to perform procedures in order to make more money, leveraging their beliefs in cardiovascular diagnostic testing is a platform for increased income. The money-making mentality among physicians and hospitals is particularly acute in some specialities and in some areas where their are too many competing physicians and hospitals per capita, and therefore physicians perform unnecessary procedures to protect their income. As an example, the U.S. has more than double the number of congenital heart surgery centers that it needs, and about 40 of those centers in the USA aren’t cooperating with authorities to report their medical statistics. Further, those non-cooperating centers have “unexpectedly high mortality rates,” according to Dr. Carl Backer, MD presenting at the 2019 Annual Meeting of the American Heart Association in Philadelphia, PA. In 2014, the Institute of Medicine released their analysis on graduate medical education, arguing there was no shortage of physicians, and that we have no need to invest more in increasing the number of new physicians who are trained annually (IOM, July 29, 2014). With an oversupply of physicians comes more procedures – unnecessary procedures; but money is made (Schroeder, 1992).

As Prof. Ralph Crawshaw, M.D. has said, “Clearly, a serious problem with an exaggerated and misanthropic human trait, greed, challenges the medical profession to move to higher moral ground in the care of the sick.” When asked why he robbed banks, Willie Sutton supposedly said “because that’s where the money is.” For the sake of  increased incomes, physicians and hospitals have created the demand for early diagnosis by leading people to believe that early diagnosis leads to better health. Establishing executive screening programs targeted to wealthy individuals who are able to pay directly for cardiovascular screening tests that are generally not covered by insurance is in vogue. Why? Because that’s where the money is.

In a new study published in the Journal of the American Medical Association Network, executive screening programs have been found to “run afoul of healthcare’s goal of evidence-based cost-effective equitable care” (Alan and Brown, 2020). Indiscriminate screening programs in healthy people can create a cascade effect and thus violate the principle of primum non nocere (first do no harm) wherein unnecessary medical tests may create a chain of adverse medical events resulting in additional ill-advised tests or treatments that may cause avoidable physical and psychological harm.

In a previous study, Prof. Ganguli, M.D. has found in a survey of practicing physicians that almost all (398 out of 400) respondents had experienced medical cascades after incidental findings that did not lead to clinically meaningful outcomes yet caused harm to patients and themselves (Ganguli et al, 2019). The problem is widespread and contributes greatly to the medicalization of America, leading to increased rates of sickness and, as described by Prof. Arnold S. Relman, M.D., former editor of the New England Journal of Medicine, the out of control industrial-medical complex (Relman, 1980; 1983; 2007). Learn how to take care of your own health because the medical-industrial complex won’t; read “Thinking And Eating For Two: The Science of Using Systems 1 and 2 Thinking to Nourish Self and Symbionts.”

References

1. Alan AG and Brown DL (2020) Assessment of Cardiovascular Diagnostic Tests and Procedures Offered in Executive Screening Programs at Top-Ranked Cardiology Hospitals. JAMA Intern Med. Published online January 13, 2020. doi:10.1001/jamainternmed.2019.6607
2. Crawshaw R (1993) Greed and the medical profession. BMJ, 3016: 151.
3. Ganguli I et al (2019) Cascades of Care After Incidental Findings in a US National Survey of Physicians. JAMA Netw Open. 2019;2(10):e1913325.
4. Relman AS (1980) The new medical-industrial complex. N Engl J Med. 303:963-970.
5. Relman AS (1983) Lessons from the Darsee Affair. N Engl J Med 1983; 308:1415-1417.
6. Relman AS (2007) Medical professionalism in a commercialized healthcare market. JAMA. 298(22):2668-2670. doi:10.1001/jama.298.22.2668.
7. Schroeder SA (1992) Physician Supply And The U.S. Medical Marketplace. Health Affairs, https://doi.org/10.1377/hlthaff.11.1.235.
8. Smetana GA et al (2016) Should We Screen for Coronary Heart Disease in Asymptomatic Persons?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center.  Ann Intern Med. 164(7):479-487.
9. Sussman J and Beyth RJ (2015) Don’t perform routine general health checks for asymptomatic adults. Society of General Internal Medicine, https://www.sgim.org/File%20Library/JGIM/Web%20Only/Choosing%20Wisely/General-Health-Checks.pdf.

The study of dermal adipocytes in the skin is leading to a new understanding of skin phsyiology, how the skin maintains and heals itself, and in the development of new procedures and products for wound healing.  Dr. Valerie Horsley, Ph.D., professor of Molecular, Cellular and Developmental Biology and Dermatology at Yale University has pioneered the work of adipocytes in the skin. Her lab has revealed that adipocytes regenerate in the skin and are essential for regeneration of the hair follicle during its normal growth cycle and following injury (Festa et al., 2011; Schmidt and Horsley, 2013). Working with Dr. Matthew Rodeheffer, Ph.D., professor of comparative medicine at Yale University, has identified mesenchymal adipose progenitor cells in the skin and showed that these cells are necessary to induce hair follicle growth (Festa et al., 2011).  These studies showed that the progenitor cells were activated after injury and required for dermal fibroblast migration during wound healing (Schmidt and Horsley, 2013). Her lab has also shown that dermal adipocyte precursor cell self-renewal process decreases as we age and that this process is dependent on PDGF and IGF-1 signaling from macrophages (Gonzalez et al., 2016).  Further, her lab showed that CD301b marks a portion of midphase macrophages and that depletion of CD301b-expressing macrophages was sufficient to induce skin repair defects observed by depletion of myeloid cells more broadly. Transplanting CD301b⁺ macrophages was sufficient to enhance re-epithelialization, dermal proliferation, and fibroblast repopulation during the midstage wound repair. Additionally, they showed that CD301b-expressing macrophage gene expression was enriched for growth factors and cytokines involved in skin regeneration. Therefore, their results identify a subset of CD301b⁺ macrophages critical for activating skin repair during midstage wound healing.  CD301b⁺ macrophage–derived signaling selectively activated the proliferation of adipocyte progenitor cells and not other myofibroblasts.  PDGFC and IGF1 released from macrophages promoted myofibroblast heterogeneity and repair (Shook et al, 2016; Shook et al, 2018). These data are compatible with the function of macrophages in tissue fibrosis, the ability of exogenous PDGFC to rescue delayed skin wound healing in diabetic mice, and the promotion of fibroblast proliferation and repair by IGF1. Further, the importance of adipose derived mesenchymal stem cells in the skin to polarize macrophages from the M1 inflammatory to a M2 anti-inflammatory phenotype may be important in this adipocyte-mediated process of wound healing (Li et al, 2015).

Another important aspect of adipocytes in the skin is to fight infection. Dr. Richard Gallo, MD, PhD, professor and chief of dermatology at UC San Diego School of Medicine, and colleagues have uncovered a previously unknown role for dermal adipocytes – they produce antimicrobial peptides (AMPs) that help fend off invading bacteria, viruses, and fungi.

So contrary to what many people have been told, Fat Isn’t All Bad, especially when considering adipocytes in the skin.

References

Festa, E et al (2011), Adipocyte lineage cells contribute to the skin stem cell niche to drive hair cycling. Cell 146, 761–71 doi:10.1016/j.cell.2011.07.019pmid:21884937

Gonzalez GC et al (2016) Skin adipocyte stem cell self-renewal is regulated by a PDGFA/AKT-signaling axis. Cell Stem Cell19, 738–751 pmid:27746098

Li Q et al (2015) Skin-Derived Mesenchymal Stem Cells Alleviate Atherosclerosis via Modulating Macrophage Function. Stem Cells Transl Med. 4(11): 1294–1301.

Schmidt V and Horsley V (2013) Intradermal adipocytes mediate fibroblast recruitment during skin wound healing.Development 140, 1517–1527 (2013). doi:10.1242/dev.087593pmid:23482487

Shook,B et al (2016) CD301b+ macrophages are essential for effective skin wound healing. J. Invest. Dermatol. 136, 1885–1891 (2016).doi:10.1016/j.jid.2016.05.107pmid:27287183

Shook B et al (2018) Myofibroblast proliferation and heterogeneity are supported by macrophages during skin repair. Science, DOI: 10.1126/science.aar2971

Careful You May Be Stuck with the Cell’s Phenotype and Genotype for a Very Long Time

Hematopoietic stem and progenitor cells (HSPCs) are responsible for generating and maintaining the extremely diverse pool of blood cells, everything from red blood cells to T-cells, for our lifetime. HSPC transplantation, also known as bone marrow transplantation, remains the only approved stem cell therapy, even though unapproved stem cell transplants for a variety of other indications continue to burgeon. The approved, clinical transplantation of human HSPCs from an allogeneic healthy donor can effectively replenish defective blood cell production caused by congenital or acquired disorders, but, as with most medical products or procedures, there are risks involved. Many case studies have reported the approved stem cell transplants to be associated with the later development of cancer (Cooley et al, 2000), and unapproved stem cell transplant procedures are notorious for side-effects, including development of cancer (Diouhy et al, 2014). Unfortunately, with most drugs and many medical procedures, the long term consequences to health are unknown. Often, when considering drugs, not until Phase IV, postmarket approval are the long term consequence of a drug discovered. Witness the many drugs pulled from market some three to four years after their approval (e.g. ProCon, 2014). Even more unfortunate, the problem is worse with medical procedures (Kumar and Nash, 2011). Such is the case with approved stem cell transplants. The effects of approved stem cell transplants in causing, or being involved, in cancer relapse are not well understood, but are thought to involve epigenetic factors in the stem cells used for the transplant (Christopher et al, 2018). In addition, any type of stem cell transplant may cause aging of the tissue as measured in T-cells using a p16 biomarker (Wood et al, 2016), indicating the increased level of cellular senescence in the surrounding tissue.

So what are some of the possible mechanisms for stem cells to cause these untoward and unpropitious side effects? First, a new study shows that transplanted stem cells (HSPCS) can survive a long time in human patients, such that they can be maintained independently of their continuous production from endogenous HSPCs (Scala et al, 2018). Second, we know that processed stem cells can carry an increasing number of genetic mutations as they are expanded, particularly the p53 mutation associated with many cancer phenotypes (Merkle et al, 2017). And, as I discussed in a previous blog, stem cells have memory, and change their phenotype, for at least many months, when they have experienced a wounding, inflammatory event (Naik et al, 2017). The new phenotype that Naik et al (2017) measured was one of an increased probability to proliferate, a cancer-like cellular behavior. An underlying mechanism for the increased probability of proliferation appeared to be epigenetic, where the DNA was less tightly bound around its histone protein. If we synthesize these data, stem cell transplants using cells that have genotypic, epigenotypic, and phenotypic changes conducive to proliferation, and given the cells ability to engraft, survive, and remain viable for long periods, means that the cells may be a cause of cancer. Coupled with the possible induction of aging in the surrounding tissue (Wood et al, 2016), another risk factor for cancer, stem cell transplants pose a significant risk for cancer, as well as other problems (Maguire, 2016). As such, the problems with stem cell transplants means they should only be used in life threatening conditions, or where their benefits clearly outweigh the risks. The problems with stem cell transplants also leads to the argument for the use of a “systems therapeutic” using stem cell released molecules (Maguire, 2014), instead of the cells (Maguire, 2013), for many indications, such as amytrophic lateral sclerosis and other neurodegenerative diseases (Maguire, 2018).

These issues will be further explored in my second book to be published in 2019.

References

Christopher MJ et al (2018) Immune Escape of Relapsed AML Cells after Allogeneic Transplantation. N. Eng. J. Med, DOI: 10.1056/NEJMoa1808777

Cooley LD et al (2000) Donor cell leukemia: report of a case occurring 11 years after allogeneic bone marrow transplantation and review of the literature. Am.J. Hematol. 63(1):46-53.

Diouhy BJ et al (2014) Autograft-derived spinal cord mass following olfactory mucosal cell transplantation in a spinal cord injury patient. J.  Neurosurgery,  DOI: https://doi.org/10.3171/2014.5.SPINE13992

Kumar S and Nash DB (2011) Health Care Myth Busters: Is There a High Degree of Scientific Certainty in Modern Medicine? Scientific American, March 25, 2011.

Maguire G (2013) Stem cell therapy without the cells. Commun Integr Biol. 6(6):e26631

Maguire G (2014) Systems biology approach to developing “systems therapeutics”. ACS Med. Chem. Lett. 5(5): 453–455

Maguire G (2016) Therapeutics from Adult Stem Cells and the Hype Curve. ACS Med. Che. Lett. 7(5):441-3

Maguire G (2018) Adult Stem Cell Released Molecules: A Paradigm Shift to Systems Therapeutics. Nova Science Publishers, New York.

Merkle FT et al (2017) Human pluripotent stem cells recurrently acquire and expand dominant negative P53 mutations. Nature 545: 229–233

Naik S et al (2017) Inflammatory memory sensitizes skin epithelial stem cells to tissue damage. Nature 550: 475–480

ProCon (2014) 35 FDA-Approved Prescription Drugs Later Pulled from the Market. ProCon, Jan 30, 2014.

Scala S et al (2018) Dynamics of genetically engineered hematopoietic stem and progenitor cells after autologous transplantation in humans. Nature Medicine 24:1683–1690

Wood WA et al (2016) Chemotherapy and Stem Cell Transplantation Increase p16^INK4aExpression, a Biomarker of T-cell Aging. EBioMedicine, 11: 227–238