Do hospital investigations alter patients’ choices?

In the UK health care system, the Care Quality Commission can conduct high-profile investigations of hospitals. In a recent article published in Health Affairs, we investigated the impact of such investigations on patients’ behavior. For three investigations, we analyzed the trends of non-emergency patient admissions and other utilization indicators. Controlling for secular trends and using a control group, we employed a difference-in-difference approach. We found that the investigations only had an impact for one hospital with significant declines in inpatient admissions, outpatient surgeries, and in numbers of patients coming for their first appointment, but the effects disappeared six months after publication of the investigation report. Apparently, the publication and dissemination of the highly critical report does not have a sustainable impact on patients’ behavior like avoidance of the hospital. Assuming that hospitals implement improvements also without the threat of losing patients, public reporting has no adverse effects on the number of patients for the hospital.

New DNA Modifications in Cancer Patients

[No idea what DNA is? Don't worry, skip the first paragraph and continue with the second!] In our latest research contribution (read here), we showed that a new DNA modification identified in our lab about a year ago is altered in some cancer patients. We discovered the responsible enzyme as well as the mutations, which corrupt its functionality. A comparison of the cancer patients with and without the mutated enzyme show other biochemical differences, which strongly proposed to individualize current cancer treatment for this subgroup of patients. And if you are lost reading this, here is a more down to earth explanation:

Each cell has DNA which contains the information about all our proteins. You should imagine the DNA as a long book with four letters A, C, G and T. Although this sounds like a rather abstract model, it is more realistic than one might think. The DNA is a huge biochemical molecule built by many smaller molecules. The most important part of DNA is a chain of millions of one out of four molecules. These four molecules – you can guess – are called Adenine, Cytosine, Guanine and Thymine. They correspond to our letters. Other molecules read them as if they would be letters. Depending on the order of the letters, enzymes can build all the different proteins in our cells. The region, which describes a protein, is called a gene.  However, all cells contain the same DNA but a liver cell is obviously rather different from a brain cell. Both cells produce different proteins. This is done by regulating which genes of the DNA are used to produce proteins. And who tells which genes should be used? The DNA itself. The DNA contains so-called regulatory regions, which tell other enzymes whether certain genes should be used to produce proteins or not. That’s the basic biochemistry in our cells. And one more step and we can talk about our research.

Some years ago, researchers realized that often the letter C is modified to an mC. This biochemical modification is important as it can change the regulation of our genes. Hence, some people talk about five instead of four letters in the DNA. The group I joined in Boston discovered just before my arrival that C is sometimes further modified to an hmC in embryonic cells (also published in Nature, click here). This was the starting point of a lot of research to understand the function of hmC and how hmC itself is regulated. The result of these efforts are now published in our new article:

Based on a suggestion of the first article, we analyzed an enzyme called Tet2. We could show that Tet is indeed involved in the modification of C / mC to hmC. How do we know this? We found that the function of Tet2 can be disrupted by mutations. The disrupted enzyme is dysfunctional and cells with the disrupted version of the enzyme have much less hmC than normal cells. Investigating the mutations of Tet2 in more detail, we realized that a subgroup of cancer patients have exactly these disrupting mutations. Using tissue samples of these patients (and, of course, control patients), we discovered that tissues from patients with dysfunctional Tet2 have less hmC than the controls. Hence, our findings of mutated Tet2 and altered DNA modifications is not just a special lab case but specifically occurs in a subgroup of one of the most terrifying diseases in the world.

Next, we analyzed the tissues in more detail. In addition to the difference in hmCs, they also differ from control patients by having less mC than C. This is rather strange because cancer patients usually have much more mC than C. In fact, cancer drugs try to reduce the abundance of mC to C in cancer patients. This is current clinical practice. However, for these special patients with mutated Tet2 and, hence, less hmC and less mC, this might be the totally wrong treatment. Besides the biochemical insights in the regulation of hmCs, this is our main finding.

Do (multi-) vitamin supplements increase the risk of cancer?

I’ve to admit that I do take vitamin supplements. Interestingly, there are two claims about vitamin supplements, slightly contradicting each other: First, vitamin supplements do not work. Second, vitamin supplements increase the risk for cancer. What is true about this? In the book ‘Think Smart’ from Richard Restak, I found the answers. Unfortunately, he doesn’t give explicit references for the following claims but the book makes overall a very well-researched impression:

First, it is true that some vitamin supplements do not work. For example, there are eight different forms of vitamin E while only one form (alpha-tocopherol) is biologically active. Only alpha-tocopherol is extracted from the blood stream while all others are directly excreted. Unfortunately, vitamin supplement producers often don’t really care about the form in the pills. Hence, some pills contain the wrong form which are just useless.

Second, it is true that vitamin supplements can increase risk for cancer (and dying). However, this only happens if one consumes too many vitamin supplements. The problem are over-dosage effects which are, for example, known for multi-vitamin pills. Men exceeding the recommended dose of one pill per day, increase their risk of prostate cancer by one third. Hence, one should not follow the naive belief if one is good, two is even better. Probably for the same reason (over-dosage), it is known that taking 400 IU (international unit) of vitamin E increases the risk of dying than just consuming vitamin E from food sources. The recommended daily value is 30 IU. The negative effects in vitamin E is due to its ability to make the blood thinner. Also for minerals like magnesium negative over-dosage effects are known (read here about a futuristic brain booster).

In summary, it might be a good idea to take vitamin supplements moderately if the daily diet doesn’t contain sufficient amounts of vitamins. However, one should be cautious not to combine different sources resulting in a vast excess of certain vitamins.

Evolution in the lab

In Nature , the group from Richard Lenski just published a really cool 20-years experiment to observe more than 40,000 generations of E. coli and how evolution is going on. The main finding is that changes in the DNA increase linearly while the increase in fitness decreases. As this cannot be explained by neutral evolution since there is a lot of evidence that the mutations are not random, they give two alternative but complex hypothesis.

First, the new environment at the beginning of the experiment might lead to competition between highly beneficial mutations and just beneficial mutations while both mutations need the same amount of DNA mutation. Thus, just beneficial mutations are out-competed and are not manifested but only highly beneficial mutations are fixed. However, in a second phase only just beneficial mutations are possible but based on the same amount of DNA mutation. Thus, genomic change would stay constant but fitness gain would decelerate.

The second alternative is that at the beginning mutations are fixed with have a high overall impact on the cell with many negative side-effects but – in balance – is still beneficial. However, this would make other mutations possible to compensate for the negative side-effects. Hence, the genomic change would stay constant but the fitness would decline.

If you want to read a more sophisticated summary, register and visit my scientific blog here!

Grant Writing in Research

Here is a very good and authentic article about the problems of funding and grant writing in research. Thanks for Florian for the hint…

Follow

Get every new post delivered to your Inbox.