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Monday, June 5, 2023

Post-acute-withdrawal syndrome

From Wikipedia, the free encyclopedia
Post-acute-withdrawal syndrome
Other namesPost-withdrawal syndrome, protracted withdrawal syndrome, prolonged withdrawal syndromes
SpecialtyPsychiatry, Toxicology

Post-acute withdrawal syndrome (PAWS) is a hypothesized set of persistent impairments that occur after withdrawal from alcohol, opiates, benzodiazepines, antidepressants, and other substances. Infants born to mothers who used substances of dependence during pregnancy may also experience a post-acute withdrawal syndrome. While post-acute withdrawal syndrome has been reported by those in the recovery community, there have been few scientific studies supporting its existence outside of protracted benzodiazepine withdrawal. Because of this, the disorder is not recognized by the Diagnostic and Statistical Manual of Mental Disorders or major medical associations.

Drug use, including alcohol and prescription drugs, can induce symptomatology which resembles mental illness. This can occur both in the intoxicated state and during the withdrawal state. In some cases these substance-induced psychiatric disorders can persist long after detoxification from amphetamine, cocaine, opioid, and alcohol use, causing prolonged psychosis, anxiety or depression. A protracted withdrawal syndrome can occur with symptoms persisting for months to years after cessation of substance use. Benzodiazepines, opioids, alcohol, and any other drug may induce prolonged withdrawal and have similar effects, with symptoms sometimes persisting for years after cessation of use. Psychosis including severe anxiety and depression are commonly induced by sustained alcohol, opioid, benzodiazepine, and other drug use which in most cases abates with prolonged abstinence. Any continued use of drugs or alcohol may increase anxiety, psychosis, and depression levels in some individuals. In almost all cases drug-induced psychiatric disorders fade away with prolonged abstinence, although permanent damage to the brain and nervous system may be caused by continued substance use.

Signs and symptoms

Symptoms can sometimes come and go with wave-like re-occurrences or fluctuations in severity of symptoms. Common symptoms include impaired cognition, irritability, depressed mood, and anxiety; all of which may reach severe levels which can lead to relapse.

The protracted withdrawal syndrome from benzodiazepines, opioids, alcohol and other addictive substances can produce symptoms identical to generalized anxiety disorder as well as panic disorder. Due to the sometimes prolonged nature and severity of benzodiazepine, opioid and alcohol withdrawal, abrupt cessation is not advised.

Hypothesized symptoms of post-acute withdrawal syndrome are:

Symptoms occur intermittently, but are not always present. They are made worse by stress or other triggers and may arise at unexpected times and for no apparent reason. They may last for a short while or longer. Any of the following may trigger a temporary return or worsening of the symptoms of post-acute withdrawal syndrome:

  • Stressful and/or frustrating situations
  • Multitasking
  • Feelings of anxiety, fearfulness or anger
  • Social conflicts
  • Unrealistic expectations of oneself

Post-acute benzodiazepine withdrawal

Disturbances in mental function can persist for several months or years after withdrawal from benzodiazepines. Psychotic depression persisting for more than a year following benzodiazepine withdrawal has been documented in the medical literature. The patient had no prior psychiatric history. The symptoms reported in the patient included, major depressive disorder with psychotic features, including persistent depressed mood, poor concentration, decreased appetite, insomnia, anhedonia, anergia and psychomotor retardation. The patient also experienced paranoid ideation (believing she was being poisoned and persecuted by co-employees), accompanied by sensory hallucinations. Symptoms developed after abrupt withdrawal of chlordiazepoxide and persisted for 14 months. Various psychiatric medications were trialed which were unsuccessful in alleviating the symptomatology. Symptoms were completely relieved by recommending chlordiazepoxide for irritable bowel syndrome 14 months later. Another case report, reported similar phenomenon in a female patient who abruptly reduced her diazepam dosage from 30 mg to 5 mg per day. She developed electric shock sensations, depersonalisation, anxiety, dizziness, left temporal lobe EEG spiking activity, hallucinations, visual perceptual and sensory distortions which persisted for years.

A clinical trial of patients taking the benzodiazepine alprazolam (Xanax) for eight weeks triggered protracted symptoms of memory deficits which were still present after up to eight weeks post cessation of alprazolam.

Dopamine agonist protracted withdrawal

After long-term use of dopamine agonists, a withdrawal syndrome may occur during dose reduction or discontinuation with the following possible side effects: anxiety, panic attacks, dysphoria, depression, agitation, irritability, suicidal ideation, fatigue, orthostatic hypotension, nausea, vomiting, diaphoresis, generalized pain, and drug cravings. For some individuals, these withdrawal symptoms are short-lived and make a full recovery, for others a protracted withdrawal syndrome may occur with withdrawal symptoms persisting for months or years.

Cause

The syndrome may be in part due to persisting physiological adaptations in the central nervous system manifested in the form of continuing but slowly reversible tolerance, disturbances in neurotransmitters and resultant hyperexcitability of neuronal pathways. However, data supports "neuronal and overwhelming cognitive normalization" in regards to chronic amphetamine use and PAWS. Stressful situations arise in early recovery, and the symptoms of post acute withdrawal syndrome produce further distress. It is important to avoid or to deal with the triggers that make post acute withdrawal syndrome worse. The types of symptomatology and impairments in severity, frequency, and duration associated with the condition vary depending on the drug of use.

Treatment

The condition gradually improves over a period of time which can range from six months to several years in more severe cases.

Flumazenil was found to be more effective than placebo in reducing feelings of hostility and aggression in patients who had been free of benzodiazepines for 4 to 266 weeks. This may suggest a role for flumazenil in treating protracted benzodiazepine withdrawal symptoms.

Acamprosate has been found to be effective in alleviating some of the post acute withdrawal symptoms of alcohol withdrawal. Carbamazepine or trazodone may also be effective in the treatment of post acute withdrawal syndrome in regards to alcohol use. Cognitive behavioral therapy can also help the post acute withdrawal syndrome especially when cravings are a prominent feature.

Drug withdrawal

From Wikipedia, the free encyclopedia
https://en.wikipedia.org/wiki/Drug_withdrawal

Drug withdrawal, drug withdrawal syndrome, or substance withdrawal syndrome, is the group of symptoms that occur upon the abrupt discontinuation or decrease in the intake of pharmaceutical or recreational drugs.

In order for the symptoms of withdrawal to occur, one must have first developed a form of drug dependence. This may occur as physical dependence, psychological dependence or both. Drug dependence develops from consuming one or more substances over a period of time.

Dependence arises in a dose-dependent manner and produces withdrawal symptoms that vary with the type of drug that is consumed. For example, prolonged use of an antidepressant medication is likely to cause a rather different reaction when discontinued compared to discontinuation of an opioid, such as heroin. Withdrawal symptoms from opiates include anxiety, sweating, vomiting, and diarrhea. Alcohol withdrawal symptoms include irritability, fatigue, shaking, sweating, and nausea. Withdrawal from nicotine can cause irritability, fatigue, insomnia, headache, and difficulty concentrating. Many prescription and legal nonprescription substances can also cause withdrawal symptoms when individuals stop consuming them, even if they were taken as directed by a physician.

The route of administration, whether intravenous, intramuscular, oral or otherwise, can also play a role in determining the severity of withdrawal symptoms. There are different stages of withdrawal as well; generally, a person will start to feel bad (crash or come down), progress to feeling worse, hit a plateau, and then the symptoms begin to dissipate. However, withdrawal from certain drugs (barbiturates, benzodiazepines, alcohol, glucocorticoids) can be fatal. While it is seldom fatal to the user, withdrawal from opiates (and some other drugs) can cause miscarriage, due to fetal withdrawal. The term "cold turkey" is used to describe the sudden cessation of use of a substance and the ensuing physiologic manifestations.

The symptoms from withdrawal may be even more dramatic when the drug has masked prolonged malnutrition, disease, chronic pain, infections (common in intravenous drug use), or sleep deprivation, conditions that drug abusers often develop as a secondary consequence of the drug. When the drug is removed, these conditions may resurface and be confused with withdrawal symptoms. Genes that encode for the Alpha5 Nicotinic Acetylcholine Receptor affect nicotine and alcohol withdrawal symptoms.

Effect on homeostasis

Homeostasis is the body's ability to maintain a certain chemical equilibrium in the brain and throughout the body. For example, the function of shivering in response to cold is to produce heat maintaining internal temperature at around 37 °C (98.6 °F). Homeostasis is impacted in many ways by drug usage and withdrawal. The internal systems perpetuate homeostasis by using different counter-regulatory methods in order to create a new state of balance based on the presence of the drug in the system. These methods include adapting the body's levels of neurotransmitters, hormones, and other substances present to adjust for the addition of the drug to the body.

Substances

Addiction and dependence glossary
  • addiction – a biopsychosocial disorder characterized by persistent use of drugs (including alcohol) despite substantial harm and adverse consequences
  • addictive drug – psychoactive substances that with repeated use are associated with significantly higher rates of substance use disorders, due in large part to the drug's effect on brain reward systems
  • dependence – an adaptive state associated with a withdrawal syndrome upon cessation of repeated exposure to a stimulus (e.g., drug intake)
  • drug sensitization or reverse tolerance – the escalating effect of a drug resulting from repeated administration at a given dose
  • drug withdrawal – symptoms that occur upon cessation of repeated drug use
  • physical dependence – dependence that involves persistent physical–somatic withdrawal symptoms (e.g., fatigue and delirium tremens)
  • psychological dependence – dependence that involves emotional–motivational withdrawal symptoms (e.g., dysphoria and anhedonia)
  • reinforcing stimuli – stimuli that increase the probability of repeating behaviors paired with them
  • rewarding stimuli – stimuli that the brain interprets as intrinsically positive and desirable or as something to approach
  • sensitization – an amplified response to a stimulus resulting from repeated exposure to it
  • substance use disorder – a condition in which the use of substances leads to clinically and functionally significant impairment or distress
  • tolerance – the diminishing effect of a drug resulting from repeated administration at a given dose

Prescription medicine

As noted above, many drugs should not be stopped abruptly without the advice and supervision of a physician, especially if the medication induces dependence or if the condition they are being used to treat is potentially dangerous and likely to return once medication is stopped, such as diabetes, asthma, heart conditions and many psychological or neurological conditions, like epilepsy, depression, hypertension, schizophrenia and psychosis. The stopping of antipsychotics in schizophrenia and psychoses needs monitoring. The stopping of antidepressants for example, can lead to antidepressant discontinuation syndrome. With careful physician attention, however, medication prioritization and discontinuation can decrease costs, simplify prescription regimens, decrease risks of adverse drug events and poly-pharmacy, focus therapies where they are most effective, and prevent cost-related under-use of medications.

Medication Appropriateness Tool for Comorbid Health Conditions in Dementia (MATCH-D) warns that people with dementia are more likely to experience adverse effects, and to monitor carefully for withdrawal symptoms when ceasing medications for these people as they are both more likely to experience symptoms and less likely to be able to reliably report symptoms.

Anti-hypertensive drugs

The latest evidence does not have evidence of an effect due to discontinuing vs continuing medications used for treating elevated blood pressure or prevention of heart disease in older adults on all-case mortality and incidence of heart attack. The findings are based on low quality evidence suggesting it may be safe to stop anti-hypertensive medications. However, older adults should not stop any of their medications without talking to a healthcare professional.

Whole genome sequencing

From Wikipedia, the free encyclopedia
https://en.wikipedia.org/wiki/Whole_genome_sequencing
 
Electropherograms are commonly used to sequence portions of genomes.
 
Schematic karyogram of a human, showing an overview of the human genome, with 22 homologous chromosomes, both the female (XX) and male (XY) versions of the sex chromosome (bottom right), as well as the mitochondrial genome (to scale at bottom left).
 

Whole genome sequencing (WGS), also known as full genome sequencing, complete genome sequencing, or entire genome sequencing, is the process of determining the entirety, or nearly the entirety, of the DNA sequence of an organism's genome at a single time. This entails sequencing all of an organism's chromosomal DNA as well as DNA contained in the mitochondria and, for plants, in the chloroplast.

Whole genome sequencing has largely been used as a research tool, but was being introduced to clinics in 2014. In the future of personalized medicine, whole genome sequence data may be an important tool to guide therapeutic intervention. The tool of gene sequencing at SNP level is also used to pinpoint functional variants from association studies and improve the knowledge available to researchers interested in evolutionary biology, and hence may lay the foundation for predicting disease susceptibility and drug response.

Whole genome sequencing should not be confused with DNA profiling, which only determines the likelihood that genetic material came from a particular individual or group, and does not contain additional information on genetic relationships, origin or susceptibility to specific diseases. In addition, whole genome sequencing should not be confused with methods that sequence specific subsets of the genome – such methods include whole exome sequencing (1–2% of the genome) or SNP genotyping (< 0.1% of the genome).

History

The first bacterial whole genome to be sequenced was of the bacterium Haemophilus influenzae.
 
The worm Caenorhabditis elegans was the first animal to have its whole genome sequenced.
 
Drosophila melanogaster's whole genome was sequenced in 2000.
 
Arabidopsis thaliana was the first plant genome sequenced.
 
The genome of the lab mouse Mus musculus was published in 2002.
 
It took 10 years and 50 scientists spanning the globe to sequence the genome of Elaeis guineensis (oil palm). This genome was particularly difficult to sequence because it had many repeated sequences which are difficult to organise.

The DNA sequencing methods used in the 1970s and 1980s were manual; for example, Maxam–Gilbert sequencing and Sanger sequencing. Several whole bacteriophage and animal viral genomes were sequenced by these techniques, but the shift to more rapid, automated sequencing methods in the 1990s facilitated the sequencing of the larger bacterial and eukaryotic genomes.

The first virus to have its complete genome sequenced was the Bacteriophage MS2 by 1976. In 1992, yeast chromosome III was the first chromosome of any organism to be fully sequenced. The first organism whose entire genome was fully sequenced was Haemophilus influenzae in 1995. After it, the genomes of other bacteria and some archaea were first sequenced, largely due to their small genome size. H. influenzae has a genome of 1,830,140 base pairs of DNA. In contrast, eukaryotes, both unicellular and multicellular such as Amoeba dubia and humans (Homo sapiens) respectively, have much larger genomes (see C-value paradox). Amoeba dubia has a genome of 700 billion nucleotide pairs spread across thousands of chromosomes. Humans contain fewer nucleotide pairs (about 3.2 billion in each germ cell – note the exact size of the human genome is still being revised) than A. dubia, however, their genome size far outweighs the genome size of individual bacteria.

The first bacterial and archaeal genomes, including that of H. influenzae, were sequenced by Shotgun sequencing. In 1996 the first eukaryotic genome (Saccharomyces cerevisiae) was sequenced. S. cerevisiae, a model organism in biology has a genome of only around 12 million nucleotide pairs, and was the first unicellular eukaryote to have its whole genome sequenced. The first multicellular eukaryote, and animal, to have its whole genome sequenced was the nematode worm: Caenorhabditis elegans in 1998. Eukaryotic genomes are sequenced by several methods including Shotgun sequencing of short DNA fragments and sequencing of larger DNA clones from DNA libraries such as bacterial artificial chromosomes (BACs) and yeast artificial chromosomes (YACs).

In 1999, the entire DNA sequence of human chromosome 22, the shortest human autosome, was published. By the year 2000, the second animal and second invertebrate (yet first insect) genome was sequenced – that of the fruit fly Drosophila melanogaster – a popular choice of model organism in experimental research. The first plant genome – that of the model organism Arabidopsis thaliana – was also fully sequenced by 2000. By 2001, a draft of the entire human genome sequence was published. The genome of the laboratory mouse Mus musculus was completed in 2002.

In 2004, the Human Genome Project published an incomplete version of the human genome. In 2008, a group from Leiden, the Netherlands, reported the sequencing of the first female human genome (Marjolein Kriek).

Currently thousands of genomes have been wholly or partially sequenced.

Experimental details

Cells used for sequencing

Almost any biological sample containing a full copy of the DNA—even a very small amount of DNA or ancient DNA—can provide the genetic material necessary for full genome sequencing. Such samples may include saliva, epithelial cells, bone marrow, hair (as long as the hair contains a hair follicle), seeds, plant leaves, or anything else that has DNA-containing cells.

The genome sequence of a single cell selected from a mixed population of cells can be determined using techniques of single cell genome sequencing. This has important advantages in environmental microbiology in cases where a single cell of a particular microorganism species can be isolated from a mixed population by microscopy on the basis of its morphological or other distinguishing characteristics. In such cases the normally necessary steps of isolation and growth of the organism in culture may be omitted, thus allowing the sequencing of a much greater spectrum of organism genomes.

Single cell genome sequencing is being tested as a method of preimplantation genetic diagnosis, wherein a cell from the embryo created by in vitro fertilization is taken and analyzed before embryo transfer into the uterus. After implantation, cell-free fetal DNA can be taken by simple venipuncture from the mother and used for whole genome sequencing of the fetus.

Early techniques

An ABI PRISM 3100 genetic analyzer. Such capillary sequencers automated the early efforts of sequencing genomes.

Sequencing of nearly an entire human genome was first accomplished in 2000 partly through the use of shotgun sequencing technology. While full genome shotgun sequencing for small (4000–7000 base pair) genomes was already in use in 1979, broader application benefited from pairwise end sequencing, known colloquially as double-barrel shotgun sequencing. As sequencing projects began to take on longer and more complicated genomes, multiple groups began to realize that useful information could be obtained by sequencing both ends of a fragment of DNA. Although sequencing both ends of the same fragment and keeping track of the paired data was more cumbersome than sequencing a single end of two distinct fragments, the knowledge that the two sequences were oriented in opposite directions and were about the length of a fragment apart from each other was valuable in reconstructing the sequence of the original target fragment.

The first published description of the use of paired ends was in 1990 as part of the sequencing of the human HPRT locus, although the use of paired ends was limited to closing gaps after the application of a traditional shotgun sequencing approach. The first theoretical description of a pure pairwise end sequencing strategy, assuming fragments of constant length, was in 1991. In 1995 the innovation of using fragments of varying sizes was introduced, and demonstrated that a pure pairwise end-sequencing strategy would be possible on large targets. The strategy was subsequently adopted by The Institute for Genomic Research (TIGR) to sequence the entire genome of the bacterium Haemophilus influenzae in 1995, and then by Celera Genomics to sequence the entire fruit fly genome in 2000, and subsequently the entire human genome. Applied Biosystems, now called Life Technologies, manufactured the automated capillary sequencers utilized by both Celera Genomics and The Human Genome Project.

Current techniques

While capillary sequencing was the first approach to successfully sequence a nearly full human genome, it is still too expensive and takes too long for commercial purposes. Since 2005 capillary sequencing has been progressively displaced by high-throughput (formerly "next-generation") sequencing technologies such as Illumina dye sequencing, pyrosequencing, and SMRT sequencing. All of these technologies continue to employ the basic shotgun strategy, namely, parallelization and template generation via genome fragmentation.

Other technologies have emerged, including Nanopore technology. Though the sequencing accuracy of Nanopore technology is lower than those above, its read length is on average much longer. This generation of long reads is valuable especially in de novo whole-genome sequencing applications.

Analysis

In principle, full genome sequencing can provide the raw nucleotide sequence of an individual organism's DNA at a single point in time. However, further analysis must be performed to provide the biological or medical meaning of this sequence, such as how this knowledge can be used to help prevent disease. Methods for analyzing sequencing data are being developed and refined.

Because sequencing generates a lot of data (for example, there are approximately six billion base pairs in each human diploid genome), its output is stored electronically and requires a large amount of computing power and storage capacity.

While analysis of WGS data can be slow, it is possible to speed up this step by using dedicated hardware.

Commercialization

Total cost of sequencing a whole human genome as calculated by the NHGRI.

A number of public and private companies are competing to develop a full genome sequencing platform that is commercially robust for both research and clinical use, including Illumina, Knome, Sequenom, 454 Life Sciences, Pacific Biosciences, Complete Genomics, Helicos Biosciences, GE Global Research (General Electric), Affymetrix, IBM, Intelligent Bio-Systems, Life Technologies, Oxford Nanopore Technologies, and the Beijing Genomics Institute. These companies are heavily financed and backed by venture capitalists, hedge funds, and investment banks.

A commonly-referenced commercial target for sequencing cost until the late 2010s was $1,000 USD, however, the private companies are working to reach a new target of only $100.

Incentive

In October 2006, the X Prize Foundation, working in collaboration with the J. Craig Venter Science Foundation, established the Archon X Prize for Genomics, intending to award $10 million to "the first team that can build a device and use it to sequence 100 human genomes within 10 days or less, with an accuracy of no more than one error in every 1,000,000 bases sequenced, with sequences accurately covering at least 98% of the genome, and at a recurring cost of no more than $1,000 per genome". The Archon X Prize for Genomics was cancelled in 2013, before its official start date.

History

In 2007, Applied Biosystems started selling a new type of sequencer called SOLiD System. The technology allowed users to sequence 60 gigabases per run.

In June 2009, Illumina announced that they were launching their own Personal Full Genome Sequencing Service at a depth of 30× for $48,000 per genome. In August, the founder of Helicos Biosciences, Stephen Quake, stated that using the company's Single Molecule Sequencer he sequenced his own full genome for less than $50,000. In November, Complete Genomics published a peer-reviewed paper in Science demonstrating its ability to sequence a complete human genome for $1,700.

In May 2011, Illumina lowered its Full Genome Sequencing service to $5,000 per human genome, or $4,000 if ordering 50 or more. Helicos Biosciences, Pacific Biosciences, Complete Genomics, Illumina, Sequenom, ION Torrent Systems, Halcyon Molecular, NABsys, IBM, and GE Global appear to all be going head to head in the race to commercialize full genome sequencing.

With sequencing costs declining, a number of companies began claiming that their equipment would soon achieve the $1,000 genome: these companies included Life Technologies in January 2012, Oxford Nanopore Technologies in February 2012, and Illumina in February 2014. In 2015, the NHGRI estimated the cost of obtaining a whole-genome sequence at around $1,500. In 2016, Veritas Genetics began selling whole genome sequencing, including a report as to some of the information in the sequencing for $999. In summer 2019 Veritas Genetics cut the cost for WGS to $599. In 2017, BGI began offering WGS for $600.

However, in 2015 some noted that effective use of whole gene sequencing can cost considerably more than $1000. Also, reportedly there remain parts of the human genome that have not been fully sequenced by 2017.

Comparison with other technologies

DNA microarrays

Full genome sequencing provides information on a genome that is orders of magnitude larger than by DNA arrays, the previous leader in genotyping technology.

For humans, DNA arrays currently provide genotypic information on up to one million genetic variants, while full genome sequencing will provide information on all six billion bases in the human genome, or 3,000 times more data. Because of this, full genome sequencing is considered a disruptive innovation to the DNA array markets as the accuracy of both range from 99.98% to 99.999% (in non-repetitive DNA regions) and their consumables cost of $5000 per 6 billion base pairs is competitive (for some applications) with DNA arrays ($500 per 1 million basepairs).

Applications

Mutation frequencies

Whole genome sequencing has established the mutation frequency for whole human genomes. The mutation frequency in the whole genome between generations for humans (parent to child) is about 70 new mutations per generation. An even lower level of variation was found comparing whole genome sequencing in blood cells for a pair of monozygotic (identical twins) 100-year-old centenarians. Only 8 somatic differences were found, though somatic variation occurring in less than 20% of blood cells would be undetected.

In the specifically protein coding regions of the human genome, it is estimated that there are about 0.35 mutations that would change the protein sequence between parent/child generations (less than one mutated protein per generation).

In cancer, mutation frequencies are much higher, due to genome instability. This frequency can further depend on patient age, exposure to DNA damaging agents (such as UV-irradiation or components of tobacco smoke) and the activity/inactivity of DNA repair mechanisms. Furthermore, mutation frequency can vary between cancer types: in germline cells, mutation rates occur at approximately 0.023 mutations per megabase, but this number is much higher in breast cancer (1.18-1.66 somatic mutations per Mb), in lung cancer (17.7) or in melanomas (≈33). Since the haploid human genome consists of approximately 3,200 megabases, this translates into about 74 mutations (mostly in noncoding regions) in germline DNA per generation, but 3,776-5,312 somatic mutations per haploid genome in breast cancer, 56,640 in lung cancer and 105,600 in melanomas.

The distribution of somatic mutations across the human genome is very uneven, such that the gene-rich, early-replicating regions receive fewer mutations than gene-poor, late-replicating heterochromatin, likely due to differential DNA repair activity. In particular, the histone modification H3K9me3 is associated with high, and H3K36me3 with low mutation frequencies.

Genome-wide association studies

In research, whole-genome sequencing can be used in a Genome-Wide Association Study (GWAS) – a project aiming to determine the genetic variant or variants associated with a disease or some other phenotype.

Diagnostic use

In 2009, Illumina released its first whole genome sequencers that were approved for clinical as opposed to research-only use and doctors at academic medical centers began quietly using them to try to diagnose what was wrong with people whom standard approaches had failed to help. In 2009, a team from Stanford led by Euan Ashley performed clinical interpretation of a full human genome, that of bioengineer Stephen Quake. In 2010, Ashley's team reported whole genome molecular autopsy and in 2011, extended the interpretation framework to a fully sequenced family, the West family, who were the first family to be sequenced on the Illumina platform. The price to sequence a genome at that time was $19,500 USD, which was billed to the patient but usually paid for out of a research grant; one person at that time had applied for reimbursement from their insurance company. For example, one child had needed around 100 surgeries by the time he was three years old, and his doctor turned to whole genome sequencing to determine the problem; it took a team of around 30 people that included 12 bioinformatics experts, three sequencing technicians, five physicians, two genetic counsellors and two ethicists to identify a rare mutation in the XIAP that was causing widespread problems.

Due to recent cost reductions (see above) whole genome sequencing has become a realistic application in DNA diagnostics. In 2013, the 3Gb-TEST consortium obtained funding from the European Union to prepare the health care system for these innovations in DNA diagnostics. Quality assessment schemes, Health technology assessment and guidelines have to be in place. The 3Gb-TEST consortium has identified the analysis and interpretation of sequence data as the most complicated step in the diagnostic process. At the Consortium meeting in Athens in September 2014, the Consortium coined the word genotranslation for this crucial step. This step leads to a so-called genoreport. Guidelines are needed to determine the required content of these reports.

Genomes2People (G2P), an initiative of Brigham and Women's Hospital and Harvard Medical School was created in 2011 to examine the integration of genomic sequencing into clinical care of adults and children. G2P's director, Robert C. Green, had previously led the REVEAL study — Risk EValuation and Education for Alzheimer's Disease – a series of clinical trials exploring patient reactions to the knowledge of their genetic risk for Alzheimer's. Green and a team of researchers launched the BabySeq Project in 2013 to study the ethical and medical consequences of sequencing an infant's DNA. A second phase, BabySeq2, was funded by NIH in 2021 and is an implementation study that expands this project, planning to enroll 500 infants from diverse families and track the effects of their genomic sequencing on their pediatric care.

In 2018, researchers at Rady Children's Institute for Genomic Medicine in San Diego, CA determined that rapid whole-genome sequencing (rWGS) can diagnose genetic disorders in time to change acute medical or surgical management (clinical utility) and improve outcomes in acutely ill infants. The researchers reported a retrospective cohort study of acutely ill inpatient infants in a regional children's hospital from July 2016-March 2017. Forty-two families received rWGS for etiologic diagnosis of genetic disorders. The diagnostic sensitivity of rWGS was 43% (eighteen of 42 infants) and 10% (four of 42 infants) for standard genetic tests (P = .0005). The rate of clinical utility of rWGS (31%, thirteen of 42 infants) was significantly greater than for standard genetic tests (2%, one of 42; P = .0015). Eleven (26%) infants with diagnostic rWGS avoided morbidity, one had a 43% reduction in likelihood of mortality, and one started palliative care. In six of the eleven infants, the changes in management reduced inpatient cost by $800,000-$2,000,000. These findings replicate a prior study of the clinical utility of rWGS in acutely ill inpatient infants, and demonstrate improved outcomes and net healthcare savings. rWGS merits consideration as a first tier test in this setting.

A 2018 review of 36 publications found the cost for whole genome sequencing to range from $1,906 USD to $24,810 USD and have a wide variance in diagnostic yield from 17% to 73% depending on patient groups.

Rare variant association study

Whole genome sequencing studies enable the assessment of associations between complex traits and both coding and noncoding rare variants (minor allele frequency (MAF) < 1%) across the genome. Single-variant analyses typically have low power to identify associations with rare variants, and variant set tests have been proposed to jointly test the effects of given sets of multiple rare variants. SNP annotations help to prioritize rare functional variants, and incorporating these annotations can effectively boost the power of genetic association of rare variants analysis of whole genome sequencing studies. Some tools have been specifically developed to provide all-in-one rare variant association analysis for whole-genome sequencing data, including integration of genotype data and their functional annotations, association analysis, result summary and visualization.

Meta-analysis of whole genome sequencing studies provides an attractive solution to the problem of collecting large sample sizes for discovering rare variants associated with complex phenotypes. Some methods have been developed to enable functionally informed rare variant association analysis in biobank-scale cohorts using efficient approaches for summary statistic storage. 

Oncology

In this field, whole genome sequencing represents a great set of improvements and challenges to be faced by the scientific community, as it makes it possible to analyze, quantify and characterize circulating tumor DNA (ctDNA) in the bloodstream. This serves as a basis for early cancer diagnosis, treatment selection and relapse monitoring, as well as for determining the mechanisms of resistance, metastasis and phylogenetic patterns in the evolution of cancer. It can also help in the selection of individualized treatments for patients suffering from this pathology and observe how existing drugs are working during the progression of treatment. Deep whole genome sequencing involves a subclonal reconstruction based on ctDNA in plasma that allows for complete epigenomic and genomic profiling, showing the expression of circulating tumor DNA in each case. 

Ethical concerns

The introduction of whole genome sequencing may have ethical implications. On one hand, genetic testing can potentially diagnose preventable diseases, both in the individual undergoing genetic testing and in their relatives. On the other hand, genetic testing has potential downsides such as genetic discrimination, loss of anonymity, and psychological impacts such as discovery of non-paternity.

Some ethicists insist that the privacy of individuals undergoing genetic testing must be protected, and is of particular concern when minors undergo genetic testing. Illumina's CEO, Jay Flatley, claimed in February 2009 that "by 2019 it will have become routine to map infants' genes when they are born". This potential use of genome sequencing is highly controversial, as it runs counter to established ethical norms for predictive genetic testing of asymptomatic minors that have been well established in the fields of medical genetics and genetic counseling. The traditional guidelines for genetic testing have been developed over the course of several decades since it first became possible to test for genetic markers associated with disease, prior to the advent of cost-effective, comprehensive genetic screening.

When an individual undergoes whole genome sequencing, they reveal information about not only their own DNA sequences, but also about probable DNA sequences of their close genetic relatives. This information can further reveal useful predictive information about relatives' present and future health risks. Hence, there are important questions about what obligations, if any, are owed to the family members of the individuals who are undergoing genetic testing. In Western/European society, tested individuals are usually encouraged to share important information on any genetic diagnoses with their close relatives, since the importance of the genetic diagnosis for offspring and other close relatives is usually one of the reasons for seeking a genetic testing in the first place. Nevertheless, a major ethical dilemma can develop when the patients refuse to share information on a diagnosis that is made for serious genetic disorder that is highly preventable and where there is a high risk to relatives carrying the same disease mutation. Under such circumstances, the clinician may suspect that the relatives would rather know of the diagnosis and hence the clinician can face a conflict of interest with respect to patient-doctor confidentiality.

Privacy concerns can also arise when whole genome sequencing is used in scientific research studies. Researchers often need to put information on patient's genotypes and phenotypes into public scientific databases, such as locus specific databases. Although only anonymous patient data are submitted to locus specific databases, patients might still be identifiable by their relatives in the case of finding a rare disease or a rare missense mutation. Public discussion around the introduction of advanced forensic techniques (such as advanced familial searching using public DNA ancestry websites and DNA phenotyping approaches) has been limited, disjointed, and unfocused. As forensic genetics and medical genetics converge toward genome sequencing, issues surrounding genetic data become increasingly connected, and additional legal protections may need to be established.

Public human genome sequences

First people with public genome sequences

The first nearly complete human genomes sequenced were two Americans of predominantly Northwestern European ancestry in 2007 (J. Craig Venter at 7.5-fold coverage, and James Watson at 7.4-fold). This was followed in 2008 by sequencing of an anonymous Han Chinese man (at 36-fold), a Yoruban man from Nigeria (at 30-fold), a female clinical geneticist (Marjolein Kriek) from the Netherlands (at 7 to 8-fold), and a female leukemia patient in her mid-50s (at 33 and 14-fold coverage for tumor and normal tissues). Steve Jobs was among the first 20 people to have their whole genome sequenced, reportedly for the cost of $100,000. As of June 2012, there were 69 nearly complete human genomes publicly available. In November 2013, a Spanish family made their personal genomics data publicly available under a Creative Commons public domain license. The work was led by Manuel Corpas and the data obtained by direct-to-consumer genetic testing with 23andMe and the Beijing Genomics Institute. This is believed to be the first such Public Genomics dataset for a whole family.

Databases

According to Science the major databases of whole genomes are:

Biobank Completed whole genomes Release/access information
UK Biobank 200,000 Made available through a Web platform in November 2021, it is the largest public dataset of whole genomes. The genomes are linked to anonymized medical information and are made more accessible for biomedical research than prior, less comprehensive datasets. 300,000 more genomes are set to be released in early 2023.
Trans-Omics for Precision Medicine 161,000 National Institutes of Health (NIH) requires project-specific consent
Million Veteran Program 125,000 Non–Veterans Affairs researchers get access in 2022
Genomics England's 100,000 Genomes 120,000 Researchers must join collaboration
All of Us 90,000 NIH expects to release by early 2022

Genomic coverage

In terms of genomic coverage and accuracy, whole genome sequencing can broadly be classified into either of the following:

  • A draft sequence, covering approximately 90% of the genome at approximately 99.9% accuracy
  • A finished sequence, covering more than 95% of the genome at approximately 99.99% accuracy

Producing a truly high-quality finished sequence by this definition is very expensive. Thus, most human "whole genome sequencing" results are draft sequences (sometimes above and sometimes below the accuracy defined above).

Cigarette smoking for weight loss

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Cigarette smoking for weight loss is a weight control method whereby one consumes tobacco, often in the form of cigarettes, to decrease one's appetite. The practice dates to early knowledge of nicotine as an appetite suppressant.

Tobacco smoking was associated with appetite suppression among Pre-Columbian indigenous Americans and Old World Europeans. For decades, tobacco companies have employed these connections between slimness and smoking in their advertisements, mainly in brands and advertisements targeting women. Culturally, the links between smoking cigarettes and controlling weight run deep. While it is unclear how many people begin or continue smoking because of weight concerns, research reveals that white female adolescents with established weight-related anxieties are particularly prone to initiate smoking. Although knowledge of nicotine's effects upon the appetite can contribute to people smoking for weight control purposes, studies have not shown that people smoke exclusively to maintain or lose weight.

Appetite suppression

Though smoking is widely discouraged by public health professionals for its countless negative health consequences, nicotine is an appetite suppressant. Nicotine could reduce appetite and influence an individual's eating habits. A study on nicotine's effects on appetite demonstrated that “net effects of nicotine include elevated blood pressure, heart rate, and gastric motility while eliciting a sustained decrease in food intake. Autonomic, sensory, and enteric neurons each constitute potentially important loci for nicotine-mediated changes in feeding behavior.” Thus, the cultural associations between smoking and weight control in part reflect the body's physiological reactions to nicotine.

Nicotine gum has similar effects to cigarettes in terms of appetite suppression, and there are some people who do not smoke, but use nicotine gum for the purpose of weight control or weight loss.

Nicotine can also lower insulin levels in a person's bloodstream, which can reduce cravings for sugary foods. Furthermore, “nicotine-triggered effects of adrenaline on the stomach’s musculature” lead to temporary feelings of subsided hunger. Other studies have shown that smokers expend more calories while engaged in activity, which echo conclusions that smokers experience heightened metabolic rates. Also worth noting are the diuretic properties of nicotine, which causes lower calcium levels in the blood.

There is however "increasing evidence that smoking is conducive to greater accumulation of visceral fat and greater insulin resistance and that smoking increases the risk of metabolic syndrome and type 2 diabetes".

There is much controversy concerning whether smokers are actually thinner than nonsmokers. Some studies have shown that smokers—including long term and current smokers—weigh less than nonsmokers, and gain less weight over time. Conversely, certain longitudinal studies have not shown correlation between weight loss and smoking at least among young persons. Accordingly, while the connection between nicotine and appetite suppression, as well as other physiological responses to nicotine consumption, has been established, whether these chemical and biological reactions translate to smokers being thinner than nonsmokers (at least concerning certain age groups), is still debated. Age may act as a compounding factor in some of these studies. Essentially, a causal relationship has not been explicitly established between physiological effects of nicotine and epidemiological findings about weight among smokers and nonsmokers.

Perceptions of weight control among adolescents

While most adults do not smoke for weight control, studies have shown that associations between tobacco use, being thin and desire for weight control do influence adolescents in terms of smoking behavior. Research demonstrates that adolescent girls that strongly value being thin are more likely to initiate smoking. Additionally, girls already engaged in risky behavior for weight control are at increased odds to begin smoking as well.

Further research needs to examine trends in ethnicity concerning women and smoking for weight control. So far, studies have shown that young white women may be more prone to use cigarettes to manage their weight. Advertisements for particular brands and types of cigarettes seem to target this demographic accordingly.

Several studies have been conducted over the past decade examining this issue in depth. While it has generally been found that white females are more apt to smoke to lose weight, one study found that smoking to lose or control weight is not limited to white females, but is prevalent across racial and gender boundaries. Within all racial groups, it was found that weight concerns and negative body perceptions were a significant factor in an adolescent's decision to smoke. The relationship between weight and smoking amongst young men was only statistically significant in white or mixed race groups.

In the past, studies have shown that adolescent girls do consider weight loss or weight control to be one of the positive values of smoking. Overall, young women and girls concerned about weight control, particularly those already using unhealthy weight control techniques, are at a higher risk of smoking.

History in advertising

It was not always socially acceptable for women to smoke cigarettes or use tobacco in public. However, over the course of about fifty years, the tobacco industry would change societal attitudes through the conduits of nicotine advertising and public relations, transforming tobacco use into a desirable pastime for the female consumer in both the United States and abroad.

Pre-1920s

Prior to the 1920s, smoking was largely a male pastime and was thought of as a taboo act for women to participate in. During the 19th century, smoking and cigarettes were commonly associated with loose morals and sexual promiscuity. A common prop in Victorian erotic pornography, cigarettes even came to be thought of as an occupational prop of prostitutes and sex workers. Even into the early 20th century, women faced possible arrest if they were caught smoking in public.

1920–1968

During the first decade of the twentieth century, women would begin experience upward socioeconomic mobility with the American women's rights movement as they gained new civil liberties. By the outbreak of World War I, as they experienced growing responsibility and freedom on the home front, an increasing number of women were using cigarettes as a tool to challenge traditional ideas about female behavior. However, it would ultimately be the tobacco industry's powerful marketing influence that would turn the cigarette from a social liability into an accepted and desirable commodity for women to openly indulge in. However, many question whether or not the cigarette would have become so ubiquitous among women if the tobacco industry had not seized on the liberating social climate of the 1920s and 30s to exploit the ideas of emancipation and power in order to recruit the untapped female market.

Targeting women's waistlines

The President of the American Tobacco Company, Percival Hill, was one of the first tobacco executives to seek out the women's market. Noting the 1920s penchant for bobbed hair cuts, short skirts and slender figures, Mr. Hill saw the potential in selling cigarettes as an appetite suppressant so that women could achieve the decade's enviably small waistlines.

"Reach for a Lucky"

Created by Albert Lasker for Mr. Hill and Lucky Strike, the “Reach for a Lucky” campaign is one of the most successful, albeit controversial advertising campaigns in the history of modern advertising. Inspired by other campaigns that offered male consumers a reason why they should smoke a given brand (i.e. the Lucky Strike “It’s Toasted” campaign), Lasker sought to give the female market a reason to smoke as well.

Borrowing from the 19th-century slogan of Lydia Pinkham's Vegetable Compound, “Reach for a Vegetable,” that was marketed towards women for the alleviation of menstrual discomfort, Lasker and Lucky Strike launched the “Reach for a Lucky Instead of a Sweet” campaign in 1925, followed by “For a Slender Figure—Reach for a Lucky Instead of a Sweet” in 1928. The print advertisement was disseminated by Edward Bernays throughout the fashion industry in numerous fashion magazines and daily newspapers featuring slender Parisian models and proclaiming the dangers of sugar consumption. Famously, Amelia Earhart would also serve as a spokeswoman for the “Reach for a Lucky” campaign.

Early on, the print advertisements simply featured an attractive woman with any of the variations of the slogan above or underneath her, accompanied by a rendering of the Lucky Strike Box. Later, the advertisements would make a more pointed statement about weight gain, featuring either a man or a woman in profile view with his or her noticeably fatter shadow silhouette behind. While these early advertisements would focus on both men and women, later variations would target women specifically.

In The Cigarette Century, Allen Brandt explains that the campaign was revolutionary in its pointed targeting of female consumers as well as in its aggressive marketing strategy that positioned it in direct opposition with candy manufacturers. Shortly after the campaign was released, the National Confectioners Association fired back at Lucky Strike, threatening legal action and publishing anti-cigarette literature that asserted the importance of candy in a balanced, healthy diet. The dispute between Lucky Strike and the National Confectioners Association ultimately drew the attention of the Federal Trade Commission who ordered Lucky Strike to “relinquish all dietary claims for Luckies” in its advertising.

Importantly, this campaign would serve to create a significant association between cigarettes and the feminine values of style, beauty and slimness. Moreover, Allen Brandt writes that the campaign ultimately “promoted a product and a behavior that...possessed specific and appealing social meanings of glamour, beauty, autonomy, and equality” that would come to be synonymous in future cigarette advertising campaigns targeting female consumers. Lucky Strike's message was highly effective, raising the company's market share by more than 200% and making it the most profitable cigarette brand for two years running.

"Torches of Freedom"

After the “Reach for a Lucky Campaign,” Lucky Strike sought to forever change smoking taboos by encouraging women to smoke openly in public. In an infamous publicity stunt, Edward Bernays hired several young, attractive women to march in the Easter Sunday parade in New York brandishing their “torches of freedom”—their Lucky Strike cigarettes. While this campaign did not market cigarettes as weight loss devices, it set the precedent for the new trends in niche marketing that would come to shape the future ways in which the industry would posit new types of cigarettes as weight loss aids. Moreover, it would forever change the public's thoughts on women smoking, transforming the act from a transgressive one into a normalized feminine behavior.

1968–present

In 1964, the Surgeon General of the United States released the Surgeon General's Advisory Committee Report on Smoking and Health. This report lead to the Federal Cigarette Labeling and Advertising Act in 1965, which would mandate that all cigarette packs display warning labels and would change the ways that the tobacco industry would reach consumers via advertising. In April 1964, with Federal Trade Commission statutes pending, the tobacco industry would take on a program of self-regulation in its advertising. This program would become known as the Cigarette Advertising Code, and as Allen Brandt explains, the program:

promised to ban all cigarette advertising aimed at those under twenty-one; to ban all unproven health claims; and to ban the ‘virility’ theme. It also assured that models under twenty-five years of age would not be used in tobacco ads, nor would testimonials by entertainers or athletes be allowed. Finally, the code prohibited ads depicting smoking as ‘essential’ to social prominence, distinction, success or sexual attraction.' 

With these regulations in place, the tobacco industry could no longer directly market cigarettes to women as weight loss aids like they had in the past. Rather, they would come to rely upon more subversive forms of marketing to target women's concerns with weight management.

Virginia Slims

In 1968, shortly after the enactment of the Cigarette Advertising Code, Philip Morris introduced a new brand of cigarettes called Virginia Slims. Following in the footsteps of Lucky Strike, Virginia Slims were marketed specifically to young, affluent, and independent women with the tagline created by the advertising agency, Leo Burnett, “You’ve come a long way, baby” referencing the history of women's liberation. With a colorful, pastel package and female-oriented print advertising featuring beautiful and elegant women, Philip Morris sought to create a cigarette that embodied women's concerns with glamour, style and body image. Moreover, the brand created rift in the market that differentiated between men's and women's cigarettes.

But perhaps most importantly, Virginia Slims appeal to women's ideals about slimness in their name: Virginia “Slims”—a key value that was not lost on consumers. In The Cigarette Century, Allen Brandt recounts United States Supreme Court case Cipollone v. Liggett Group, Inc., in which habitual tobacco user, Rose Cipollone, filed suit against Liggett and Myers, Lorillard and Philip Morris in five separate tort cases, citing their cigarettes as the cause of her cancer. During her deposition, Cipollone recounted her smoking history, noting that she switched to Virginia Slims in 1968 because female-centered marking appealed to her. Brandt writes that Cipollone described the cigarettes as “the first cigarette for women only...designed slimmer for a woman’s slimmer hands and lips...and packed in a slim purse pack.” 

While Federal Trade Commission regulations prohibited brands from claiming any health benefits like weight loss, Virginia Slims appeal to women's concerns with aesthetic slimness with their elongated shape and narrow circumference. While traditional cigarettes are 84mm in length, Virginia Slims come in both 100 and 120mm lengths that give the cigarette a more dainty or elegant appearance. Moreover, with a 23mm circumference, slim cigarettes are said to produce less smoke than traditional cigarettes. Slim cigarettes are becoming popular in certain countries.

Virginia Slims and athleticism

Cigarettes have a long tradition of being coupled with athletics, health and fitness. As early as the mid-to-late 19th century, Bull Durham cigarettes were the official sponsors of professional baseball, horse racing and golf, and by the 1950s, Camel commonly used sports imagery in their print advertisements.

Thus, it was not unheard of when Virginia Slims sponsored the Women's Tennis Association in 1970, then known as the “Virginia Slims Circuit”. With this prominent sponsorship came a whole slew of advertisements that featured tennis greats like Billie Jean King and Rosemary Casals alongside the Virginia Slims logo.

Other Virginia Slims advertisements feature slender women in varying states of activity (dancing, running, ice skating, etc.) thus promoting a general attitude of health and fitness.

New gender issues

A new area of study examines the ways in which tobacco companies are targeting the gay community through advertising. Like early niche advertisements that appealed to female consumers, gay tobacco advertisements draw on themes of virility and body image, although it is unclear if gay men tend to smoke to control weight. While the tobacco industry's marketing of the gay community is legal, many within the community have expressed disapproval of the industry's pointed tactics.

Smoking cessation

Weight gain as a side effect of smoking cessation remains a major aspect of smoking and weight control. People can be discouraged by weight gain experienced while quitting smoking. Weight gain is a common experience during smoking cessation, with roughly 75% of smokers gaining weight after quitting. As nicotine is an appetite suppressant and smokers expend more energy, weight gain due to smoking cessation is generally attributed to increased calorific intake and a slowed metabolic rate.

Weight gain can be a deterrent in the smoking cessation process, even if many smokers did not smoke for weight control purposes. Those in the process of quitting smoking are recommended to follow a healthy diet and to exercise regularly. Most quitting advice encourages people to not be discouraged should they experience weight gain while quitting smoking, as the health benefits of quitting almost always exceed the costs of weight gain. Studies have shown that weight gain during the smoking cessation process can often be lost eventually through diet and exercise.

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