North Carolina Health News
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Cancer Care Disparities: Where You Live Matters


When it comes to cancer care, where a patient lives makes a difference. But in some instances, distance could be an advantage.

By Stephanie Soucheray

All cancer care is not created equal. That’s the main message of two studies published in the most recent edition of the North Carolina Medical Journal.

Using provider data, Medicaid and Medicare enrollees and census information, researchers illustrated that where patients live and how their care is managed were major factors in the quality of care they received during cancer treatments.

Cancer cells in tissue culture from human connective tissue, at a magnification of 500x.

Cancer cells in tissue culture from human connective tissue, at a magnification of 500x. Image source: National Cancer Institute

“Often [it’s] related to things outside of the biology of the disease,” said Stephanie Wheeler, an assistant professor in health policy and management at the Gillings School of Global Public Health at UNC-Chapel Hill.

There are “vast differences” in the quality of care, she said.

Wheeler studied publicly insured cancer patients being treated in so-called patient centered medical homes to measure the frequency and severity of chemotherapy-related adverse events.

“The majority of the Medicaid population in this time is enrolled in the medical home, but we don’t know the data in terms of outcomes,” she said. Medicaid provides coverage for about 1.6 million low-income children, pregnant women and people with disabilities in North Carolina.

Community Care of North Carolina (CCNC) is a medical-home program started in the 1990s that has long received national attention for its patient-centered care and positive outcomes for approximately 750,000 North Carolinians on Medicaid, most of whom are women and children.

Wheeler said studying this group was important because the Affordable Care Act has many medical-home provisions and more states will start relying on medical homes for managing the care of their Medicaid patients.

She and her colleagues looked at low-income women who received chemotherapy for early-stage breast cancer between 2003 and 2007. Those in the medical-home system had fewer inpatient admissions for adverse events.

However, patients enrolled in a medical home had no difference in outpatient and emergency room admissions.

Still, breast cancer is the most prevalent cancer among women in the state and the diagnosis makes up one-third of all new cancer diagnoses, Wheeler said. Any reduction in patient visits ends up reducing Medicaid costs.

Location, location, location

Wheeler also performed a second study which investigated the connection between rural and urban living and access to radiation. Patients receiving radiation therapy have to come to the hospital for treatment daily, which can be burdensome in terms of time and travel.

For this study, Medicare enrollees who were recommended to receive radiation therapy for cancer were followed for two years during and after treatment.

Medicare is the federally funded program for seniors and some people with disabilities. Almost everyone in the U.S. over the age of 65 years old is covered by Medicare, and data about these patients is available to researchers.

By geocoding the provider and patient’s addresses, Wheeler and her colleagues were able to determine how geographic settings encouraged or detracted patients from getting radiation therapy.

“The results were somewhat counterintuitive,” she declared.

“For urban patients, increased distance meant a lesser likelihood in receiving radiation,” Wheeler said. “For rural patients, those living less than 10 miles away from a provider were also less likely to receive [radiation therapy].”

map of rural counties around Wake Forest

Map of rural counties around Wake Forest Baptist Medical Center from which patients come to the hospital’s Comprehensive Cancer Center. Data courtesy Kathryn Weaver

But she found the patients most likely to comply with recommendations for radiation therapy were rural patients living 10 to 20 miles away from their provider.

“These patients are used to driving these distance of about a half hour,” said Wheeler. She said the disparity among urban patients could have to do with their reliance on public transportation, rather than having cars of their own.

“This study shows that where you live does matter,” she said.

Urban vs rural

The results in Wheeler’s studies both echo and complicate the results of a study published by Wake Forest Baptist Medical Center last year. In particular, that research looked at the health behaviors of about 7,600 adult cancer survivors in rural and urban settings throughout the country and found that these survivors had very different lifestyle factors. Her data came from the National Health Interview Survey, a population-based sample of adults, conducted by the National Center for Health Statistics, part of the Centers for Disease Control and Prevention.

rural urban cancer stats

Data courtesy Kathryn Weaver, Wake Forest Baptist Medical Center

Weaver, who practices at the Wake Forest Baptist Comprehensive Cancer Center said the center draws patients from the western half of the state, which is largely rural. “We needed to get a better sense of who our rural cancer survivors are and what they are facing.”

“We found that rural survivors were more likely to smoke and were more sedentary,” said Kathryn E. Weaver, assistant professor of social sciences and health policy at Wake Forest Baptist, author of the study, which was published in Cancer Causes and Control. “And survivors who smoked reported worse health and were more likely unemployed.”

Weaver said both smoking and being sedentary are health factors and behaviors that link cancer survivors to subsequent cancer diagnoses and survival rates. She said previous studies have showed that rural cancer patients were more likely to be uninsured, and said access to care is a considerable issue for this patient population.

“In my own clinical practice, I’ve seen patients who have to drive an hour to get to the Cancer Center,” said Weaver. “They routinely live more than 60 miles away.”

Weaver said she hopes her study can help open the conversation about meeting patients’ needs where they live. She said telecounseling for smoking cessation and at-home fitness routines should be part of post-cancer patient education for rural survivors.

“Meeting patients where they are has to be a priority,” she said.


Big Money, Big Research for Global Health at UNC


By Hyun Namkoong

The evaluation of how well public-health dollars are spent in nations across the globe received a major boost yesterday, with the announcement of the second-largest research grant UNC-Chapel Hill has ever received.

A group of deans, researchers and politicians gathered at the Carolina Inn for Chancellor Carol Folt’s announcement of a $180 million grant from the U.S. Agency for International Development.

UNC-Chapel Hill Chancellor Carol Folt and TKTK celebrate their U.S.AID grant with a cake and balloons.

UNC-Chapel Hill Chancellor Carol Folt and MEASURE Evaluation project director Jim Thomas celebrate their U.S.AID grant with a cake and balloons. Photo credit: Hyun Namkoong

The recipient is the university’s Carolina Population Center for its Monitoring and Evaluation to Access and Use Results Evaluation project, more commonly known as MEASURE Evaluation.

“[Funding] is for phase four of this project and it will keep the work going for another five years,” Folt said.

The MEASURE Evaluation project is the U.S. AID’s flagship program for identifying gaps in data, collecting and analyzing data and making decisions to fund projects based on data.

In the past, many projects had been funded based on political favors or hunches, according to Jim Thomas, MEASURE Evaluation project director and an associate professor of epidemiology at UNC-Chapel Hill’s Gillings School of Global Public Health. Better data has helped change that paradigm throughout the developing world.

The goal of the project is to measure and evaluate public-health programs worldwide to ensure government dollars in 80 countries are used wisely.

The overall emphasis of phase four, Thomas said, “is to build sustainability so that these [health information] systems can continue on long term without us.”

Sustainability has long been identified as a priority of public-health projects, particularly those implemented in low- and middle-income countries.

Among those attending the press conference were Rep. David Price; Aldona Wos, secretary of the state Department of Health and Human Services; and representatives from the office of U.S. Sen. Richard Burr.

The MEASURE Evaluation project began in 1997 and has received funding from a number of sources, including the President’s Emergency Plan for AIDS Relief.

The project has developed several methodologies for collecting data to better inform public-health programs and policies, especially in the areas of reproductive health, HIV/AIDS and other infectious diseases.

“Monitoring and evaluation – what’s important here is that not only are we applying a toolkit, we’re inventing the toolkit,” said Barbara Entwisle, vice chancellor for research at UNC-Chapel Hill.

Benefits to the state

While the focus of MEASURE Evaluation is on global health and strengthening health information systems worldwide, Folt and Thomas believe that North Carolinians will benefit from the $180 million grant.

“It’s a global project with a lot of local influence,” Folt said. “It’s supported more than 100 jobs here in North Carolina.”

Folt also said that research at UNC has led to the creation of spinoff companies such as FHI 360, which is headquartered in Durham.

MEASURE Evaluation has worked on public-health projects for infectious diseases such as HIV/AIDS in South Africa and tuberculosis in Latin America, both of which can result in epidemics, or even pandemics.

“Epidemics that are controlled worldwide are less able to affect our own country,” Thomas said.

He also said that the Triangle has become a hub for global-health research similar to how Wilmington has become a hub for the film industry.

When asked about how phase four of the MEASURE Evaluation project might directly affect and translate into health improvements for North Carolinians, Thomas said, “We don’t have [anything] in place for making sure that it translates, but that’s something that we would be very much open to talking about.”

“For decades, I did work domestically in epidemiology in the public sector,” he said. “I would be very interested in talking to anyone who wanted [to learn] about how we could translate some of these things that we’re doing in MEASURE Evaluation to benefit, in particular, some of the rural areas of the state.”

Study: BPA Can Activate Breast Cancer Cells


A study from Duke University researchers offers new evidence of BPA’s dangers

By Stephanie Soucheray

It’s everywhere, lining metal cans, in sippy cups, on receipts from the store: It’s BPA, a chemical used to make plastics and epoxy resins.

BPA has been in the news the last two years as the Food and Drug Administration has weighed the pros and cons of banning it in food containers. The chemical has been widely banned throughout the European Union and is currently banned from baby bottles in the United States. A known endocrine disruptor, BPA has been shown to mimic estrogen in the body.

Unlike other breast cancers, inflammatory breast cancer may not cause a lump in the breast. Instead, it may cause the breast to be swollen, red, and warm.

Unlike other breast cancers, inflammatory breast cancer may not cause a lump in the breast. Instead, it may cause the breast to be swollen, red and warm. Image courtesy MyHealth, Alberta, Canada

Now, more bad news about BPA: Duke researchers shared new evidence this week that Bisphenol A, or BPA, not only accelerates cell growth in breast cancer but also makes disease treatment less effective.

“We hope to alert clinicians that this is a potential risk factor,” said Scott Sauer. Sauer‘s work was presented as an abstract at the annual joint meeting of the International Society of Endocrinology and the Endocrine Society in Chicago this week.  “Doctors should look to see if women with breast cancer have high circulating BPA.”

In 2011, about 160 women per 100,000 in North Carolina were diagnosed with breast cancer. Five percent of those women were diagnosed with inflammatory breast cancer.

Though rare, inflammatory breast cancer is hard to treat because it’s often detected at an already advanced stage and can be hormone receptor negative – meaning traditional hormone inhibitors, like tamoxifen, don’t work to block the growth of cancerous cells. One drug, lapatinib, is often used successfully to treat the cancer if it is HER2-positive.

HER2 is the human epidermal growth factor receptor, and is found in inflammatory breast cancer, or IBC.

Sauer and his colleagues wanted to see which commonly circulating chemicals were most active in cancer cells. In the study, they screened markers in breast cancer cells for a panel of compounds found in plastics, fertilizers and pesticides.

BPA was clearly the most active in IBC cells.

Though many plastic manufacturers now advertise BPA-free products, the chemical is not widely banned in the United States.

Though many plastic manufacturers now advertise BPA-free products, the chemical is not widely banned in the United States. Image credit: Wikimedia creative commons

Sauer’s work showed that BPA, the chemical commonly found in plastic and food-container linings, stimulated the aggressive cell line that causes IBC. What’s worse, even at normal blood levels BPA blocked the efficacy of cancer drugs used to fight IBC.

“I think this is going to be an interesting area of study because targeted therapies are popular because they shouldn’t have off-target effects,” Sauer said. “But when you rely on only one mechanism for treatment, anything in the environment can throw it off course.”

“These results are certainly consistent with a long line of prior studies showing that BPA can enhance proliferation in breast cancer cells,” said Heather Patisaul, a professor and researcher at North Carolina State University. “What’s striking about this study is the potential mechanism of action. Although BPA has primarily been considered a chemical that interferes with estrogen, this work emphasizes that it may also act via other means.”

Sauer said the work offers a new opening for the FDA to understand just how disruptive BPA can be in adults.

“We’re hoping this will add to a body of evidence,” he said. “The FDA has said, ‘Yes, BPA in fetal development is not good, but we’re not prepared to make a comment on how it effects adults.’ Now we can show it increases cancer and affects treatment.”

Mapping Access to Clean Water in the State


A group of students and professors at UNC’s school of public health is breaking new ground when it comes to the study of race, water quality and health in the South.

By Stephanie Soucheray

Historically, nothing has been more important to the protection of public health than access to safe, potable drinking water. And while several Triangle researchers are attempting to maximize exposure to clean water in the developing world, some scientists at UNC-Chapel Hill are looking at disparities in accessibility to clean drinking water closer to home.

A professor of environmental science and students from The Water Institute are using census data, mapping technology and interviews to establish a definitive map of water-access sites in the state.

Water Drips

Image courtesy of Gaz Haywood, Flickr Creative Commons

“This is the first study of its kind,” said Jackie MacDonald Gibson, a professor of environmental science and engineering at UNC’s Gillings School of Global Public Health and part of UNC’s Water Institute. “To my knowledge, no one has looked at each county in a state before to map water access and disparity.”

Gibson, who leads a team of graduate students on this project, first got interested in the idea after a conversation with former state health director Jeff Engel.

“We were working on a project and discussing water priorities,” she said. “We were looking at the issue of community water service, or piped water coming to homes from a community water supply.” These communities rely on private wells, which can suffer from a lack of maintenance and high septic-system failures.

Engel queried county health directors on how many North Carolina communities had water systems like this.

“Less than half of county health people could get that information,” Gibson said.

Gibson is using water samples and public records along with mapping tools to create a map of water access in the state, and is currently in the middle of her two-year project. She said the communities most at risk for poor water access are those like Rogers Road in Chapel Hill, the historically black community on the city’s borders.

“It’s not very urban or very rural communities where we see [disparity],” said Gibson. “It’s communities near towns and cities that could have clean water just across the street.”

map of Wake County African American census tracts lacking community water service.

Wake County African American census tracts lacking community water service. Map courtesy The Water Institute, UNC-Chapel Hill

Households that rely on these wells have septic systems with high failure rates (approximately 40 percent) and no sewers. Gibson said these communities are common throughout the South.

“It’s a legacy of Jim Crow,” she said. “These communities got left behind.”

For example, Gibson said preliminary results from Wake County show that black communities are significantly less likely than white communities to access municipal drinking water.

Julia Naman recently graduated from UNC with a master’s degree in public health and is working on the project. She conducted in-depth interviews with several people in unincorporated communities in the Piedmont, along the coast and in the mountains. She also interviewed other stakeholders, including mayors, county commissioners and utility providers.

“People talk about septic tanks overflowing and going into nearby creeks,” said Naman, who noted that children also play in yards where untreated water sits.

She said that many of the people she interviewed live only a mile or two outside the city limits but have no access to municipal police, fire department, garbage pickup or water and sewer access.

Hannah Leker, a current master’s student, works with GIS technology to create maps of these communities.

“We’re trying to figure out if race is a predictor, and what information we can get through the census,” she said. “It’s a very interesting environmental-justice issue.”

Last year, the Pender County community of Maple Hill, near Wilmington, made news when it successfully implemented a wastewater treatment system after years of failing to get the community incorporated. Instead, citizens used funds from the N.C. Rural Economic Development Center and the N.C. Clean Water Management Trust Fund.

Naman said there are small pockets of communities just like Maple Hill throughout the state.

“We have to find them,” she said.

Research Indicates Health Disparities for Lesbian, Gay and Bisexual Communities


By Taylor Sisk

Results released recently from a study conducted by researchers at UNC-Chapel Hill’s Gillings School of Global Public Health indicate that lesbian, gay and bisexual North Carolinians face heightened health risks in several regards.

Stress-related mental health issues are of particular concern.

Derrick Matthews

Derrick Matthews co-authored and conducted the analysis in a study of health disparities among sexual minorities. Photo credit: UNC Gillings School of Global Public Health

The report, titled “A Profile of North Carolina Lesbian, Gay and Bisexual Health Disparities, 2011”  was published in the American Journal of Public Health, offering the first statewide evidence of these disparities. In 2011, the state asked about sexual orientation for the first time in its Behavioral Risk Factor Surveillance System polling.

The survey helped develop a profile for lesbians, gays and bisexuals that includes health status, chronic-disease risk behavior, injury prevention, screening behavior, health care access and variables in social environment that can influence health or health behavior.

“For the first time, we have really good data,” said co-author Lee, a Gillings School doctoral student. “For us to intervene and work against existing health disparities, we first have to know what they are.”

The South experiences poorer health outcomes than the rest of the country in a number of areas, regardless of sexual orientation, said co-author Derrick Matthews, a recent Gillings School graduate now on faculty at the University of Pittsburgh’s Graduate School of Public Health. Many health indicators were no different for sexual minorities than for the general population.

But disparities were revealed that are consistent with findings from other states, including those related to mental health and smoking.

Approximately 2 percent of survey respondents identified as lesbian, gay or bisexual. These individuals were more likely to report experiencing five or more days of bad mental health in the past 30 days.

“It’s a very strong and consistent finding across states and surveys, especially for mental health outcomes that are stress related,” Lee said, citing anxiety and depression that result from feelings of alienation or exposure to discrimination.

The survey also found that sexual-minority women were more likely than heterosexual women to smoke and to be stressed about having enough money to pay rent or a mortgage.

James Miller, executive director of the LGBT Center of Raleigh, expressed surprise at the higher incidence of smoking, saying that considerable effort had been made to discourage tobacco use among the people for whom his organization advocates.

He called QuitlineNC, a free phone service that helps people kick tobacco, an “example of an amazing government-funded program” that works.

Advocacy ahead

“From a policy standpoint, making the case for change requires this data,” Miller said.

“Research being done on this topic moves the dial forward and it gives individuals and organizations the knowledge base to best advocate for our communities,” he said. “We’ve known these disparities exist anecdotally, but having evidence to support our causes truly empowers us.”

Lee hopes to use the data to “build into the state’s programs and policies better strategies for including LGBT people and working on reducing some of these disparities.”

It’s important, he said, that LGBT communities be key participants in public-health efforts, serving, for example, on advisory boards and helping shape communication initiatives.

The researchers now plan to look at the effects of the passing of Amendment One on the health of sexual minorities in North Carolina. Lee said that data from other states has indicated that when similar legislation has been passed, there’s been a spike in stress-related mental health outcomes, and when marriage-equality legislation is passed there’s a drop.

NC Researchers Take a Position on Climate Change

By Stephanie Soucheray

Hot on the heels of the White House statement on climate change, North Carolina researchers are sharing their findings on climate change’s potential to impact North Carolinians’ health.

And they’re finding that North Carolina possesses unique vulnerabilities because of its varied geography, vulnerable coastline and rural populations.

picture of high waves hitting houses on the coast

Photo courtesy David Baird, Geograph creative commons

Last October, researchers and scientists along with municipal leaders convened at the sixth-annual Research Triangle Environmental Health Collaborative summit to discuss climate change and public health. Their findings have been recently published and will be summarized in an upcoming editorial in Environmental Health Perspectives, published by the National Institute of Environmental Health Sciences.

“One of the things that was helpful and interesting that came out of the workshop, something we’re trying to promote on a federal level, is good collaboration between different sectors to help people respond to increased risk for climate change,” said John Balbus, a senior advisor on climate change at NIEHS.

The researchers presented their findings from working groups and suggested that climate change will continue to lead to adverse weather events along the coast, in both rural and urban areas.

While the National Climate Assessment does provide state-by-state analysis for the country, the collaborative incorporated North Carolina’s vast regional differences when considering how climate change could effect the population.

“We have mountains, the Piedmont and the coast to consider,” said Martin Armes, spokesperson for the collaborative.

Balbus agreed and said the variety of the state’s geography was one of the recurring themes of the workshop.

“One of the things that’s interesting about North Carolina is our varied vulnerabilities,” he said. “Land and agricultural workers are effected by high heat and flooding, for example.”

Balbus said he crafted the summit to capture the differences among these areas and determine what’s similar so researchers can attack climate-change problems in the most efficient ways possible.

“We need to bring together people who are front lines of health in North Carolina,” he said. “Mayors, people from local health departments, industry leaders [have to] work together to attack climate-change health threats.

The threat to the coastline represents the potentially biggest loss of revenue for the state, as tourism, fishing and other industry rely on a healthy coastline. Flooding, sea-level rise and damaged infrastructure are the main threats to public health on the coast, according to the collaborative’s editorial.

Rural areas, which tend to be agricultural hubs in the state, could suffer the most from temperature rises.

“This is a warm state, and the heat can be a threat to people in the summer months, especially the elderly,” said Balbus. The editorial makes mention of a dearth of medical centers, cooling centers and other places for medical care in rural areas.

There was also concern raised over environmental-justice issues, including access to water sources. In urban areas, air pollution and disaster management were the main issues.

UNC Chancellor Carol Folt spoke at the meeting, and emphasized the role the state’s universities – including UNC – will have in finding solutions to the problems posed by climate change. Armes said the collaborative’s next step is to convene a planning committee to develop official recommendations.

The Research Triangle Environmental Health Collaborative was organized in 2006 as an environmental-health think tank to identify and discuss environmental-health problems, given the unique research concentration in the area. The group is nonpartisan and, Balbus said, does not look at climate change as a political issue.

“Climate change is a health issue everyone should be concerned with,” he said.

Domestic Abuse Linked to Perinatal Mood Disorders


Pregnancy was once considered to be a “protected time” for women, but now research is revealing how pregnant and newly delivered  moms are at risk for depression, violence and worse.

By Stephanie Soucheray

A new study from researchers at NC State University shows just how harmful domestic abuse can be for pregnant and postpartum women.

In a survey of 100 women who responded to ads posted in YMCAs, yoga studios and doctors’ offices, 70 percent reported experiencing abuse (physical, emotion or sexual) from their partner in pregnancy, while 61 percent had symptoms of perinatal mood disorders. Forty-seven reported symptoms at “clinical” levels, which means symptoms were of moderate severity, meaning psychiatric medications, counseling or a combination of both would be recommended.

The paper, titled “Intimate partner abuse before and during pregnancy as risk factors for postpartum mental health problems,” is published online in the open-access journal BMC Pregnancy and Childbirth.

Sarah Desmarais headshot

Sarah Desmarais. Photo courtesy NC State University

“This response is pretty alarming,” said Sarah Desmarais, one of the lead authors of the paper and an assistant professor of psychology at N.C. State. “Eighty-four percent of participants said they experienced intimate-partner abuse before they got pregnant.

“Pregnancy is usually seen as a respite in abusive relationships, but this survey offers another take.”

Desmarais said that any abuse was associated with higher rates of perinatal mood disorders, and that certain types of abuse were associated with different mental health disorders. Physical abuse, for example, was correlated with post-traumatic stress disorder, while sexual abuse was linked to depression. Marital status, education and poor socioeconomic levels all were correlated with higher rates of abuse.

Fifty years ago, doctors thought that pregnancy and the postpartum period were protected times, when elevated levels of estrogen defended against depression. Now depression, anxiety, obsessive-compulsive disorder and post-traumatic stress disorder are known to be among the most common afflictions of the perinatal period. Many estimates suggest that 20 percent of women will experience a perinatal mood disorder in her lifetime.

Dramatic hormonal fluctuations in the gestational and postpartum period play a role, but clinicians have long hypothesized that social and environmental stressors can prime some women for perinatal mood disorders.

“We found that women who suffered previous abuse were much more likely to experience a perinatal mood disorder,” said Desmarais, who noted that the closer the abuse was to the pregnancy, the more likely the woman suffered from a mood disorder.

“I think that [postpartum depression] is linked with all kinds of abuse and trauma in the relationship,” said Edith Gettes, a psychiatrist specializing in women’s mood disorders who practices at the UNC Center for Women’s Mood Disorders. “It certainly seems they are at a higher risk for PPD.”

Although abuse is highly correlated to postpartum mood disorders, women are not currently screened for abuse at their six-week postpartum check-up, when tests like the Edinburgh Postnatal Depression Scale help providers screen for depression and anxiety. Gettes said she currently asks her patients if they feel supported by their partner or in their home, but doesn’t explicitly ask about abuse.

Desmarais said one of the goals of her study was to push for better and more thorough screening of pregnant and postpartum women, and to open up the definition of “abuse.”

“We included psychological and sexual abuse, and that could mean being coerced into a sexual situation you don’t want,” she said.

Desmarais also said the women who participated in the study answered an advertisement to participate in a wellness survey; neither postpartum mood disorders nor domestic abuse were mentioned in the fliers.

“This was not a clinically based population at high risk for abuse or perinatal mood disorders,” she said. “That’s what’s really surprising.”

Last month, state attorney general Roy Cooper announced that there were 108 North Carolinians killed in acts of domestic violence in 2013. That’s 14 fewer than in 2012.

Guilford County had the most domestic violence killings, with 11.

States and counties keep track of domestic-violence murders, but abuse is notoriously hard to monitor, said Dana Mangum, interim executive director of the North Carolina Coalition Against Domestic Violence. Many incidents are underreported, and Desmarais’ study included a broad definition of abuse, not just physical violence.

Moreover, Mangum said her coalition does not track the number of pregnant women seeking services in the state.

But she said that there is a push for more health care providers to screen for domestic abuse during the perinatal period.

“The Affordable Care Act has a mandate for health care professionals to do domestic-abuse screening,” said Mangum. “That’s a huge open door to address this issue through health care providers.”

Yawns Are Contagious, But Not a Sign of Empathy


Yawns have long confounded scientists: There’s little consensus on why we yawn, what yawns mean and why yawn’s seem to be contagious.

By Stephanie Soucheray

It happens in business meetings, at church, in line at the post office: Somebody yawns and soon enough everyone around them is covering their mouths. Yawns, we’ve been told, are contagious.

And because they can be “caught,” those who yawn after seeing someone else do it have long been considered more empathetic than those who don’t. But new research from Duke University shows that while yawns may be contagious, they have little to do with empathy.

baby yawning

Image courtesy Bjorn Rixman, flickr creative commons

“Yawns were not correlated with empathy levels in our test subjects,” said Elizabeth Cirulli, a professor and researcher at the Duke Center for Human Genome Variation. Cirulli’s work was published recently in the online journal PLoS One.

Cirulli has measured the yawns of more than 300 people after they watched a three-minute video of a person yawning. Each time the test participants yawned, they clicked a button that tallied their wide-open mouths.

“We tested for intelligence, age, gender, sleepiness, energy levels and empathy,” said Cirulli. “And nothing had a big impact. Most of the variation could not be explained, but older people did seem to yawn less.”

Empathy was measured by a standardized survey that asked participants how they thought or felt in a given situation.

Two thirds of the participants demonstrated contagious yawns, with some yawning up to 15 times during the three-minute video. Others resisted the urge to yawn completely. While yawning may be a curious research topic, it’s long been a mystery to scientists, who know very little about why we yawn.

“It can be related to boredom or tiredness,” said Cirulli. “A more recent hypothesis is that it’s cooling the brain.” She said modern science discredits the idea that spontaneous yawning has to do with oxygen levels, and now her work disproves the empathetic nature of contagious yawns.

Sam Kean, a science writer who’s written about yawns, said the subject is ripe for scientific exploration.

“Only humans, chimpanzees and some dogs yawn, so it’s a really fun and mysterious thing to study,” he said.

Kean said that while this study suggests empathy isn’t behind yawns, there are some interesting examples from science that show just how deeply ingrained social yawning is.

“Blind people sometimes contagiously yawn,” he said. “And people paralyzed on one side of their body can yawn and even stretch their arms. Because it originates in the brain stem, [yawns] are a really primitive reflex.”

“Contagious yawns may just be some form of mimicry,” said Cirulli.

Her work will now focus on finding a genetic link between people who yawn contagiously and those who don’t. She said she’s performing genetic analysis on more than 500 subjects to look for variants in the genome associated with yawning.

“The vast majority of genetic research is on disease,” said Cirulli. “I feel like there are a lot of other traits that are very interesting but neglected, and I focus on the ones that are easy to collect. Like yawning.”

Besides yawns, Cirulli works on time perception, facial recognitions and night vision.

“All these things have a really interesting biology,” she said.

And, said Kean, can help us understand the mysterious workings of our brain.

N.C. Researchers Re-examine Blood Pressure, Stroke and Cholesterol Advice


Changes in the recommendations about high blood pressure, stroke prevention and heart-disease prevention are being driven by researchers from North Carolina, which, as a state, has one of the highest rates of cardiovascular disease in the country.

By Stephanie Soucheray

One out of every three Americans has high blood pressure. Or do they?

The U.S. National Heart, Lung and Blood Institute put into question that oft-cited Centers for Disease Control and Prevention statistic earlier this spring when a panel announced new guidelines for treating blood pressure. Now, for adults over the age of 60, the treatment goal of blood-pressure medications and lifestyle intervention will be 150/90, 10 points higher than previous guidelines.

“These new guidelines were controversial, because not everyone on the panel agreed with them,” said Ann Marie Navar-Boggan, a cardiology fellow at Duke University School of Medicine.

Navar-Boggan just published a paper in the Journal of the American Medical Association that looks at the implications of the new guidelines, the first change to blood-pressure recommendations since 2003.

Historically, good blood pressure is a reading at or below 120/80, and until March physicians were expected to begin treatment for high blood pressure when adult patients had consistent readings above 140/90. In North Carolina, the United Health Foundation estimates that 30 to 40 percent of the adult population have blood pressure above 140/90.

picture of a blood pressure cuff

Image courtesy Medisave UK, flickr creative commons

Navar-Boggan and colleagues quantified how the new threshold reclassifies Americans with hypertension by using more than 16,000 blood-pressure readings from the National Health and Nutrition Examination Survey (NHANES) conducted by the CDC.

According to the study, 13.5 million adults whose blood pressure was considered uncontrolled now have numbers within the blood-pressure target. U.S. adults considered eligible for hypertension treatment would decrease from 40.6 percent under the old guidelines to 31.7 percent under the new guidelines.

Navar-Boggan said that 5.8 million of those adults were on medication. While she said that the new guidelines are no reason to flush your blood-pressure pills down the drain, they do open up some options for patients who had side effects from medication.

“These guideline are a departure, but they reflect a general increasing knowledge in the area,” said Navar-Boggan.

Lowering pressure a ‘good thing’

Lowering blood pressure has always been the goal for stroke victims, except those with poor collateral blood-vessel formation near the site of stroke. For years, medical folk wisdom thought these patients should “ride high” with blood pressure to prevent another stroke.

“The thinking was that if you have a pipe that’s partially blocked, you increase pressure to force more water through the blockage,” said William Powers, a neurologist at UNC-Chapel Hill.

picture of an electronic blood pressure machine

Image courtesy Morgan, flickr creative commons

Powers just published a paper in Neurology that reverses this thinking. He found that lowering blood pressure in these patients helped prevent a second stroke by 22 percent.

“I was surprised by the findings,” he said. “I thought lowering blood pressure would be good for the heart and brain, but I didn’t necessarily think it would prevent a second stroke.”

Using PET scans, Power looked at 91 patients with poor collateral flow; only three of the 40 patients with low to normal blood pressure suffered a second stroke, while 10 of the 51 with high blood pressure had another stroke.

Powers said this study helps offer guidance in the clinic. “There’s a fear in the absence of data that you could make a good argument either way in terms of letting blood pressure ride high,” he said. “Now we know for certain that lowering blood pressure is a good thing.”

Cholesterol up

Besides blood-pressure monitoring, tracking cholesterol levels is a gold standard in monitoring and preventing heart disease. Last November, the American Heart Association established new guidelines for blood cholesterol, and Duke biostatistician Michael Pencina took existing data to quantify their potential impact.

The new cholesterol guidelines see half of Americans over the age of 40 as candidates for statin therapy.

Blood Test image courtesy Neeta Lind, flickr creative commons

Blood test image courtesy Neeta Lind, flickr creative commons

“The new guidelines increase statin use by 12.8 million between the ages of 40 and 75,” said Pencina, whose results were published in the New England Journal of Medicine. Almost half, or 56 million people, are recommended to use statins, which is an 11 percent increase.

“When you break it [down] by age, it turns out the new recommendations don’t differ very much in younger years,” said Pencina. “It’s over 60 where the vast majority of increase happens.”

He said the staggering statin recommendations are not a uniquely American problem; such recommendations have also been made in the Netherlands and Eastern Europe.

“Statins are quite safe, but they do have uncommon side effects,” said Pencina. “The question is: Are we comfortable with a situation in which half of the nation between 40 and 75 is on a pharmaceutical treatment?”

He said that increasing statin therapy among this population could prevent as many as 500,000 heart attacks and strokes in the next decade.

Prevention of disease is something Peg O’Connell thinks about when she thinks about blood pressure and cholesterol in North Carolina. O’Connell used to be a member of the Justus-Warren Heart Disease Task Force, which makes recommendations about cardiovascular health to the General Assembly.

“We’ve made remarkable progress,” said O’Connell. She said that 20 years ago, North Carolina was third in the nation for cardiovascular disease and is now seventh. That change, which follows national trends in lowering the number of deaths caused by coronary disease, is often attributed to treating high blood pressure and cholesterol with medicine.

Still, heart disease is the second-leading cause of death in the state and stroke is the fourth. And according to the Justus-Warren task force, cardiovascular disease cost the state almost $6 billion in hospital charges in 2010.

No Escape from Seasonal Allergies


Get ready for the yellow snow … the kind that coats your cars, windows and driveways.

By Stephanie Soucheray

After this unseasonably long winter, most of us are itching for spring. But for allergy sufferers, “itching for spring” takes on a whole new meaning when pine pollen, grass and other common allergens start sharing the landscape with their hair-trigger immune systems.

Are you ready for the annual coating of yellow stuff? Photo courtesy Alastair Vance, flickr creative commons

Are you ready for the annual coating of yellow stuff? Photo courtesy Alastair Vance, flickr creative commons

Take for example UNC professor Eric Downing. Every April, he enters a four-week period of misery.

“It kicks in like a demon every year,” said Downing.

Though Downing, a comparative literature scholar, said he suffered from some seasonal allergies growing up in New Jersey, he’s never experienced anything as bad as springtime in North Carolina.

“The only solution would be to leave North Carolina during April,” said Downing, who gets some relief from Zyrtec and other antihistamines. “And that isn’t going to happen.”

But now, new research from the National Institute of Environmental Health Sciences in Research Triangle Park has news for people like Downing: Leaving North Carolina may not relieve allergies, and in fact, could just expose you to different allergens with their own brand of misery.

Tip of a tulip stamen with many grains of pollen

Tip of a tulip stamen with many grains of pollen. Image courtesy JJ Harrison, Wikimedia creative commons

“Many studies conducted here in the U.S. have suggested that there are huge regional differences when it comes to allergens, including food allergens, outdoor and indoor allergens,” said Päivi Salo, an epidemiologist at NIEHS. “But our study shows that prevalence among allergy sufferers is the same across the nation. The bottom line is that people are going to be allergic to whatever is in the environment.”

Having allergic reactions, Salo said, is a dynamic process, meaning they change with time, age, hormonal states and environment.

Downing believes he’s allergic to the maple and red oak buds that blossom in North Carolina. According to the new research, if he were living in Arizona, his immune system might trigger a response to dust mites.

“People can grow in or out of allergies,” said Salo. “But once you have experienced allergies, you’re more susceptible to sensitization in different environments.”

Salo’s work is published in the Journal of Allergy and Clinical Immunology. She and her colleagues based their work on blood serum samples collected from 10,000 Americans as part of the National Health and Nutrition Examination Survey in 2005 and 2006. The serum samples were used to identify indoor, outdoor, pet and food allergies.

While prevalence was the same among adults, children under 5 in the South were more likely to be allergic than their peers elsewhere. Salo said those allergies can be attributed to dust mites and cockroaches. There also seems to be a higher incidence of indoor allergies in the South and outdoor allergies in the West.

Lindsey Brandt moved to North Carolina five years ago from Montana. Like Downing, she remembers mild but insignificant allergies as a kid; but in 2012, her allergies “blew up.”

A scanning electron microscope image of redbud pollen.

A scanning electron microscope image of redbud pollen. Image courtesy Kleopatra, wikimedia creative commons

“They are definitely worse in the spring and summer, but I am also sensitive to fall leaf molds,” she said. “The indoor allergies” – dust mites, molds – “are year-round but are worse when it is hot and humid. In the winter, I can usually stop taking medication.” Brandt said her allergies disappear in Montana.

For Brandt and Downing, allergies significantly impact their quality of life, something Salo notes in her research.

“Several papers have reported that the prevalence of allergies has risen over past decades dramatically,” Salo said. “But why? That’s the billion-dollar question I wish I could answer.”

For now, Downing is trying his best to stay ahead of the inevitable onslaught.

“I’m dreading [April],” he said. “My eyes get crazy, I get terrible headaches, it’s hard to do work, so I’m working hard now.”

Cover photo: Pollen from a variety of common plants: sunflower, morning glory, hollyhock, lily, primrose and castor bean. Image courtesy Dartmouth Electron Microscope Facility, Wikimedia creative commons

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