Deodorant Changed the Ecosystem of North Carolina Armpits
North Carolina researchers are exploring the far reaches of … our belly buttons. And armpits.
By Laura Pellicer
They linger on your skin, burrow in your stomach and occupy every nook and cranny in your body: microorganisms – the bacteria, parasites and even viruses that make up your microbiome. It may sound unpleasant, but scientists are eagerly working to identify which microorganisms are in – and on – your body, as new connections emerge between these microscopic critters and your overall health.
North Carolinians are doing their part to contribute to this research. Dozens of residents, many recruited through the N.C. Museum of Natural Sciences, have stepped up to have their own bodies swabbed for science.
Julie Horvath, a comparative evolutionary genomicist with North Carolina Central University, is just one of the researchers across North Carolina who are working to answer the question of the relationship between microbial diversity and human health. But first she wants to find out just which microorganisms are making a home in your body.
For Horvath, this quest started with the armpit, and a collaboration with Rob Dunn, a biologist in the Department of Biological Sciences at North Carolina State University who heads a project called Your Wild Life that explores the ecology of everyday life, including the biodiversity of your backyard, home and body.
“I said, ‘Let’s do the armpit! That sounds really gross and nasty but it’ll be engaging,’” Horvath recalled of the initial conversation with Dunn that sparked her latest microbiome research.
The researchers kicked off their armpit and belly button study by swabbing their own bodies and growing microbes from the swabs in the lab. Horvath’s belly button turned out to be an enigma.
“The other people in the lab all had things growing on their plates,” she said. “My plates were blank. And I got a little freaked out because I’m a scientist. You’re supposed to have microbes on your skin, and nothing’s growing on my plates?”
After a round of discussions with her fellow researchers, Horvath determined the antiperspirant she was using might be to blame.
“I had just gotten this job and didn’t like public speaking very much; it made me nervous. So I was wearing clinical strength antiperspirant. And so, potentially, when I would take a shower, it would wash down over my body, and so maybe it was getting in my belly button and that’s why nothing was growing in my belly button.”
From the colorful Genomics & Microbiology Research Lab that she heads, enclosed in the glass walls of North Carolina’s Museum of Natural Sciences, Horvath got museum employees and a horde of volunteers to offer up their pits for science. The microbial denizens of those armpits are on display in an online gallery.
Researchers split the participants into three groups. One group wore antiperspirant, another deodorant and the third group was asked to forgo conventional pit protocol and ditch the products.
The results, published in the journal PeerJ, show the use of deodorant or antiperspirant has a strong effect on types of bacteria living on the surface of the skin. Participants who used product had significantly more staph (Staphylococcaceae) than Corynebacterium. Those who didn’t wear product had more Corynebacterium than staph. By wearing antiperspirant, these citizen scientists were also killing off microbes and lowering the bacterial density on the skin.
“The main point is the products you put on your skin can significantly change the abundance and composition of the microbes on your skin,” Horvath said. “If you look at some of the other primates, you see that they don’t have as much of the staph and Corynebacterium that we do. Potentially, humans have evolved for some reason to have a lot more staph and Corynebacterium, and maybe that’s partly due to the product use that we have.”
Armpit sweat to earwax
Horvath has now set her sights on the generally underappreciated realm of earwax, and is actively swabbing, recording and analyzing the white (or yellow) stuff with the hopes of determining whether certain earwax types harbor different microbes.
“We know microbes feed on your sweat. If you either produce a lot of sweat or wet earwax, versus if you don’t, do you have different microbes growing on you?” Horvath asks. “We know that a lot of these play a role in your health. Any microbes that live on your skin are going to play a role in your immune system.”
Despite her enthusiasm to probe the dark depths of ears and armpits for the sake of microbiome research, Horvath warns against throwing caution to the wind for the sake of microbiome diversity.
“You don’t want to just go advocate, ‘Hey, go roll in the dirt and don’t wash your hands!’ Because that’s what some people are getting at,“ she said.
“But I would say, think about what you’re putting on your body. We know antiperspirant and deodorant have an effect. We know antibacterial products have an effect. Try to limit your use of things you know are going to kill off good microbes. Because killing off your good microbes is potentially going to have negative consequences.”
Following the gut
Scientists who are plugging away at human microbiome research are eager to compare petri dishes of blossoming bacteria with samples from our closest living ancestors: primates.
Using behavioral data from chimpanzees in Gombe, Tanzania – the same group of chimps Jane Goodall and her team have been monitoring since 1960 – researchers at Duke University have discovered a key connection between socialization and the gut microbiome.
Anne Pusey, chair of Duke’s evolutionary anthropology department, is the keeper of this behavioral data. She heads a project to digitize all the information gathered on these chimpanzees in the field and is a contributing author on a recent study published in Science Magazine.
This new research highlights socialization as a factor for the diversity of gut microbes and complements a long-term study from Jenny Tung, an assistant professor of biology at Duke who found connections between the intermingling of wild baboons and the gut microbiome.
“In humans, [researchers] know about the microbiome being transferred from mother to baby during a normal birth but not during cesarean,” Pusey said.
Based on this principle, Pusey says a reasonable assumption is that related chimps would have a more similar gut microbiome than non-related chimps. But instead, she found chimpanzees who spent time interacting had similar gut microorganisms, independent of whether they were related.
“That suggests that there’s transfer going on between individuals in ways other than just by birth,” Pusey said.
Steffen Foerster, a senior research scientist in Duke’s department of evolutionary anthropology, developed models to study the complex social relationships between these chimpanzees.
“It’s very dynamic, much like in humans. As we move around our daily lives, we meet people, spend some time with them and then leave when we want to,” Foerster said.
By following a different chimpanzee each day, recording social interactions and collecting fecal samples, researchers determined that the level of gregariousness of the chimps correlated with the richness or diversity of their gut microbes.
So what implications does this have for humans? A key difference in human versus chimpanzee interaction is that people don’t swap fecal matter quite as readily as chimpanzees.
“When they’re together, they groom each other, they play, they mate and also they – because they’re near each other – they’re defecating and they’re walking around in the same areas where each other have defecated,” Pusey said.
But our modern battle against dirt, germs, bacteria, parasites and general foul smells may be a setback for a diverse human microbiome.
“What people are starting to realize is, not having anything to fight against is making our immune system fight against itself,” Foerster said. “This increased prevalence of autoimmune disease might have to do with not having to fight off these parasites.”
ECU, UNC Researchers Join to Study High Blood Pressure In Rural Southern Blacks
Researchers from ECU’s Brody School of Medicine and UNC-Chapel Hill’s School of Medicine and Cecil G. Sheps Center for Health Services will examine strategies for reducing high blood pressure among low-income African-Americans.
By Taylor Sisk
Researchers from East Carolina University and the University of North Carolina-Chapel Hill have been selected to participate in a $9.5 million grant to address health disparities in the rural South.
This will be a five-year, multi-institutional study to compare strategies for reducing high blood pressure among low-income African-Americans throughout the rural southeast. Research teams have been assembled at ECU’s Brody School of Medicine, the University of North Carolina School of Medicine and the UNC Cecil G. Sheps Center for Health Services and the University of Alabama at Birmingham
The project is funded by the Washington, D.C.-based Patient-Centered Outcomes Research Institute, established under the Affordable Care Act.
Researchers will study rural communities throughout the “Black Belt,” a region, stretching from Maryland to eastern Texas, so called for its high percentage of rural black communities. It has the nation’s highest rate of cardiovascular disease mortality.
High blood pressure – or hypertension – can lead to heart disease and stroke.
‘A multitude of factors’
According to the Centers for Disease Control and Prevention, nearly one in three adults in the U.S. has hypertension. The rate is higher still among rural residents, and the rate for blacks in the U.S. is among the highest in the world.
An ECU press release last week announcing the study states: “According to the N.C. State Center for Health Statistics, 38.9 percent of adults in eastern North Carolina reported being told by a doctor that they had hypertension. Even more alarming was the 46.6 percent of African-American respondents in the East who reported having hypertension – a rate approximately 25 percent higher than that reported by white respondents.”
The study will focus on what the researchers refer to as the “‘triple threat’ of risk factors,” related to race, geography and income status.
In an interview, Doyle Cummings, a professor of family medicine and public health at the Brody School of Medicine who will head the ECU team of researchers, said, “It seems very clear that African-Americans who live in rural areas and have a lower socioeconomic status account for a very high proportion of the risk.
“That’s the group that seems to be at highest risk for developing hypertension in general and uncontrolled hypertension in particular.”
Cummings said there are a “multitude of factors” that make this demographic so susceptible to uncontrollable hypertension. He cited first poor access to health care services in rural areas.
“People in rural areas sometimes don’t have access to the same quality of care, the same breath of care, as folks in other areas,” he said.
He then cited affordability issues and a shortage of “opportunities to be healthy: access to healthy food and to safe places to exercise and to keep weight lower.”
Health literacy is also an issue.
“A number of our patients don’t even understand that high blood pressure is a high risk factor for stroke,” Cummings said. “They may know they have high blood pressure, but they don’t connect that with having a stroke or having a heart attack down the road.”
This research will employ two strategies: One will explore the issue from within the health care-delivery system – specifically, how patients who are at high risk for uncontrolled blood pressure are being treated in doctors’ offices.
The researchers will look, for example, at how effectively practices are recognizing the risks for uncontrolled blood pressure, whether it’s being appropriately diagnosed, if practices tend to measure blood pressure correctly, do they intensify medications when necessary and how well are they educating their patients.
The objective of this approach, Cummings said, is to better systematize care. He said the practice-based approach is in keeping with a movement to conduct research that partners academic centers with practices in underserved areas.
The other strategy is a community-based intervention. The researchers will deploy “peer advisers”: individuals from the community in which they’ll work, many with hypertension themselves, trained to deliver what Cummings called a “carefully scripted intervention strategy” to those at risk.
The advice they’ll offer will include the importance of seeing a doctor regularly and ensuring the patient has the proper medications and is taking them.
It’ll also entail helping those at risk better understand the effects of lifestyle behaviors and help with changes to diet and exercise that can lead to weight loss and blood pressure control.
One cohort in the study will participate in both strategies, another in one or the other strategy and a third will be followed as they continue with their usual care without intervention.
Cummings said both ECU and the University of Alabama at Birmingham have used the peer-adviser approach in the past, and that it’s been particularly effective within black communities, where there’s often a distrust of the health care-delivery system, founded in large measure, historically, on limited or no access to the system or mistreatment.
The researchers intend to study some 2,000 patients at 80 practices in Alabama and North Carolina.
Cummings said that probably about two-thirds of the practices his team will work with will be in the eastern part of the state.
The overall objectives, he said, are to better understand how to help primary care practices make changes to bring more patients’ blood pressure under control, and to examine which of the two strategies seems to work more effectively or if future initiatives should pursue the two together.
This research, Cummings said, is “absolutely central to the mission of the Brody School of Medicine. Our mission is really about trying to improve the health status in North Carolina and, in particular, in eastern North Carolina.
“We’re very concerned about this idea of disparities – that in North Carolina there are some folks who don’t seem to have access to care and outcomes that we’d like to see.”
A New Editor-in-Chief in Town
A conversation with Sally Perreault Darney, the new head of Environmental Health Perspectives.
By Gabe Rivin
Sally Perreault Darney tends to say “we” when she’s talking about the U.S. Environmental Protection Agency. She laughs when she catches herself, and admits it’s a deeply ingrained habit.
That she has the habit makes sense, because for more than 30 years Darney worked at the EPA in Research Triangle Park. For nearly 25 of those years, she researched reproductive toxicology. Later she ascended into supervisory roles and helped set the course for the agency’s health research.
But now the “we” of the EPA will have to become “they.” That’s because at the end of August, Darney took the position of editor-in-chief at Environmental Health Perspectives, one of the country’s most respected research journals and a free, open-access publication that’s funded by the National Institute of Environmental Health Sciences.
To learn more about Darney’s vision for the journal, North Carolina Health News sat down with her in her new office in Morrisville, near NIEHS’s campus.
NCHN: What’s most exciting for you in environmental health sciences right now?
Darney: One of my favorites is life-course health, the appreciation that your health as an adult is a function of what you were exposed to when you were in utero, when you were a child and breast feeding, when you were in school, in day care.
An emerging area is how the microbiome – the critters, the bacteria and little bugs that live inside us – can also influence our health and our internal environment. That’s a really hot area.
Another area where we see a lot more integrative types of papers is the use of layered maps, which let you look at multiple factors in geographic sets. If you’re looking at a city, you might look at where the hospitals are, where the schools are, and you can ask questions about the relationship between the natural environment and the built environment and the health of people living in that one location.
There’s a big revolution with toxicity testing, called Tox21. There is a lot of really hot science that, in the future, should make it possible to predict the toxicity much more efficiently of thousands of chemicals, rather than needing to test them one at a time in animals.
NCHN: The Research Triangle seems like a unique place for environmental-health research. What’s happening here that isn’t happening in other places?
Darney: I think the decision years ago to locate NIEHS here, as opposed to in Bethesda, where all the other institutions are, and to locate EPA’s Office of Research and Development here, created a concentration of environmental health research that had a lot of governmental clout behind it. So that was kind of the groundwork.
And I think that encouraged the local universities – like Duke and N.C. State and UNC – to expand their environmental-health programs. Now they’re all powerhouses. So then you put all these people together and you have a critical mass of expertise in one place. That attracts new scientists to this area.
NCHN: What influenced you to go into this field?
Darney: I’m a child of the ‘60s. John F. Kennedy, in founding the Peace Corps, I think, set up in my generation a motivation for service. And that was an era with the first Earth Day and The Population Bomb. Both of those interacted with me, in terms of my strong interest in reproductive health and women being able to understand their health and how to plan their family.
When I interviewed [at EPA], I realized there were some great people doing a variety of research – whether you’re looking at contraceptive development, which was my first interest, or you’re looking to develop chemical ways to prevent pregnancy.
NCHN: You’ve got a distinctive background as a researcher, a federal employee and a journal editor. How does that influence your approach at EHP?
Darney: Having first-hand research experience is critical because I’ve been at the other end of the peer review. Working as an associate editor and an editor for several small journals made me very familiar with what it takes to do good peer review.
In some of the work I did at EPA as a program planner, I was working with a team of leaders, looking at what we should be researching: How do you identify the most important environmental-health problems to fund? That gave me a broader picture of what will have an impact on the field.
NHCN: What’s a research journal’s role in reaching a mainstream audience?
Darney: EHP includes a big news section. We have a news editor. That’s one of the things about the journal that really attracted me to this job.
I think scientists really struggle to communicate their findings, which are often very technical and complex to a lay audience – an audience that has different agendas.
Our stakeholders include teachers, physicians, parents and other students in other fields. Non-academic stakeholders really don’t want to read peer-reviewed journal articles. They want the bigger picture. They want to see what’s been published in the last five or 10 years. A news article can do that.
NHCN: Sometimes it’s hard for non-scientists to read about, say, BPA, and then to feel like they have any kind of confidence making decisions for themselves.
Darney: The public gets bombarded with a variety of information. Some of it is inflammatory. Some of it is cautionary. For some of it, the source has an agenda.
What’s important is to try to provide very trustworthy information that can help people make their own choices. And that may be to say, “We don’t know the answer to this in any great detail. The science is divided.”
To have a reputation that says this is reliable information, I think, makes the public feel more confident that the decisions they are making are valid. And then, of course, the information in scientific journals is used by policy-makers, who then can make more official public health recommendations.
NCHN: Where would you like to see the journal grow over the short, medium or long term?
Darney: I think the challenge will be to move into these new [research] areas and publish a variety of articles that help link them together, taking a more systems approach to the whole question of environmental health.
Evolving with technology, we already have ceased publishing in paper. We think there may be some new tools for making information more searchable, more accessible. That will help the readers.
NCHN: What’s your perspective on having publicly funded research available for free to the public?
Darney: As a taxpayer, I can say, “My taxes support this research, I want to be able to read it.” On the other hand, the publishers have to exist and they have to have their expenses paid.
And so a lot of times it’s not only the government that’s paying for the research; the government is paying to make it accessible. The author has a grant from the government. The grant has built into it publication charges, which [researchers] pay the publisher so that their paper can be published … and made accessible to everybody.
It’s a little complicated, isn’t it? But we’ve shown that it can be done, and I think it’s a pretty reasonable investment.
This interview has been condensed and lightly edited for clarity.
When It Comes to Sex Ed and Teens, Parents Matter
Had “the talk” with your kids yet? A review of the research says it’s time to get started.
By Rose Hoban
If you are an adult of a certain age, you remember how it went: A parent clearing their throat repeatedly, talking in metaphors, referring you to a book. Maybe when it was over, you were even more confused than before.
When, as a teenager, Anu Kumar’s mother wanted to have “the talk” with her, she sent her brother and father out of the house before sitting down to stammer out a few words about sex.
“That was the only time we talked about it,” Kumar said of her mother, a South Asian academic who was teaching in Utah. “That was a big deal for her. I mean, I come from India, no one talks about this stuff in India. For her to sit me down and have that discussion was big.”
Kumar, on the other hand, has been talking to her kids, a 19-year-old son and 14-year-old daughter, since they were toddlers.
“You have to start talking about it pretty early, and talking about anatomy,” said Kumar, who now lives in Chapel Hill. “Kids notice differences in anatomy. So the more accurate you can be, you know ‘what it’s for, what you use it for.’”
Kumar’s approach is the right one, said Laura Widman, a psychology researcher at N.C. State University. She’s just published a study in JAMA Pediatrics showing that parents talking to their kids really matters.
“We found … adolescents who talk to their parents about sexual-health topics are more likely to use contraception and condoms than teens who didn’t have those conversations,” Widman said.
Friends, books, the Internet
Kids have many more places to find information about sex these days, Widman said. The Internet is a virtual cornucopia of information about sex, from porn websites to videos created by comedian John Oliver; from young-adult literature to movies that can be blushingly explicit.
“There’s so much that’s sex based that the kids have access to,” said Michelle Delin, a single mom to two teens, a boy and a girl. “The videos, the movies, the phone. Things are vulgar and one-dimensional.”
But Widman said parents really do matter. She studies communication between teenagers, how teens negotiate things like their first dating relationship and talking about safer sex.
“A big place where kids learn these skills is at home,” she said.
Delin said she tries to be a foil to the other information out in the world, talking to her kids “about self-esteem, about being kind, about caring.”
You’ve convinced me. I’ll talk to my kids about sex. But I need some resources!
Tools for parents, created by Planned Parenthood to help parents talk to their kids.
A resource page created by SHIFT NC. The website also has great data about North Carolina.
More tools for parents and kids, created by professionals from the Nemours Children’s Health System, based in Delaware.
Birds + Bees + Kids: Created by an educator with experience as a sex-ed counselor.
Starting early is important, Widman said, because, cognitively, kids are different when they’re 12 and 13, more easily influenced, than even a few years later.
A Facebook query of parents drew responses such as: “I started the day I brought them home from the hospital so they could never say I didn’t tell them anything.” And, “Had the first talk with my son last spring. He was six.”
But others made comments like: “Not there yet and fretting over it.”
Kumar recounted talking to her kids all along. And Delin said she’s always been “up front” with her kids about sex.
Widman said that’s smart.
“If you wait to have ‘the talk’ and that talk comes at 14, 15 or 16 when kids have already started experimenting with sex, and have already been heavily influenced by the media and by peers, you’re going to be much less effective than if that was an ongoing conversation that started much earlier,” she said.
Kumar has also used conversations with her son as a roundabout way to talk to her younger daughter. She said her son, who’s now in college, has been in a serious relationship for a year.
“So I’m talking to him about how you don’t want to be pregnant until you’re done with school, and my daughter is sitting there listening and absorbing it all,” she said. “You don’t even have to have the conversation with them, just around them.”
‘From you, mom.’
Schools teaching sex education do play an important part in the conversation, said Elizabeth Finley, a spokesperson for SHIFT NC, which promotes adolescent and young-adult sexual health.
“Kids who get zero sex education initiate a little earlier than kids who get comprehensive or abstinence-only sex ed,” she said.
Once kids do start having sex – and the research shows nearly 70 percent of high school kids will have sex before they graduate – that’s where the differences in education come in.
“Kids who get comprehensive sex-education programs are more likely to use contraceptives or condoms than kids who get abstinence-only,” Finley said.
But everyone interviewed for this story said they don’t look to schools to teach values. That’s done at home, by parents.
“I spoke to my daughter about what guys would try to do, to tell you, to get you into bed,” Delin said. “So you don’t fall into the lure of, ‘Oh, I love you.'”
Nonetheless, she’s made condoms available to her daughter, who’s just turning 16.
“Even if kids are getting really good sex education in schools, it’s always meant to be supplemental to what you’re saying at home,” Finley said. ‘Parents are the place to have conversations about expectations and values, because school will never have the capacity to get to those things.”
“When my son was in middle school, I asked him if they talked about contraception, and he said, ’No,’” Kumar said. “And then I asked him where he’s getting information and he rolled his eyes and said, ‘From you, mom.’”
But she also said more education about contraceptives has contributed to downward trends in the teen-pregnancy rate. In 2004, the teen-pregnancy rate in North Carolina was 62.4 per 1,000 girls. The latest data, from 2013, shows the rate down to 35.2 per 1,000.
“If you use more contraception and condoms, you’ll have a lower pregnancy rate,” Finley said. “When we look at the research on why teen-pregnancy rates have declined so heavily in recent decades, the biggest reason is increased contraceptive use.”
“The role of schools is not necessarily to communicate values around sex; that’s what a parent can do,” Widman said. “A school can provide basic health information – you know, what are sexually transmitted diseases, what are the symptoms, how can they be prevented?”
Widman said that her research found kids need information from lots of different sources.
“Getting it from families and parents, getting it from schools, getting it from friends,” she said. “I think each of those may have a role to play.”
Biotech Leaders Recap, Look Ahead
Executives from the biotechnology sector gathered this week to look back at this years’ legislative session and begin planning for next year.
By Rose Hoban
Usually by the time the N.C. Biosciences Organization has its annual meeting in mid-October, the legislative session has been over for months and members of the biotechnology community have had time to digest any changes legislators delivered to their businesses.
But this year’s meeting at the N.C. Biotechnology Center in Research Triangle Park on Thursday ended up focusing on the results of this year’s session, which was one of the longest “long” sessions in recent history. And the meeting was an opportunity for biotech executives to figure out the challenges and opportunities created by the General Assembly’s actions this year.
“If you look strategically at what NCBIO got this year, everything we proposed has been adopted by somebody, except the R&D tax credit,” said Sam Taylor, the lobbyist for NCBIO, referring to about $40 million in tax credits that used to be available to larger biosciences companies to help defray some of the costs of research and development.
Earlier in the summer, Taylor had worried about his industry, as the Senate budget did not fund many of the biotechnology community’s requests, and even eliminated funds for the Biotechnology Center.
In the final budget, lawmakers declined to renew the tax credit, while funding many other biotech priorities, including the center.
Instead of the credit, the legislature funded a new Venture Multiplier Fund, with money that comes from the state Escheats Fund: unclaimed insurance, estates, properties and other monies that end up reverting to state coffers. The state Escheats Fund has close to $480 million, and the Venture Multiplier Fund could use as much as 10 percent of that fund.
The venture money will be targeted towards companies that are earlier in their development, Taylor told several hundred people gathered at the meeting. “[It] is designed to increase the amount of private venture capital in North Carolina for commercialization and company scale-up.”
“I know there are different capital needs and capital challenges depending on where you are in the process,” Rep. Nelson Dollar (R-Cary) said, referring to early-stage companies that don’t yet have investors but need money in order to continue researching and growing.
“We know that in North Carolina, one of the areas we are in need of is venture capital,” Dollar said. “There’s a lot of us that believe there is money here in various places if we can find ways to get that off the sidelines and get it more engaged.”
Crossing the ‘valley of death’
Incubating new companies is something Taylor said is a priority for NCBIO. In particular, biotech executives worry about that part of the company development cycle that science entrepreneurs call the “valley of death,” when initial excitement over, and investment in, an idea has faded and a fledgling company needs the next infusion of cash to grow. But often, investors have by then moved onto the next big thing.
Legislators put $5.25 million over the next two years into a fund that will provide up to $50,000 in matching funds to companies that have already received federal small-business innovation, research and technology transfer grants.
“It’s more than just the money,” Taylor told the crowd. “I think we’ve actually convinced legislators that this is a program that has merit, instead of just a place to put money for one year and see what happens.”
“We get huge dividends from biotechnology and R&D companies,” Sen. Bill Rabon (R-Southport) told the gathering. “The statistics show that you folks who start here and are incubated here tend to stay here and you bring good business and good jobs.… I appreciate it.
Taylor did say that in order for North Carolina to put a $50,000 state match to every company receiving the federal credits, the legislature would have to allocate an additional $5 million over the two-year budget cycle.
“But we’re well ahead of where we were two years ago, which was zero,” he said.
Replacing the R&D credit
Taylor told the group that late in the legislative session, after the usual June 30 deadline for the budget to be completed, he was approached by legislators to put together a grant program to replace the R&D tax credit program.
“I’d really like to see something formulated to start-up companies and people who are trying to get off the ground with something new,” Rabon said. “We could have the mechanism to do that with credits, or whether it’s grants or whatever.
“It’s much easier to budget with a grant program than with a credit program,” he said.
Taylor said he worked with biotech executives to propose an alternative incubator fund that would refund between 1.5 and 2.5 percent of any company’s spending on research and development, wages or services.
“It would have been a progressive credit, so that smaller companies get the larger percentage and larger companies would have gotten the smaller credit,” Taylor said, calling it a “rain-shower” approach to funding research.
“That will have to be hashed out and compromised,” Rabon said.
Many Hospitals Don’t Follow Guidelines for Child Abuse Patients, Study Finds
By Alana Pockros
About half of young children brought to hospitals with injuries indicating that they have been abused were not thoroughly evaluated for other injuries, and the use of proper care is less likely to happen in general hospitals than in those that specialize in pediatrics, a study released this summer found.
The researchers examined whether hospitals are adhering to guidelines from The American Academy of Pediatrics that all children younger than 2 years old suspected of being victims of child abuse undergo skeletal surveys, a series of X-rays used to identify broken bones that are not readily apparent, called occult fractures.
The results, published in the journal Pediatrics, reveal a significant variation in hospitals’ evaluation of occult injuries, despite the AAP’s recommendations.
“In the young population, medical providers can miss important injuries.… Skeletal surveys can help identify them,” said Joanne Wood, an assistant professor of pediatrics at the University of Pennsylvania Perelman School of Medicine and senior author of the study.
Wood and her colleagues highlight the importance of skeletal surveys, explaining how the detection of occult fractures can point to the need for additional medical services, provide additional evidence of abuse and help protect the child.
The study looked at records for nearly 4,500 children treated at 366 hospitals around the country between 2009 and 2013. That group included children under the age of 2 who had been diagnosed with physical abuse and children under the age of 1 with high-risk injuries.
Past research has demonstrated that skeletal surveys are key to assessing young children suspected as victims of abuse. Prior to this study, however, there was little information on how hospitals in general have adhered to the AAP’s protocol.
Researchers in the current study found that across all the hospitals, 48 percent of the children younger than 2 with an abuse diagnosis underwent proper occult fracture examinations. But a prior study by Wood and her colleagues reveal that approximately 83 percent of children suspected of being victims of child abuse underwent skeletal surveys when treated in pediatric hospitals.
This study reveals “a need for standardization of care” across hospitals, said Wood.
Robert Sege, the director of family and child advocacy at Boston Medical Center and member of the AAP Committee on Child Abuse and Neglect, said in an interview the disparity in hospital practices is due to “a big educational gap for colleagues who primarily see adults.”
“Doctors who treat children should be trained to know about [occult-evaluation] procedures when there is abuse suspicion,” he said.
In a commentary accompanying the study, Kristine Campbell, assistant professor of pediatrics at the University of Utah, suggested that follow-up research is necessary, as “no study reveals how often occult fractures provide the critical evidence to assure a child’s protection.”
Lyme Disease-Bearing Ticks Creeping Their Way Slowly South
Evidence is mounting that ticks carrying Lyme disease are spreading into North Carolina from Virginia.
By Rose Hoban
There are few diseases more controversial than Lyme disease.
The tick-borne virus has been the subject of debate over how many cases occur in the U.S. annually, the correct test and the correct treatment for chronic cases of the disease and whether the chronic form of the disease even exists.
But there are a couple of things that are less subject to debate: that you’re vastly more likely to get Lyme in the Northeast, where the disease was first identified, or in the upper Midwest, where it’s becoming more widespread.
Now there’s increasing evidence that Ixodes scapularis ticks bearing Borrelia burgdorferi, the bacteria that causes the disease, are becoming more common farther south, increasing the risk of contracting the disease in North Carolina.
Video showing the spread and geographical distribution of Lyme disease-bearing ticks since 2000. Maps courtesy CDC
A recent paper published by researchers from the Centers for Disease Control and Prevention mapped the geographic distribution of confirmed Lyme cases and data showing the geographic distribution of where I scapularis (commonly known as blacklegged ticks) were found to be carrying B. burgdorferi to define “high-risk” counties. The research indicated a slow, but steady, spread of increased risk areas extending down the Appalachians.
“Our results show that geographic expansion of high-risk areas is ongoing, emphasizing the need to identify broadly implementable and effective public health interventions to prevent human Lyme disease,” wrote the authors, who published their findings in the August issue of Emerging Infectious Diseases.
“Over the past 15 years, you can see a clear progression of the disease from the DC area along the foothills, almost to the North Carolina border,” said State Public Health Veterinarian Carl Williams. “We see cases reported in North Carolina in areas immediately south of what appears to be an emerging area in southwestern Virginia.”
Williams said he’s specifically concerned about Allegheny and Wilkes counties, and expects to start seeing the numbers of cases climb there.
“We’ve been in a position where Lyme disease cases were a much lower incidence rate here, but we’ve seen the incidence rate for Lyme really increase in Virginia,” Williams said.
“The real challenge in North Carolina is that we’re next to an endemic state,” said Duke University infectious disease researcher Paul Lantos.
Lantos said that a look at the epidemiology of Lyme in the Southeast since 2000 indicates that there are about 11,000 confirmed cases, and all but 1,000 of those are in Virginia.
“There’s been a dramatic expansion in Virginia over this time,” he said. “What we found is that northern Virginia has intensified, but there’s also been a rapid expansion down the Appalachians into Blacksburg and Roanoke possibly.”
Lantos also said ticks collected by researchers in Virginia back up the epidemiology.
Jory Brinkerhoff, a researcher at the University of Richmond, saw an increase in the number of Lyme diagnoses, and determined there were probably infected ticks in those areas.
When Brinkerhoff went looking, he found big populations of blacklegged ticks at higher elevations, and many of those were carrying B. burgdorferi.
“When you’re looking at case data, you take it with a grain of salt,” he said. “But corroborated with tick data, you can see there’s a lot of opportunity for infection because there are the ticks crawling around.”
But some say Lyme is much more prevalent in North Carolina than this research shows. Included among them is Marcia Herman-Giddens, who advises the Tick-Borne Infections Council of North Carolina.
Herman-Giddens, who teaches at UNC-CH’s Gillings School of Global Public Health, said part of the story of underdiagnosis has to do with how Lyme is diagnosed, using a two-step series of tests for antibodies that she said is overly strict, ruling out any cases where the reading might be equivocal.
In addition, she said, those borderline cases can be misinterpreted to mean there was no disease.
“There’s not a good test, and there’s not a test of cure,” she said, while allowing that it can be difficult to prove the absence of disease for most diseases. She noted that part of the problem with Lyme is that once someone is exposed to B. burgdorferi their bodies will make antibodies for years, which will then be detected on a subsequent test.
“People do stay positive for some of the [readings] of the test, sometimes for years,” Herman-Giddens said. “So one of the areas is that if people get sick again, and you get another tick bite, then it’s really a mess. They may have antibodies from a previous infection.”
She drew some comfort from an update sent to medical providers around the state by the North Carolina state epidemiologist this April. The memo reminded doctors that testing fewer than two weeks after a rash was not enough time for the antibodies to form.
That memo also noted the presence in North Carolina of another tick-borne disease that’s been dubbed STARI, for Southern tick-associated rash illness. But STARI is caused by the bite of a different species of tick, and researchers are still unsure of what bacteria actually causes it.
“[STARI is] impossible to distinguish from early Lyme disease,” Lantos said. “So I think a lot of cases in North Carolina are diagnosed as Lyme disease because you can’t distinguish between the two.”
Everyone agrees that having around more than one tick-borne bacteria that creates similar symptoms confounds the situation and adds to the controversy over identification, diagnosis and treatment for both diseases.
This year, the Centers for Disease Control and Prevention revised their estimates for annual Lyme disease diagnoses dramatically upwards. For years, the agency counted only cases reported by state health departments, tallying about 30,000 cases per year.
But looking at lab and insurance data yielded many more diagnoses, coming in at anywhere between 288,000 and 329,000 cases per year nationally.
While Herman-Giddens pointed to this revision as evidence of overdiagnosis, Lantos argued there are a lot of false positives in the testing for Lyme, and that people who really had STARI were treated for Lyme using powerful antibiotics, potentially causing harm.
“There probably are more cases,” Lantos conceded. “The range is getting larger and we are diagnosing it more and have more sensitive surveillance to capture more patients.”
Things people can agree on
No matter the controversies over diagnosis, everyone agreed that there’s more of an issue with tick-borne diseases. And all the researchers in North Carolina bemoaned the dismantling of the state’s public health entomology unit in 2011, after it was defunded by the General Assembly. The group had been tracking the presence and spread of insect-borne diseases in the state.
Now that Lyme is poised to really take off in North Carolina, such a group would be a valuable addition to the work of TickNET, a collaboration of academics and state and federal public health entities focused on tracking, researching and preventing tick-borne diseases.
Another point of agreement was that people need to do a better job at preventing tick bites. That includes wearing long pants into the woods and gardens, tucking pants into socks and using insect repellents like DEET.
“People don’t realize you have to rub the DEET into your skin,” Herman-Giddens said. She also has found that permethrin-impregnated clothing is effective at keeping ticks off of her when she leaves her Chatham County house to go into the woods.
She also suggested saving any ticks you pull off of yourself. She tapes the tick to a card and writes the date on it, along with the place on her body where it was biting.
“If you walk into a doctor’s office with a tick on a card, that makes a difference,” she said. “And if someone is knowledgeable, they can identify the tick.”
The guidance from the state epidemiologist noted that five North Carolina counties are now defined as “endemic,” meaning that at least two lab-confirmed cases have been identified in people who did not travel outside their county of residence during the month-long disease-incubation period. Those counties are Allegheny, Guilford, Haywood, Wake and Wilkes.
“A lot more is headed in this direction, and the ticks don’t know from Virginia,” Lantos said.
UNC Study Finds Rural Medicare Recipients Less Likely to Receive Follow-up Care
Many older patients discharged from rural hospitals end up back in a hospital bed too soon.
By Taylor Sisk
A team of UNC-Chapel Hill researchers has found Medicare patients in rural areas are less likely to receive adequate follow-up care after leaving the hospital than patients in urban areas.
As a result, they may well be at greater risk of winding up back in the hospital or the emergency room soon after discharge.
Matthew Toth, now a research public health analyst at RTI International, was lead author of the study, conducted while he was earning a doctorate in health policy and management at UNC’s Gillings School of Global Public Health and serving as a research assistant with the Cecil G. Sheps Center for Health Services’ N.C. Rural Health Research Program.
The results, published in the September issue of Medical Care, found that Medicare patients living in rural areas were 19 percent less likely to receive follow-up care within 30 days of leaving the hospital than those living in urban areas.
Patients discharged from hospitals in relatively smaller rural areas faced a 42 percent higher risk of being readmitted to the hospital within 30 days than patients discharged from hospitals in urban areas. Patients discharged from hospitals in larger rural areas were 32 percent more likely to be readmitted than their counterparts in urban areas.
Patients living in small rural areas were also 44 percent more likely to be seen in the emergency department within 30 days, while those in large rural areas were 52 percent more likely.
The study comes shortly after the release of the fourth year of federal data showing the 30-day readmission rates for most hospitals in the nation. This year, a majority of hospitals will face Medicare fines for having patients frequently return within a month of discharge.
Barriers to care
The UNC study looked at some 12,000 Medicare-eligible patients with hospital admissions between 2000 and 2010, using data from the Medicare Current Beneficiary Survey.
Toth pointed to workday schedules as a barrier to primary care for people who cannot get to the doctor during regular business hours. He suggested extending weekend clinic hours as a potential solution.
Toth and his colleagues also outline some potential policy initiatives to address the problems they found, including investment in telehealth, care management and transitional care and policies to enhance primary care services.
“Policymakers and researchers ought to continue to monitor the utilizations and outcomes among rural beneficiaries to better understand some of the specific barriers to care that they’re experiencing,” Toth said in an interview.
This could “help shape some of the payment and delivery-system reforms that are taking place in our health care settings,” he said.
CMS officials will penalize 2,592 hospitals across the country this year, all will receive lower payments for every Medicare patient admitted to that hospital for the coming year.
The penalties will be assessed starting in October. They’re mandated by the Hospital Readmissions Reduction Program, created as part of the Affordable Care Act to encourage hospitals to more closely monitor what happens to patients after discharge.
The hospitals penalized will lose a combined $420 million. The percentage of North Carolina hospitals that will be fined is higher than the national average: 68 percent compared with 54 percent.
Toth placed the results of his team’s study in the context of the Hospital Readmissions Reduction Program.
“Consistent with previous research on safety-net and low-volume hospitals, our study finds that rural hospitals serving elderly Medicare beneficiaries may be disproportionately penalized under this program,” he said in a press release announcing the results. “If so, poor readmission outcomes among these hospitals may be exacerbated.”
A deeper understanding of the reasons for the discrepancies between rural and urban areas could help inform efforts to improve care, he said. “For example, are patients of rural hospitals more likely discharged to under-resourced settings, or are there more likely gaps in post-discharge instructions in the inpatient setting?”
“Especially with new ‘pay-for-performance’ programs tying reimbursement to hospital performance on patient outcomes, [our] results highlight the need for policies to improve follow-up care for patients in rural areas,” he said.
Bad Health Outcomes for Adults Who Don’t Get Help as Teens
By Lisa Gillespie
Young people with health problems left uncared for in adolescence face higher risks of leading unhealthy lives as adults, a new study finds.
A study of 14,800 people found that the odds of adverse adult health conditions were 13 to 52 percent higher among those who reported unmet health needs as adolescents than for those who did not have unmet needs as teens but who were otherwise comparable. The study was conducted first in 1994-95 when many subjects were in their mid-teens, and again in 2008 when many were in their late 20s.
An article about the study was published Monday in Pediatrics, the journal of the American Academy of Pediatrics.
This isn’t the first study to find a link between health services for adolescents and better adult health, but past research relied on country-level data from sources such as the World Bank. The latest study is the most extensive one using individual data, said lead researcher Dougal Hargreaves, a research fellow at Boston Children’s Hospital.
Teenagers with depression whose needs were unmet then were one and a half times more likely to have depressive symptoms in adulthood than counterparts who received help in adolescence. Similarly, poor general health, functional impairment, missed work or thoughts of suicide in a person’s early years – if not addressed – are a predictor for those issues in later life, researchers said.
The study compared people who had reported unmet health needs in adolescence with subjects with similar adolescent health issues, insurance coverage and socioeconomic backgrounds but no unmet health needs.
There could be two reasons for unresolved teenage problems that carry into adulthood, the study’s authors wrote. One explanation might be that health care not provided in adolescence exacerbates a condition in adulthood – although they said they did not study that specifically. Another possibility is teenagers who don’t take care of their health follow the same habit as adults, the authors speculated.
Adolescence is a time when people begin to form attitudes about health and seeking help when it’s needed that stick with them for life. “Adult behavior may be influenced by experiences in childhood as well as adolescence,” the Pediatrics article said.
Adolescent subjects in the study often didn’t perceive their health needs as important. That was the most common reason those needs were not met. Cost was the least common reason, the authors wrote. Other reasons cited were teens’ fear of negative consequences if they sought help and their lack of confidence that their privacy would be protected.
“Oftentimes, we’re worried about financial access problems. But for adolescents, often the access challenge isn’t related to the ability to pay, but the ability to understand the importance of treating problems now and to find a trusted provider who can offer care in a nonjudgmental way,” said Matthew Davis, a professor of pediatrics at the University of Michigan.
Scott Benson, a child psychiatrist for 35 years in Pensacola, Fla., said the study reported in Pediatrics affirmed the stigma he sees many teen patients come in with. Many have no idea they have depression and wonder why they are sad. While many teens had depression symptoms in the study, he said outcomes could have gotten worse because they were not addressed early.
Hargreaves’ takeaway was that teens need to use services more easily, and get around the stigma of getting help, especially for mental illness. They should be able to talk with health professionals about subjects awkward to them, he said.
This story originally appeared in Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.
What to Do with 264 Billion Pounds of Coal Ash
UNC-Charlotte engineers are developing novel techniques to manage coal ash, but time is running short.
By Gabe Rivin
John Daniels claimed he could make water stand on a block of coal ash.
“Have I ever given you my little show-and-tell trick?” he asked, as he rushed to his cabinet. He returned with a chalky gray cylinder and a bottle of water. “Making stuff water repellent, to me, is just neat.”
Daniels laid two drops of water on the flat face of the cylinder. One droplet began to sink. Soon all that remained was a dark-gray spot.
But on the other side of the cylinder’s face, the water droplet remained globular and inert, repelled by a seal of water-resistant chemicals.
“If it’s water repellent, water’s not getting in,” Daniels said. “Water’s not getting in, water’s not getting out.”
Daniels is one of several engineers at UNC-Charlotte helping to answer a multi-billion-dollar question: What should Duke Energy do with its bounty of coal ash in North Carolina?
The ash, created when coal is burnt to produce electricity, has proven vexing for Duke, environmentalists and state lawmakers, all of whom are jockeying over its fate.
On one hand, the science seems clear. North Carolina’s coal ash is stored in large basins that are dug into the ground. These were constructed without liners, and so toxic metals in the ash, such as arsenic and chromium, can leach out of the basins.
The metals can find their way into subsurface water, or groundwater. This migration has the potential to contaminate drinking water for nearby residents who draw their water from wells drilled into the ground.
After a new round of tests near coal ash ponds, the N.C. Department of Environment and Natural Resources in April raised the possibility that coal ash is contaminating residents’ drinking water.
How to eliminate this threat though has been passionately contested, with some calling on Duke to move its ash to lined landfills and others saying that Duke can safely keep much of the ash where it is, provided that it’s dried out and covered up.
For either method, Duke faces an enormous engineering challenge. Duke’s surfeit of ash, a total of some 264 billion pounds, is also spread across 32 basins in the state, some of which are filled with water.
Duke also faces several tight timelines to close its sites.
All of which helps explain the urgency behind UNCC’s research.
Although North Carolina’s legislators prescribed much of Duke’s cleanup plan, there’s still a lot to learn about coal ash, the researchers say. And there are plenty of soon-to-be-proven methods to transform the ash, whether that means turning it into waterproof construction material or using it to build barriers that keep the rest of the ash dry.
In the lab
Milind Khire pointed at what looked like a metal drum, inside of which was a pair of metal arms.
“This is a geo-centrifuge,” he said. “We can actually create a prototype of a dam or a levy system here.”
Khire, another engineering researcher at UNCC, is planning to use the centrifuge with coal ash. By spinning wet ash at high speeds, he’ll be able to measure some of its fundamental physical properties. These include the behavior of water when ash is stacked in 200-foot piles, as may be the case at Duke’s landfills.
Khire said that much of this research is new.
“Very little strength and hydraulic property measurement has been done by anybody for coal ash,” he said.
And that’s a problem, he said, given some of the rushed deadlines for Duke’s ash basins. For three of its sites, Duke has until 2019 to dig up its coal ash and transport it to landfills.
But Khire said Duke should be given more time as engineers work to better understand ash and develop novel techniques to manage it in place, rather than shipping it to other communities.
Daniels, who has advised Duke on ash management, also criticized a one-size-fits-all approach to coal ash, such as environmentalists’ demand that Duke excavate and landfill all of its ash.
“The notion of excavating every site and putting it on a bunch of trucks – or even rail – and hauling it hundreds of kilometers or miles to some other far-flung site and entombing it is not necessarily the best approach,” he said. “Jumping from, ‘Every site has an impact, therefore excavate,’ to me is understandable, but it’s irresponsible from an engineering perspective.”
Daniels said novel engineering techniques could protect people’s health, at a fraction of the cost.
Those techniques may include deploying organosilanes, a chemical class that can render coal ash waterproof. Since 2007, Daniels has run small-scale tests using the compounds. He’s found organosilanes could efficiently transform large quantities of coal ash, allowing it to serve as a cover for ash ponds.
Khire is experimenting with a similar technique. By mixing coal ash with North Carolina’s soils, it’s possible to create a spongy material that keeps water out of an ash basin, he said. This too could serve as a cover for Duke’s ash.
Elsewhere in his lab, Khire is developing a technique that could improve Duke’s ability to pump water from its ponds. The technique uses charged electrodes to attract water while leaving behind the coal ash.
This technique would help Duke to dry out the ash so it doesn’t leach metals into groundwater. Combined with a waterproof cover, the ash would be protected from rain. Such a combination, the researchers believe, could protect the public’s health while saving enormous costs.
The problem with water tables
“The role of research and development in this entire process is really key,” Erin Culbert, a spokeswoman for Duke, said.
Culbert said researchers have extensively studied ash recycling; coal ash can be used to make concrete and wallboard, among other products. But closing ash basins “in a somewhat urgent timeline is really a place where we feel like there could be a lot of additional assistance and reconnaissance,” she said.
While Khire said Duke’s deadlines are needlessly rushed, environmental groups aren’t so patient.
D.J. Gerken, an attorney with the Southern Environmental Law Center, said that Duke and state regulators have known about these problems for years.
“When you start the clock from the time that Duke Energy and the state discovered that these ash pits were failing and contaminating nearby rivers, we are by no means on an aggressive timeline,” he said
He also argued that a system of dewatering and covering the ash, as Khire envisions, would not work. Many of Duke’s ponds were dug below the water table, the highest vertical level of groundwater, he said. And that means groundwater can flow into and out of ash basins, toxic compounds in tow.
Khire admitted this is possible. But he said Duke could still dewater and seal its ponds and continuously pump out any groundwater. He admitted this would be expensive though.
Gerken was skeptical of this plan.
“It is an engineering Band-Aid that must be continuously operated by Duke Energy forever if we’re going to protect groundwater and rivers,” he said.
Regardless of the method, Duke’s priority is to protect groundwater, the company’s spokeswoman Culbert said. When evaluating the options for a site, she said, Duke wouldn’t choose to cap an ash basin if doing so would allow for contamination.
Who will take it?
For now, state regulators have paused their work to determine the fate of Duke’s ash in response to a court fight between Gov. Pat McCrory and the General Assembly.
Nonetheless, Duke has plowed ahead. The company is beginning to excavate – or plans to excavate – 20 ash basins across the state. Duke says it will recycle the ash or transfer it to lined landfills. This meets the strictest requirements under the 2014 coal ash law.
But that hasn’t appeased some environmentalists. Several groups have protested Duke’s proposal to place ash in two abandoned clay mines, even though the ash will be blocked off with liners.
Gerken takes a different view. He said that while there’s no perfect solution for coal ash, “Having it in a modern, properly lined facility anywhere is better than having it in an unlined pit.”
And there’s still 264 billion pounds of waste – the byproduct made from powering refrigerators and air conditioners, North Carolina’s hospitals and homes for several generations – that remains to be disposed of safely.
And it has to go somewhere.