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The Hazard Hunters


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After 50 years, NIEHS stays focused on assessing environmental risks but in ways few could have predicted back in 1966.

By Catherine Clabby

When the United States Public Health Service launched the National Institute of Environmental Health Sciences in 1966, the marching orders were simple:

Track down environmental hazards, describe how exposure occurs, and pinpoint who gets hurt.

Fifty years on, insights into the complexity of both human biology and the range of risks make that detective work much harder.

Herbert Needleman, MD, NIEHS grantee, led pioneering studies providing first clear evidence that lead, even at very low levels, can affect the IQ of children.

Herbert Needleman, MD, NIEHS grantee, led pioneering studies providing first clear evidence that lead, even at very low levels, can affect the IQ of children. Photo courtesy: NIEHS

“Much of the work done 50,40, 30 years ago was really dealing with high levels of exposure, the kinds of studies we can still do today in places like Beijing or Delhi into high levels of pollution,” said Linda Birnbaum, director of NIEHS.

Scientists now understand people are exposed to more potentially risky compounds than ever before. And variations in people’s genes, life histories and habits make some of us more vulnerable than others.

“We now know that very low levels of exposure to a wide variety of compounds can affect our health,” Birnbaum said, noting those include compounds that large numbers of people can encounter day after day.

It’s in that context that NIEHS – for all of 2016 – has been celebrating a forward-looking 50th birthday, with leaders emphasizing the power of their newest tools to tackle high-stakes puzzles, despite scientific challenges and political uncertainty.

Local and international

NIEHS is the only one of 27 entities within the National Institutes of Health not located within a morning’s commute to Washington, D.C. Gov. Terry Sanford, a pivotal Southern supporter of John F. Kennedy’s presidential bid, and U.S. Sen. Sam Ervin in the 1960s lobbied hard to draw federal research-oriented jobs to a fledgling Research Triangle Park.

Sweetening the pot, The Research Triangle Foundation sold 509 acres of RTP land to the federal government for just $1.

It worked, said U.S. Rep. David Price.

Having NIEHS and an Environmental Protection Agency campus in RTP has made the Triangle region an international leader in environmental sciences. “It’s also been a major job creator,” said Price, one of multiple members of Congress who have advocated for continued federal support for both agencies.

NIEHS' campus in Research Triangle Park.

NIEHS’ campus in Research Triangle Park. Photo courtesy: NIEHS

NIEHS does not make federal environmental policy, but it informs policies created by the EPA and other agencies. The institute employs some 650 people directly, including many scientists, but its impact on environmental research spreads far beyond this state. NIEHS spends more than 64 percent of its $681 million budget funding research, most of it elsewhere.

The National Toxicology Program, headquartered within NIEHS, coordinates assessments of health risks from industrial compounds and consumer products for federal agencies. It assesses everything from known carcinogens such as hexavalent chromium, to the cell phones millions of people use worldwide each day.

To be precise

Environmental scientists used to assume that “the dose makes the poison,” meaning that the higher the exposure to a hazardous natural or human-made threat, the greater the health threat. In some cases, say with arsenic in drinking water, or soot particles in the air, that can still stand.

Photo of a pile of books/ reports titled: Report on Carcinogens. In 1978, Congress mandated that the Secretary of the US Dept. of Health and Human Services publish a science-based, public health report that identifies agents, substances, mixtures, or exposures in our environment that pose a hazard to people.

In 1978, Congress mandated that the Secretary of the US Dept. of Health and Human Services publish a science-based, public health report that identifies agents, substances, mixtures, or exposures in our environment that pose a hazard to people. Image courtesy: NIEHS

But it’s now known that some materials can do harm in extremely low doses. Lead is an example, where now no level of exposure is considered completely safe.

In addition, the timing of exposure over a lifespan is important. Contact with some pesticides, can be more harmful to a developing fetus than to an adult.

Researchers given NIEHS grants are expected to help sort out what matters most.

“NIEHS is the NASA of RTP,” said Heather Patisaul, a North Carolina State University biologist who has been an NIEHS grantee. “It is the premier incubator of scientific discovery within the realm of toxicology and environmental science not just nationally, but globally.

“Because of these discoveries we have, for example, cleaner air, safer plastics, and flame-retardant free furniture.”

With NIEHS funding, Patisaul has been able to study the molecular effects of endocrine disruptors, compounds that, because they resemble human hormones, can short circuit normal hormone production. One of her areas of expertise is bisphenol a (BPA), the compound often found in plastic containers which can leak into food, including baby formula.

One U.S. survey estimated detectable levels of BPA could be found in 93 percent of Americans age six and older. Studies of lab animals have found subtle developmental effects in fetuses and newborns after low exposures to the compound.

New frontiers

Along with those emerging threats, NIEHS these days funds research exploring risks from nanomaterials, products constructed with engineered particles small enough to maybe slip through human skin, the lining of lungs or other protective tissue. Identifying environmental contributors to disorders such autism, heart disease and asthma are also on the NIEHS research agenda.

Photo of model of a strand of DNA. NIEHS and collaborators at the University of Utah pinpointed the BRCA1 gene that, when defective, is believed to be responsible for inheriting breast and ovarian cancer susceptibility.

NIEHS and collaborators at the University of Utah pinpointed the BRCA1 gene that, when defective, is believed to be responsible for inheriting breast and ovarian cancer susceptibility. Image courtesy: NIEHS

In recent years, NIEHS has pushed researchers to depend less on lab animals, such as mice. It has helped develop study approaches using human cells and computer modeling to identify dangers.

UNC-Chapel Hill cell biologist Mark Zylka showed the value of that approach this year when he found that a commonly used agricultural fungicide produced genetic changes in human cells that resemble those seen in some people with autism.

“We have a better understanding of how animal data, cell culture data and computational data can help inform us,” Birnbaum said.

Rocky roads

While widely respected in the field of environmental science, NIEHS has attracted criticism too. Industry groups have accused NIEHS-affiliated scientists of exaggerating risks posed by some chemicals and environmentalists have faulted NIEHS for working too closely with industry.

In 2008, then-NIEHS director David Schwartz resigned after only two years at the helm. He is a pioneer in linking genetic activity and environmental exposure to greater vulnerability to lung diseases, such as asthma and pulmonary fibrosis.

A Congressional inquiry had turned up allegations Schwartz was consulting for law firms involved in asbestos lawsuits and spending NIEHS funds intended for other uses for his own lab. Schwartz apologized and said any errors he made were from ignorance, not ill intent.

Some scientists are concerned about how strongly federal leaders will support environmental research in coming months and years. The person appointed by President-elect Donald Trump to lead his transition at the EPA, for one, is a climate-change skeptic.

Unlike EPA, Price said, NIEHS has not been singled out for cuts in Congress in the past. The agency’s position within the NIH, and the endurance of bi-partisan support of biomedical research, appears to have sheltered it.

That said, federal funding for all scientific research has been declining, Price said, a trend he said needs to be reversed.

“There’s been a slow and steady lowering of resources available to research. That’s a product of budget policy,” Price said.

Since 2005, federal investments in research and development have declined by over 13 percent, Price said.

NIEHS leaders, at least publicly, are focusing on the positive. “NIH has a long history of bipartisan support and stands ready to work with the new Administration to improve people’s health and reduce the burden of disease through biomedical research,” Birnbaum said.

For one, there is that year-long birthday celebration to finish. Next month, for instance, NIEHS will be making the scientists it funds a lot more visible than usual in North Carolina.

Such researchers are expected to be the majority of people NIEHS expects at a multi-day science festival in downtown Durham the first week of December. NIEHS officials expect 1,200 people to join in.

NC Cancer Centers Cite Progress Based on Teamwork


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North Carolina’s cancer centers push the boundaries of research into the dreaded disease.

By Thomas Goldsmith

Radiation. Cancer chemotherapy. Lumpectomy. Mastectomy. Could all of these interventions be overkill for many women with breast cancer?

A “wait and watch” approach to the breast condition known as DCIS may be more appropriate for many women than more aggressive treatment, said a Duke physician recently.

photo of Dr. Shelly Hwang hugging a patient

Surgeon Shelley Hwang (right) with one of her patients. Photo courtesy: Twitter/ @DukeCancer

The setting for those remarks was an annual breakfast presented Nov. 10 in Durham by the American Cancer Society’s Cancer Action Network with the goal of celebrating achievement and raising awareness and funding for research in the field. Representatives of North Carolina’s three National Cancer Institute-designated comprehensive cancer centers updated brought on recent progress, each citing a team-based approach.

Shelley Hwang, a surgeon at the Duke Cancer Institute, spoke about her role as a principal co-investigator in a $13.4 million study of low-risk ductal carcinoma in situ, or DCIS. The condition, affecting 60,000 American women annually, involves cancerous cells contained in the ducts of the breast, that have not yet spread, Hwang said.

“We treat it very much like we do cancer, and it has very much the same treatment side effects,” she said. “It really hasn’t brought about the reduction in breast cancer we would like to see.”

Hwang: Some patients treated too aggressively

Based on cooperation among different medical and scientific disciplines, Hwang said, clinicians have been asking questions about when treatment for such conditions is warranted and when an aggressive approach might outweigh benefits.

“Why are these people continuously radiated and treated … and potentially have both breasts removed?” she asked. “The alternative to this would be close monitoring, with treatment only if the patient develops cancer.”

Hwang said if a woman is 60 years old and diagnosed with DCIS, “You are much more likely to die of non-breast cancer related causes.”

The U.S. health care system currently spends $250 million annually treating DCIS, in many cases without strong evidence to justify the treatment, said Hwang, who was recognized along with Dr. Laura Esserman, of the University of California, San Francisco, as one of Time magazine’s 100 most influential people of 2016.

Diagram of how ductal carcinoma in situ grows in breast tissue.

According to the National Cancer Institute, DCIS is: “A noninvasive condition in which abnormal cells are found in the lining of a breast duct. The abnormal cells have not spread outside the duct to other tissues in the breast.” Image courtesy: NCI

Musician Melissa Etheridge, a breast cancer survivor, told Time she applauds the trend toward less invasive treatment.

“… I’m happy to see doctors like Laura Esserman and Shelley Hwang, who are at the top of their field, saying, ‘Whoa, let’s put a brake on all these radical surgeries,’ Etheridge said in the magazine. “Maybe there is a middle step. Let’s try that before we go to the radical step.”

Hwang also touched on trials involving PVS-RIPO, a genetically engineered poliovirus that is being investigated as a new anti-cancer agent at Duke.

Trials using mice, and some people, have shown good results against some brain tumors.

14 million survivors

Lance Miller, core director of the Wake Forest Baptist Comprehensive Cancer Center, outlined growth and progress at the center, where professionals are organized into disease-oriented teams.

“We have organized in teams to try to confront them in a cross-disciplinary mode,” said Miller. “Team science is the future of cancer research.”

Dr. Chad Ellis, associate director at UNC-Lineberger Comprehensive Cancer Center, noted that

80 percent of all children diagnosed with cancer will be cured of their disease and that two-thirds

of adults diagnosed with the disease will live at least five years.

“There are 14 million cancer survivors alive in the United States,” Ellis said.

UNC is recruiting people from across the scientific and academic spectrum to examine how the disease affects different population groups, Ellis said. A related area of intense activity is personalized medicine, where clinicians determine the specific treatment that will cure a cancer, but not harm the patient.

“We identify the particular characteristics of a tumor in a patient … and we pick exactly the right treatment,” Ellis said.

What is a NCI-designated Cancer Center?

UNC, Duke and Wake Forest are each home to one of 47 U.S. comprehensive cancer centers designated by the National Cancer Institute, the principal federal agency for cancer research.

The designation recognizes the centers for their “scientific leadership, resources, and the depth and breadth of their research in basic, clinical, and/or population science.” To merit the  “comprehensive” designation, a center must demonstrate additional depth and breadth of research, as well as research that crosses disciplinary lines.

The National Cancer Institute, set up by federal legislation in 1937, is part of the National Institutes of Health, one of 11 agencies under the federal Department of Health and Human Services.

Source: National Cancer Institute

 

Lewy Body Dementia Finally Merits Attention, Research


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Most people are now familiar with Alzheimer’s disease, while few people know about Lewy Body Dementia. But that’s changing.

By Thomas Goldsmith

At a recent Raleigh workshop on Lewy Body dementia, an audience member who believes a relative has the disease asked presenter Dan Kaufer where to tell a doubting young doctor to go.

A microscopic image of Lewy bodies. Image shows reddish blots in pink tissue. Image courtesy Dr. Andreas Becker/ Wikimedia Commons

A microscopic image of Lewy bodies. Image courtesy Dr. Andreas Becker/ Wikimedia Commons

“I can think of a four-letter word,” Kaufer said to laughter, adding, “LBDA.”

Kaufer, director of the UNC Memory Disorders Program, was referring to the Lewy Body Dementia Association, a nonprofit provides that information and advocacy about this, one of the most frequent causes of dementia, which still remains relatively unknown.

But even as Kaufer announced promising new clinical trials, his response reflected frustration about a general lack of knowledge of the disease, which affects about 1.4 million people in the United States, according to the LBDA. The disorder recently garnered attention after an autopsy showed the actor and comedian Robin Williams was suffering from Lewy Body dementia before his 2014 death.

The annual Raleigh event known as “Candlelight Reflections” in honor of those with dementia is scheduled for 6:30-7:30 p.m., Thursday, Nov. 3, at the N.C. State Fairgrounds, 1025 Blue Ridge Road.The terms associated with the disease, characterized by deposits of misformed protein molecules in the brain, can make it confusing for the unfamiliar. According to the National Institutes of Health, dementia with Lewy bodies describes a form in which cognitive problems such as hallucinations or sleep problems show up within a year of a patient developing mobility problems including slowness of gait and rigidity. On the other hand, Parkinson’s disease dementia refers to a form in which the cognitive problems show up later, more than a year after such movement issues start.

Alzheimer’s North Carolina, the Raleigh-based nonprofit and advocacy organization, welcomed a standing-room-only audience of about 80 to Kaufer’s presentation at Paragon Bank on Glenwood Avenue. Questions from the audience showed that many attendees knew or suspected that someone in their care had a form of Lewy Body dementia.

“I think the key thing is to have hope, to transform the negative feelings into positive energy, to make a difference, to change the status quo,” Kaufer said.

“For the first time in a decade we are studying not one, but two potential treatments for [Dementia with Lewy Bodies.]”

Trials are underway

Dr. Dan Kaufer talks to attendees after an Alzheimer's NC workshop in Raleigh on Lewy Body disease.

Dr. Dan Kaufer talks to attendees after an Alzheimer’s NC workshop in Raleigh on Lewy Body disease. Photo credit: Thomas Goldsmith

A trial  involving the investigational drug Nelotanserin is exploring the safety and efficacy of the drug, as well as patients’ ability to tolerate it.

“This drug may affect not only neuropsychiatric disturbances, but could also have an effect on sleep,” Kaufer said.

The second study concerns RVT-101, an investigational drug that raises levels of a neurotransmitter believed to affect motor and memory functions. The drug, originally developed by GlaxoSmithKline, has also been tested extensively for Alzheimer’s disease.

“They start digging”

Lisa Levine, program director at Alzheimer’s NC, said the organization has noticed an upswing in the number of patients with Lewy Body disease who seek help.

“We have a really active support group and we’re getting more calls about it,” Levine said.

“They are very often misdiagnosed. A lot of times the family says, ‘It’s Alzheimer’s, but it’s not.’

That’s when they start digging.”

Learn more:

For the Research Triangle Lewy Body dementia support group, contact facilitator Loree Idol at idol.loree_at_gmail.com.

For information about walks or other events in honor of people with Alzheimer’s, visit alznc.org

Kaufer noted that correctly diagnosing and treating a patient with a Lewy Body disease often takes three steps: An initial consultation with a family doctor, a referral to a general neurologist, and another referral to a specialist in this type of disorder.

“I think there are many, many cases of LBD that are lumped into Alzheimer’s disease,” he said.

An incorrect diagnosis can cause problems in situations such as an emergency department admission if professionals treat the person with a Lewy Body disease with drugs appropriate for Alzheimer’s disease.

Treating the brain

Another attendee’s question led Kaufer to discuss his hopes for changes in the way these kinds of diseases are described.

“In his mind he has Parkinson’s,” the attendee said of her brother. “We have never used the word ‘dementia’ with him for fear of depression.”

If Kaufer could, he said, he would delete all mentions of “dementia.” A more accurate term would be “neurocognitive disorders.”

“‘Dementia’ has a lot of negative connotations,” he said. “‘Neurocognitive means, ‘I have a problem that has something to do with my brain.’

“We need to take care of the person and we need to treat the brain. Up to now we have been taking care of the person and are just starting to treat the brain.”

The basics of Lewy Body Dementia

“LBD is a disease associated with abnormal deposits of a protein called alpha-synuclein in the brain. These deposits, called Lewy bodies, affect chemicals in the brain whose changes, in turn, can lead to problems with thinking, movement, behavior, and mood. LBD is one of the most common causes of dementia, after Alzheimer’s disease and vascular disease.

“Dementia is a severe loss of thinking abilities that interferes with a person’s capacity to perform daily activities such as household tasks, personal care, and handling finances. Dementia has many possible causes, including stroke, brain tumor, depression, and vitamin deficiency, as well as disorders such as LBD, Parkinson’s, and Alzheimer’s.”

— Alzheimer’s Disease Education and Referral Center, National Institute on Aging, National Institutes of Health

 

 

 

Mending a Native Food Web


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The Eastern Band of Cherokee Indians are using research and new partnerships to expand access to wild foods at the heart of their culture.

By Catherine Clabby

On an Appalachian Mountains slope coated with trees and low plants, Tommy Cabe got on his knees to look for shiny black seeds inside a late-season ramp patch.

“Here there are five seedpods but no seeds,” the forest resource specialist for the Eastern Band of Cherokee Indians pronounced, adding quickly, “Here’s one!”

Ramp seeds were visible atop the rich, damp soil on north-facing, sloped land, precisely where ramps are likely to grow. Photo of seeds.

Ramp seeds were visible atop the rich, damp soil on north-facing, sloped land, precisely where ramps are likely to grow. Photo credit: Catherine Clabby

As Cabe reported every wild onion seed or pod he spotted, Michelle Baumflek, an ethnobotanist at Virginia Tech, logged numbers on a clipboard. With help from a measurement grid that Cabe moved from one research plot to the next in the patch, Baumflek cited precise locations too.

The meticulous work on secluded land may help Eastern Band tribe members regain the right to forage for wild ramps in Great Smoky Mountains National Park, a practice banned since 2007.

That would be momentous. Cherokee people have collected and consumed the plants for thousands of years. National park property bordering tribal land in far western North Carolina, the Qualla Boundary, were long a reliable source.

As important as it is, the ramp research is just one way the Cherokee tribe is working today to expand both access to and protections for native plants they treasure. Many new partnerships are cropping up along the way.

“Ultimately we’re talking about food sovereignty,” is the way Cabe explains the growing drive to help steer policy on these fronts. “Tribes have inherited rights to this.”

Broader goals

In addition to the ramps, the Eastern Band is seeking permission to harvest leaves from sochan plants, also called green-headed coneflowers, on national park land. Cherokee people collect the plant’s young leaves, the mineral contents of which can compare favorably to other health-food greens.

Tommy Cabe, forest resource specialist for the Eastern Band of Cherokee Indians, and ethnobotanist Michelle Baumflek at work counting ramp seeds in a research plot in the Appalachian Mountains. Photo by Catherine Clabby

Tommy Cabe, forest resource specialist for the Eastern Band of Cherokee Indians, and ethnobotanist Michelle Baumflek at work counting ramp seeds in a research plot in the Appalachian Mountains. Photo credit: Catherine Clabby

And the tribe has signed an agreement with the North Carolina Arboretum, the U.S. Forest Service Southern Research Station and the U.S. Geological Survey to share traditional knowledge and scientific findings to better monitor climate change effects on wild plants the Cherokee favor.

It has also commissioned botanist/chemist Joe-Ann McCoy, who runs the arboretum germplasm repository — a seed bank, to protect the seeds of the wild plants and to document their nutritional value.

“They still eat native foods. They want to collect those foods the way their ancestors did,” said McCoy, who also has a research project underway comparing Cherokee harvesting of ramps to other methods.

Expanding consumption of wild foods could have positive health implications as well. Cherokee people in North Carolina are three times more likely to be diagnosed with type 2 diabetes, a potentially lethal condition, than other people in this state.

Wild foods that Cherokee Indians have traditionally consumed — greens, berries and nuts among them — are healthful alternatives to high sugar and carbohydrate-laden meals associated with diabetes, said Robin Callahan, a registered dietician with Cherokee Choices, an Eastern Band diabetes prevention program.

“Traditional foods are whole foods. They are not processed or refined,” Callahan said.

Multiple forces have prompted the expanding number of Cherokee partnerships focused on plants. Fundamental to it all is the Eastern Band’s ability to finance some research with profits from Harrah’s Cherokee Casino, money that is subsidizing tribal public services in many arenas.

At the same time, federal agencies seem to be more awake to American Indians’ expertise in and connections to wild native plants.

Tommy Cabe slices into the bulbs of ramp plants during harvest, leaving a portion of the bulb,the rhizome and roots in the ground.

Tommy Cabe slices into the bulbs of ramp plants during harvest, leaving a portion of the bulb,the rhizome and roots in the ground. Photo credit: Catherine Clabby

In August, a new rule approved by the Obama administration allowed national parks to permit federally recognized Indian tribes to remove plants for traditional purposes. That paved the way for the Great Smoky Mountains National Park to launch talks with Eastern Band members about ramp and sochan harvesting.

The southern Appalachian Mountains is a prime spot for foraging for diverse types of plants due to the land’s ecological heritage. It contains more plant and animal diversity than most temperate ecosystems in the world.

Cherokee people in North Carolina have had a long time to explore those natural treasures, contact many American Indians in the eastern United States lost in the 1800s they were coerced or forced to move from their traditional homelands to distant reservations.

When the U.S. government started its armed clearance of Cherokee from the Appalachian region, an estimated 10 percent stayed, some by hiding in the forest. Many eventually became part of the Eastern Band, enabling knowledge of local plants gained over thousands of years to stay put too.

“Now it’s a big issue. How does western science incorporate the traditional knowledge?” Baumflek asked.

Traditional expertise

The story of how the Cherokee lost access to ramps and other plants within Great Smoky Mountains National Park is a reminder of the importance of incorporating American Indian insights, Cabe said.

Decades ago many considered ramps a poor person’s fare in the Appalachians, eaten by impoverished Indians and whites alike. Cabe recounted how a public school teacher once kicked him out of a classroom after complaining that he did not like the smell of the pungent wild onions on him.

But by the 2000s, appetites for regional foods had swelled in the United States. Exotic and sharp tasting ramps became favorites at upscale farmers markets, on foodie blogs, and at high-dollar restaurants in Manhattan. To satisfy demand, more and more people had started picking them in the Great Smoky Mountains park.

That became a concern because a study by a park service researchers dating to the 1990s found that an extensively harvested ramp patch could take 20 or more years to recover to pre-harvest levels. As a result, the park started prohibiting most of the public from harvesting them in 2002. The Cherokee were exempt until 2007 after the park’s leadership said they didn’t have the legal authority to make that exception.

Tommy Cabe packs up the grid he and Michelle Baumflek use to denote the location of the ramp plants within their research plots.

Tommy Cabe packs up the grid he and Michelle Baumflek use to denote the location of the ramp plants within their research plots. Photo credit: Catherine Clabby

But the red-flag study’s conclusions were based on a harvesting method that yanks ramps out the ground roots and all, not the traditional Cherokee approach. The Cherokee way leaves a small portion of the plant’s bulb, its nourishment-storing rhizome, and its roots in the ground, a foundation for a plant to grow back.

The study Baumflek designed, enacted among giant basswood, poplar tulips and buckeye trees, is comparing the Cherokee technique to the more aggressive approach on research plots in three remote locations on preserve land. The study is tracking how plants fare at all growth stages, hence the early autumn hunt for the tiny black seeds.

Baumflek and Tyson Sampson, another Eastern Band tribe member, are also recording interviews with Cherokee people about how they find, collect and use ramps, accounts that are expected to reinforce the cultural importance of the food. All findings are expected to be published in academic journals.

Given the negative experiences Cherokee Indians have had with non-tribe members, people who long ago evicted so many ancestors from their land and banned Cherokee language from their schools, tribe members aren’t always keen to give anything to outside researchers, Sampson said.

But this time, many understand that talking about traditional plants may help protect them.

“This is us sharing our identity to preserve our identity. And that identity is the plants,” Sampson said.

Tutoring the Textile Industry on Risky Flame Retardants


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An industry group welcomes a Duke researcher to explain the troubling legacy of chemicals intended to to make materials fire resistant

By Catherine Clabby

Before environmental chemist Heather Stapleton briefed a roomful of textile industry professionals about how people get exposed to potentially harmful flame retardants, she acknowledged the obvious.

“I just want to thank the organization for this invitation to this meeting,” the Duke University assistant professor Thursday told members of the Association of Textile, Apparel & Materials Professionals gathered in Cary for two days this week. “It’s a very different venue and a very different group of people than I normally interact with.”

Heather Stapleton supervises a lab that offers free chemical tests of residential foam. Photo courtesy National Institute of Environmental Health Sciences

Heather Stapleton supervises a lab that offers free chemical tests of residential foam. Photo courtesy National Institute of Environmental Health Sciences

“I know this can be a very controversial issue. There are hundreds of different fire retardants on the market. And there is really more of an environmental concern for a handful of them,” she said. “That is where most of my research has fallen.”

With that, Stapleton launched into summaries of a long list of experiments she and the members of her laboratory have conducted in recent years. They’ve been looking at a subset of fire-supressing chemicals that can easily shed potentially toxic small-molecule chemicals inside our homes, directly onto our bodies and even into indoor air.

Long lasting

That’s a concern, Stapleton said, because these chemicals—designed to keep working for years, long enough to deter fire in long-lasting products—don’t break down easily. Some accumulate over time within people, increasing the levels and length of exposure a child or adult experiences over time.

Stapleton has focused much of her research on a flame-retardant mixture called PentaBDE (PBDE), manufacture of which was phased out in the United States in 2004 but remains in many home products, including those containing polyurethane foam. Animal studies indicate it may be toxic to the human liver, the thyroid and impair normal neurological development.

She is also interested in the chemicals developed to replace PBDE since the phase-out, the make-up of which have not always been disclosed for “proprietary” reasons; those include tris (1,3-dichloro-2-propyl) phosphate (TDCPP). Animal studies suggest this new flame retardant harms brain cells, disrupts normal hormone messaging, and hinders normal reproduction.

Through highly technical detective work with sensitive instruments, Stapleton has found flame retardants in car seats, portable crib mattresses, baby carriers, changing table pads, nursing pillows and high chairs. She also has found them in camping tents. Some of the househould discoveries came from samples she and colleagues at Duke have collected and analyzed for free as part of a research project. Her research team has also documented the chemical’s presence in household dust, as well as human blood and the urine of pregnant women.

Contentious issues

Stapleton explained all this near the end of the two-day conference called Shining a Light on Flammability in Textile Applications.

For much of the meeting, which drew participants from multiple states, Central America, South America and Europe, the focus was on less controversial topics, including fire science, new protective clothing for firefighters, and laundering effects on flame retardant materials.

Chemical flame retardants are used to limit fires, but they've been linked with several health problems. Photo courtesy macwagen, Flickr Creative Commons

Chemical flame retardants are used to limit fires, but they’ve been linked with multiple health problems. Photo courtesy macwagen, Flickr Creative Commons

Thursday afternoon was reserved for items producing more friction within the industry. In addition to Stapleton’s research, participants heard about stepped up federal regulation of chemicals that could, in time, limit the use of some flame retardants. They also were briefed on court cases brought against manufacturers using California’s Proposition 65, a “right to know” law that requires manufacturers of consumer products to notify consumers when some potentially cancer-causing chemicals are contained in products beyond a certain threshold.

A bill to ban some flame retardants in North Carolina has been introduced several times in recent years without making much progress in the General Assembly.

Bert Truesdale, a senior director at TenCate Protective Fabrics in Georgia and an organizer of the meeting, said Thursday’s talks were vital for a diverse industry that wants to be educated about everything relevant to its practices. “It helps us understand the priorities,” he said.

Making changes in materials used in manufacturing isn’t always simple, stressed Maggie Baumann, a marketing advisor to FRX polymers, based in Massachusetts.

“There is always a trade off when you make change in a formula. It can be difficult to maintain the performance standards in the products,” she said.

FRX has developed a different approach to producing flame retardants, one that embeds that ability into stable polymers instead of using easy-to-escape compounds like those Stapleton studies. Trouble is, they are more expensive.

New regulations may nudge the industry into using these more expensive components, she said.

Away from her presentation, Stapleton said she considers wider potential costs when it comes to the chemicals that she studies. Her research shows that children, particularly infants, have the highest exposure to potentially toxic flame retardants. Infants, she has concluded, are more sensitive to exposure to these chemicals and more research is needed to detect whether their exposures are linked to neurodevelopmental disorders, such as attention deficit, autism and cancer.

But before she stepped away from the podium, Stapleton offered one bit of advice from the research realm to the industry people who listened politely to her technical talk.

Her recommendation was to always think about exposure.

“Risk is a function of exposure and toxicity,” she said. “If there are ways to reduce the emission of these chemicals, that would reduce the risk.”

Tainted Waters: New Drinking Water Threat Concerns Scientists, Officials


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A coalition of researchers, utilities and state regulators have made progress tracking an unregulated and unwelcome contaminant in river water feeding drinking water supplies. Can they stop it?

By Catherine Clabby

When the EPA ordered drinking water systems nationwide to test their water for a long list of unregulated contaminants, North Carolina water systems scored high on tests most systems would wish to fail.

Some of the highest levels nationally of a likely cancer-causing chemical 1,4 dioxane were detected in North Carolina water systems in the Cape Fear River Basin, which supplies water to more than 120 public water systems used by 1.5 million residents.

taintedwaterslogoFinding the human-made substance, used in many types of manufacturing, was unwelcome for two big reasons. Long-term exposure to 1-4 dioxane, even at very low levels, likely causes cancer, the EPA says. And conventional water treatment technologies cannot remove it.

“If you ask me about my biggest concern in drinking water in North Carolina right now, it’s 1-4 dioxane” says Tom Reeder, Assistant Secretary for the Environment at the state Department of Environmental Quality.

Welcome to the complex reality of emerging threats to surface waters, the streams, rivers and lakes that supply most of the drinking water North Carolinians consume. Research has improved our ability to understand and detect such risks.

Problem is, eliminating them is never simple.

Detective work over two years by North Carolina State University researchers, water utility managers and the DEQ has pinpointed three likely “hot spot” sources of 1,4-dioxane contamination in the Cape Fear basin. Levels of discharge into the basin have fallen. But the substance is not yet evicted.

By January 2015, some North Carolina water systems were reporting a disproportionately high amounts of 1,4 dioxane to EPA. Contaminant levels at 3.5 parts per billion (equal to ug/L) are 10 times higher than the level believed to produce the risk one cancer case among a million people after long exposure. Source: Chad Hamm, Fayetteville Public Works Commission

By January 2015, some North Carolina water systems were reporting a disproportionately high amounts of 1,4 dioxane to EPA. Contaminant levels at 3.5 parts per billion (equal to ug/L) are 10 times higher than the level believed to produce the risk one cancer case among a million people after long exposure. Source: Chad Hamm, Fayetteville Public Works Commission

And no one expects this will be the last challenging water pollutant to float our way.

Tracking a contaminant

The U.S. Safe Drinking Water Act requires the EPA to compile a list of unregulated but emerging contaminants of concern every five years. Larger water systems must then look for those contaminants. Knowing the distribution and amounts of water contaminants helps EPA prioritize new regulations.

EPA included 1,4-dioxane because animals develop nasal cavity, liver and gall bladder tumors after exposure in laboratory studies. Useful as a solvent, a production ingredient for aluminum containers, and sometimes produced as a byproduct, 1,4-dioxane is present in the manufacture of a long list of products. Paint strippers and dyes, prescription medicines and the polyethylene terephthalate (PET) plastics used to make bottles and polyesters are among them.

North Carolina State University water quality scientist Detlef Knappe and graduate student Catalina Lopez at work in Raleigh. Among other things, the research team is investigating whether microbes native to the Cape Fear River watershed can be induced to degrade 1,4-dioxane. Photo by Julie Williams Dixon

North Carolina State University water quality scientist Detlef Knappe and graduate student Catalina Lopez at work in Raleigh. Among other things, the research team is investigating whether microbes native to the Cape Fear River watershed can be induced to degrade 1,4-dioxane. Photo by Julie Williams Dixon

While EPA does not regulate 1,4-dioxane, it has calculated that long-term exposure to concentrations at .35 parts per billion (ppb) could increase the risk of cancer in one out of 1 million people. North Carolina has calculated that the same concentration poses the same risk in waterways feeding water supplies.

Higher concentrations would pose higher risks.

People are most likely to be exposed to 1,4-dioxane in drinking water. That fact that most water systems don’t have the costly water treatment technologies that can successfully remove the human-made compound made finding the source in the Cape Fear River a priority.

In 2013, NC State University water quality researcher Detlef Knappe’s lab was dropping brown glass bottles in Cape Fear basin waters to collect samples and test for contaminants on the EPA list. When a water testing laboratory contact tipped the environmental engineering researcher that some North Carolina water systems were finding elevated levels of 1,4-dioxane, Knappe decided to look for that too.

Screening for tiny amounts of chemicals in the changing composition and flow levels of streams and rivers is not simple. Rainy periods can drop concentrations while dry periods can raise them; varying amounts of waste get released into streams and rivers from day to day. The first analytic approach Knappe used in surface waters — no EPA-approved method yet exists — didn’t make foolproof measurements, but it was evidence that 1,4-dioxane or something resembling it was present in open waters.

In 2014 Knappe approached drinking water utilities and the state Department of Environmental Quality with his team’s evidence that 1,4-dioxane was present in basin waterways feeding public drinking water supplies. The groups joined forces to track down the source. With fast-track grants awarded quickly by the National Science Foundation and the Urban Water Consortium, funded by North Carolina water utilities, Knappe and DEQ started systematic sampling for 1,4-dioxane in the Cape Fear River basin water.

“There was an expectation that we needed to do something instead of waiting for the state or federal government to figure out what to do. That didn’t seem like the right thing,” says Mick Noland, the chief of operations at Fayetteville’s water system where testing has turned up 1,4-dioxane levels as high as 8.8 parts per billion, 25 times higher than the EPA’s level of concern.

Source:

Knappe’s laboratory developed a faster and more sensitive testing method and focused its sampling on 40-plus sites in the Haw and Deep rivers, the upper reaches of the Cape Fear basin closer to the N.C. State campus. The DEQ water sciences program sampled 12 sites lower in the Cape Fear River, but also with overlap to make sure the measurements of 1,4-dioxane in river water were consistent.

By 2015 Knappe’s lab had pinpointed three likely 1,4-dioxane sources: wastewater released from communities near the basin’s headwaters in Reidsville, Asheboro and Greensboro. Since 1,4-dioxane is not used in wastewater treatment, it was likely that industries in these communities were discharging 1,4-dioxane into their sewer pipes.

Unwelcome waste

To track down potential sources of 1,4-dioxane in their wastewater, Reidsville, Asheboro, and Greensboro water managers surveyed their commercial clients to see if they used 1,4-dioxane or sampled the wastewater lines serving such customers, looking for the highest concentrations. Each identified businesses using the chemical. With no stick of state or federal rules limiting the release of 1,4-dioxane into municipal sewers, the water systems approached the businesses with the problem.

To lower sample bottles from a bridge, graduate students Catalina Lopez and Zachary Hopkins use a plastic cord dispenser, a long rope, and PVC pipe drilled with holes so it can sink to move a sample bottle into the Haw River and back up again. Photo by Julie Williams Dixon

To lower sample bottles from a bridge, graduate students Catalina Lopez and Zachary Hopkins use a plastic cord dispenser, a long rope, and PVC pipe drilled with holes so it can sink to move a sample bottle into the Haw River and back up again. Photo by Julie Williams Dixon

In Asheboro sampling turned up one source: StarPet Inc., a local plant that produces food-grade plastic stock and is owned by Indorama Ventures in Thailand, which describes itself as a leading global manufacturer of Polyethylene Terephthalate (PET). StarPet has been highly cooperative about finding a way to stem the flow, says Michael Rhoney, Asheboro’s water resources director. StarPet is waiting for directions from the city on how to best pretreat its discharges, Rhoney said.

By surveying, Reidsville has identified two potential sources, Unifi, Inc., a Greensboro-based manufacturer of polyester and nylon yarns with other North Carolina plants in Madison and Yadkinville, as well as DyStar, owned by Kiri Holding Singapore and a producer of dyes and other chemicals. “They are looking at ways to remove it from their raw material so they can have their finalized products be the same,” said Kevin Eason, the city’s director of public works.

Water sampling requires meticulous record keeping. Amie McElroy, a graduate student in Knappe’s water quality and treatment research group logs an entry on the Bynum Bridge crossing the Haw River. Photo by Julie Williams Dixon

Water sampling requires meticulous record keeping. Amie McElroy, a graduate student in Knappe’s water quality and treatment research group logs an entry on the Bynum Bridge crossing the Haw River. Photo by Julie Williams Dixon

Steve Drew, director of water resources in Greensboro would not disclose the name of the company his water system has identified as a potential 1-4-dioxane emitter, saying an exemption to state public records law related to billing allows him to shield its identity.

“Right now it’s more of a ‘please’ and ‘thank you’ environment. We want to work with them to give them time to do good work without the risk of feeling villainized for not doing something they were not required to do,” Drew says.

North Carolina Health News has filed a state’s freedom of information query to obtain the company’s identity.

Keeping it going

DEQ isn’t finished assessing the scale of 1,4-dioxane contamination in North Carolina waters feeding drinking water supplies. Reeder, the assistant secretary, says DEQ intends to require water utilities discharging wastewater to monitor for the compound and report the results.

State environmental regulators are still sampling in the Cape Fear basin and are applying for nearly a quarter of a million dollars in grant money from the National Fish and Wildlife Foundation to continue testing there for the 1,4-dioxane and another chemical called bromide. They want to look for both in the Neuse and Yadkin river basins.

A preliminary state Department of Environmental Quality study based on river samples concluded that major sources of 1,4-dioxane originated in the upper watersheds of the Haw and Deep Rivers, which empty into the Cape Fear River. Source: DEQ Water Science Section.

A preliminary state Department of Environmental Quality study based on river samples concluded that major sources of 1,4-dioxane originated in the upper watersheds of the Haw and Deep Rivers, which empty into the Cape Fear River. Source: DEQ Water Science Section.

While DEQ has labelled waters below the Reidsville, Asheboro and Greensboro wastewater release sites 1-4-dioxane “hot spots,” that does not mean they are the only source in the Cape Fear River basin. Water samples taken downstream from one abandoned mill also found elevated levels. Groundwater polluted by 1,4-dioxane reaching stream and river water might carry the contaminant, too.

Knappe says he favors swift action to stop 1-4-dioxane discharges into North Carolina waters. While a better understanding of its health threats are recent, the compound may have been reaching Cape Fear River drinking water taps for decades, he said. UNC researchers reported detecting it in unspecified amounts in the Haw River in the 1980s. And if EPA decides to regulate it in drinking water, that could take years.

“Industry is constantly producing different chemicals,” Knappe says. “We need to go beyond what EPA is regulating to stay ahead of it.”

He is tracking water contamination by bromide, a by-product of drinking water disinfecting that can boost the supply of cancer-causing contaminants in water as well as perfluoroalkyl substances, compounds found on nonstick cookware and stain-resistant coatings, too.

Knappe says what he’d most like to see is a voluntary end to the release of the compound into waterways used for drinking water supplies. If that does not occur, an existing North Carolina law intended to limit health-threatening contamination of waterways that feed drinking water supplies should be deployed, he said.

Reeder agrees that North Carolina has the regulatory authority to limit 1,4-dioxane discharges within a statute that says toxic substance concentrations in drinking water (and fish) cannot exceed levels that protect people’s health.

Required monitoring in discharge permits is an initial step to find contamination sources. Once those are certain, DEQ could determine acceptable discharge limits that are informed by health risks, though not everyone may support the restrictions.

“I believe that the administrative code gives us the ability to regulate a potential carcinogen,” Reeder says. “There might be some people who disagree.”

downstreamdioxane

This is the first installment of North Carolina’s Health News‘ occasional series Tainted Water, which will explore threats to the North Carolina waterways that supply drinking water and countless ecological services to residents of this state. The series is made possible with a grant from the Z. Smith Reynolds Foundation to examine environmental health issues in North Carolina.

High Death Rates in Cancer ‘Hotspots’ Across NC


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In parts of North Carolina, people die from cancers at much higher rates. Some cancers have been linked to malnutrition, race and poverty while others don’t have clear risk factors.

By Minali Nigam

Cancer has been the leading cause of the death in North Carolina since 2009, when it surpassed heart disease as the Grim Reaper’s best friend here.

Combining death rates from all types of cancer, in 2013 North Carolina saw 167.7 deaths out of 100,000 people, which is about the national average.

But there are pockets of the state where death rates are considerably higher than average, and one of the worst areas, not just in the state but in the country, is in northeast North Carolina, said Sam Cykert, UNC-Chapel Hill’s director of health and clinical informatics.

Researchers at UNC have been looking at survival outcomes for adults with one type of blood cancer called acute myeloid leukemia (AML). In a study, published in June, they found three “hotspots” associated with higher death rates from AML including parts of northeastern North Carolina, a region near Greenville, and a region in northern Wake County, extending into Durham.

“Our study wasn’t able to pick out the exact reasons for this,” said Ashley Freeman, a clinical fellow at UNC and one of the study’s authors. “But it was interesting to note that it wasn’t a simple relationship with race or income level, education level and things like that.”

“We believe this means there’s something more complex going on with the local health care structure and possibly at the provider level that’s affecting outcome for patients.”

NCMortalityRates

Data and map, courtesy NC State Center for Health Statistics.

A complex disease

Each type of cancer has its own “complex mechanisms” and can present differently from patient to patient, and even from state to state, said Andrew Olshan, the director of the epidemiology department for UNC’s Gillings School of Global Public Health.

“Different cancers have different risk factors and some are definitely driven by things that are linked with socioeconomic status and poverty,” he said, “Some cancers don’t follow that pathway.”

For example, people in geographic areas with high death rates from colorectal cancer, Olshan said, often don’t get the screening and treatment to remove the cancer, a result of inadequate access to healthcare facilities.

AML is a cancer that follows a different pathway.

“AML is a pretty rare disease so not every physician out there is going to be familiar with the treatment, diagnosis and follow-up,” said Freeman. It’s important to have specialists who know what they’re seeing.”

So it was hard to draw a straight line between the location and the reason why more people died in that place from AML, Freeman said. But the study did find one high-risk region having fewer general practitioners and radiation oncologists.

An IV chemotherapy bag hangs in the chemo wards at the North Carolina Cancer Hospital in Chapel Hill.

An IV chemotherapy bag hangs in the chemotherapy ward at the North Carolina Cancer Hospital in Chapel Hill. Photo credit: Rose Hoban

“It may be that there are less services available in those areas and may be affecting things like referrals,” to the correct specialist, she said.

North Carolina is uniquely positioned because there are three National Cancer Institute (NCI) centers, said UNC cancer epidemiology researcher Anne Marie Meyer. She was also involved with the AML study.

Meyer says some states don’t even have cancer centers. Yet, even though North Carolina has several NCI cancer centers, “we still see patients in the state who aren’t being referred.”

Part of the problem, she said, could be that doctors in rural areas are overwhelmed by diseases such as Type II diabetes, heart failure and stroke and they fail to refer patients to specialists.

“In the AML context, timing is of the essence, with regard to getting a patient diagnosed and into care and into intensive chemotherapy,” Meyer said.

According to the American Cancer Society, “this leukemia can progress quickly if not treated and would probably be fatal in a few months.”

“Some patients who have preventable and treatable cancers are missed. It’s really a function of not only demographics and [socioeconomics], but also health care infrastructure that’s available in specialty care,” Meyer said.

‘Moving the dial’

Doctors, state legislators and cancer survivors came together over the past several years to help write the North Carolina Comprehensive Cancer Control Plan for 2014 to 2020. The plan addresses ongoing healthcare needs and treatments for six different types of preventative cancers that are linked to factors such as tobacco use, poverty and health care coverage.

“When we look at breast, cervical and colon cancer, even after we control for race and poor insurance coverage, we still see inequalities that are potentially geographic in nature,” said Meyer.

“What this tells us is cancer is a complex disease,” she said.

In an effort to reduce geographic cancer disparities in the state, the cancer control plan calls for early detection through routine screenings, partnerships with transportation, employment and housing services for underserved patients, and education programs.

x-ray image of a chest. Both sides of the lungs are visible with a growth on the left side of the lung, which could be lung cancer.

X-ray image of a chest. Both sides of the lungs are visible with a growth on the left side of the lung, which could be lung cancer. Photo courtesy: Wikimedia creative commons

“We are trying to move the dial in North Carolina to lessen mortality and lessen disparities by region, by racial ethnic group, etc.,” said Olshan.

One clear intervention is screening for colorectal cancer, he said.

“It’s a tractable problem and among the most common cancer,” which is why research is targeting a more precise definition of colorectal cancer hotspots and increase screening in those areas.

People don’t have access to the services needed to get colonoscopies to more patients. “We’re not going to go in overnight and obviously reduce poverty” and other barriers to screening, Olshan said.

“We have to work with the health department, healthcare providers, a whole variety of network groups… It’s clearly a multidisciplinary approach to try and implement an intervention and spread the dissemination of a proven intervention like screening.”

Dispatch From the International AIDS Conference: Social Media, Isolation and Risky Behavior


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Lee Storrow, the head of the NC AIDS Action Network, is in Durban, South Africa for the 2016 International Conference on AIDS to present his own research. This week, NC Health News will be featuring some stories from Lee about the conference and where North Carolina fits into the global fight against HIV/AIDS.

By Lee Storrow

The poster presentation section at the International Conference on AIDS is overwhelming. The five sections line the perimeter of the second floor of the convention center, a space twice the size of Raleigh’s Halifax Mall. Hundreds of posters are on display each day.

You can read the details of the results on LaGrand’s abstract here.On Tuesday, I spoke with Dr. Sara LeGrand, Assistant Research Professor of Global Health at the Duke Global Health Institute. She was presenting her research on whether the use of social networking (Facebook, Instagram) and dating/hook-up sites (Grindr, Jack’d) in young black men who have sex with men (MSM) in North Carolina could predict whether these men felt socially isolated.

Apps such as Grindr and Instagram are here to stay. The question is how HIV prevention advocates can get their messages out to users.

Apps such as Grindr and Jack’d are here to stay. The question is how HIV prevention advocates can get their messages out to users. Image courtesy: Grindr

The study reveals that young black MSM are, indeed, using social networking accounts and using those accounts may reduce these men’s feelings of social isolation.

Across the survey of N.C. teens, participants reported an average of 7.35 hours of Internet use per day and the average number of social networking platforms – such as Facebook or Grindr –  that participants used was 3.62. The study found that the more social network sites used translated into decreased feelings of social isolation, as well as increased searching for sex partners online.

“I think the results of this study are especially important for young people in rural areas of North Carolina who often face greater stigma around their sexuality,” said Dr. LeGrand.

Dr. Mehri McKellar and Dr. Jessica Seidelman present their research on the willingness of primary care providers to prescribe PrEP at the International Conference on AIDS in Durban, South Africa.

Dozens of North Carolina researchers are at the 2016 International AIDS Conference in South Africa this week. Here, Drs. Mehri McKellar and Jessica Seidelman from Duke University present their research on the willingness of primary care providers to prescribe PrEP at the International Conference on AIDS in Durban, South Africa. Photo credit: Lee Storrow

There’s been a lot of chatter about the rise of dating and hook-up apps and their potentially negative role in changing the nature of gay sex. At the same time, gay men in rural parts of North Carolina have limited support systems and often live in homophobic environments. If Grindr can provide even a limited outlet to remind a closeted gay man that he is not alone, it might be beneficial.

Dating and hook-up apps aren’t going away any time soon. HIV prevention advocates need to think about how to harness those apps to disseminate positive prevention messages and build support systems for those most at risk.

Study: North Carolina Minors Have Easy Online Access to E-Cigs


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Despite legislators’ and parents’ efforts, kids have no problem buying electronic cigarettes online.

By Bradley Allf

Gone are the days of the Marlboro Man, but the tobacco industry is finding new ways to lure young people. Though today’s youth smoke far fewer cigarettes than their counterparts did 20 years ago, an emerging market for electronic cigarettes is providing a new outlet for nicotine use among young people.

Since funding for North Carolina's teen smoking cessation program was cut, more teens are using nicotine, either by lighting up or using e-cigarettes.

Since funding for North Carolina’s teen smoking cessation program was cut, more teens are using nicotine, either by lighting up or using e-cigarettes. Photo courtesy Nerissa’s Ring, flickr creative commons

Despite a state law prohibiting the sale of these products to people younger than 18, a study by UNC-Chapel Hill researchers found that North Carolina minors can easily obtain electronic cigarettes over the internet.

“E-cigarettes,” as they are called, are a group of various battery-operated devices that allow users to inhale nicotine vapor.

Originally promoted as smoking cessation devices, the products are now exploding in popularity among teens, many of whom have never smoked conventional cigarettes. One recent study found that high school seniors are now twice as likely to use e-cigarettes as conventional cigarettes. Of the estimated 4.7 million middle and high-school students in the US that used tobacco products in 2015, 3 million were e-cigarette users.

The e-cigarette business, almost nonexistent 10 years ago, has burgeoned into a multi-billion-dollar industry. Effective policies have struggled to keep pace, leading one FDA official to label the market the “wild, wild West.”

North Carolina, for its part, outlawed the sale of e-cigarettes to minors in 2013. Researcher Rebecca Williams from UNC-Chapel Hill wanted to find out how effective this law was in preventing minors from purchasing e-cigarettes online.

To test this, her team recruited 11 teenagers from 14 to 17 years old to try to purchase e-cigarettes over the internet. The research is described in an article in JAMA Pediatrics.

The research

The team identified 98 online e-cigarette vendors for the study. They then allowed the 11 teens, under supervision, to attempt to buy e-cigarette products from the different vendors.

Of the 98 purchase attempts, only 5 failed due to age-verification requirements.

Durham Tobacco Co advertisement

NC State Fair Premium List, 1893. Image courtesy of Government & Heritage Library, North Carolina State Library, via Flickr Creative Commons

In fact, more than 80 percent of vendors either did not attempt to verify age, or used clearly ineffective means of verifying age, such as offering a check box. The only consistently effective age-verification techniques that Williams and her team found were requirements to enter a date of birth in conjunction with a social security number.

Williams is a researcher at the UNC Lineberger Comprehensive Cancer Center and Center for Health Promotion and Disease Prevention. She has done similar studies on youth access to conventional cigarettes and anticipated these results.

“The rate of success with e-cigarettes is similar to what we found with cigarettes,” she said. “So it didn’t surprise me at all that it was easy to buy e-cigarettes online for teens.”

So why aren’t online vendors following North Carolina law? Williams explains that part of the issue is jurisdictional.

“When you’re making an online purchase, where is that purchase taking place? Is it taking place where the person who is ordering is located? Is it where the website is hosted? Is it where the business is located?” she asked. “Those all may be in different states and different countries.”

It can be tough to know where exactly the boundaries of enforcement fall when dealing with online purchases. It is also exceedingly difficult to track down these vendors, many of whom operate internationally.

Better than cigarettes?

According to a report released by the American Heart Association last year, “[e]- cigarettes are mostly unregulated and their health effects are not fully known, especially when associated with long-term use.”

Research on the effects of traditional cigarettes accumulated over decades. However, because e-cigarettes sprang quickly onto the US market in 2007, there hasn’t been enough time for researchers to determine how e-cigarettes affect the human body.

Some of the e-cigarette liquids for sale in N.C. today. Flavors from left to right: watermelon, Irish Cream and appletini.

Some of the e-cigarette liquids for sale in N.C. today. Flavors from left to right: watermelon, Irish Cream and appletini. Photo credit: Rose Hoban

Despite this, there are already some known risks associated with e-cigarettes. One instance concerns the chemicals used to flavor the vapor. While these chemical products are approved by the Food and Drug Administration for ingestion, they have not been approved for inhaling.

“Safe to ingest does not mean safe to vaporize and inhale,” Williams says. “When they vaporize a product at a high temperature, it creates more and more dangerous chemicals that can be damaging to lung tissue and other tissue.”

Chemicals such as diacetyl (butter or popcorn flavor) and cinnamaldehyde (cinnamon flavor), both of which are found in many e-cigarette flavorings, pose known health risks.

In addition, nicotine itself is highly addictive and can have long-term consequences for brain development, particularly for young people.

Taken together, these health risks have many people concerned.

“I think we know they’re not safe and we’re still finding out how unsafe they are,” says Peg O’Connell of the North Carolina Alliance for Health. “I think that’s the public health message.”

Policy changes

At the national scale, the FDA announced in May that it will begin regulating the sale of e-cigarettes in August. This policy was partially informed by the Internet Tobacco Vendors Study, which based its suggestions on the research findings of Williams and her team.

Williams believes this is a step in the right direction. She said a national policy would address some of the jurisdictional problems associated with having different regulations in different states. She hopes that the FDA will end up enacting strict age-verification requirements for online vendors at both the point of order and the point of delivery to keep minors from getting access to e-cigarettes.

Locally, North Carolina health organizations are working on a number of fronts to enact policies designed to stem the rising number of young people who are using e-cigarettes.

O’Connell is working with the North Carolina Alliance for Health to bring back the state’s formerly award-winning youth tobacco prevention program. According to O’Connell, education initiatives such as the state’s previous anti-tobacco effort may be effective in keeping e-cigarettes away from minors.

The Orange County Board of Health, in concert with the Orange County Board of Commissioners and counties across the state, has been advocating other e-cigarette control policies.

Orange County health educator Coby Jansen Austin said those two bodies support a public policy of giving jurisdictions the right to raise the minimum sale age for tobacco and e-cigarettes from 18 to 21.

According to Austin, policy actions make a real difference in decreasing the number of young people who start using tobacco products.

“What we know has worked in tobacco control and contributed to a lot of the drop in tobacco use that we’ve seen over the last five or six decades are some of the policies around tobacco,” she says. “And so I think the FDA regulations are a good example of where we have the appropriate research and we take appropriate policy actions. It’s not just about education and sharing information, though those are also components.”

Correction: This article originally stated the research was published in the Journal of the American Medical Association.

Study Finds Encouraging Surgical Outcomes at Critical Access Hospitals


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By Taylor Sisk

On the heels of a report warning that more than a third of the nation’s critical access hospitals are in danger of closure comes some encouraging news. A new study indicates certain procedures are being performed in these small hospitals more safely and at a lower cost than in larger institutions.

A University of Michigan team of researchers looked at four common surgeries – appendectomy, gall bladder removal, hernia repair and removal of all or part of the colon – and found no statistically significant difference in 30-day mortality rates between critical access and other hospitals.

Further, critical access hospitals experienced serious complications in performing these procedures 6.4 percent of the time as compared with 13.9 percent of the time in other hospitals.

CAHs also billed Medicare an average of $1,400 less for the procedures.

CAHs serve many of the nation’s remotest regions. By definition, they have fewer than 25 beds and are more than 35 miles from the next nearest hospital. They must maintain an average length of stay of 96 hours or less for acute-care patients and provide 24-hour emergency-care services. In return, they receive preferential reimbursement from Medicare, which covers more of their costs.

North Carolina had 20 critical access hospitals as of Nov. 2014. Since that time, Yadkin Valley TKTK Hospital has closed. Blue areas on the map indicate non-metropolitan counties.

North Carolina had 20 critical access hospitals as of Nov. 2014. Since that time, Yadkin Valley Community Hospital has closed. Blue areas on the map indicate non-metropolitan counties. Map courtesy UNC Sheps Center for Health Services Research

There are 1,284 CAHs throughout the country; North Carolina has 20.

Two CAHs in the state have shut down in just over two years: Vidant Pungo Hospital in Belhaven in February 2014 and Yadkin Valley Community Hospital in Yadkinville in May of last year.

Doing what they should

The Michigan researchers examined more than 1.6 million Medicare-beneficiary admissions to 828 CAHs and 3,676 other hospitals. Their results were published last week in the Journal of the American Medical Association.

Transylvania Regional Hospital. Photo credit: John Warner

Transylvania Regional Hospital. Photo credit: John Warner

The researchers found that patients who had any of the four types of operations at CAHS tended to be healthier upon admission than patients treated for the same procedures at other hospitals. They said this indicated CAH surgeons appropriately selected patients who they felt would be most likely to have positive outcomes, while sending higher-risk patients to larger hospitals.

“From a surgical standpoint, these hospitals appear to be doing exactly what we would want them to be doing: common operations on appropriately selected patients who are safe to stay locally for their care,” lead author Andrew Ibrahim said in a release.

That said, even after correcting for differences in health status at the time of the operations, the CAHs had equal or better outcomes.

‘On the firing line’

In rural communities throughout the country, small hospitals in general, and critical access hospitals in particular, are facing mounting challenges including reduced reimbursements; aging, declining populations; and difficulties recruiting health care professionals.

“Critical access hospitals are on the firing line. They’re in the middle of the target,” Alvin Hoover, past chairman of the American Hospital Association’s Small or Rural Governing Council and current board chair of the Mississippi Hospital Association, said in a recent interview. “It’s hard for me to understand why you want to target those guys, because if you look at the cost of care, they do it cheaper than anybody else.

“If you can keep that person home, right there in that local community, your cost of treatment of that pneumonia patient, [for example], is going to be way less than it is if you have to send them to the big university.”

The outcomes found in this research, the study’s authors write, should “inform legislators about the valuable role critical access hospitals provide in the U.S. health care system.”

This story was made possible by a grant from the Winston-Salem Foundation to examine issues in rural health in North Carolina.
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