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

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

By Stephanie Soucheray

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

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

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

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

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

picture of a blood pressure cuff

Image courtesy Medisave UK, flickr creative commons

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

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

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

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

Lowering pressure a ‘good thing’

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

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

picture of an electronic blood pressure machine

Image courtesy Morgan, flickr creative commons

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

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

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

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

Cholesterol up

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

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

Blood Test image courtesy Neeta Lind, flickr creative commons

Blood test image courtesy Neeta Lind, flickr creative commons

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

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

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

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

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

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

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

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

No Escape from Seasonal Allergies

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

By Stephanie Soucheray

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

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

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

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

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

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

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

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

Tip of a tulip stamen with many grains of pollen

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

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

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

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

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

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

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

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

A scanning electron microscope image of redbud pollen.

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

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

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

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

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

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

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

UNC Develops First Flowchart for Alcohol-related Hospital Admissions

By Stephanie Soucheray

Alcohol-related hospitalizations can cost about $5.1 billion annually in health care spending. Considering that alcohol consumption is the third-highest cause of preventable death in the United States, that number isn’t surprising.

But it is high for a condition for which hospital admittance protocols aren’t agreed upon by institutions, doctors or nurses.

“Some of us would admit these patients, while some of us would send them home,” said John Stephens.

Stephens, a professor of medicine at UNC-Chapel Hill, recently published a new protocol – a medical flowchart, if you will – that helps standardize the approach to hospital admissions of alcohol-related diagnoses.

“This population had a subset with a lot of readmissions,” he said. “Many would get better, we’d send them home and then they’d be readmitted in the same month.”

Stephens said that a protocol could potentially help admit fewer of these people into the hospital, which would cut down on the “excessive utilization of resources.” In other words, admitting fewer patients and guiding them towards outpatient care can save hospitals a lot of money.

In order to create the one-page flowchart for physician use, Stephens created a task force with three doctors, a nurse practitioner and a case manager at UNC Hospitals. The group met several times to look at the medical literature on alcohol-related diagnoses before crafting their recommendations.

The protocol and the results of an 18-month follow-up on its implementation at UNC Hospitals show some promising trends: alcohol-related admissions per month dropped from about 19 to 16 patients. According to the study, that translates into a cost savings of $315,000 per year.

Stephens said the flowchart, however, did little to influence re-admittance rates.

“The best thing from our perspective is that we can standardize care,” he said. “When we’re called into the ER, then we can say, ‘We need to use this approach.’”

Stephens said the flowchart is part of a broader trend in medicine partially based on The Checklist Manifesto by Atul Gawande. Gawande’s book argues for the use of flowcharts and checklists to help medical professionals streamline decision-making.

UNC Alcohol detox protocol and checklist.

UNC Alcohol detox protocol and checklist. Image courtesy: UNC Healthcare

Mentally Ill at Higher Risk of Victimization, Study Says

By Taylor Sisk

Almost one of every three adults living with mental illness is likely to be the victim of violence in any six-month period, according to research conducted by RTI International, NC State, Duke, the University of California, Davis and Simon Fraser University.

The researchers found that 30.9 percent of those interviewed had been victims of violence in the previous six months. Of those who said they had been victimized, 43.7 percent said it had occurred on multiple occasions.

“We had a pretty good idea that people with mental illness are more likely to be victimized than they are to actually perpetrate violence, but that’s not the way things are portrayed in the media,” said Richard Van Dorn, a senior mental health services researcher at RTI and co-author of the study.

The research team further found that 23.9 percent of those in the study had committed a violent act within the same time period. Almost two-thirds of those acts took place in residential settings; only 2.6 percent were committed in schools or workplaces.

“The victimization certainly doesn’t get as much attention as the violence does,” Van Dorn said.

Regarding the correlation between being a victim of violence and committing a violent act, Van Dorn said, “We’re not saying that victimization is causing the violence or that the violence is causing the victimization, just that those two things are very closely related.”

The study was part of a broader National Institute of Mental Health project focused on the co-occurrence of violence and victimization in adults with mental illness. It was funded by a grant from the NIMH and appears in the current issue of the American Journal of Public Health.

Further studies will examine potential causes of violence and victimization and treatment outcomes.

Large group surveyed

The researchers compiled a database of 4,480 mentally ill adults who had been interviewed in five previous studies that focused on issues ranging from antipsychotic medications to treatment approaches. All of those interviewed were asked questions related to violence and victimization.

Van Dorn said there’s a great deal yet to be learned about the relationship between having a mental illness and committing a violent act. Substance abuse, he pointed out, is certainly a factor.

A 2009 study published in the Journal of the American Medical Association found that 28 percent of people diagnosed with schizophrenia who also had substance-abuse issues had been convicted of violent crimes. The conviction rate for those who had schizophrenia and no substance-abuse issues was 8 percent and for the general population, 5 percent.

Van Dorn called the victimization of people with mental illness a “substantial public health concern.”

He said that previous studies have shown that adherence to treatment often reduces the likelihood of violence. The research team plans to further explore that, as well as looking at ways in which family dynamics might be improved to help prevent stressful situations from escalating into confrontations.

“Can we reduce violence and victimization in adults with mental illness? I think that’s the ultimate goal of this study,” he said.

“We think [this research] has a chance to move the field forward and get at some of these things.”

Image courtesy Run Jane Fox, flickr creative commons

Triangle Researchers are Building a Better Toilet

Everyone poops, but few people like to think about where it all goes – except some researches from RTI International.

By Stephanie Soucheray

A million and a half children around the world die from diarrhea each year. That’s more kids dying from diarrhea than HIV infection and malaria combined.

It’s a stark statistic to reckon with, yet diarrhea and fecal-borne illnesses remain one of the largest public health problems in developing nations. For decades, scientists have focused on water – access, quality, cleanliness – as the way to prevent diarrhea illnesses, but scientists in the Research Triangle say that way of thinking looks at the problem all wrong.

“You’ve got to build a better toilet,” said Brian Stoner, an investigator at RTI. “You can have perfectly clean water, but without sanitation, sludge and waste ends up near kids.”

Stoner, along with team members from RTI, North Carolina State University and Duke, have spent the last 18 months designing that toilet. As the recipient of a Gates Foundation challenge, Stoner and his colleagues have rethought toilet sanitation, making a prototype that is suitable for use in places with no municipal waste stream, electricity or access to water.

“There’s 2.5 billion people in the world without access to effective sanitation,” said Stoner. “I’m optimistic about this work.”

In March, they’ll take their prototype to Delhi, India, where their lab model will be part of a toilet fair attended by local politicians and investors. For Stoner, a material scientist who’s worked in water sanitation, the trip will be a jumping off point to test his toilet in the field.

Father and local toilet salesman, Antonia dos Santos in his home village of Lisadila. Antonia creates concrete toilets with the use of a mould and sells them at the market place in Maubara and to neighbouring villages.

Father and local toilet salesman, Antonia dos Santos in his home village of Lisadila, Timor Leste. Antonia creates concrete toilets with the use of a mold and sells them at the market. Photo courtesy Australia Department of Foreign Affairs and Trade.

“I’m very excited because [the toilet project] includes multiple technical disciplines and a social aspect,” he said. “Most new technology fails because people don’t understand the social and economic needs of an area. We’ve taken that information into consideration.”

Stoner’s design is based on simple facts about human waste: The dirty things that come out of us can also be cleaning resources. Urine contains salts that can purify and sanitize like chlorine – while excrement, or solid waste, can dry and be burned as fuel.

“In many parts of the world, dung is used as a fuel source. We put those two pieces together,” he said, referring to urine and feces, “and it’s the basis for our design.”


This new toilet is different from the one you have in your bathroom. Stoner said the technology behind the toilets we use is 200 years old and based on the same designs put forth by Thomas Crapper, the British plumber associated with our flush system. Our toilets depend on a sideways “s” tube that pushes water up, down and back up the toilets to flush out sewer gases and move waste into municipal sewer systems.

Stoner said the new toilet uses an open-screw mechanism to push dried excrement up and into something that resembles a large camp stove, where it’s burned for fuel, converted to electricity and powers the toilet. Liquid waste is converted to salts and chlorine, which disinfects the liquid waste and converts it to non-potable water.

In other words, the toilet is a self-cleaning, self-contained sanitation machine.

The design is meant for large urban areas in which most family dwellings do not have a toilet. Instead, these areas have communal toilets or shared bathroom facilities that dot the landscape of urban slums.

And it’s such a novel approach that the new toilet is even getting some attention from the art world. Stoner’s design caught the eye of Steve Gottlieb, a photographer who wrote a coffee table book on toilets called Flush. Gottlieb photographed RTI’s toilet team for his book, an event Stoner said was a lot of fun.

Number of toilets needed to meet the sanitation target by 2015: To halve the proportion of people without sustainable access to sanitation.

Number of toilets needed to meet the sanitation target by 2015: To halve the proportion of people without sustainable access to sanitation. Map courtesy Australia Department of Foreign Affairs and Trade

Cover image courtesy Sustainable Sanitation, flickr creative commons

N.C.-based Research Sheds Understanding on Cancer and Aging Link

Getting older often means facing cancer, and now local researchers may understand why.

By Stephanie Soucheray

Cancer doesn’t care who you are, where you live or how much money you make. The disease can strike anyone at any time, and has thus become the great leveler of modern health.

But new research from the Triangle’s National Institute of Environmental Health Sciences is proving that some cancers do care how old you are, and that age, and the common genetic processes that follow, are a big disease risk.

NIEHS cancer researcher Jack Taylor said scientists have known for years that age is a leading risk factor for certain cancers. But now a new understanding of DNA shows why aging leads to cancer. This work is part of NIEHS’s broader examination of the environment’s impact on epigenitics and human health.

Taylor said the aging problem seems to come from a process called “methylation,” a modification that is usually associated with a reduced ability of DNA to be transcribed into RNA.

Research is showing that certain sites in the genome display overmethylation in seven types of cancer.

Overmethylation is akin to dust settling on a gene. Methylation does not alter the DNA, but it can cause it to fail to turn a cell on or off, thus making that cell vulnerable to cancer mutations.

Video courtesy National Institute of Environmental Health Sciences

“The real surprise came when we looked at data about tumors and different types of cancer,” said Taylor, whose research was published online this month in the journal Carcinogenesis. Zongli Xu was the co-author on the study. “Seventy to 90 percent of the sites associated with age showed significant overmethylation in all seven cancer types.”

It’s known that aging affects methylation and known that methylation is frequently implicated in cancer, but this is the first study that looks at aging across the genome. Taylor said his work suggests that aging-related methylation may make it easier for certain cells to turn into cancer.

Taylor and Xu’s work is based on the Sister Study, which uses DNA from women who are currently healthy but have a sister with breast cancer.

Using blood samples, they looked at 27,000 separate methylation sites across the genome. They found that 30 percent, or 749, of the sites showed a significant methylation association with age. By the time a person is middle-aged, they may have 50 of these methylated sites, and each year they increase.

“We don’t know the answer as to why cancer hits some people instead of other people,” said Taylor. “It may be that diet and lifestyle may modulate methylation. And an environmental exposure might be good for you in one tissue but cause overmethylation in another.”

Taylor said this new understanding offers new pathways for cancer treatment. Most notably to Taylor, he hopes his work leads to interventions that can prevent overmethylation, and thus cancer from ever happening.

“My career is targeted towards prevention,” he said. “Exercise, drug exposure and lifestyle can affect the methylation.”

And because aging is a nearly universal experience, the next step for Taylor and his colleagues is understanding which early-life exposures influence methylation.

“In order for those things to show up as overmethylated in tumors, the theory is that the genes were overmethylated at the time the tumor began,” said Taylor. “That’s a big clue to understanding this disease.”

UNC Study: Young Women Know Tanning Beds Harm, Use Them Anyway

By Rose Hoban

As lawmakers worked their way through a bill to ban tanning beds for teens under 18 years old last summer, researchers at UNC-Chapel Hill were asking young women what they thought about tanning beds and how often they use them.

And they found a few surprises, including the big revelation that most of the young women who use tanning beds know it can be bad for their skin in the long run, but that it had no effect on how often they used them.

tanning bed, Image courtesy flickr creative commons, Evil Erin

The UNC study found about half of young women had used tanning beds, most starting when they were in high school. Image courtesy: Evil Erin, flickr creative commons

“The big motivator is appearance; they think it makes them look better,” said lead researcher Seth Noar, a faculty member at the School of Journalism and Mass Communications who is associated with the Lineberger Cancer Center at UNC Hospitals.

But he also found an association for some tanning bed users with mood enhancement, and some parallels to tobacco use.

Noar and his students in a health communications class surveyed more than 700 sorority members from UNC. He said that while other studies done on tanning bed use have surveyed only 100 to 200 people, he got assistance from the Pan-Hellenic Society at UNC, which promoted participation in the study in an effort to help its sisters stay healthier.

The survey found that close to half (45 percent) of the young women had used a tanning bed. Of that number, two-thirds had tanned in the past year; the rest were more occasional users.

“The prom ends up being the significant, number-one event that they tanned for the first time for,” said Noar, who found that 80 percent of the women used indoor tanning in high school.

“If you want to do true prevention, that’s the time to intervene,” he said.

But Noar said that other factors influencing tanning bed use were particularly intriguing.

For example: While a majority of women went tanning for the first time with their friends, a significant number started alongside their mothers.

“And we found that women who reported going with mothers the first time were more likely to become regular tanners than women who did not,” Noar said.

The other surprising phenomenon Noar found was that many of the women reported significant mood enhancement from tanning.

“It was the idea that going tanning was relaxing. It lifts one’s spirits, makes someone feel good, and is enjoyable,” he said. “That’s the most potent factor.”

Noar said these findings indicate that some tanners actually develop something like an addiction to indoor tanning.

“There’s some interesting research on the UV light and mood, which might make it more difficult in terms of trying to persuade regular tanners to reduce or stop tanning,” he said.

Noar found such behavior to be eerily similar to tobacco use.

“People know there are risks, [but] they still do it,” he said. “There’s a mood component and, for some, a dependence component.”

“Most tobacco users want to quit, but they’re addicted,” Noar said. “It’s not a perfect parallel, but there are some parallels between tanning and smoking.”

The indoor-tanning industry was launched in the 1970s and gained widespread use in the ’80s and ’90s. It’s only now, Noar said, that dermatologists are seeing the effects in the form of a sharp uptick in young white women being diagnosed with skin cancer and melanoma.

An effort to ban tanning bed use for teens passed the state House of Representatives last summer and will likely be before the Senate during the short legislative session this summer.

HIV Work Leads Local Researchers ‘Tantalizingly’ Close to Breakthroughs

The Triangle has been a powerhouse for HIV research, a trend that shows no sign of abating.

By Stephanie Soucheray

If the first month of the new year is any indication, 2014 will be a big year for HIV research in the Triangle.

For the last three decades, Duke University, the University of North Carolina-Chapel Hill and several Triangle public health organizations have made breakthroughs in the understanding, treatment and prevention of HIV. And now, newly published research from UNC shows scientists are one step closer to a cure, while Duke researchers now have the first human HIV vaccine trials slated on the calendar.

J. Victor-Garcia headshot

J. Victor-Garcia. Photo courtesy UNC-Chapel Hill Center for AIDS Research.

“A decade ago, you wouldn’t even think about saying the word ‘cure,’” said J. Victor Garcia, an infectious disease researcher at UNC. “But now the progress being made is tantalizing.”

Garcia was the co-author of a study published earlier this month in PloS Pathogens. The study details a novel combination therapy of antibodies and bacterial toxins that can destroy HIV-infected cells.

It’s a new take on the “kick and kill” theory for curing HIV. Currently, patients with HIV are treated with antiretroviral therapies (ART), cocktails of drugs that reduce the numbers of virus in a patient’s body.

ART can keep the virus out of the blood stream, but the minute therapies are stopped, the virus returns with a vengeance. Researchers, Garcia said, need to find a way to “kick” the virus out of cells where it can lay dormant while patients receive antiretroviral therapies and “kill” the virus so it completely evacuates the patient’s bloodstream.

“We describe the analogy as a guided missile head that finds infected cells,” said Garcia. He and his fellow researchers used mice that have been bred to have an immune system that mimics that of an HIV-infected person.

Despite receiving high doses of ART, HIV persisted in the mice’s cells. It was only when injected with a compound called 3B3-PE38 that HIV was destroyed in the mice’s bodies. Garcia said the antibody component of the compound recognized HIV-infected cells and overwhelmingly allowed the bacteria toxin to destroy the cells.

Now, Garcia said, his work is to find the right “kick” step to match his new killing machine.

“I’m itching to get going with those experiments,” said Garcia. “I have to be careful to find the best possible induction strategies to kick the virus out in patients. We need to try to think outside the box and outsmart [to get] results that eventually translate into a patient’s cure.”

Prevention – not a cure – is at the heart of CHAVI, or Duke’s Center for HIV/AIDS Vaccine Immunology. Earlier this month, CHAVI researchers published a paper in the Proceedings of the National Academy of Sciences. The new research helps create a successful plan for the first HIV human vaccine by identifying what researchers call the “Achilles heel” of the protein coating of HIV, the gp41 membrane proximal external region (MPER). This is the structure that infects healthy cells.

Diagram of the human immunodeficiency virus. The gp-41 MPER is shown in green.

Diagram of the human immunodeficiency virus. The gp-41 MPER is shown in green. Image courtesy U. S. National Institutes of Health.

Barton Haynes, director of the Duke Human Vaccine Institute, said the current work is a road map for vaccine development.

“The virus has sites on its surface that make it vulnerable,” he said. “But it has evolved so that those sites … fool the body’s immune system to think it can’t respond to those sites. We’re now coming up with strategies to get around this.”

Barton F Haynes headshot

Barton Haynes. Photo courtesy Duke University, Human Vaccine Institute.

CHAVI is developing a vaccine composed of a man-made lipid that has a piece of HIV in its outer envelope. Called a lipsome, the vaccine has been tested in mice and rhesus macaques.

“We’re looking at December of 2014 for the first human trials,” said Haynes. He said the trials will most likely be in the United States. “We’ve opened up the black box and now it’s time to really move.”

HIV has killed more than 30 million people worldwide and infected 33 million more. Both Garcia and Haynes said they were hopeful to see a cure and a vaccine in their lifetimes.

Out-of-pocket Costs Hinder Cancer Healing

Studies from several Triangle researchers show challenges for patients.

By Stephanie Soucheray

It’s the ultimate rubbing of salt in the proverbial wound: A cancer diagnosis leads to a treatment that could save your life, but paying for that treatment could cost you thousands of dollars in out-of-pocket expenses each month that your insurance doesn’t cover.

“Every five days, I was paying $397 for my chemo pills,” said Chris Tribble.

Eighteen months ago, the 39-year-old from Statesville was diagnosed with stage III colorectal cancer, which had spread to his liver. He traveled to Duke to get treatment with Yousef Zafar, but the chemotherapy pills prescribed to Tribble were too expensive.

UNC associate professor Stacie Duzetzina.

UNC associate professor Stacie Duzetzina. Image courtesy UNC.

Unfortunately, this scenario is familiar to thousands of Americans each year who abandon their cancer treatment plans because they simply can’t afford it.

According to a new study co-authored by UNC-Chapel Hill professor of public health policy Stacie Dusetzina and published last week in the Journal of Clinical Oncology, up to 16 percent of cancer patients quit their treatment plans because they can’t afford the costs of expensive but life-saving oral chemotherapy.

“A percentage of people are quitting their treatments and medications within the first six months,” said Dusetzina.

Her study looked at patient compliance and oral chemotherapy. Imatinib, a tyrosine kinase inhibitor (TKI), is one of the most successful stories in modern oncology.  Used in patients with chronic myeloid leukemia, the daily pill helps patients go from a life expectancy of five years to the life expectancy of their cancer-free peers.

“It’s a very amazing drug and can really give someone an almost normal lifespan,” said Dusetzina.

Dusetzina used an insurance-claims data source that creates a transaction whenever someone uses insurance benefits to pay for prescription drugs. She said she was surprised by a few things in the study.  On one hand, the median patient co-pay for their medicine was only $30 per month.

“We knew from other reports that the treatment was expensive, so we expected them to be paying more,” said Dusetzina. “That said, we were looking at privately insured people in large group health plans.”

The majority of subjects paid a reasonable co-pay each month. But 6 percent of people in the study paid more than $500 a month; for a drug that’s prescribed indefinitely, that cost led to people quitting their therapies. Seventeen percent of patients with higher co-payments quit taking their medications in the first six months. More surprising was the finding that 10 percent of patients with lower out-of-pocket costs also stopped taking their medications in the first six months.

Duke University oncologist Yousef Zafar.

Duke University oncologist Yousef Zafar. Image courtesy Duke Medicine.

“I think the biggest point of the study is that out-of-pocket costs have huge impact on patients to take their prescriptions – impact the ability to take their treatments,” said Dusetzina.

That impact on patient adherence is something Zafar, a medical oncologist, thinks about in his practice.

“I’m frequently seeing more and more insured patients having more problems paying,” he said. “There are occasions where I can substitute interventions to avoid out-of-pocket costs.”

Zafar completed a study last year that looked at these very questions.

“We asked patients about whether or not they talked to their doctor about costs,” he said. “Fifty percent said they had some desire to talk about costs, but only a small minority had the questions.”

One-third of patients said they wanted the best care for their cancer treatments and thought that bringing up cost could jeopardize their treatment. Others were embarrassed to bring up costs with their doctors, and others still said they did not think it was of any interest to the doctor.

At first, Tribble didn’t think Zafar would have any interest in the cost of his medicine. But when Zafar brought up costs, Tribble confessed the oral chemotherapy was too expensive for him.

Zafar offered Tribble the intravenous-fusion version of chemotherapy, which his insurance did cover.

“Differences in co-payments could impact long-term adherence to drugs,” said Zafar. “When we think of health care costs, we think of big numbers, numbers in the millions and trillions. But small differences in costs impact lives and outcomes.”

As of the first of the year, Tribble was cancer free, and he’s glad he spoke openly with Zafar about keeping his treatment costs down.

“The first step is that it’s OK to talk about costs with doctors,” said Zafar. “We want to know what our patients are experiencing.”

Top 10 N.C. Health Care Stories of 2013

Health care in North Carolina was often the big story in 2013, from Medicaid to the Affordable Care Act to controversy surrounding North Carolina’s health and human services secretary Aldona Wos and some of her hires.

But these weren’t the only hot topics in North Carolina’s health care scene this past year. Issues ranged from a fight over abortion in the General Assembly to the emergence of newly-identified tick-borne diseases.

This is North Carolina Health News’ list of the Top 10 health stories of 2013.

(Disagree with our list? Think we missed something? Let us know in the comments section)

1. Mental health group homes look for a way to survive

Bradley Gauriluk, 37, said he lived in a group home in Raleigh as he recovered from mental illness. Now he lives independently in an apartment Knightdale. Photo credit: Rose Hoban.

Bradley Gauriluk, 37, said he lived in a group home in Raleigh as he recovered from mental illness. Now he lives independently in an apartment Knightdale. Photo credit: Rose Hoban.

Even though this was a big story and a big issue around new year’s 2013, there’s no solution for mental health group homes that house thousands of people with disabilities.

The problem started when the federal government compelled North Carolina to abide by a 20-year-old law that requires equal treatment for people with disabilities living in institutions and in their own homes. Instead of raising rates for everyone, state legislators cut rates for mental health group homes.

People in the mental health community have continued to rally around this issue all year, but a solution that will allow the homes to remain viable remains elusive.

2.Wos blames Goodwin for Medicaid refusal

It always makes news when a state official “misspeaks” about policy or a program. N. C. Health News broke the story on how Department of Health and Human Services Secretary Aldona Wos claimed Insurance Commissioner Wayne Goodwin was responsible for the state’s decision not to expand Medicaid.

DHHS spokesman Ricky Diaz said it was all taken out of context. N.C. Health News has the tape of the interaction, you can decide for yourselves.

3. Obamacare off to wobbly start in North Carolina

What will coverage on the individual market cost you? Get an estimate on our interactive map.

What will coverage on the federal individual market cost you? Get an estimate on our interactive map.

Obamacare has had a rocky rollout in North Carolina as it has also had in many states that chose to become part of the federal health care marketplaces. By mid-December, more than 9,000 North Carolinians had signed up for coverage on the online portal, but one thing slowing down enrollment in North Carolina is the high cost of the insurance policies, particularly in rural areas, as displayed by our interactive map.

Why are rates in rural areas so high? N.C. Health News took an in depth look here  and here.

4. Mental health system keeps shifting

Health and Human Services Secretary Aldona Wos demonstrating how her agency would like to "bend the cost curve" on health care costs. Image courtesy News 14 Carolina.

Health and Human Services Secretary Aldona Wos demonstrating how her agency would like to “bend the cost curve” on health care costs. Image courtesy News 14 Carolina.

North Carolina’s mental health system has been in flux for more than a decade and this year was no different. N.C. Health News continued our in-depth coverage of those changes, best exemplified the troubles at the Western Highlands Network. WHN was one of the larger and more respected mental health local management entities, but soon after making the transition to a full-fledged managed care organization, the agency got into trouble.

By the end of the year, state officials had announced that the remaining 10 mental health managed care organizations will consolidate down to four agencies by the end of 2014, something N. C. Health News predicted back in March, 2013. 

5. State hospital systems merging

Hospital mergers picked up steam this past year, as changes in the way health care gets paid for started to really take effect. Some of those changes are a function of the Affordable Care Act, and some of them are a function of the fact that insurers and other payers are finding that it makes more sense to pay for “episodes” of care and outcomes, rather than simply paying doctors and hospitals for doing procedures and not tying payment to how well patients actually do.

Image courtesy Ohio Health Insurance, flickr creative commons

Image courtesy Ohio Health Insurance, flickr creative commons

This change in reimbursement accelerating a trend of consolidation in hospitals around the state, particularly those in rural areas. N.C. Health News also ran a series of articles on how these changes are affecting rural hospitals and how some rural hospitals are responding more creatively than others.

Part 1: Changes in Hospital Finance Drives Flurry of Mergers
Part 2: Rural Hospital Mergers Make for Improved Bottom Lines, Mixed Feelings
Part 3: Rural Hospitals Drive Local Economies as They Evolve

6. Legislators enact stricter restrictions on abortion

During the General Assembly session, debate flared about the state’s abortion restrictions. North Carolina Health News added to the conversation with the first of a series of interactive maps. Folks found some of the statistics about abortion from around the state to be surprising.

The map was only one part of North Carolina Health News’ coverage of this issue and how it played out in the legislature. Questions from the media finally compelled the state’s Obstetrical and Gynecological Society to take a position on the issue after a long silence.

7. N.C. General Assembly contemplates rescinding motorcycle helmet laws

Photo credit Jason Edward Scott Bain, flickr creative commons

Photo credit Jason Edward Scott Bain, flickr creative commons

During the General Assembly session, lawmakers attempted to pass a repeal to North Carolina’s motorcycle helmet law, and NC Health News readers reacted. The stories about this bill garnered some of the highest readership and most comments of any story this year.

But in the end, efforts to repeal the helmet law… crashed.

8. Medical schools inflate general practice numbers

For years, North Carolina has had four medical schools in the state (Campbell U. just added a fifth this year) and for years, those schools have talked about how many of their graduates go into primary care. But the numbers tell a different story.

It turns out only East Carolina University’s Brody School of Medicine has had real success at getting people into primary care practice.

9. Bartonella is everywhere, so why don’t we know more about it?

Vectors of Bartonella infections include fleas, body lice, and sand flies.

Vectors of Bartonella infections include fleas, body lice, and sand flies, as well as animals. Image courtesy Centers for Disease Control and Prevention.

Bartonella is a bacteria transmitted by fleas, ticks, animals, even spiders, but few people know about it except as the causative agent for “cat scratch” disease. But new methods for diagnosing it are showing it’s more common than previously thought, and may have more profound effects than imagined.

A professor from NC State has made it his business to get the word out about Bartonella, literally.

10. McCrory administration officials alter response to a Medicaid audit

Incoming DHHS officials edited an audit of the Medicaid program delivered in January in a way that made the program appear more troubled than it is. 

An investigation by NC Health News editor Rose Hoban uncovered documents in which DHHS officials sat on information that would have depicted North Carolina’s lauded Medicaid program in a better light. The most telling document is a “track changes” edition of the DHHS response to an audit showing how Medicaid officials eliminated detailed explanations of alleged high administrative costs, management problems and budget overruns in past years.

State Auditor Beth Wood describes the results of her audit of the state Medicaid program, while Governor Pat McCrory listens.

State Auditor Beth Wood describes the results of her audit of the state Medicaid program, while Governor Pat McCrory listens.

The resulting document accepts the criticism in the audit wholesale and paints the health care program that covers 1.6 million North Carolinians as “broken.” That critique was also used as justification to reject expansion of Medicaid that would have been paid for by the federal government under the Affordable Care Act. The flawed audit response was also used to justify a push to privatize the program.

Guaranteed: Medicaid will continue to be a big story in 2014, and you can get up to speed on what’s happened in the past year here.

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