Study Finds Encouraging Surgical Outcomes at Critical Access Hospitals
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.
There are 1,284 CAHs throughout the country; North Carolina has 20.
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.
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.”
New Testing Technique Could Make Identifying Potentially Hazardous Chemicals Easier
Recent work in finding more efficient ways of testing chemicals is almost more important than the potential hazards of the chemicals themselves.
By Catherine Clabby
When UNC-Chapel Hill scientists spilled commonly used fungicides onto mouse brain cells, genes inside those cells changed. Activity levels among some of the genes shifted to distinctive patterns observed in the brains of people with autism.
First hear this: No one has proven that a class of popular crop-field fungicides causes brain damage. For starters, mouse brain cells are not human brain cells (though they are more alike than many people know). And cell studies don’t prove that chemical X produces human brain abnormality Y.
That said, the recently published research is compelling evidence that the potential of human health risks from a popular class of farm fungicides may merit closer study.
“There are so many questions to be answered,” said UNC cell biologist Mark Zylka, who led the chemical-screening project. “Do these chemicals get in the blood? Do they get into the brain? If so, in what concentrations?
Despite uncertainties about a real-world risk, Zylka is confident there is promise in the technique used to make this headline-grabbing discovery. The approach is a step forward in the scientific quest to more rapidly screen chemicals for potential impacts on human health, this time in the brain.
Trial and error
The breadth and accuracy of toxicology studies are vital in today’s chemical-laden world. Their results strongly influence government rulings on safe and unsafe levels of the tens of thousands of manufactured chemicals registered for use in the United States alone.
For nearly 100 years, many toxicology studies exposed mice or other lab animals to chemicals to see if they do harm. Damage to skin, disruption of reproduction and the growth of tumors all flag concerns.
But it isn’t always clear how to extrapolate data from one strain of mice to diverse populations of people. And animal studies can’t clarify precisely how chemicals affect functioning in cells, information that both help prevent and treat illness.
Several federal research agencies, particularly those located in North Carolina, are promoting newer toxicology screens. These use automated laboratory tools, computer analysis and plates of cells or tissues as research subjects to help predict ways that compounds might affect people and the environment.
Automated cell-based screenings broaden the number of chemical targets that can be screened and pick up the pace of studies because they can be cheaper and quicker than animal-based tests, said Scott Auerbach, a molecular toxicologist at the National Toxicology Program in Research Triangle Park.
“The idea is to get us closer more quickly to the things that we should be looking at. Potentially no stone will get left unturned,” said Auerbach, whose program is part of the Toxicology in the 21st Century initiative. So is the National Institute of Environmental Health Sciences, where NTP is based; the Food and Drug Administration; and other federal agencies.
Environmental Protection Agency staff in RTP, also Tox21 participants, compiled nearly 300 chemicals that Zylka’s team screened. Those included pesticides, fungicides, herbicides and compounds used to make plastics, among others.
The UNC researchers employed genomic sequencing tools to capture changes in gene activity in its mouse neurons after they were dosed.
The rates at which genes direct the production of proteins in different types of cells is essential to health. Overactive or underactive genes are less likely to produce the amount of proteins that cells require to grow or function normally.
Increasingly, genetic studies are linking patterns of abnormal gene activity to specific illnesses and disorders. Differences detected in brain cells of people with autism, for instance, include reduced activity of genes involved in transmission of signals between neurons and increased activity among genes involved in immune responses.
Zylka’s team found that exposure to fungicides called quinone outside inhibitors produced those very types of changes in the mouse neurons, in addition to other effects. Among the fungicides screened were pyraclostrobin, trifloxystrobin, famoxadone and fenamidone, agricultural chemicals modeled after an antifungual chemical forest mushrooms emit to protect themselves.
Agricultural chemical companies in North Carolina – BASF, Bayer and Syngenta – are among the producers of products using this class of fungicides. With names such as Cabrio, Reason and Abound, they suppress damaging fruit rot, mold, mildew and other blights on everything from berries to lettuce and nuts and improve farmers’ yields.
In food-crop fields and other agricultural settings, these types of fungicides work by impairing structures inside fungi cells called mitochondria. The structures are important in cells of many organisms because they produce the chemical energy cells can use to power many activities.
In their paper, Zylka’s team cites FDA and U.S. Department of Agriculture data showing that residue from quinone outside inhibitors has been detected on food, including spinach and apples, but in extremely tiny amounts measured in parts per million. Federal studies have documented residue from this class of fungicides on food, particularly leafy green vegetables.
Darren Wallis, a Bayer spokesman, said his company is committed to producing safe products that must undergo rigorous testing before release and are monitored by the company and regulatory agencies around the world once in circulation. Bayer scientists, he said, will certainly review the UNC findings and assess if any next steps are needed.
“The people of Bayer take our jobs of creating products to help improve the lives of people, plants and animals very seriously,” Wallis said.
Effects from exposure to chemicals released into the environment is an active area in autism research. Evidence exists, for instance, that pregnant women living close to farmlands and exposed to a limited number of pesticides are at increased risk of giving birth to children who will be diagnosed with autism, one clue that exposures may increase risk of the disorder.
Given indications that prenatal exposures play a role in autism, good research that sheds light on how chemicals affect neurons is needed, said Geraldine Dawson, director of the Center for Autism and Brain Development at Duke University, who was not involved in the UNC study.
“Zylka and his team have developed a really efficient way to test how a wide range of toxins influence the expressions of genes involved in neuronal development and function,” Dawson said. ”This high-throughput approach will be critical for identifying which combinations of toxins are associated with increased risk.”
Because of what they saw in the brain cells exposed to fungicides, the expanded use of the compounds and their detection on food, the UNC scientists in their paper called for “greater scrutiny” on the fungicides’ effects outside cells too.
There is now reason to observe effects on brains, they said, and behavior.
Though Zika Unlikely a Risk in N.C., Local Efforts Are Scaling Up
Research and response teams in North Carolina are preparing.
By Rose Hoban
It’s cold in North Carolina right now. So people aren’t sitting on their porches swatting at mosquitoes.
But even when the weather warms up and the local bloodsucking bugs start flying, the question for many people is: Is it possible to get the Zika virus in North Carolina?
The answer, according to researchers from UNC-Chapel Hill, is, essentially, “No.”
“There’s not zero risk of anything, but I wouldn’t worry about transmission of Zika in the U.S.,” said Aravinda de Silva, an infectious-disease researcher at UNC who specializes in dengue virus, another mosquito-borne virus in the same family as Zika.
Though there are mosquitoes in the U.S. capable of carrying Zika, de Silva said there’s an exceedingly slim chance of someone in this country getting Zika from a mosquito.
There have been small outbreaks of dengue in Key West and along the Texas-Mexico border. But da Silva said Zika diagnoses in the U.S. will overwhelmingly come from travelers who bring it home from their Caribbean or Latin American vacation.
“Let’s put the U.S. aside for a moment. There’s more globally; all these people living in endemic areas,” he said. “There are huge populations living in these large urban centers, millions and millions of people who are at risk of getting dengue, and those same populations are at risk of getting Zika.”
“If it wasn’t for the microcephaly, it wouldn’t be unique,” said UNC infectious-disease specialist David Weber, referring to a strongly suspected link between Zika infection in pregnant women in Brazil and a sharp uptick in a birth defect known as microcephaly.
“Otherwise, [Zika] is just a mild illness, which is why there’s been so little research,” he said.
According to da Silva and Weber, who both presented last week, researchers from the university are mobilizing to study the disease.
Even as the UNC researchers were presenting, a study was released in the New England Journal of Medicine showing direct links between even mild Zika infections in pregnant women and the birth defect. What is disturbing to the authors of that study was that only about a third of the women tested actually had a fever; the rest never knew they were sick.
Air conditioning and window screens
Zika is closely related to dengue, which has been spreading widely in Latin America and the Caribbean for the past few years. Commonly known as “breakbone fever,” dengue usually causes mild fever. But in a limited percentage of patients, its muscle and joint pains can be just plain awful.
Yet out of the estimated 390 million cases of dengue worldwide in 2013, only 794 were diagnosed in the U.S. Most of those were travelers who acquired the disease while abroad.
There has been some local transmission in the U.S., but the spread has been limited. Even in places in the U.S. like Key West and along the Texas-Mexico border where there are the right kind of mosquitoes – namely, Aedes aegypti and Aedes albopictus – and the weather is warm enough, there’s reduced risk of those bugs actually carrying disease from one person to another.
“This has mostly to do with lifestyle factors such as air conditioning and window screens, which limit the spread of mosquito-borne viruses here,” said Helen Lazear, a UNC microbiologist who studies mosquito-borne diseases, during last week’s presentation.
In a recent Key West dengue outbreak, there were only 28 confirmed cases of locally transmitted disease between August 2009 and March 2010.
More than the U.S.
Lazear floated the suspicion that prior infection with dengue, as is common in Brazil and other countries where Zika is currently raging, can actually make Zika cases worse.
According to Lazear and da Silva, Zika triggers the immune response created after a person has gotten dengue.
“Unfortunately, dengue and Zika are too close and it’s very difficult with the [existing test] to see whether someone is having a dengue or a Zika infection,” da Silva said.
That makes it harder for researchers to actually confirm that a patient has Zika while they’re still sick. Instead, the best diagnosis is made using sensitive DNA-based testing; but that’s expensive and needs to be done in a lab.
UNC researcher Sylvia Becker-Dreps, who has been doing epidemiology research in Nicaragua for a decade, will be leading a collaboration between UNC and a university in that country to study Zika.
“Right now, it’s mostly a naîve population; they’re only starting to get their first cases, something between 300 and 600 cases detected in Nicaragua,” Becker-Dreps said.
The idea is to help the government with its response, but resources in that country are poor and Becker-Dreps said the ministry of health is only testing every tenth blood sample it receives.
She said one of the most important things to do is monitor what happens with pregnant women as the disease spreads across Nicaragua.
“The rainy season begins in May,” she said. “So the epidemic is only arriving now in Nicaragua. Then wait nine months and see.”
It’s important to understand what’s happening with Zika now, da Silva said, because inevitably the disease will make the jump to Asia, with its megacities of tens of millions of people.
“You have huge populations living in these large urban centers, millions and millions of people who are at risk of getting dengue, and those same populations are at risk of getting Zika,” he said.
Even if only a small proportion of pregnancies in Zika-infected women in those megacities end with babies having birth defects, it could still be tens of thousands of cases.
Closer to home, state public health officials are leveraging the publicity around Zika to beef up their surveillance and response capacity around bug-borne diseases.
North Carolina was one of the only states in the country to have a small cadre of entomologists, embedded in the Division of Public Health, to track mosquito-borne diseases and other diseases carried by bugs, known as “vector-borne” diseases.
But the vector-borne disease branch was eliminated during budget cutting in 2010 and 2011.
Now the Division of Public Health is looking for two entomologists, one to be based in Raleigh and the other to do fieldwork throughout the state, according to Danny Staley, who heads the division.
Essentially, that’s the same level of staffing as in the older program.
Staley said a number of counties, including New Hanover and Brunswick, have active vector-control programs. Those counties have historically been mosquito hot spots.
Staff go out, either in response to complaints or to known hot spots, he said, and look for birdbaths or containers with larvae.
Staley said spraying has fallen out of favor as the preferred method of mosquito control. Instead, public health interventions are more targeted: Teams go to hot spots, look for larvae, trace the feeding patterns of the mosquitoes and monitor what happens after they apply larvacide or drain waters.
“You can have three or four broods coming off of one container in a day,” Staley said.
He said the newly hired state-level entomologists will coordinate with local departments and will track what’s happening statewide to prepare for “new and novel viruses that are coming our way.”
“Last year, it was chikungunya; a few years earlier, it was West Nile virus,” Staley said.
As happens often in public health efforts, funds get cut when there’s no disease activity; then when there’s an outbreak, agencies scramble to rebuild.
“I will say that North Carolina is not unique in this situation,” Staley said. “In Florida and other states, there are similar situations; programs that were once very popular have faded.”
The entomologist job postings closed last week. Staley said the division is “aggressively” moving to get the new hires in place before North Carolina’s mosquitoes get active.
Distant Echoes of Slavery Affect Breast-feeding Attitudes of Black Women
Black women have some of the lowest rates of breast-feeding. One midwife found some surprising reasons why that might be so.
By Rose Hoban
As certified nurse-midwife Stephanie Devane-Johnson works with her patients in Greensboro, she talks to them about a lot of health issues. But for her pregnant clients, one of the biggest topics is breast-feeding.
“I’m asking about whether they’re going to breast-feed or bottle-feed,” Devane-Johnson said. “If they say they’re going to bottle feed, I say, “What about breast-feeding?’’
But to her frustration, for many black women breast-feeding their babies isn’t the first option.
National data show that only about 59 percent of black women breast-feed, compared to 79 percent of whites and 80 percent of Hispanic women. In North Carolina, those rates are even lower: Only about 44 percent of black mothers breast-feed.
This led Devane-Johnson to explore why more black women aren’t breast-feeding.
Some of the answers she found were surprising: The echoes of slave women being forced to give up their milk still resounded. And black women didn’t talk to their sisters, daughters and granddaughters about how to feed their babies; the bottle was just assumed.
And for some women, breast-feeding was a “white thing.”
As part of her research for a doctoral degree at the UNC-Chapel Hill School of Nursing, Devane-Johnson held focus groups to ask black women about breast-feeding. She presented her research at the annual UNC-Chapel Hill Minority Health Conference, held last week at the Friday Center in Chapel Hill.
Devane-Johnson described how she recruited 39 women ranging in age from 18 to 89 years old and asked them what conversations they’d had with family members.
Turns out, many hadn’t had conversations at all.
“In the formula-feeding group, it was just assumed,” she said.
She said some women who had breast-fed said it was a topic that couldn’t be addressed in their families.
“If they did breast-feed, they didn’t breast-feed at, say, their aunt’s house, [because] they would tell them, ‘You can’t do that in my house. Breast-feeding is nasty,’” Devane-Johnson said. “You don’t talk about ‘boobies,’ because breasts are sometimes seen as sexual and not as functional.”
And then there was the enduring legacy of slavery.
“There were some older black women who wanted to disassociate themselves from the past, from slavery and the wet-nursing,” she said, explaining that often young slave women were impressed into giving their milk to white infants.
“Grew up thinking breast-feeding was a white thing.” – focus group participant“That image of a ‘mammy’ when people would say that,” reads one of the quotes Devane-Johnson collected from her focus groups. “It did conjure up those pictures of the women feeding the white babies and all that.”
And the cultural memory had been passed down even to younger women.
“It really was amazing…. In my 18-to-29-year-old breast-feeding group, there was a young lady in there who said, ‘Yeah, the white men used to steal the slaves’ milk,’” she said.
Devane-Johnson explained that often slave women had to be away from their own children, at the cost of their own children’s lives.
“A lot of slave babies died during slavery because they weren’t breast-fed. They were fed concoctions of dirty water and cows milk,” she said. Meanwhile, those children’s mothers were giving white children their milk.
And women reported that oral histories have been reinforced by modern technology.
“These pictures are all on social media,” Devane-Johnson said. “Then someone gets pregnant and people talk about breast-feeding. They’ll say, ‘You don’t have to do that anymore.’”
Teaching for change
There are also societal, economic and practical barriers to breast-feeding, Devane-Johnson said, things she’s working with her patients to change.
For starters, breast-feeding isn’t exactly easy, especially at first.
“When you have a sleep-deprived mom trying to breast-feed at three o’clock in the morning, and a matriarch at home is saying, ‘Get that out of that baby’s mouth and get that baby a bottle,’ it’s very enticing,” she said.
“There was an empowerment in being able to choose that bottle and not say I’m going to be sitting here with the baby attached to me.” – focus group participantBreast-feeding also can be something of a class issue, Devane-Johnson said. For some women, using formula was “empowering.”
“If you’re raised in your thought process, ‘I have a job, I can afford to formula-feed,’ to them breast-feeding is associated with being poor,” she said. “To some black women. Not to all, but to some.”
And using formula means a woman doesn’t have to be “tied down” to their baby.
Devane-Johnson said part of the solution is teaching women about how much healthier breast-fed babies are: Research shows they have lower rates of obesity, fewer colds and lower rates of diabetes later in life.
But there are also workplace barriers to breast-feeding. She said women need coaching to ask their supervisors about accommodations, which are required by state and federal law.
Marva Price, a black nurse who spent years teaching women to breast-feed, discussed how she’s helped women approach that discussion.
“They have to ask for that – if they can take time away,” Price said. “Can they take time away, can they even pump in their work space or go someplace and have a clean place, even a storeroom?”
She said that over the years she’s worked with patients to help them figure out what to do and how to negotiate with their bosses. Then there are logistical issues: a refrigerator to store the milk, a place to store the pump, a quiet, out-of-the-way place to pump.
“It takes a lot of support,” Price said.
NIEHS Looks for Higher Local Profile
By Rose Hoban
If you have ever received an email from anyone at the National Institute of Environmental Health Sciences, the bottom of the email has a statement that starts, “Hopefully, you’ve heard of NIEHS, but if not …”
Brand recognition seems to be a problem for NIEHS, the only one of the National Institutes of Health located outside of the DC metropolitan area.
And, yes, NIEHS is located in North Carolina, in Research Triangle Park. It was actually the first large tenant in RTP, back in the ’60s.
NIEHS leader Linda Birnbaum is determined to raise the organization’s profile in this, its 50th anniversary year. She also wants to get her researchers out into the local community more.
“If you’re going to study the environment, you absolutely have to work with the community,” Birnbaum said at an event held last week.
Birnbaum had come to a monthly meeting of RTP 180, a social, networking and educational TED-like event held at The Frontier, a co-working and event space in RTP. She brought with her several NIEHS grantees to talk about their work.
“Several of our centers are at local universities,” Birnbaum said. Both UNC-Chapel Hill and Duke host Superfund Centers. N.C. State University hosts an environmental health center, and there are multiple grantees at universities throughout North Carolina.
“We spend almost $250 million a year in the local environment,” she said. “We’re a pretty well-kept secret.”
Getting the word out
But if the grantees Birnbaum had with her last week were any indication, NIEHS won’t be a secret for long.
N.C. State researcher Heather Patisaul had the crowd laughing along as she presented on what she’s learned from prairie voles, little mouse-like critters that are actually quite social.
There’s active recruitment in North Carolina for several studies, including the Body Weight and Puberty Study and a study on Bisphenol A exposure, both being conducted on the NIEHS campus in RTP. Patisaul explained how the voles mate for life and are more interested in hanging out with their mates than by themselves or with “an alluring stranger.” That’s more similar to humans than other rodents.
With help from NIEHS, she’s been able to look at the hormones in the voles similar to those in humans and has studied how those hormones get disrupted.
“We can study how a chemical like bisphenol A, or BPA, interacts with the brain and the nervous system to change behavior,” she said.
Another presenter, Dave Peden from UNC, grabbed attention with his description of exactly how air pollution damages the lungs.
Peden, who studies asthma, told the crowd that someone with asthma is more likely to have a delayed reaction to air pollution; attacks come a day or so after exposure. That realization is what led researchers to believe that inflammation is important.
“It takes awhile to make pus in your lungs. There’s an image for you.” he said as people audibly groaned. “If you inhale a particle, it takes awhile for your lungs to get annoyed with it.”
Peden said research shows, for example, that if people are worried about pollution, then exercising in the morning may be better than exercising in the afternoon if you exercise outside, because there’s less pollution in the morning.
“There are things that you do to protect yourself,” he said.
More to come
Event emcee Will Hardison said the 300-some people at last week’s event constituted one of the biggest crowds RTP 180 has attracted, so big that the event ran out of food and beer.
Afterwards, Peden said he thinks it’s important for scientists to get out and talk about their research in ways that are engaging to the public.
If that’s the case, Birnbaum may be calling him again. The Institute is planning a series of events throughout 2016, from a screening of WALL-E at Marbles Kids Museum in Raleigh and Women’s Health Awareness Day events in Durham, both in April, to lectures and symposia scattered throughout the year.
“We’ll be having events all year,” Birnbaum said. “Some of the best ways for me to meet the community is to hold an open forum.”
Biden Urges Cancer Research Community to Aim High
As part of President Obama’s “Cancer Moonshot” initiative, Vice President Joe Biden visited Duke yesterday.
By Rose Hoban
The future of cancer treatment is within reach. It just needs some rocket fuel.
That was the message given Wednesday by Vice President Joe Biden at Duke University, where he visited to boost President Barack Obama’s “Cancer Moonshot” initiative, announced during the State of the Union address in January.
In that speech, Obama tasked Biden with leading a nationwide effort to accelerate efforts to find cures for the many forms of cancer. The initiative includes proposals for billions in additional dollars for the National Institutes of Health, with close to $200 million for the National Cancer Institute.
In 2015, Biden lost his 46-year-old son, Beau, to an aggressive form of brain cancer. He said the new initiative was “not his idea,” but when Obama approached him about leading the effort he said he jumped on it.
Biden also said he’s ready to make the fight against cancer a “major component of what I’m going to be doing with the rest of my life.”
During the nearly two-hour event, Biden discussed aspects of cancer research and treatment, barriers to care and what needs to happen to advance the science. He also took suggestions and input from researchers and patient advocates involved with cancer care throughout the Triangle.
“One area of consensus is that we really are at an inflection point,” Biden said about what he’s learned since starting work on the initiative. “I was stunned to learn how much has changed in the last five years.”
While Biden said several times that he was “not naive” about the difficulty of finding cures for the many forms of cancer, he also expressed optimism.
“The science is ready,” he said repeatedly.
Big data, big promise
By the end of Biden’s presentation, no one could doubt his enthusiasm for the potential of “big data” in cancer research and treatment. He used the phrase at least a dozen times to talk about genetic data, information on treatment responses and pharmaceutical knowledge being collected by cancer researchers.
“Big data” is the term used to refer to reams of information, which, on the surface, doesn’t reveal much. But once the data are aggregated with the assistance of sophisticated statistical analyses, researchers can pull revelations from the mountains of raw bits and bytes.
As an example, Biden talked about a recent study showing that women with ovarian cancer taking one type of blood pressure medication lived significantly longer than others with the same diagnosis who didn’t take that pill.
“The way that was found is comparing outcomes,” he said. “It’s something that never would have happened or been picked up by biology alone, or researchers working in silos, but it did get picked up because of data and computing advances and the ability to look across wide patient populations.”
He encouraged researchers, drug companies and academics to share information more freely about what works, urging pharmaceutical companies, in particular, to collaborate.
“Getting that done is like getting a nuclear deal with Iran,” he said to laughter from the crowd.
“We have to make sure the information is being shared so that oncologists in Fayetteville can access information from a world-class institution like Duke,” Biden said.
Getting treatment where it’s needed
“People of color, as with any other chronic illness, we fare worse,” Gayle Harris, Durham County’s health director, told Biden during the round-table portion of his visit. “Most of the times, our illnesses are detected far, too far, into the progression of the disease.”
And of the only 5 percent of patients who end up in clinical trials, few are minorities.
James Atkins, a researcher with the Southeast Clinical Oncology Research Consortium, made an emotional plea for easing access to clinical trials for oncologists outside academic research centers.
Clinical trials should be made available to any oncologist credentialed by the NCI, Atkins said, cutting off Biden’s response.
“If somebody comes into my office today with a malignant tumor for which I do not have a clinical trial, but there is one at the government.com, I go ahead and access it; I download the forms off the Internet,” he said. “I fax it in, the drugs are shipped,”
“It doesn’t have to be as complicated as it is,” Atkins said.
Atkins also made specific suggestions about streamlining FDA audits, which drew murmurs of approval from the crowd.
“I’m going to ask you to be willing tomorrow to get on the phone with one of the docs in my operation and lay out in detail just what you said here,” Biden responded, telling him to be as specific as possible with his suggestions.
Cost: the final frontier?
Biden concentrated primarily on the science, but several observers noted one of the biggest barriers to cancer care is cost.
Harris recounted the story of a cousin who spent enormous amounts of money looking to cure a case of pancreatic cancer. She told of how the family exhausted treatment at three academic centers, to no avail, while also exhausting their savings.
“That wreaks havoc on a budget,” she said. “And they had the skills to navigate the system.”
That cost of care is what preoccupies Duke oncologist Yousef Zafar.
“We need to focus on how to get the right care to the right patient at the right time,” said Zafar, who did not attend the Biden presentation. “Part of getting the right care to patients involves understanding the cost of that treatment.”
“It doesn’t take hundreds of thousands of dollars of medical debt for patients to feel the pinch,” he said.
Zafar said there’s evidence showing that out-of-pocket costs as little as $100 per month can induce cancer patients to stop life-prolonging treatment.
“Some patients might say, ‘I’d rather not have my family go into medical debt even if this therapy could extend my life,’” he said.
Deodorant Changed the Ecosystem of North Carolina Armpits
North Carolina researchers are exploring the far reaches of … our belly buttons. And armpits.
By Laura Pellicer
They linger on your skin, burrow in your stomach and occupy every nook and cranny in your body: microorganisms – the bacteria, parasites and even viruses that make up your microbiome. It may sound unpleasant, but scientists are eagerly working to identify which microorganisms are in – and on – your body, as new connections emerge between these microscopic critters and your overall health.
North Carolinians are doing their part to contribute to this research. Dozens of residents, many recruited through the N.C. Museum of Natural Sciences, have stepped up to have their own bodies swabbed for science.
Julie Horvath, a comparative evolutionary genomicist with North Carolina Central University, is just one of the researchers across North Carolina who are working to answer the question of the relationship between microbial diversity and human health. But first she wants to find out just which microorganisms are making a home in your body.
For Horvath, this quest started with the armpit, and a collaboration with Rob Dunn, a biologist in the Department of Biological Sciences at North Carolina State University who heads a project called Your Wild Life that explores the ecology of everyday life, including the biodiversity of your backyard, home and body.
“I said, ‘Let’s do the armpit! That sounds really gross and nasty but it’ll be engaging,’” Horvath recalled of the initial conversation with Dunn that sparked her latest microbiome research.
The researchers kicked off their armpit and belly button study by swabbing their own bodies and growing microbes from the swabs in the lab. Horvath’s belly button turned out to be an enigma.
“The other people in the lab all had things growing on their plates,” she said. “My plates were blank. And I got a little freaked out because I’m a scientist. You’re supposed to have microbes on your skin, and nothing’s growing on my plates?”
After a round of discussions with her fellow researchers, Horvath determined the antiperspirant she was using might be to blame.
“I had just gotten this job and didn’t like public speaking very much; it made me nervous. So I was wearing clinical strength antiperspirant. And so, potentially, when I would take a shower, it would wash down over my body, and so maybe it was getting in my belly button and that’s why nothing was growing in my belly button.”
From the colorful Genomics & Microbiology Research Lab that she heads, enclosed in the glass walls of North Carolina’s Museum of Natural Sciences, Horvath got museum employees and a horde of volunteers to offer up their pits for science. The microbial denizens of those armpits are on display in an online gallery.
Researchers split the participants into three groups. One group wore antiperspirant, another deodorant and the third group was asked to forgo conventional pit protocol and ditch the products.
The results, published in the journal PeerJ, show the use of deodorant or antiperspirant has a strong effect on types of bacteria living on the surface of the skin. Participants who used product had significantly more staph (Staphylococcaceae) than Corynebacterium. Those who didn’t wear product had more Corynebacterium than staph. By wearing antiperspirant, these citizen scientists were also killing off microbes and lowering the bacterial density on the skin.
“The main point is the products you put on your skin can significantly change the abundance and composition of the microbes on your skin,” Horvath said. “If you look at some of the other primates, you see that they don’t have as much of the staph and Corynebacterium that we do. Potentially, humans have evolved for some reason to have a lot more staph and Corynebacterium, and maybe that’s partly due to the product use that we have.”
Armpit sweat to earwax
Horvath has now set her sights on the generally underappreciated realm of earwax, and is actively swabbing, recording and analyzing the white (or yellow) stuff with the hopes of determining whether certain earwax types harbor different microbes.
“We know microbes feed on your sweat. If you either produce a lot of sweat or wet earwax, versus if you don’t, do you have different microbes growing on you?” Horvath asks. “We know that a lot of these play a role in your health. Any microbes that live on your skin are going to play a role in your immune system.”
Despite her enthusiasm to probe the dark depths of ears and armpits for the sake of microbiome research, Horvath warns against throwing caution to the wind for the sake of microbiome diversity.
“You don’t want to just go advocate, ‘Hey, go roll in the dirt and don’t wash your hands!’ Because that’s what some people are getting at,“ she said.
“But I would say, think about what you’re putting on your body. We know antiperspirant and deodorant have an effect. We know antibacterial products have an effect. Try to limit your use of things you know are going to kill off good microbes. Because killing off your good microbes is potentially going to have negative consequences.”
Following the gut
Scientists who are plugging away at human microbiome research are eager to compare petri dishes of blossoming bacteria with samples from our closest living ancestors: primates.
Using behavioral data from chimpanzees in Gombe, Tanzania – the same group of chimps Jane Goodall and her team have been monitoring since 1960 – researchers at Duke University have discovered a key connection between socialization and the gut microbiome.
Anne Pusey, chair of Duke’s evolutionary anthropology department, is the keeper of this behavioral data. She heads a project to digitize all the information gathered on these chimpanzees in the field and is a contributing author on a recent study published in Science Magazine.
This new research highlights socialization as a factor for the diversity of gut microbes and complements a long-term study from Jenny Tung, an assistant professor of biology at Duke who found connections between the intermingling of wild baboons and the gut microbiome.
“In humans, [researchers] know about the microbiome being transferred from mother to baby during a normal birth but not during cesarean,” Pusey said.
Based on this principle, Pusey says a reasonable assumption is that related chimps would have a more similar gut microbiome than non-related chimps. But instead, she found chimpanzees who spent time interacting had similar gut microorganisms, independent of whether they were related.
“That suggests that there’s transfer going on between individuals in ways other than just by birth,” Pusey said.
Steffen Foerster, a senior research scientist in Duke’s department of evolutionary anthropology, developed models to study the complex social relationships between these chimpanzees.
“It’s very dynamic, much like in humans. As we move around our daily lives, we meet people, spend some time with them and then leave when we want to,” Foerster said.
By following a different chimpanzee each day, recording social interactions and collecting fecal samples, researchers determined that the level of gregariousness of the chimps correlated with the richness or diversity of their gut microbes.
So what implications does this have for humans? A key difference in human versus chimpanzee interaction is that people don’t swap fecal matter quite as readily as chimpanzees.
“When they’re together, they groom each other, they play, they mate and also they – because they’re near each other – they’re defecating and they’re walking around in the same areas where each other have defecated,” Pusey said.
But our modern battle against dirt, germs, bacteria, parasites and general foul smells may be a setback for a diverse human microbiome.
“What people are starting to realize is, not having anything to fight against is making our immune system fight against itself,” Foerster said. “This increased prevalence of autoimmune disease might have to do with not having to fight off these parasites.”
ECU, UNC Researchers Join to Study High Blood Pressure In Rural Southern Blacks
Researchers from ECU’s Brody School of Medicine and UNC-Chapel Hill’s School of Medicine and Cecil G. Sheps Center for Health Services will examine strategies for reducing high blood pressure among low-income African-Americans.
By Taylor Sisk
Researchers from East Carolina University and the University of North Carolina-Chapel Hill have been selected to participate in a $9.5 million grant to address health disparities in the rural South.
This will be a five-year, multi-institutional study to compare strategies for reducing high blood pressure among low-income African-Americans throughout the rural southeast. Research teams have been assembled at ECU’s Brody School of Medicine, the University of North Carolina School of Medicine and the UNC Cecil G. Sheps Center for Health Services and the University of Alabama at Birmingham
The project is funded by the Washington, D.C.-based Patient-Centered Outcomes Research Institute, established under the Affordable Care Act.
Researchers will study rural communities throughout the “Black Belt,” a region, stretching from Maryland to eastern Texas, so called for its high percentage of rural black communities. It has the nation’s highest rate of cardiovascular disease mortality.
High blood pressure – or hypertension – can lead to heart disease and stroke.
‘A multitude of factors’
According to the Centers for Disease Control and Prevention, nearly one in three adults in the U.S. has hypertension. The rate is higher still among rural residents, and the rate for blacks in the U.S. is among the highest in the world.
An ECU press release last week announcing the study states: “According to the N.C. State Center for Health Statistics, 38.9 percent of adults in eastern North Carolina reported being told by a doctor that they had hypertension. Even more alarming was the 46.6 percent of African-American respondents in the East who reported having hypertension – a rate approximately 25 percent higher than that reported by white respondents.”
The study will focus on what the researchers refer to as the “‘triple threat’ of risk factors,” related to race, geography and income status.
In an interview, Doyle Cummings, a professor of family medicine and public health at the Brody School of Medicine who will head the ECU team of researchers, said, “It seems very clear that African-Americans who live in rural areas and have a lower socioeconomic status account for a very high proportion of the risk.
“That’s the group that seems to be at highest risk for developing hypertension in general and uncontrolled hypertension in particular.”
Cummings said there are a “multitude of factors” that make this demographic so susceptible to uncontrollable hypertension. He cited first poor access to health care services in rural areas.
“People in rural areas sometimes don’t have access to the same quality of care, the same breath of care, as folks in other areas,” he said.
He then cited affordability issues and a shortage of “opportunities to be healthy: access to healthy food and to safe places to exercise and to keep weight lower.”
Health literacy is also an issue.
“A number of our patients don’t even understand that high blood pressure is a high risk factor for stroke,” Cummings said. “They may know they have high blood pressure, but they don’t connect that with having a stroke or having a heart attack down the road.”
This research will employ two strategies: One will explore the issue from within the health care-delivery system – specifically, how patients who are at high risk for uncontrolled blood pressure are being treated in doctors’ offices.
The researchers will look, for example, at how effectively practices are recognizing the risks for uncontrolled blood pressure, whether it’s being appropriately diagnosed, if practices tend to measure blood pressure correctly, do they intensify medications when necessary and how well are they educating their patients.
The objective of this approach, Cummings said, is to better systematize care. He said the practice-based approach is in keeping with a movement to conduct research that partners academic centers with practices in underserved areas.
The other strategy is a community-based intervention. The researchers will deploy “peer advisers”: individuals from the community in which they’ll work, many with hypertension themselves, trained to deliver what Cummings called a “carefully scripted intervention strategy” to those at risk.
The advice they’ll offer will include the importance of seeing a doctor regularly and ensuring the patient has the proper medications and is taking them.
It’ll also entail helping those at risk better understand the effects of lifestyle behaviors and help with changes to diet and exercise that can lead to weight loss and blood pressure control.
One cohort in the study will participate in both strategies, another in one or the other strategy and a third will be followed as they continue with their usual care without intervention.
Cummings said both ECU and the University of Alabama at Birmingham have used the peer-adviser approach in the past, and that it’s been particularly effective within black communities, where there’s often a distrust of the health care-delivery system, founded in large measure, historically, on limited or no access to the system or mistreatment.
The researchers intend to study some 2,000 patients at 80 practices in Alabama and North Carolina.
Cummings said that probably about two-thirds of the practices his team will work with will be in the eastern part of the state.
The overall objectives, he said, are to better understand how to help primary care practices make changes to bring more patients’ blood pressure under control, and to examine which of the two strategies seems to work more effectively or if future initiatives should pursue the two together.
This research, Cummings said, is “absolutely central to the mission of the Brody School of Medicine. Our mission is really about trying to improve the health status in North Carolina and, in particular, in eastern North Carolina.
“We’re very concerned about this idea of disparities – that in North Carolina there are some folks who don’t seem to have access to care and outcomes that we’d like to see.”
A New Editor-in-Chief in Town
A conversation with Sally Perreault Darney, the new head of Environmental Health Perspectives.
By Gabe Rivin
Sally Perreault Darney tends to say “we” when she’s talking about the U.S. Environmental Protection Agency. She laughs when she catches herself, and admits it’s a deeply ingrained habit.
That she has the habit makes sense, because for more than 30 years Darney worked at the EPA in Research Triangle Park. For nearly 25 of those years, she researched reproductive toxicology. Later she ascended into supervisory roles and helped set the course for the agency’s health research.
But now the “we” of the EPA will have to become “they.” That’s because at the end of August, Darney took the position of editor-in-chief at Environmental Health Perspectives, one of the country’s most respected research journals and a free, open-access publication that’s funded by the National Institute of Environmental Health Sciences.
To learn more about Darney’s vision for the journal, North Carolina Health News sat down with her in her new office in Morrisville, near NIEHS’s campus.
NCHN: What’s most exciting for you in environmental health sciences right now?
Darney: One of my favorites is life-course health, the appreciation that your health as an adult is a function of what you were exposed to when you were in utero, when you were a child and breast feeding, when you were in school, in day care.
An emerging area is how the microbiome – the critters, the bacteria and little bugs that live inside us – can also influence our health and our internal environment. That’s a really hot area.
Another area where we see a lot more integrative types of papers is the use of layered maps, which let you look at multiple factors in geographic sets. If you’re looking at a city, you might look at where the hospitals are, where the schools are, and you can ask questions about the relationship between the natural environment and the built environment and the health of people living in that one location.
There’s a big revolution with toxicity testing, called Tox21. There is a lot of really hot science that, in the future, should make it possible to predict the toxicity much more efficiently of thousands of chemicals, rather than needing to test them one at a time in animals.
NCHN: The Research Triangle seems like a unique place for environmental-health research. What’s happening here that isn’t happening in other places?
Darney: I think the decision years ago to locate NIEHS here, as opposed to in Bethesda, where all the other institutions are, and to locate EPA’s Office of Research and Development here, created a concentration of environmental health research that had a lot of governmental clout behind it. So that was kind of the groundwork.
And I think that encouraged the local universities – like Duke and N.C. State and UNC – to expand their environmental-health programs. Now they’re all powerhouses. So then you put all these people together and you have a critical mass of expertise in one place. That attracts new scientists to this area.
NCHN: What influenced you to go into this field?
Darney: I’m a child of the ‘60s. John F. Kennedy, in founding the Peace Corps, I think, set up in my generation a motivation for service. And that was an era with the first Earth Day and The Population Bomb. Both of those interacted with me, in terms of my strong interest in reproductive health and women being able to understand their health and how to plan their family.
When I interviewed [at EPA], I realized there were some great people doing a variety of research – whether you’re looking at contraceptive development, which was my first interest, or you’re looking to develop chemical ways to prevent pregnancy.
NCHN: You’ve got a distinctive background as a researcher, a federal employee and a journal editor. How does that influence your approach at EHP?
Darney: Having first-hand research experience is critical because I’ve been at the other end of the peer review. Working as an associate editor and an editor for several small journals made me very familiar with what it takes to do good peer review.
In some of the work I did at EPA as a program planner, I was working with a team of leaders, looking at what we should be researching: How do you identify the most important environmental-health problems to fund? That gave me a broader picture of what will have an impact on the field.
NHCN: What’s a research journal’s role in reaching a mainstream audience?
Darney: EHP includes a big news section. We have a news editor. That’s one of the things about the journal that really attracted me to this job.
I think scientists really struggle to communicate their findings, which are often very technical and complex to a lay audience – an audience that has different agendas.
Our stakeholders include teachers, physicians, parents and other students in other fields. Non-academic stakeholders really don’t want to read peer-reviewed journal articles. They want the bigger picture. They want to see what’s been published in the last five or 10 years. A news article can do that.
NHCN: Sometimes it’s hard for non-scientists to read about, say, BPA, and then to feel like they have any kind of confidence making decisions for themselves.
Darney: The public gets bombarded with a variety of information. Some of it is inflammatory. Some of it is cautionary. For some of it, the source has an agenda.
What’s important is to try to provide very trustworthy information that can help people make their own choices. And that may be to say, “We don’t know the answer to this in any great detail. The science is divided.”
To have a reputation that says this is reliable information, I think, makes the public feel more confident that the decisions they are making are valid. And then, of course, the information in scientific journals is used by policy-makers, who then can make more official public health recommendations.
NCHN: Where would you like to see the journal grow over the short, medium or long term?
Darney: I think the challenge will be to move into these new [research] areas and publish a variety of articles that help link them together, taking a more systems approach to the whole question of environmental health.
Evolving with technology, we already have ceased publishing in paper. We think there may be some new tools for making information more searchable, more accessible. That will help the readers.
NCHN: What’s your perspective on having publicly funded research available for free to the public?
Darney: As a taxpayer, I can say, “My taxes support this research, I want to be able to read it.” On the other hand, the publishers have to exist and they have to have their expenses paid.
And so a lot of times it’s not only the government that’s paying for the research; the government is paying to make it accessible. The author has a grant from the government. The grant has built into it publication charges, which [researchers] pay the publisher so that their paper can be published … and made accessible to everybody.
It’s a little complicated, isn’t it? But we’ve shown that it can be done, and I think it’s a pretty reasonable investment.
This interview has been condensed and lightly edited for clarity.
When It Comes to Sex Ed and Teens, Parents Matter
Had “the talk” with your kids yet? A review of the research says it’s time to get started.
By Rose Hoban
If you are an adult of a certain age, you remember how it went: A parent clearing their throat repeatedly, talking in metaphors, referring you to a book. Maybe when it was over, you were even more confused than before.
When, as a teenager, Anu Kumar’s mother wanted to have “the talk” with her, she sent her brother and father out of the house before sitting down to stammer out a few words about sex.
“That was the only time we talked about it,” Kumar said of her mother, a South Asian academic who was teaching in Utah. “That was a big deal for her. I mean, I come from India, no one talks about this stuff in India. For her to sit me down and have that discussion was big.”
Kumar, on the other hand, has been talking to her kids, a 19-year-old son and 14-year-old daughter, since they were toddlers.
“You have to start talking about it pretty early, and talking about anatomy,” said Kumar, who now lives in Chapel Hill. “Kids notice differences in anatomy. So the more accurate you can be, you know ‘what it’s for, what you use it for.’”
Kumar’s approach is the right one, said Laura Widman, a psychology researcher at N.C. State University. She’s just published a study in JAMA Pediatrics showing that parents talking to their kids really matters.
“We found … adolescents who talk to their parents about sexual-health topics are more likely to use contraception and condoms than teens who didn’t have those conversations,” Widman said.
Friends, books, the Internet
Kids have many more places to find information about sex these days, Widman said. The Internet is a virtual cornucopia of information about sex, from porn websites to videos created by comedian John Oliver; from young-adult literature to movies that can be blushingly explicit.
“There’s so much that’s sex based that the kids have access to,” said Michelle Delin, a single mom to two teens, a boy and a girl. “The videos, the movies, the phone. Things are vulgar and one-dimensional.”
But Widman said parents really do matter. She studies communication between teenagers, how teens negotiate things like their first dating relationship and talking about safer sex.
“A big place where kids learn these skills is at home,” she said.
Delin said she tries to be a foil to the other information out in the world, talking to her kids “about self-esteem, about being kind, about caring.”
You’ve convinced me. I’ll talk to my kids about sex. But I need some resources!
Tools for parents, created by Planned Parenthood to help parents talk to their kids.
A resource page created by SHIFT NC. The website also has great data about North Carolina.
More tools for parents and kids, created by professionals from the Nemours Children’s Health System, based in Delaware.
Birds + Bees + Kids: Created by an educator with experience as a sex-ed counselor.
Starting early is important, Widman said, because, cognitively, kids are different when they’re 12 and 13, more easily influenced, than even a few years later.
A Facebook query of parents drew responses such as: “I started the day I brought them home from the hospital so they could never say I didn’t tell them anything.” And, “Had the first talk with my son last spring. He was six.”
But others made comments like: “Not there yet and fretting over it.”
Kumar recounted talking to her kids all along. And Delin said she’s always been “up front” with her kids about sex.
Widman said that’s smart.
“If you wait to have ‘the talk’ and that talk comes at 14, 15 or 16 when kids have already started experimenting with sex, and have already been heavily influenced by the media and by peers, you’re going to be much less effective than if that was an ongoing conversation that started much earlier,” she said.
Kumar has also used conversations with her son as a roundabout way to talk to her younger daughter. She said her son, who’s now in college, has been in a serious relationship for a year.
“So I’m talking to him about how you don’t want to be pregnant until you’re done with school, and my daughter is sitting there listening and absorbing it all,” she said. “You don’t even have to have the conversation with them, just around them.”
‘From you, mom.’
Schools teaching sex education do play an important part in the conversation, said Elizabeth Finley, a spokesperson for SHIFT NC, which promotes adolescent and young-adult sexual health.
“Kids who get zero sex education initiate a little earlier than kids who get comprehensive or abstinence-only sex ed,” she said.
Once kids do start having sex – and the research shows nearly 70 percent of high school kids will have sex before they graduate – that’s where the differences in education come in.
“Kids who get comprehensive sex-education programs are more likely to use contraceptives or condoms than kids who get abstinence-only,” Finley said.
But everyone interviewed for this story said they don’t look to schools to teach values. That’s done at home, by parents.
“I spoke to my daughter about what guys would try to do, to tell you, to get you into bed,” Delin said. “So you don’t fall into the lure of, ‘Oh, I love you.'”
Nonetheless, she’s made condoms available to her daughter, who’s just turning 16.
“Even if kids are getting really good sex education in schools, it’s always meant to be supplemental to what you’re saying at home,” Finley said. ‘Parents are the place to have conversations about expectations and values, because school will never have the capacity to get to those things.”
“When my son was in middle school, I asked him if they talked about contraception, and he said, ’No,’” Kumar said. “And then I asked him where he’s getting information and he rolled his eyes and said, ‘From you, mom.’”
But she also said more education about contraceptives has contributed to downward trends in the teen-pregnancy rate. In 2004, the teen-pregnancy rate in North Carolina was 62.4 per 1,000 girls. The latest data, from 2013, shows the rate down to 35.2 per 1,000.
“If you use more contraception and condoms, you’ll have a lower pregnancy rate,” Finley said. “When we look at the research on why teen-pregnancy rates have declined so heavily in recent decades, the biggest reason is increased contraceptive use.”
“The role of schools is not necessarily to communicate values around sex; that’s what a parent can do,” Widman said. “A school can provide basic health information – you know, what are sexually transmitted diseases, what are the symptoms, how can they be prevented?”
Widman said that her research found kids need information from lots of different sources.
“Getting it from families and parents, getting it from schools, getting it from friends,” she said. “I think each of those may have a role to play.”