A New Editor-in-Chief in Town
A conversation with Sally Perreault Darney, the new head of Environmental Health Perspectives.
By Gabe Rivin
Sally Perreault Darney tends to say “we” when she’s talking about the U.S. Environmental Protection Agency. She laughs when she catches herself, and admits it’s a deeply ingrained habit.
That she has the habit makes sense, because for more than 30 years Darney worked at the EPA in Research Triangle Park. For nearly 25 of those years, she researched reproductive toxicology. Later she ascended into supervisory roles and helped set the course for the agency’s health research.
But now the “we” of the EPA will have to become “they.” That’s because at the end of August, Darney took the position of editor-in-chief at Environmental Health Perspectives, one of the country’s most respected research journals and a free, open-access publication that’s funded by the National Institute of Environmental Health Sciences.
To learn more about Darney’s vision for the journal, North Carolina Health News sat down with her in her new office in Morrisville, near NIEHS’s campus.
NCHN: What’s most exciting for you in environmental health sciences right now?
Darney: One of my favorites is life-course health, the appreciation that your health as an adult is a function of what you were exposed to when you were in utero, when you were a child and breast feeding, when you were in school, in day care.
An emerging area is how the microbiome – the critters, the bacteria and little bugs that live inside us – can also influence our health and our internal environment. That’s a really hot area.
Another area where we see a lot more integrative types of papers is the use of layered maps, which let you look at multiple factors in geographic sets. If you’re looking at a city, you might look at where the hospitals are, where the schools are, and you can ask questions about the relationship between the natural environment and the built environment and the health of people living in that one location.
There’s a big revolution with toxicity testing, called Tox21. There is a lot of really hot science that, in the future, should make it possible to predict the toxicity much more efficiently of thousands of chemicals, rather than needing to test them one at a time in animals.
NCHN: The Research Triangle seems like a unique place for environmental-health research. What’s happening here that isn’t happening in other places?
Darney: I think the decision years ago to locate NIEHS here, as opposed to in Bethesda, where all the other institutions are, and to locate EPA’s Office of Research and Development here, created a concentration of environmental health research that had a lot of governmental clout behind it. So that was kind of the groundwork.
And I think that encouraged the local universities – like Duke and N.C. State and UNC – to expand their environmental-health programs. Now they’re all powerhouses. So then you put all these people together and you have a critical mass of expertise in one place. That attracts new scientists to this area.
NCHN: What influenced you to go into this field?
Darney: I’m a child of the ‘60s. John F. Kennedy, in founding the Peace Corps, I think, set up in my generation a motivation for service. And that was an era with the first Earth Day and The Population Bomb. Both of those interacted with me, in terms of my strong interest in reproductive health and women being able to understand their health and how to plan their family.
When I interviewed [at EPA], I realized there were some great people doing a variety of research – whether you’re looking at contraceptive development, which was my first interest, or you’re looking to develop chemical ways to prevent pregnancy.
NCHN: You’ve got a distinctive background as a researcher, a federal employee and a journal editor. How does that influence your approach at EHP?
Darney: Having first-hand research experience is critical because I’ve been at the other end of the peer review. Working as an associate editor and an editor for several small journals made me very familiar with what it takes to do good peer review.
In some of the work I did at EPA as a program planner, I was working with a team of leaders, looking at what we should be researching: How do you identify the most important environmental-health problems to fund? That gave me a broader picture of what will have an impact on the field.
NHCN: What’s a research journal’s role in reaching a mainstream audience?
Darney: EHP includes a big news section. We have a news editor. That’s one of the things about the journal that really attracted me to this job.
I think scientists really struggle to communicate their findings, which are often very technical and complex to a lay audience – an audience that has different agendas.
Our stakeholders include teachers, physicians, parents and other students in other fields. Non-academic stakeholders really don’t want to read peer-reviewed journal articles. They want the bigger picture. They want to see what’s been published in the last five or 10 years. A news article can do that.
NHCN: Sometimes it’s hard for non-scientists to read about, say, BPA, and then to feel like they have any kind of confidence making decisions for themselves.
Darney: The public gets bombarded with a variety of information. Some of it is inflammatory. Some of it is cautionary. For some of it, the source has an agenda.
What’s important is to try to provide very trustworthy information that can help people make their own choices. And that may be to say, “We don’t know the answer to this in any great detail. The science is divided.”
To have a reputation that says this is reliable information, I think, makes the public feel more confident that the decisions they are making are valid. And then, of course, the information in scientific journals is used by policy-makers, who then can make more official public health recommendations.
NCHN: Where would you like to see the journal grow over the short, medium or long term?
Darney: I think the challenge will be to move into these new [research] areas and publish a variety of articles that help link them together, taking a more systems approach to the whole question of environmental health.
Evolving with technology, we already have ceased publishing in paper. We think there may be some new tools for making information more searchable, more accessible. That will help the readers.
NCHN: What’s your perspective on having publicly funded research available for free to the public?
Darney: As a taxpayer, I can say, “My taxes support this research, I want to be able to read it.” On the other hand, the publishers have to exist and they have to have their expenses paid.
And so a lot of times it’s not only the government that’s paying for the research; the government is paying to make it accessible. The author has a grant from the government. The grant has built into it publication charges, which [researchers] pay the publisher so that their paper can be published … and made accessible to everybody.
It’s a little complicated, isn’t it? But we’ve shown that it can be done, and I think it’s a pretty reasonable investment.
This interview has been condensed and lightly edited for clarity.
When It Comes to Sex Ed and Teens, Parents Matter
Had “the talk” with your kids yet? A review of the research says it’s time to get started.
By Rose Hoban
If you are an adult of a certain age, you remember how it went: A parent clearing their throat repeatedly, talking in metaphors, referring you to a book. Maybe when it was over, you were even more confused than before.
When, as a teenager, Anu Kumar’s mother wanted to have “the talk” with her, she sent her brother and father out of the house before sitting down to stammer out a few words about sex.
“That was the only time we talked about it,” Kumar said of her mother, a South Asian academic who was teaching in Utah. “That was a big deal for her. I mean, I come from India, no one talks about this stuff in India. For her to sit me down and have that discussion was big.”
Kumar, on the other hand, has been talking to her kids, a 19-year-old son and 14-year-old daughter, since they were toddlers.
“You have to start talking about it pretty early, and talking about anatomy,” said Kumar, who now lives in Chapel Hill. “Kids notice differences in anatomy. So the more accurate you can be, you know ‘what it’s for, what you use it for.’”
Kumar’s approach is the right one, said Laura Widman, a psychology researcher at N.C. State University. She’s just published a study in JAMA Pediatrics showing that parents talking to their kids really matters.
“We found … adolescents who talk to their parents about sexual-health topics are more likely to use contraception and condoms than teens who didn’t have those conversations,” Widman said.
Friends, books, the Internet
Kids have many more places to find information about sex these days, Widman said. The Internet is a virtual cornucopia of information about sex, from porn websites to videos created by comedian John Oliver; from young-adult literature to movies that can be blushingly explicit.
“There’s so much that’s sex based that the kids have access to,” said Michelle Delin, a single mom to two teens, a boy and a girl. “The videos, the movies, the phone. Things are vulgar and one-dimensional.”
But Widman said parents really do matter. She studies communication between teenagers, how teens negotiate things like their first dating relationship and talking about safer sex.
“A big place where kids learn these skills is at home,” she said.
Delin said she tries to be a foil to the other information out in the world, talking to her kids “about self-esteem, about being kind, about caring.”
You’ve convinced me. I’ll talk to my kids about sex. But I need some resources!
Tools for parents, created by Planned Parenthood to help parents talk to their kids.
A resource page created by SHIFT NC. The website also has great data about North Carolina.
More tools for parents and kids, created by professionals from the Nemours Children’s Health System, based in Delaware.
Birds + Bees + Kids: Created by an educator with experience as a sex-ed counselor.
Starting early is important, Widman said, because, cognitively, kids are different when they’re 12 and 13, more easily influenced, than even a few years later.
A Facebook query of parents drew responses such as: “I started the day I brought them home from the hospital so they could never say I didn’t tell them anything.” And, “Had the first talk with my son last spring. He was six.”
But others made comments like: “Not there yet and fretting over it.”
Kumar recounted talking to her kids all along. And Delin said she’s always been “up front” with her kids about sex.
Widman said that’s smart.
“If you wait to have ‘the talk’ and that talk comes at 14, 15 or 16 when kids have already started experimenting with sex, and have already been heavily influenced by the media and by peers, you’re going to be much less effective than if that was an ongoing conversation that started much earlier,” she said.
Kumar has also used conversations with her son as a roundabout way to talk to her younger daughter. She said her son, who’s now in college, has been in a serious relationship for a year.
“So I’m talking to him about how you don’t want to be pregnant until you’re done with school, and my daughter is sitting there listening and absorbing it all,” she said. “You don’t even have to have the conversation with them, just around them.”
‘From you, mom.’
Schools teaching sex education do play an important part in the conversation, said Elizabeth Finley, a spokesperson for SHIFT NC, which promotes adolescent and young-adult sexual health.
“Kids who get zero sex education initiate a little earlier than kids who get comprehensive or abstinence-only sex ed,” she said.
Once kids do start having sex – and the research shows nearly 70 percent of high school kids will have sex before they graduate – that’s where the differences in education come in.
“Kids who get comprehensive sex-education programs are more likely to use contraceptives or condoms than kids who get abstinence-only,” Finley said.
But everyone interviewed for this story said they don’t look to schools to teach values. That’s done at home, by parents.
“I spoke to my daughter about what guys would try to do, to tell you, to get you into bed,” Delin said. “So you don’t fall into the lure of, ‘Oh, I love you.'”
Nonetheless, she’s made condoms available to her daughter, who’s just turning 16.
“Even if kids are getting really good sex education in schools, it’s always meant to be supplemental to what you’re saying at home,” Finley said. ‘Parents are the place to have conversations about expectations and values, because school will never have the capacity to get to those things.”
“When my son was in middle school, I asked him if they talked about contraception, and he said, ’No,’” Kumar said. “And then I asked him where he’s getting information and he rolled his eyes and said, ‘From you, mom.’”
But she also said more education about contraceptives has contributed to downward trends in the teen-pregnancy rate. In 2004, the teen-pregnancy rate in North Carolina was 62.4 per 1,000 girls. The latest data, from 2013, shows the rate down to 35.2 per 1,000.
“If you use more contraception and condoms, you’ll have a lower pregnancy rate,” Finley said. “When we look at the research on why teen-pregnancy rates have declined so heavily in recent decades, the biggest reason is increased contraceptive use.”
“The role of schools is not necessarily to communicate values around sex; that’s what a parent can do,” Widman said. “A school can provide basic health information – you know, what are sexually transmitted diseases, what are the symptoms, how can they be prevented?”
Widman said that her research found kids need information from lots of different sources.
“Getting it from families and parents, getting it from schools, getting it from friends,” she said. “I think each of those may have a role to play.”
Biotech Leaders Recap, Look Ahead
Executives from the biotechnology sector gathered this week to look back at this years’ legislative session and begin planning for next year.
By Rose Hoban
Usually by the time the N.C. Biosciences Organization has its annual meeting in mid-October, the legislative session has been over for months and members of the biotechnology community have had time to digest any changes legislators delivered to their businesses.
But this year’s meeting at the N.C. Biotechnology Center in Research Triangle Park on Thursday ended up focusing on the results of this year’s session, which was one of the longest “long” sessions in recent history. And the meeting was an opportunity for biotech executives to figure out the challenges and opportunities created by the General Assembly’s actions this year.
“If you look strategically at what NCBIO got this year, everything we proposed has been adopted by somebody, except the R&D tax credit,” said Sam Taylor, the lobbyist for NCBIO, referring to about $40 million in tax credits that used to be available to larger biosciences companies to help defray some of the costs of research and development.
Earlier in the summer, Taylor had worried about his industry, as the Senate budget did not fund many of the biotechnology community’s requests, and even eliminated funds for the Biotechnology Center.
In the final budget, lawmakers declined to renew the tax credit, while funding many other biotech priorities, including the center.
Instead of the credit, the legislature funded a new Venture Multiplier Fund, with money that comes from the state Escheats Fund: unclaimed insurance, estates, properties and other monies that end up reverting to state coffers. The state Escheats Fund has close to $480 million, and the Venture Multiplier Fund could use as much as 10 percent of that fund.
The venture money will be targeted towards companies that are earlier in their development, Taylor told several hundred people gathered at the meeting. “[It] is designed to increase the amount of private venture capital in North Carolina for commercialization and company scale-up.”
“I know there are different capital needs and capital challenges depending on where you are in the process,” Rep. Nelson Dollar (R-Cary) said, referring to early-stage companies that don’t yet have investors but need money in order to continue researching and growing.
“We know that in North Carolina, one of the areas we are in need of is venture capital,” Dollar said. “There’s a lot of us that believe there is money here in various places if we can find ways to get that off the sidelines and get it more engaged.”
Crossing the ‘valley of death’
Incubating new companies is something Taylor said is a priority for NCBIO. In particular, biotech executives worry about that part of the company development cycle that science entrepreneurs call the “valley of death,” when initial excitement over, and investment in, an idea has faded and a fledgling company needs the next infusion of cash to grow. But often, investors have by then moved onto the next big thing.
Legislators put $5.25 million over the next two years into a fund that will provide up to $50,000 in matching funds to companies that have already received federal small-business innovation, research and technology transfer grants.
“It’s more than just the money,” Taylor told the crowd. “I think we’ve actually convinced legislators that this is a program that has merit, instead of just a place to put money for one year and see what happens.”
“We get huge dividends from biotechnology and R&D companies,” Sen. Bill Rabon (R-Southport) told the gathering. “The statistics show that you folks who start here and are incubated here tend to stay here and you bring good business and good jobs.… I appreciate it.
Taylor did say that in order for North Carolina to put a $50,000 state match to every company receiving the federal credits, the legislature would have to allocate an additional $5 million over the two-year budget cycle.
“But we’re well ahead of where we were two years ago, which was zero,” he said.
Replacing the R&D credit
Taylor told the group that late in the legislative session, after the usual June 30 deadline for the budget to be completed, he was approached by legislators to put together a grant program to replace the R&D tax credit program.
“I’d really like to see something formulated to start-up companies and people who are trying to get off the ground with something new,” Rabon said. “We could have the mechanism to do that with credits, or whether it’s grants or whatever.
“It’s much easier to budget with a grant program than with a credit program,” he said.
Taylor said he worked with biotech executives to propose an alternative incubator fund that would refund between 1.5 and 2.5 percent of any company’s spending on research and development, wages or services.
“It would have been a progressive credit, so that smaller companies get the larger percentage and larger companies would have gotten the smaller credit,” Taylor said, calling it a “rain-shower” approach to funding research.
“That will have to be hashed out and compromised,” Rabon said.
Many Hospitals Don’t Follow Guidelines for Child Abuse Patients, Study Finds
By Alana Pockros
About half of young children brought to hospitals with injuries indicating that they have been abused were not thoroughly evaluated for other injuries, and the use of proper care is less likely to happen in general hospitals than in those that specialize in pediatrics, a study released this summer found.
The researchers examined whether hospitals are adhering to guidelines from The American Academy of Pediatrics that all children younger than 2 years old suspected of being victims of child abuse undergo skeletal surveys, a series of X-rays used to identify broken bones that are not readily apparent, called occult fractures.
The results, published in the journal Pediatrics, reveal a significant variation in hospitals’ evaluation of occult injuries, despite the AAP’s recommendations.
“In the young population, medical providers can miss important injuries.… Skeletal surveys can help identify them,” said Joanne Wood, an assistant professor of pediatrics at the University of Pennsylvania Perelman School of Medicine and senior author of the study.
Wood and her colleagues highlight the importance of skeletal surveys, explaining how the detection of occult fractures can point to the need for additional medical services, provide additional evidence of abuse and help protect the child.
The study looked at records for nearly 4,500 children treated at 366 hospitals around the country between 2009 and 2013. That group included children under the age of 2 who had been diagnosed with physical abuse and children under the age of 1 with high-risk injuries.
Past research has demonstrated that skeletal surveys are key to assessing young children suspected as victims of abuse. Prior to this study, however, there was little information on how hospitals in general have adhered to the AAP’s protocol.
Researchers in the current study found that across all the hospitals, 48 percent of the children younger than 2 with an abuse diagnosis underwent proper occult fracture examinations. But a prior study by Wood and her colleagues reveal that approximately 83 percent of children suspected of being victims of child abuse underwent skeletal surveys when treated in pediatric hospitals.
This study reveals “a need for standardization of care” across hospitals, said Wood.
Robert Sege, the director of family and child advocacy at Boston Medical Center and member of the AAP Committee on Child Abuse and Neglect, said in an interview the disparity in hospital practices is due to “a big educational gap for colleagues who primarily see adults.”
“Doctors who treat children should be trained to know about [occult-evaluation] procedures when there is abuse suspicion,” he said.
In a commentary accompanying the study, Kristine Campbell, assistant professor of pediatrics at the University of Utah, suggested that follow-up research is necessary, as “no study reveals how often occult fractures provide the critical evidence to assure a child’s protection.”
Lyme Disease-Bearing Ticks Creeping Their Way Slowly South
Evidence is mounting that ticks carrying Lyme disease are spreading into North Carolina from Virginia.
By Rose Hoban
There are few diseases more controversial than Lyme disease.
The tick-borne virus has been the subject of debate over how many cases occur in the U.S. annually, the correct test and the correct treatment for chronic cases of the disease and whether the chronic form of the disease even exists.
But there are a couple of things that are less subject to debate: that you’re vastly more likely to get Lyme in the Northeast, where the disease was first identified, or in the upper Midwest, where it’s becoming more widespread.
Now there’s increasing evidence that Ixodes scapularis ticks bearing Borrelia burgdorferi, the bacteria that causes the disease, are becoming more common farther south, increasing the risk of contracting the disease in North Carolina.
Video showing the spread and geographical distribution of Lyme disease-bearing ticks since 2000. Maps courtesy CDC
A recent paper published by researchers from the Centers for Disease Control and Prevention mapped the geographic distribution of confirmed Lyme cases and data showing the geographic distribution of where I scapularis (commonly known as blacklegged ticks) were found to be carrying B. burgdorferi to define “high-risk” counties. The research indicated a slow, but steady, spread of increased risk areas extending down the Appalachians.
“Our results show that geographic expansion of high-risk areas is ongoing, emphasizing the need to identify broadly implementable and effective public health interventions to prevent human Lyme disease,” wrote the authors, who published their findings in the August issue of Emerging Infectious Diseases.
“Over the past 15 years, you can see a clear progression of the disease from the DC area along the foothills, almost to the North Carolina border,” said State Public Health Veterinarian Carl Williams. “We see cases reported in North Carolina in areas immediately south of what appears to be an emerging area in southwestern Virginia.”
Williams said he’s specifically concerned about Allegheny and Wilkes counties, and expects to start seeing the numbers of cases climb there.
“We’ve been in a position where Lyme disease cases were a much lower incidence rate here, but we’ve seen the incidence rate for Lyme really increase in Virginia,” Williams said.
“The real challenge in North Carolina is that we’re next to an endemic state,” said Duke University infectious disease researcher Paul Lantos.
Lantos said that a look at the epidemiology of Lyme in the Southeast since 2000 indicates that there are about 11,000 confirmed cases, and all but 1,000 of those are in Virginia.
“There’s been a dramatic expansion in Virginia over this time,” he said. “What we found is that northern Virginia has intensified, but there’s also been a rapid expansion down the Appalachians into Blacksburg and Roanoke possibly.”
Lantos also said ticks collected by researchers in Virginia back up the epidemiology.
Jory Brinkerhoff, a researcher at the University of Richmond, saw an increase in the number of Lyme diagnoses, and determined there were probably infected ticks in those areas.
When Brinkerhoff went looking, he found big populations of blacklegged ticks at higher elevations, and many of those were carrying B. burgdorferi.
“When you’re looking at case data, you take it with a grain of salt,” he said. “But corroborated with tick data, you can see there’s a lot of opportunity for infection because there are the ticks crawling around.”
But some say Lyme is much more prevalent in North Carolina than this research shows. Included among them is Marcia Herman-Giddens, who advises the Tick-Borne Infections Council of North Carolina.
Herman-Giddens, who teaches at UNC-CH’s Gillings School of Global Public Health, said part of the story of underdiagnosis has to do with how Lyme is diagnosed, using a two-step series of tests for antibodies that she said is overly strict, ruling out any cases where the reading might be equivocal.
In addition, she said, those borderline cases can be misinterpreted to mean there was no disease.
“There’s not a good test, and there’s not a test of cure,” she said, while allowing that it can be difficult to prove the absence of disease for most diseases. She noted that part of the problem with Lyme is that once someone is exposed to B. burgdorferi their bodies will make antibodies for years, which will then be detected on a subsequent test.
“People do stay positive for some of the [readings] of the test, sometimes for years,” Herman-Giddens said. “So one of the areas is that if people get sick again, and you get another tick bite, then it’s really a mess. They may have antibodies from a previous infection.”
She drew some comfort from an update sent to medical providers around the state by the North Carolina state epidemiologist this April. The memo reminded doctors that testing fewer than two weeks after a rash was not enough time for the antibodies to form.
That memo also noted the presence in North Carolina of another tick-borne disease that’s been dubbed STARI, for Southern tick-associated rash illness. But STARI is caused by the bite of a different species of tick, and researchers are still unsure of what bacteria actually causes it.
“[STARI is] impossible to distinguish from early Lyme disease,” Lantos said. “So I think a lot of cases in North Carolina are diagnosed as Lyme disease because you can’t distinguish between the two.”
Everyone agrees that having around more than one tick-borne bacteria that creates similar symptoms confounds the situation and adds to the controversy over identification, diagnosis and treatment for both diseases.
This year, the Centers for Disease Control and Prevention revised their estimates for annual Lyme disease diagnoses dramatically upwards. For years, the agency counted only cases reported by state health departments, tallying about 30,000 cases per year.
But looking at lab and insurance data yielded many more diagnoses, coming in at anywhere between 288,000 and 329,000 cases per year nationally.
While Herman-Giddens pointed to this revision as evidence of overdiagnosis, Lantos argued there are a lot of false positives in the testing for Lyme, and that people who really had STARI were treated for Lyme using powerful antibiotics, potentially causing harm.
“There probably are more cases,” Lantos conceded. “The range is getting larger and we are diagnosing it more and have more sensitive surveillance to capture more patients.”
Things people can agree on
No matter the controversies over diagnosis, everyone agreed that there’s more of an issue with tick-borne diseases. And all the researchers in North Carolina bemoaned the dismantling of the state’s public health entomology unit in 2011, after it was defunded by the General Assembly. The group had been tracking the presence and spread of insect-borne diseases in the state.
Now that Lyme is poised to really take off in North Carolina, such a group would be a valuable addition to the work of TickNET, a collaboration of academics and state and federal public health entities focused on tracking, researching and preventing tick-borne diseases.
Another point of agreement was that people need to do a better job at preventing tick bites. That includes wearing long pants into the woods and gardens, tucking pants into socks and using insect repellents like DEET.
“People don’t realize you have to rub the DEET into your skin,” Herman-Giddens said. She also has found that permethrin-impregnated clothing is effective at keeping ticks off of her when she leaves her Chatham County house to go into the woods.
She also suggested saving any ticks you pull off of yourself. She tapes the tick to a card and writes the date on it, along with the place on her body where it was biting.
“If you walk into a doctor’s office with a tick on a card, that makes a difference,” she said. “And if someone is knowledgeable, they can identify the tick.”
The guidance from the state epidemiologist noted that five North Carolina counties are now defined as “endemic,” meaning that at least two lab-confirmed cases have been identified in people who did not travel outside their county of residence during the month-long disease-incubation period. Those counties are Allegheny, Guilford, Haywood, Wake and Wilkes.
“A lot more is headed in this direction, and the ticks don’t know from Virginia,” Lantos said.
UNC Study Finds Rural Medicare Recipients Less Likely to Receive Follow-up Care
Many older patients discharged from rural hospitals end up back in a hospital bed too soon.
By Taylor Sisk
A team of UNC-Chapel Hill researchers has found Medicare patients in rural areas are less likely to receive adequate follow-up care after leaving the hospital than patients in urban areas.
As a result, they may well be at greater risk of winding up back in the hospital or the emergency room soon after discharge.
Matthew Toth, now a research public health analyst at RTI International, was lead author of the study, conducted while he was earning a doctorate in health policy and management at UNC’s Gillings School of Global Public Health and serving as a research assistant with the Cecil G. Sheps Center for Health Services’ N.C. Rural Health Research Program.
The results, published in the September issue of Medical Care, found that Medicare patients living in rural areas were 19 percent less likely to receive follow-up care within 30 days of leaving the hospital than those living in urban areas.
Patients discharged from hospitals in relatively smaller rural areas faced a 42 percent higher risk of being readmitted to the hospital within 30 days than patients discharged from hospitals in urban areas. Patients discharged from hospitals in larger rural areas were 32 percent more likely to be readmitted than their counterparts in urban areas.
Patients living in small rural areas were also 44 percent more likely to be seen in the emergency department within 30 days, while those in large rural areas were 52 percent more likely.
The study comes shortly after the release of the fourth year of federal data showing the 30-day readmission rates for most hospitals in the nation. This year, a majority of hospitals will face Medicare fines for having patients frequently return within a month of discharge.
Barriers to care
The UNC study looked at some 12,000 Medicare-eligible patients with hospital admissions between 2000 and 2010, using data from the Medicare Current Beneficiary Survey.
Toth pointed to workday schedules as a barrier to primary care for people who cannot get to the doctor during regular business hours. He suggested extending weekend clinic hours as a potential solution.
Toth and his colleagues also outline some potential policy initiatives to address the problems they found, including investment in telehealth, care management and transitional care and policies to enhance primary care services.
“Policymakers and researchers ought to continue to monitor the utilizations and outcomes among rural beneficiaries to better understand some of the specific barriers to care that they’re experiencing,” Toth said in an interview.
This could “help shape some of the payment and delivery-system reforms that are taking place in our health care settings,” he said.
CMS officials will penalize 2,592 hospitals across the country this year, all will receive lower payments for every Medicare patient admitted to that hospital for the coming year.
The penalties will be assessed starting in October. They’re mandated by the Hospital Readmissions Reduction Program, created as part of the Affordable Care Act to encourage hospitals to more closely monitor what happens to patients after discharge.
The hospitals penalized will lose a combined $420 million. The percentage of North Carolina hospitals that will be fined is higher than the national average: 68 percent compared with 54 percent.
Toth placed the results of his team’s study in the context of the Hospital Readmissions Reduction Program.
“Consistent with previous research on safety-net and low-volume hospitals, our study finds that rural hospitals serving elderly Medicare beneficiaries may be disproportionately penalized under this program,” he said in a press release announcing the results. “If so, poor readmission outcomes among these hospitals may be exacerbated.”
A deeper understanding of the reasons for the discrepancies between rural and urban areas could help inform efforts to improve care, he said. “For example, are patients of rural hospitals more likely discharged to under-resourced settings, or are there more likely gaps in post-discharge instructions in the inpatient setting?”
“Especially with new ‘pay-for-performance’ programs tying reimbursement to hospital performance on patient outcomes, [our] results highlight the need for policies to improve follow-up care for patients in rural areas,” he said.
Bad Health Outcomes for Adults Who Don’t Get Help as Teens
By Lisa Gillespie
Young people with health problems left uncared for in adolescence face higher risks of leading unhealthy lives as adults, a new study finds.
A study of 14,800 people found that the odds of adverse adult health conditions were 13 to 52 percent higher among those who reported unmet health needs as adolescents than for those who did not have unmet needs as teens but who were otherwise comparable. The study was conducted first in 1994-95 when many subjects were in their mid-teens, and again in 2008 when many were in their late 20s.
An article about the study was published Monday in Pediatrics, the journal of the American Academy of Pediatrics.
This isn’t the first study to find a link between health services for adolescents and better adult health, but past research relied on country-level data from sources such as the World Bank. The latest study is the most extensive one using individual data, said lead researcher Dougal Hargreaves, a research fellow at Boston Children’s Hospital.
Teenagers with depression whose needs were unmet then were one and a half times more likely to have depressive symptoms in adulthood than counterparts who received help in adolescence. Similarly, poor general health, functional impairment, missed work or thoughts of suicide in a person’s early years – if not addressed – are a predictor for those issues in later life, researchers said.
The study compared people who had reported unmet health needs in adolescence with subjects with similar adolescent health issues, insurance coverage and socioeconomic backgrounds but no unmet health needs.
There could be two reasons for unresolved teenage problems that carry into adulthood, the study’s authors wrote. One explanation might be that health care not provided in adolescence exacerbates a condition in adulthood – although they said they did not study that specifically. Another possibility is teenagers who don’t take care of their health follow the same habit as adults, the authors speculated.
Adolescence is a time when people begin to form attitudes about health and seeking help when it’s needed that stick with them for life. “Adult behavior may be influenced by experiences in childhood as well as adolescence,” the Pediatrics article said.
Adolescent subjects in the study often didn’t perceive their health needs as important. That was the most common reason those needs were not met. Cost was the least common reason, the authors wrote. Other reasons cited were teens’ fear of negative consequences if they sought help and their lack of confidence that their privacy would be protected.
“Oftentimes, we’re worried about financial access problems. But for adolescents, often the access challenge isn’t related to the ability to pay, but the ability to understand the importance of treating problems now and to find a trusted provider who can offer care in a nonjudgmental way,” said Matthew Davis, a professor of pediatrics at the University of Michigan.
Scott Benson, a child psychiatrist for 35 years in Pensacola, Fla., said the study reported in Pediatrics affirmed the stigma he sees many teen patients come in with. Many have no idea they have depression and wonder why they are sad. While many teens had depression symptoms in the study, he said outcomes could have gotten worse because they were not addressed early.
Hargreaves’ takeaway was that teens need to use services more easily, and get around the stigma of getting help, especially for mental illness. They should be able to talk with health professionals about subjects awkward to them, he said.
This story originally appeared in Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.
What to Do with 264 Billion Pounds of Coal Ash
UNC-Charlotte engineers are developing novel techniques to manage coal ash, but time is running short.
By Gabe Rivin
John Daniels claimed he could make water stand on a block of coal ash.
“Have I ever given you my little show-and-tell trick?” he asked, as he rushed to his cabinet. He returned with a chalky gray cylinder and a bottle of water. “Making stuff water repellent, to me, is just neat.”
Daniels laid two drops of water on the flat face of the cylinder. One droplet began to sink. Soon all that remained was a dark-gray spot.
But on the other side of the cylinder’s face, the water droplet remained globular and inert, repelled by a seal of water-resistant chemicals.
“If it’s water repellent, water’s not getting in,” Daniels said. “Water’s not getting in, water’s not getting out.”
Daniels is one of several engineers at UNC-Charlotte helping to answer a multi-billion-dollar question: What should Duke Energy do with its bounty of coal ash in North Carolina?
The ash, created when coal is burnt to produce electricity, has proven vexing for Duke, environmentalists and state lawmakers, all of whom are jockeying over its fate.
On one hand, the science seems clear. North Carolina’s coal ash is stored in large basins that are dug into the ground. These were constructed without liners, and so toxic metals in the ash, such as arsenic and chromium, can leach out of the basins.
The metals can find their way into subsurface water, or groundwater. This migration has the potential to contaminate drinking water for nearby residents who draw their water from wells drilled into the ground.
After a new round of tests near coal ash ponds, the N.C. Department of Environment and Natural Resources in April raised the possibility that coal ash is contaminating residents’ drinking water.
How to eliminate this threat though has been passionately contested, with some calling on Duke to move its ash to lined landfills and others saying that Duke can safely keep much of the ash where it is, provided that it’s dried out and covered up.
For either method, Duke faces an enormous engineering challenge. Duke’s surfeit of ash, a total of some 264 billion pounds, is also spread across 32 basins in the state, some of which are filled with water.
Duke also faces several tight timelines to close its sites.
All of which helps explain the urgency behind UNCC’s research.
Although North Carolina’s legislators prescribed much of Duke’s cleanup plan, there’s still a lot to learn about coal ash, the researchers say. And there are plenty of soon-to-be-proven methods to transform the ash, whether that means turning it into waterproof construction material or using it to build barriers that keep the rest of the ash dry.
In the lab
Milind Khire pointed at what looked like a metal drum, inside of which was a pair of metal arms.
“This is a geo-centrifuge,” he said. “We can actually create a prototype of a dam or a levy system here.”
Khire, another engineering researcher at UNCC, is planning to use the centrifuge with coal ash. By spinning wet ash at high speeds, he’ll be able to measure some of its fundamental physical properties. These include the behavior of water when ash is stacked in 200-foot piles, as may be the case at Duke’s landfills.
Khire said that much of this research is new.
“Very little strength and hydraulic property measurement has been done by anybody for coal ash,” he said.
And that’s a problem, he said, given some of the rushed deadlines for Duke’s ash basins. For three of its sites, Duke has until 2019 to dig up its coal ash and transport it to landfills.
But Khire said Duke should be given more time as engineers work to better understand ash and develop novel techniques to manage it in place, rather than shipping it to other communities.
Daniels, who has advised Duke on ash management, also criticized a one-size-fits-all approach to coal ash, such as environmentalists’ demand that Duke excavate and landfill all of its ash.
“The notion of excavating every site and putting it on a bunch of trucks – or even rail – and hauling it hundreds of kilometers or miles to some other far-flung site and entombing it is not necessarily the best approach,” he said. “Jumping from, ‘Every site has an impact, therefore excavate,’ to me is understandable, but it’s irresponsible from an engineering perspective.”
Daniels said novel engineering techniques could protect people’s health, at a fraction of the cost.
Those techniques may include deploying organosilanes, a chemical class that can render coal ash waterproof. Since 2007, Daniels has run small-scale tests using the compounds. He’s found organosilanes could efficiently transform large quantities of coal ash, allowing it to serve as a cover for ash ponds.
Khire is experimenting with a similar technique. By mixing coal ash with North Carolina’s soils, it’s possible to create a spongy material that keeps water out of an ash basin, he said. This too could serve as a cover for Duke’s ash.
Elsewhere in his lab, Khire is developing a technique that could improve Duke’s ability to pump water from its ponds. The technique uses charged electrodes to attract water while leaving behind the coal ash.
This technique would help Duke to dry out the ash so it doesn’t leach metals into groundwater. Combined with a waterproof cover, the ash would be protected from rain. Such a combination, the researchers believe, could protect the public’s health while saving enormous costs.
The problem with water tables
“The role of research and development in this entire process is really key,” Erin Culbert, a spokeswoman for Duke, said.
Culbert said researchers have extensively studied ash recycling; coal ash can be used to make concrete and wallboard, among other products. But closing ash basins “in a somewhat urgent timeline is really a place where we feel like there could be a lot of additional assistance and reconnaissance,” she said.
While Khire said Duke’s deadlines are needlessly rushed, environmental groups aren’t so patient.
D.J. Gerken, an attorney with the Southern Environmental Law Center, said that Duke and state regulators have known about these problems for years.
“When you start the clock from the time that Duke Energy and the state discovered that these ash pits were failing and contaminating nearby rivers, we are by no means on an aggressive timeline,” he said
He also argued that a system of dewatering and covering the ash, as Khire envisions, would not work. Many of Duke’s ponds were dug below the water table, the highest vertical level of groundwater, he said. And that means groundwater can flow into and out of ash basins, toxic compounds in tow.
Khire admitted this is possible. But he said Duke could still dewater and seal its ponds and continuously pump out any groundwater. He admitted this would be expensive though.
Gerken was skeptical of this plan.
“It is an engineering Band-Aid that must be continuously operated by Duke Energy forever if we’re going to protect groundwater and rivers,” he said.
Regardless of the method, Duke’s priority is to protect groundwater, the company’s spokeswoman Culbert said. When evaluating the options for a site, she said, Duke wouldn’t choose to cap an ash basin if doing so would allow for contamination.
Who will take it?
For now, state regulators have paused their work to determine the fate of Duke’s ash in response to a court fight between Gov. Pat McCrory and the General Assembly.
Nonetheless, Duke has plowed ahead. The company is beginning to excavate – or plans to excavate – 20 ash basins across the state. Duke says it will recycle the ash or transfer it to lined landfills. This meets the strictest requirements under the 2014 coal ash law.
But that hasn’t appeased some environmentalists. Several groups have protested Duke’s proposal to place ash in two abandoned clay mines, even though the ash will be blocked off with liners.
Gerken takes a different view. He said that while there’s no perfect solution for coal ash, “Having it in a modern, properly lined facility anywhere is better than having it in an unlined pit.”
And there’s still 264 billion pounds of waste – the byproduct made from powering refrigerators and air conditioners, North Carolina’s hospitals and homes for several generations – that remains to be disposed of safely.
And it has to go somewhere.
Study: Rural Black Women Suffer Less Depression
Southern African-American women who live in rural areas are far less likely to suffer from depression than those living in urban or suburban areas, a new study finds. For white women, geography appears to play less of a role.
By Emily Goldstein
Rural African-American women who live in the South are less likely to suffer from major depression than their urban counterparts, a research report published in JAMA Psychiatry says.
This is true even though black rural women are more likely to live in poverty and have lower rates of education – factors that are associated with the incidence of major depression.
While rural black women fared better with depression, rural white women, on the other hand, fared slightly worse, the study found.
The researchers speculate that the lower rate of depression among rural black women may be because these women have better systems of social support than the other groups considered in the study.
Researchers at the University of Michigan sought to understand how factors such as poverty and low rates of education affect mental illness among rural women. Overall, women are 1.5 to 3 times more likely to report being depressed than men.
The study used data gathered from the National Survey of American Life, a large, long-term study designed to explore racial and ethnic differences in mental health disorders.
Respondents were categorized by where they live, their race and whether they suffered from depression. The full sample used in the paper included 3,570 black women and 891 white women.
About 4 percent of rural African-American women in the South experienced depression at some point in their lives, versus about 10 percent for urban black women. (The data has been adjusted so it more accurately reflects the population the researchers sought to study.)
Suburban African-American women in the South had the highest rate of depression for blacks, at about 13 percent, though the margin of error in sampling could account for that difference. (The study had a standard error of 1.0 and 0.9 percent for rural and urban black women and 5.9 percent for suburban black women.)
Among white women in the South, geography appeared to play a less important role in predicting whether a woman had suffered depression at some point in her life. Depression was more prevalent overall among white women (ranging from 21 percent for rural white women to about 19 percent for suburban white women). But there was far less difference in rates of depression among rural, suburban and urban white women.
Overall, white women in the study were twice as likely as African-American women to have suffered from depression.
Although the relationship between depression and race is complex and multifaceted, the authors theorized that varying levels of social support networks between black and white women contributed to the findings.
Factors such as strong familial support and social ties, high levels of spirituality and a sense of solidarity with other rural women of color could contribute to the lower rates of depression, the study said.
The authors noted more research would be needed to better understand the needs of rural communities and to formulate successful intervention strategies.
NCGA Budgets Make Cuts in Biotech Funding
Cuts in both the House and Senate budgets have members of the biotechnology industry concerned.
By Rose Hoban
Driving through Research Triangle Park at night, it’s not uncommon to see the lights of the experimental greenhouses backlighting the trees.
Those lights, and those of other biotech companies that have made North Carolina home, have burned brightly over the past few years. However, proposed changes to state budgets at the General Assembly have people in the life sciences and research industries worried those lights may dim some.
At the top of the list of concerns are cuts made by the Senate in their proposed budget, which eliminates more than $12 million in funding for the North Carolina Biotechnology Center, as well as eliminating several tax credits used widely in the biotech industry.
Hits to biotech also come from the House.
“Both the chambers failed to extend the research and development tax credit,” said Sam Taylor, head of NCBIO, the trade association for the biotech industry in the state. “Thirty-eight other states have R&D tax credits. We’ve had one for as long as I can remember.”
Taylor said the research and development tax credit added up to about $44 million last year. He said other cuts to the budget are harder to put numbers to, such as a tax break on maintenance and repair of lab equipment. Formerly, businesses were charged only 1 percent sales tax for equipment, capped at $80 total. Now the fee goes up to the general state sales tax rate of 4.75 percent (with add-ons for county and municipal sales taxes), with a $500 cap on any sales taxes.
“It makes it harder for smaller companies to own and operate expensive research equipment,” Taylor said.
Filling the gap
One of the main purposes of the Biotechnology Center, established in 1989, is to provide grants and loans for biotech start-ups.
One particularly difficult period for fledgling firms – nicknamed the “valley of death” – is the time after grant funding for discovery runs out but before company leaders are able to take a product to market. Few venture capitalists, or even banks, will make loans at this point in a company’s development.
That’s where the Biotech Center has stepped in. The organization has given 239 business loans to 168 companies at that point in their development.
According to an analysis done in 2014 by the business analytics firm Battelle, 95 of those 168 companies are still operating in North Carolina, generating at least $1.9 billion and as much as $2.9 billion in revenues annually.
The same report calculated those revenues returned at least $45 million in state taxes and another $25 million in county and municipal tax revenues.
“North Carolina is a good example of states that create special initiatives,” said Brad Fenwick, a vice-president for academic publisher Elsevier, which presented on North Carolina’s research environment at the General Assembly in May. Fenwick, a veterinary pathologist, brought several ideas to market during his time in academia.
“I know that the private sector is increasingly risk averse,” Fenwick said. “They’re trying to control the risk, because if they don’t they get penalized by shareholders.”
Fenwick said R&D tax credits and loans made by organizations such as the Biotech Center “essentially help to reduce the risk threshold, and that allows industry to be more able to be engaged in taking a greater level of risk.”
Ted Voller, a professor at UNC’s Kenan Flagler School of Business, said the biotech industry is “hitting a real hard patch.”
To start, federal funding for basic sciences research is shrinking, making the competition for dollars even fiercer among universities where the basic research gets done.
Then there’s less money for the next step, translating basic science into products. Voller said part of the problem is that most venture capitalists don’t have the patience to invest in biotech.
“Life sciences investments take five to seven years to produce the return [venture capitalists] want,” he said. “Venture capitalists want to see turnarounds in three to five years. So they’ve vacated that market.”
On top of skittish venture capitalists, the pharmaceutical industry is also going through some big changes. Gone are the days of blockbuster drugs producing hundreds of millions in annual profit.
Instead, Voller said, pharmaceutical companies are looking to buy smaller biotech firms along with their intellectual property rather than develop new drugs themselves. He pointed to the recent downsizing at GlaxoSmithKline, where last month the company announced plans to lay off 150 more workers, after 900 were let go last year.
“Right now, we’re dealing with significant market restructuring,” Voller said. “This is when we need to shore up life sciences in the Research Triangle Park, because it’s one of our most competitive sectors.”
At the research presentation at the General Assembly in May, Barbara Entwistle, UNC-CH’s vice chancellor for research, told lawmakers the environment in North Carolina is enhanced by having strong ties between academia, industry and government.
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She argued that an essential part of the team is academic institutions that draw the scientific talent to North Carolina, and that they require some level of state support.
“The very best faculty have lots of options,” Entwistle said. “If you are really good at what you do, you get an email once a week, at least, enticing you to come some other place.”
She said the competition for talent and money is no longer just among cities in the U.S., but among other countries trying to develop biotech industries.
“If faculty were to leave, you cannot replace them,” Entwistle said. “It’s more cost efficient to just keep them here and have them not pay attention to all those emails enticing them away.”
She and Fenwick made the point that the state’s investments in research and infrastructure make it the kind of place where it’s easy for top talent to come.
But layering university cuts on top of cuts to state incentives can start to erode that vibrant research environment.
“The universities, as much as they are a powerhouse, they do the initial research; they don’t do the translation and testing to make products ready for market,” Voller said. “You need a bridge.”
He called biotech the “goose that laid the golden egg” for North Carolina, but expressed concern about the “stability and vitality of the Research Triangle early-stage biosciences market.”
“The early-stage fundamentals are not being supported, and we could lose our competitive edge,” he said.