March 26, 2010
NIH Podcast Episode #0106
Balintfy: Welcome to episode 106 of NIH Research Radio with news about the ongoing medical research at the National Institutes of Health—the nation's medical research agency. I'm your host Joe Balintfy. Coming up in this episode new information about sudden infant death syndrome and a link to serotonin; a knitting campaign to save newborn babies in Rwanda; and details on food allergy guidelines:
"Not just an academic text that someone will put up on their shelf in their library in their office, but actually have rolled up in their pocket and be using on a daily basis."
Balintfy: Plus a chance to comment on the guidelines. But first, this news update.
Balintfy: Scientists are reporting that breast cancer risk assessments to predict a woman's chance of developing breast cancer, do not perform better when they include common inherited genetic variants recently linked to the disease. Findings from studies to date have pinpointed several locations in the human genome where genetic variation is associated with cancer risk. But researchers say including these newly discovered genetic factors showed some improvement in the performance of risk assessments for breast cancer, but not enough improvement to matter for the great majority of women. Therefore, recommendations for breast cancer screening or treatments will remain unchanged for most women. The study, led by investigators from the National Cancer Institute, appears in a recent issue of the New England Journal of Medicine.
Although they emerged more than 90 years apart, the 1918 and 2009 pandemic flu viruses share a structural detail that makes both susceptible to neutralization by the same antibodies. Scientists at the National Institute of Allergy and Infectious Diseases suggest this detail might be exploited to design vaccines matched to future pandemic influenza virus strains. Researchers explain that ordinarily, antibodies made in response to one year’s seasonal flu strain do not fully react with seasonal flu strains that come along just a few years later. But in a set of experiments in mice, a vaccine made from inactivated 1918 influenza virus protected against the 2009 H1N1 virus. The reverse was true as well. Researchers say this provides understanding of how pandemic viruses evolve into seasonal strains, and provides direction for developing vaccines to slow or prevent that transformation. The research appears online in the journal Science Translational Medicine.
News updates are compiled from information at www.nih.gov/news. Coming up after this break, news about a serotonin link to SIDS, and much more. Stay tuned.
(BREAK FOR PUBLIC SERVICE ANNOUNCEMENT)
SIDS Linked to Low Levels of Serotonin
Balintfy: A new research study is showing that the brains of infants who died of sudden infant death syndrome or SIDS, produced low levels of serotonin, a brain chemical that plays a vital role in regulating breathing, heart rate, and sleep. Wally Akinso has the details.
Akinso: Infants who die from sudden infant death syndrome produce low levels of serotonin in the brain.
Dr. Willinger: The neurotransmitter, serotonin, is decreased in the brain stem of the babies who died from SIDS.
Akinso: Dr. Marian Willinger is the Special Assistant for SIDS research at the Eunice Kennedy Shriver National Institute of Child Health and Human Development.
Dr. Willinger: In this part of the brain the transmission of nerve impulses takes information from outside sensory information. For example, your temperature, how much carbon dioxide or oxygen that’s in your blood. And then it may tell the body to increase how you breathe or wake up.
Akinso: In a NICHD study, researchers theorize that this newly discovered serotonin abnormality may reduce infants’ capacity to respond to breathing challenges, such as low oxygen levels or high levels of carbon dioxide. Dr. Willinger talks about what these high levels may result from.
Dr. Willinger: If a baby's face is covered by bedding they may re-breathe their expired air and that expired air is rich in carbon dioxide and low in oxygen, that is what you breathe out.
Akinso: Researchers analyzed brain tissue from infants who died from SIDS and controls that died of other causes. Included in the analysis were 35 infants who died of SIDS, five infants who died unexpectedly of other causes, and five infants who were hospitalized and died for reasons associated with lack of oxygen.
Dr. Willinger: In SIDS babies, they had lower levels of serotonin in about 26 percent lower level, in the brain stem. They also had lower levels of an enzyme called tryptophan hyroxylase, which makes serotonin. So their ability to make serotonin was reduced.
Akinso: Dr. Willinger says the current findings provide important clues to the biological basis of SIDS and may ultimately lead to ways to identify infants most at risk.
Dr. Willinger: We may have specific information on deficits in the baby but we need to do a lot more work. We need to understand how low serotonin levels in the brain actually translate to initiating a process that leads to death in these babies.
Akinso: Dr. Willinger hopes that these findings will one day lead to a test that measures infants’ serotonin in the blood or other tissues that reflect brain serotonin levels. For information on SIDS, visit www.nichd.nih.gov. This is Wally Akinso at the National Institutes of Health Bethesda, Maryland.
Rosenberg Launches Cap Campaign to Save Newborns
Balintfy: Another risk factor for babies is hypothermia; that’s when the body temperature drops below 95-degrees Fahrenheit. Alice Rosenberg is a registered nurse specialist who developed and now helps manage NIH’s collaboration with the D.C. department of health to fight the District’s HIV/AIDS epidemic. She has volunteered to coordinate a knit-a-cap campaign to protect infants in Rwanda from hypothermia. Belle Warring brings us the story.
Waring: The brain of a newborn baby is too immature to maintain body temperature. Even a healthy, full-term infant has few defenses against cold stress. If an infant’s temperature dips too low for too long, cold injury can trigger a chain reaction that results in hypothermia, an abnormally low body temperature which can end in death. That’s why delivery room nurses slip stockinette caps onto newborn heads. But not everywhere. At the request of the nonprofit organization Partners in Health, registered nurse specialist Alice Rosenberg has volunteered to coordinate a knit-a-cap campaign to save infant lives in Rwanda.
Rosenberg: My youngest daughter worked for three years for Paul Famer at Partners in Health and she sent me an email and said ‘Mom, there’s babies in our hospitals in Rwanda that are dying of hypothermia, and they need hats. Do you think you could knit some?’ I said, ‘Say no more!’ And I started a small network among friends and in a couple of knitting shops in Bethesda and have so far acquired 280 hats and sent them off to Partners in Health to be distributed in Rwanda.
Waring: Rwanda, in east-central Africa, is near the equator. Yet because it’s in a mountainous region, Rwanda gets cold. Preemies are especially vulnerable, but even full-term newborns need caps.
Rosenberg: No baby should die because they’re cold. This is a third world nation that’s been through a horrendous genocide ten years ago, and I can’t help with a lot of things, but I can help with babies. That’s a simple connection for me. And I’m happy to do it. Rwanda is still pretty rough, and still without resources and the hospitals in rural settings are really unsupplied. And this is easy and it feels good. It doesn’t take any time or money.
Waring: Even though she works full-time managing NIH’s collaboration with the D.C. department of health to fight the District’s HIV/AIDS epidemic, Rosenberg finds time to knit.
Rosenberg: When I’m at home I knit during a football game, or a movie, when I’m talking on the phone. It’s very comforting, it’s peaceful if I take an airplane trip I knit when I’m on the plane. It takes me about an hour to make the smallest one for the smallest preemie and it takes about two hours to make the largest one.
Waring: Her project, though it’s starting small, is about global health. Dr. Francis Collins has described global health as an area he wants to focus on while serving as NIH Director.
Rosenberg: I’ve talked to Dr. Collins about global health many times and he is very interested. It’s an interest that I think most people in medicine have now, or at least have an eye on it. There are a lot of things in the world that need fixing and I can’t be in Haiti fixing their troubles, but I can knit hats for the babies in Rwanda.
Waring: Rosenberg says she’s happy to hear from anybody who wants help out with the knit-a-cap campaign. She can be reached via email at firstname.lastname@example.org. This is Belle Warring, National Institutes of Health, Bethesda, Maryland.
Balintfy: Thanks Belle. Again Alice Rosenberg’s email if you’re interested in knitting a hat is email@example.com. Coming up after this break, another opportunity for feedback, this time about food allergy guidelines.
(BREAK FOR PUBLIC SERVICE ANNOUNCEMENT)
Public Comment Sought On Draft Guidelines for the Diagnosis and Management of Food Allergy
Balintfy: The National Institute of Allergy and Infectious Diseases is seeking public comment on a draft publication: "Guidelines for the Diagnosis and Management of Food Allergy." The public comment period is open for 60 days from March 8 to May 6. Health care professionals and interested members of the public are encouraged to review the guidelines and participate in the open comment period. But what exactly are the "Guidelines for the Diagnosis and Management of Food Allergy?" I talked to two experts: First, Dr. Joshua Boyce, associate professor of medicine at Harvard, and co-director of the Research Section on Inflammation and Allergic Diseases in the Division of Rheumatology, Immunology and Allergy at Brigham and Women’s Hospital. He is also chair of the expert panel that developed the guidelines. Also, we’ll hear from Dr. Matthew Fenton, chief of the Asthma, Allergy and Inflammation Branch at NIAID. You heard Dr. Fenton at the start of the show. Here’s how he explains why the guidelines were put together.
Dr. Fenton: There already, over the years, have been practice guidelines, clinical practice guidelines, for food allergy that have been generated, but they’ve been largely generated by allergists and used by allergists. And we recognize that this is a clinical condition that’s seen by physicians across a wide variety of specialties: pediatrics, pulmonary medicine, dermatology, emergency physicians. And we were—we became aware that the physician community really needed to be brought up to speed on the current understanding of the state of science in food allergy, the current methods for diagnosing this disease and managing this disease, and to be very consistent in terms of how these patients are evaluated, and be able to provide the most optimal care as a consequence of that.
Dr. Boyce: Speaking from the perspective of somebody who does some clinical allergy.
Balintfy: That’s Dr. Boyce who says many of the referrals that he sees are for children who have been identified as potentially food-allergic by their pediatricians. Based on a history of a reaction, the kids are subjected to a bunch of tests, then. . .
Dr. Boyce: Found to be at risk for allergy to multiple foods. And it’s then our job as food allergists to sort of sort through what’s real and what, in fact, is just an abnormal laboratory value.
Balintfy: Dr. Boyce points out that food allergy has become an increasingly important public health problem with all of the available data suggesting that there’s been an increase in the prevalence of food allergies, particularly in children. So Dr. Boyce agrees that guidelines are a way to get the clinicians all on the same page to help identify and treat food allergy. But how do you do that? Again Dr. Fenton:
Dr. Fenton: Well, we organized a workshop a little over two years ago that had as members of the group more than 33 different professional societies, patient advocacy groups and federal agencies that participated in a round table discussion to address the question: Do we need food allergy guidelines? What’s missing in the current guidelines? And how can we improve the product and deliver better health care as a consequence? And the decision that the group made was that what was really needed was something that was feasible, usable, short, sweet, and to the point that could picked up and used by a family practitioner in an urban or rural area, a specialist working out of a hospital, or a nurse practitioner working in a neighborhood clinic. And we wanted to be able to address all of those health professionals’ needs using a single document.
Balintfy: A single document, but many sections. Again, Dr. Boyce:
Dr. Boyce: So, the sections are, a section on definitions of food allergy, what is a food allergy, what’s an allergen, what are the foods that cause allergy, what are the diseases? There was a section on natural history. What happens to food allergy once you’ve got it and does it matter if it’s peanut or milk or egg? And we know the natural histories of those food allergies are quite different from one another. There was a section on diagnosis. How do you make a diagnosis of food allergy? What are the appropriate tests? When do you prove the presence or absence of food allergy based on an oral challenge test? And the fourth section was on management. What do you do to manage food allergy once you’ve made the diagnosis? And then the last section was treatment of acute, severe reactions to food, namely, anaphylaxis.
Balintfy: Anaphylaxis is a severe, whole-body allergic reaction. Though rare, it is life-threatening. So the guidelines are based on solid, scientific research.
Dr. Boyce: First of all, it began with a thorough and critical evaluation of the world’s literature, and that was conducted by an outside contractor so as to maintain objectivity.
Dr. Fenton: So, the strength of these guidelines comes from the fact that they’re based on a body of evidence.
Balintfy: Twelve-thousand documents’ worth of evidence says Dr. Fenton.
Dr. Fenton: And it was based on that body of scientific literature that the expert panel of physicians that we helped to assemble, who draft these guidelines, would use this literature as a scientific evidence base from which to create the document.
Balintfy: Though the guidelines are designed for physicians, specialists, and nurse practitioners, this information will ultimately benefit the patient. Dr. Fenton adds that there’s a patient- and family-friendly synopsis in the works as well.
Dr. Fenton: Absolutely, because we feel that the best way to provide care in this area is not only to have the physicians using a feasible, practical document that’s shared across the various specialties, but also to have the patients be informed and be able to work with their health care professional to get the most out of the document. So, in order to achieve that goal, we’re preparing, in parallel with the guidelines, a patient and family-friendly synopsis, which will explain in plain English what the various issues are and the topics addressed in the guidelines and to kind of work through, in terms that don’t use a lot of technical jargon, what the pros and the cons of the various points regarding diagnosis and management of food allergy would be as it applies to patients and their families.
Balintfy: But the guidelines are not quite finished. There is a public comment period going on now until May 6. Dr. Fenton explains.
Dr. Fenton: The guidelines, as I mentioned before, were drafted by a panel of 25 health care professionals, and NIAID facilitated that process, but it was important to get the opinion of the public — both professionals in the health care field, patients, their families, policymakers — and have them really look at this draft document and say, "Is this understandable? Is this feasible? Does this make sense from a health delivery point of view?" and make sure that we were able to answer those questions, resolve any ambiguities and provide something that’s very clear and useful.
Dr. Boyce: And I think that what we all hope for in the food allergy committee is that one of the things that we accomplish in this process, aside from, you know, providing a template for clinical practice, is to identify the areas where there needs to be more study and where there are scientific gaps and where research resources need to be directed so that we have a more thorough understanding of what are the causes of food allergy and what are the effective ways of treating it.
Balintfy: Dr. Boyce adds that while he anticipates that most of the guidelines’ information will probably be filtered through physicians, he hopes that there will be less fear and anxiety about food allergy for the general public.
Dr. Boyce: I think that the take-home message for the lay public is that there are clearly proper ways of making the diagnosis of food allergy, that simply having a positive test in the absence of a good clinical history does not mean you have a food allergy -- I think that’s been a major source of confusion about this process -- that there are diagnostic tests that are very robust and valid and some that are not so robust or valid, and that there are some nutritional practices that have been sort of widely adopted to try to prevent food allergy where there’s really no clear-cut evidence base.
Balintfy: Dr. Boyce draws a comparison between these food-allergy guidelines and the guidelines for the diagnosis and management of asthma. Over the 20 years of existence for those guidelines, he says they’ve gone through several iterations and revisions, because when the asthma guidelines were first put together, there were still key research questions left unanswered. He and Dr. Fenton expect the food-allergy guidelines to be updated in the future as well, but hope to have this first set out soon.
Dr. Fenton: Well, we’re hoping to complete the 60-day public comment period, analyze those comments, incorporate ones where they’re needed, and to prepare a final document by the summer. We then go back to a group called the coordinating committee that oversees this whole process, and we get them to review the final product, and they will, in the end, approve it and endorse it, and then it’s ready for public release, so, end of the summer, maybe the fall.
Dr. Boyce: And it will be distributed through the NIH website. It will also be published as a supplement in the "Journal of Allergy and Clinical Immunology," and it will be available as a hardcopy document.
Balintfy: That’s Dr. Joshua Boyce at Harvard and Dr. Matthew Fenton at NIAID. If you’d like more information on the Draft Guidelines for the Diagnosis and Management of Food Allergy, the easiest way to get details is to visit the NIAID home page, www.niaid.nih.gov, and search "food allergy public comment." Or, here’s the link: www.niaid.nih.gov/topics/foodAllergy/clinical/comments.htm. Your comments are welcome.
Balintfy: And that’s it for this episode of NIH Research Radio. Please join us again on Friday, April 9 when our next edition will be available for download. If you have any questions or comments about this program, or have story suggestions for a future episode, please let me know. Best to reach me by email—my address is firstname.lastname@example.org. I'm your host, Joe Balintfy. Thanks for listening.
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