April 23, 2010
NIH Podcast Episode #0108
Balintfy: Welcome to episode 108 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 two reports important to moms: news on vitamin supplements, and delivery options; also a couple reports on HIV/AIDS: stopping the virus and stepping up awareness; plus the importance of taking medications they way you’re supposed to. But first, this news update.
Balintfy: Scientists have developed a brain implant that essentially melts into place, snugly fitting to the brain’s surface. Researchers say these implants have the potential to maximize the contact between electrodes and brain tissue, while minimizing damage to the brain. This current study in animals gives researcher hope there may be applications for epilepsy, spinal cord injuries and other neurological disorders in the future. Right now, this silk-based technology can already record brain activity more faithfully than thicker implants.
Also, the traditional ‘Heel Stick’ test is not an effective screening tool for a leading cause of hearing loss in children. About 20,000-30,000 infants are born infected with cytomegalovirus, CVM for short. Of those babies, roughly two- to four-thousand are at risk for eventually developing hearing loss. Researchers say that because the heel-stick is a simple test already being used to screen for other diseases in newborns across the United States, it seemed like a good candidate for a possible universal screening program for CMV. However, study findings show that, at least with current technologies, the heel-stick test should not be used as a primary newborn screening tool for CMV.
News updates are compiled from information at www.nih.gov/news. Coming up next, how vitamin C and E supplements do not reduce risk for blood pressure disorders of pregnancy, and new insights on something called VBAC. Plus HIV/AIDS, and adherence. More next!
(BREAK FOR PUBLIC SERVICE ANNOUNCEMENT)
Vitamin C and E Supplements do not Reduce Risk for Blood Pressure Disorders of Pregnancy
Balintfy: In last episode’s news segment, I mentioned a study where researchers found that taking some vitamin supplements during pregnancy does not reduce the risk for some pregnancy complications. Wally Akinso has more details in this report.
Akinso: Vitamin C and E supplements failed to reduce the risk of preeclampsia, a potentially fatal form of hypertension in pregnancy, according to a National Institutes of Health study.
Spong: Taking vitamin C and vitamin E supplements do not reduce the risk of either hypertension, the complications associated with hypertension in pregnancy, or preeclampsia.
Akinso: Dr. Catherine Spong is the Chief of the Eunice Kennedy Shriver National Institute of Child Health and Human Development's Pregnancy and Perinatology Branch and co-author of the study.
Spong: We found this out because we do a very large randomized control trial of over 10,000 women who were relatively low risk meaning they didn't have problems such as hypertension or diabetes or other medical things that can increase your risk for developing preeclampsia.
Akinso: The findings appear in a recent issue of the New England Journal of Medicine. Dr. Spong explains how the study worked.
Spong: These women were randomized either to the vitamin C and vitamin E or to a matching placebo. They were then followed throughout their pregnancies and evaluated to determine whether or not they developed pregnancy induced hypertension complication to associate with hypertension or preeclampsia.
Akinso: The findings are in contrast to suggestions in some previous small studies that the vitamins could reduce the risk of preeclampsia. Dr. Spong adds that the study was conducted at 16 sites within the NICHD’s Maternal-Fetal Medicine Units Network.
Spong: So the Maternal-Fetal Medicine Units Network undertook this study to look at the largest group of women, who were at risk for preeclampsia, women in their first pregnancy, to determine whether or not vitamin C and vitamin E would be beneficial in preventing preeclampsia. Not only did we find no benefit for treatment with vitamin C or vitamin E, there was also another trial ongoing in Britain where they looked at high risk women, women with diabetes or hypertension or women who were obese. And they found not only that vitamin C and vitamin E were not beneficial they actually found a higher rate of smaller babies and of hypertension in the women who received the vitamin C and vitamin E.
Akinso: Dr. Spong says these results are very useful because they show researchers that what originally appeared to be a promising treatment did not actually offer any benefit clinically. Major funding for the study was provided by the NICHD, the National Heart, Lung, and Blood Institute, and the National Center for Research Resources. For more on the study, visit www.nichd.nih.gov. This is Wally Akinso at the National Institutes of Health Bethesda, Maryland.
Vaginal Birth After Cesarean: New Insights
Balintfy: For most of the 20th century, once a woman had undergone a cesarean delivery, or c-section, clinicians believed that her future pregnancies also required cesarean delivery. In the 1980s through 1996, the option for a woman with a previous c-section to attempt a trial of labor was offered and exercised more often. But beginning in 1996, the number of VBACs as they’re called – short for vaginal delivery after cesarean – has declined, contributing to the overall increase in cesarean delivery. Anahita Hamidi reports on an independent panel convened recently to review and assess currently available data regarding VBACs.
Hamidi: Most women who deliver their first child by cesarean will opt to do the same for subsequent pregnancies. A panel of scientific experts convened by the National Institutes of Health, met recently to assess currently available data on vaginal birth after cesarean in a State-of-the-Science conference entitled: Vaginal Birth After Cesarean (VBAC)—New Insights.
Cunningham: This was stimulated by the obviously well-known rising cesarean section overall in this country, as well as the world, and we know that a primary cesarean (or one for the first time) will begat other cesareans and this has created some problems.
Hamidi: Dr. Gary Cunnningham is Chair in Obstetrics and Gynecology at the University of Texas Southwestern Medical Center at Dallas and served as the Panel Chair for the conference. He points out that, in some cases, women who have previously delivered via cesarean are not even given the option to attempt a vaginal birth—commonly referred to as trial of labor.
Cunningham: Another problem has been the voice of many women who have bemoaned the fact that they have not had access to care where a trial of labor can be offered as an alternative to an operative delivery and this, of course, is mirrored by the fact that the VBAC rate in the United States is diminished in the last almost fifteen years to 30 percent from about 10 percent — which is a marked change.
Hamidi: While the panel was clear in stating that their report should not be referenced as a set of guidelines, but rather as a consensus report, they did acknowledge that previous data indicates VBACs should be considered a safe alternative. The panel also pointed out that while VBACs are generally safe, the risks for pregnant woman must be weighed in combination with their individual health status. In particular, women who have had a low-transverse uterine incision—as opposed to the older and less popular vertical incision method—are considered to be a lower-risk group for a VBAC.
Cunningham: What we found was that the use or the employment of a vaginal delivery after caesarean with a trial of labor is certainly a safe alternative for the majority of women who have had one prior cesarean section, assuming that it’s of so-called low-transverse variety.
Hamidi: The panel also identified a variety of obstacles that may, in part, explain the significant decline of VBAC deliveries that ranged from fear of worst-case scenario complications to physician fears of medical malpractice lawsuits.
Cunningham: For example, we found that there is a medical/legal consideration that puts up some of these barriers. This is generated by the rather large awards that occur only rarely with bad outcomes to babies. And the fear of this has driven a lot of providers out of the business or the practice of offering VBAC because of those rare, but catastrophic, complications.
Hamidi: The panel concluded that given the available evidence, trial of labor is a reasonable option for many pregnant women with a prior low transverse uterine incision. The panel's complete and updated draft state-of-the-science statement is available at consensus.nih.gov. This is Anahita Hamidi, National Institutes of Health, Bethesda, Maryland.
Closing the Implementation Gap to Stop HIV/AIDS
Balintfy: Now some news on HIV/AIDS. Treatments to battle the epidemic have advanced significantly in the past two decades. Researchers say implementing strategies to reach certain minority populations, like those suffering from drug addiction, are still necessary to close the gap and stop the disease. Jeff Levine files this report.
Levine: Can people addicted to drugs be treated for AIDS in spite of their struggle against two diseases? For Dr. Julio Montaner the answer is unequivocally yes. And he says it's crucial to controlling the epidemic.
Montaner: Why are we not doing what we're supposed to be doing which is to offer treatment to the people who need treatment?
Levine: Montaner heads the International AIDS Society and serves as clinical director of a major AIDS research and treatment program in Vancouver, Canada. Much of Montaner's work is supported by the Canadian government as well as the National Institute on Drug Abuse at NIH. Montaner makes the case for what he calls the "treatment as prevention" approach. He points out how his studies of Vancouver patients along with other research shows the value of treating patients many think are likely to fail.
Montaner: We have been able to show as a result first decreased morbidity and mortality related to AIDS, among these populations which are extremely important. But secondly, we showed that the clinical benefit that they derive is the same as the non-drug user. And thirdly, a societal benefit that is equally important is that we saw a fifty percent decrease in new HIV infections among drug users. So, the treatment is working better for the patients and it's working better for society.
Levine: Montaner emphasizes that his results clearly show that, when it comes to HIV/AIDS, treatment means prevention.
Montaner: The data is all in; the mathematics are sound; the cost effectiveness is a no-brainer; the benefit to the individual is absolute. Listen, let's be clear. I'm not talking here about treating people who do not have a medical indication for treatment. I am specifically saying that we need to make our treatments accessible to 100 percent of those who have a medial indication for treatment. If we don't address the epidemic in these minorities, whether it's sex trade workers or substance users or homosexual minorities or racial minorities, we will not be able to address the epidemic.
Levine: Montaner says he will work with NIDA Director Dr. Nora Volkow and others to press the case for expanding HIV treatment to drug abusers worldwide at the International AIDS Conference in Vienna this July. He spoke recently at a lecture on the NIH campus. For more information on drug addiction, visit www.nida.nih.gov; and for details on AIDS research, visit www.niaid.nih.gov. This is Jeff Levine, National Institutes of Health, Bethesda, Maryland.
HIV/AIDS AwarenessBalintfy: Awareness of HIV/AIDS prevention, and treatment tools to combat the epidemic, are key for a variety of populations. Jillian Mitchell reports on some campaigns.
Mitchell: African-Americans have the highest HIV/AIDS rate among all racial and ethnic groups in the United States. The virus also continues to affect women and teenage girls disproportionately. Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, emphasizes the importance of awareness.
Fauci: We have a program that we have, what's called a DC NIH Partnership, in which we're partnering with the Department of Health of the District of Columbia, to test the feasibility of seeking out testing and treating and getting into care those who are HIV infected, we're doing it with a sister city, the South Bronx in New York City.
Mitchell: Inner city areas have a higher prevalence of infection and the chances for an individual coming into contact with someone who is HIV/AIDS positive is far greater than in other communities.
Fauci: One of the important issues that has arisen over the past months to a year now is the importance of treating people early in the course of infection. So we need to implement programs in which we can access and test as many people as we possibly can test on a voluntary basis.
Mitchell: Dr. Fauci says that if treated early, infected individuals are more likely to lead healthy lives than individuals who receive treatment later. Additionally, early treatment can lower the viral load in an infected individual, thus decreasing the chance of transmitting infection to others. The key is prevention, treatment and care.
Fauci: If you’re infected you could be getting under therapy. You could be counseled. And if you’re not infected, we can counsel you about how to avoid infection. So testing is the message.
Mitchell: For more information about HIV/AIDS visit, www.niaid.nih.gov. This is Jilliene Mitchell, National Institutes of Health, Bethesda, MD.Balintfy: Whether is HIV/AIDS meds or 10-day’s worth of antibiotics, up next the importance of taking drugs as prescribed. Stay tuned!
(BREAK FOR PUBLIC SERVICE ANNOUNCEMENT)
The Health Consequences of Low Adherence among Practitioners and Patients
Balintfy: Adherence is a term that refers to the extent to which a person who’s been given a prescription for a medical condition takes the prescription as it was intended. In other words, are you taking your medications the way you’re supposed to? I talked with Dr. Brian Haynes, from McMaster University in Canada while he was here at NIH. Isn’t adherence one of the most important aspects of prescriptions?
Haynes: It’s probably the biggest barrier to people getting value for money out of the treatments that they’ve been prescribed because about half the people drop out of care before they’ve had benefit, and of the people who stay in care, half of them don’t take the treatment in large enough dosage to get the benefit that that treatment would have.
Balintfy: So Dr. Haynes, one example if I’ve been prescribed antibiotics for ten days and don’t finish it, are there risks?
Haynes: Yes, there are some conditions for which if you don’t take the whole treatment you have risk of recurrence and antibiotics for 10-day course for, say, strep throat would be one of those examples. Typically, people stop the treatment when they start to feel better, and that’s not enough to eradicate the organism.
But the main problem these days is with chronic diseases where the treatment had to be taken essentially for the rest of the person’s life: for high blood pressure, for high lipids, for diabetes, for congestive heart failure, other sorts of medical conditions. And for those the problem exists in the same degree as it does for the short-term treatments, but the consequences are often even more severe.
Balintfy: What is important for a health care provider to understand about adherence?
Haynes: Health care providers first of all need to recognize the problem and frequently they don’t in their own patients. The patients don’t tell them voluntarily, and the physician often doesn’t ask, or at least ask in a way that makes it possible for the patient to state what they’re doing. And often when there isn’t an appropriate treatment response, the physician assumes either the treatment’s wrong or it needs to be given in a bigger dose, when, more often than not, it’s actually the patient not taking the treatment as prescribed.
Balintfy: When a person goes to the doctor for care, why doesn’t he or she always follow the doctor’s advice?
Haynes: Patients have many reasons -- they have their doubts about whether they have the condition, they have their doubts about whether they’ll get adverse effects from the treatment and that those adverse effects will be worse than the disease itself or the treatment that can benefit them. And they may not be able to afford the medications or not have high enough priority compared with other competing things for their resources, and so on. So they have a variety of reasons. Often they don’t want to have the disease. They go into denial. They’d just rather not deal with it. So there’s lots of reasons why people might not take the treatment as prescribed.
Balintfy: Then what can you tell a medical care provider so they can help patients take their medicine properly?
Haynes: There are a number of things practitioners can do. First of all, prescribe treatments that are known to be effective, that’s an obvious one. The second one would be to ask the patient at each visit if they’re having any difficulty following the treatment, and during the past week, for example, have they missed any of their tablets for the treatment. About half the people will—who are not taking the treatment—will let the practitioner know that that’s the case, in which case the physician can go into more detail about the reasons for that and see if there’s some alternatives that might be more satisfactory, or encourage the patient to carry on with the treatment.
Physicians often don’t pay much attention when patients don’t show up for appointments, but that’s a pretty strong signal that the patient isn’t following the treatment so really that needs to be paid attention to. Physicians can help patients follow the treatment by—obviously by telling them how well they are doing and what needs to be done to get to the next level of success with the treatment, and give them reinforcement for what they’ve done to try to follow the treatment program, and also by not making the treatments too complex. For a condition like diabetes, for example, the regimens can get terribly complicated. They start with exercise and diet and then they go on to many medications for the diabetes, for the high blood pressure, monitoring your blood sugar, monitoring your lipids, and so on. So, if practitioners had to take their own medicines, they probably wouldn’t follow them very well either. Really need to be practical about what is possible to do, and work with the patient to find a regimen that they can follow as closely as possible.
Balintfy: Dr. Haynes, it sounds like communication is one of the key aspects regarding adherence?Haynes: It is a key and, in fact, patients need to do their part on this. For example, there was a study that showed that the better a patient liked their practitioner, the less they were likely to tell them if they weren’t following the treatment because they didn’t want to offend their physician, presumably. So that’s not going to be a very good—a very successful formula for getting benefit out of the treatment. And really the patient, if they’re not following the treatment, needs to find a way to communicate that to the practitioner, and try to figure out if there’s alternatives that might work better for them.
Balintfy: One last question: Has adherence changed?
Haynes: Well, I think the major difference nowadays compared with the past is that we have so many treatments that are effective. In the past, you’d almost say that non-adherence was an act of self-defense because a lot of treatments weren’t all that good, or they did more harm than good. But nowadays we have many, many treatments that do more good than harm. And we haven’t actually changed the way that people follow those treatments very much. We don’t know enough about it. We haven’t been successful in finding ways to help people that are any better than we had in the old days, so there’s a bigger gap now between what current medical treatments could accomplish if people took them and what’s actually happening on the ground, and I think that it is a major area that we need patients’ help to sort out. So people ought to speak up and, if they don’t like the treatment, tell the doctor. If they’re not following it, they should certainly let the doctor know that, and try to look for alternatives that they can work with that will get them better success with the treatments that are available.
Balintfy: Thanks to Dr. Brian Haynes, from McMaster University. He presented at NIH as part of the NIH Behavioral and Social Sciences Seminar Series. For more on his topic The Health Consequences of Low Adherence among Practitioners and Patients, visit the Office of Behavioral and Social Sciences Research website at obssr.nih.gov.
Balintfy: And that’s it for this episode of NIH Research Radio. Please join us again on Friday, May 7th when our next edition will be available. 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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