June 04, 2010
NIH Podcast Episode #0111
Balintfy: Welcome to the one-hundred-eleventh episode 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 with findings important to infants: first regarding food allergy, then about a potentially blinding eye condition. Later, in-depth insights on the future of primary care—research is leading to new ideas about healthcare. But first, this news update.
Balintfy: A team of scientists has developed a new treatment that protects mice from a particular bacterial infection, also known as rabbit fever. This new experimental therapy works by stimulating the host immune system to destroy the invading microbes. This is different from traditional treatment with antibiotics—they work by directly attacking invading bacteria. Frequent use of antibiotics often leads to microbes developing resistance to these medications. This new therapeutic has the potential to enhance the action of antibiotics and provide an alternative to them.
In a major study, investigators have compared how individuals with Parkinson's disease respond to deep brain stimulation at two different sites in the brain. Contrary to current belief, patients who received deep brain stimulation at either site in the brain experienced comparable benefits. Parkinson's disease belongs to a group of conditions called motor system disorders, which are the result of the loss of dopamine-producing brain cells. Researchers say these study results show that deep brain stimulation at two different places in the brain can have equivalent effects on tremor, stiffness and other motor symptoms of Parkinson’s disease.
And volunteers are being sought for a clinical study examining the subtle changes that may take place in the brains of older people many years before symptoms of Alzheimer’s disease appear. Alzheimer’s disease is an irreversible, progressive brain disease that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks of daily living. Researchers are looking for people with the very earliest complaints of memory problems. To volunteer or learn more about the study, contact the NIA Alzheimer's Disease Education and Referral Center by calling 1-800-438-4380 or by visiting www.nia.nih.gov/Alzheimers
News updates are compiled from information at www.nih.gov/news. Coming up next information about infants on allergy and blindness. Plus the medical home later. Stay tuned.
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In Infants with Egg or Milk Allergy, Can Future Peanut Allergy Be Predicted?
Balintfy: Welcome back to NIH Research Radio. Preliminary results from a study of infants with egg or milk allergy is showing that those babies are highly likely to test positive for antibodies associated with peanut allergy. This unexpected finding suggests that these infants are at risk for developing peanut allergy later in life and should be evaluated by a health care professional before introducing peanuts into their diet. Elizabeth Goers files this report:
Goers: Early results in a study involving more than 500 infants show that infants who are already allergic to milk and/or egg are at high risk for developing a peanut allergy. Dr. Marshall Plaut is the Chief of the Allergic Mechanisms Section, Asthma, Allergy and Inflammation Branch with the National Institute of Allergy and Infectious Diseases.
Plaut: The purpose of this study is to look at the natural history of development of allergy to milk, egg and peanuts, and we started out with infants who were at high risk of development of peanut allergy in the hope that we would be able to look at certain measures that would correlate those who do develop peanut allergy and those who don't develop peanut allergy as well as those who start out with milk allergy and lose it.
Goers: Researchers enrolled infants between 3 and 15 months old for the ongoing observational study.
Plaut: There were two criteria for entry into the study either they had a known allergy to milk and/or egg because they had had a reaction to them, or they had a positive allergy test for milk or egg, not necessarily a known allergy to it, but they also had moderate or severe eczema or atopic dermatitis.
Goers: These infants will be followed until they are five years old. The infants are tested over time with blood samples and prick skin testing to monitor the allergic antibodies in their system.
Plaut: Even though we anticipated that there would be kids who already had allergic antibodies to peanut, we were very surprised about the proportion of kids who were very allergic to peanut. The majority of infants in the study already had evidence of allergic antibodies to peanut. And over a little bit more than a quarter of them had evidence of such high levels of antibody to peanut, that they’re probably at risk for being truly allergic to peanuts when and if they start eating them.
Goers: Researchers recommend that high risk infants should be tested for the allergy and seen by their physician before given peanuts. The findings appear in the May issue of the Journal of Allergy and Clinical Immunology. For more information on infant allergies, visit www.niaid.nih.gov. This is Elizabeth Goers, National Institutes of Health, Bethesda, Maryland.
Strategy Confirmed to Help Doctors Determine When to Treat Retinopathy of Prematurity
Balintfy: More news regarding infants. In this next report, we learn about a strategy that can help doctors decide when to treat an eye condition that could lead to blindness in premature babies. Wally Akinso has the details.
Akinso: Scientists have shown in a recent study, that through an eye exam, doctors can identify infants who are most likely to benefit from early treatment for a potentially blinding eye condition.
Brooks: The subject of this study was a condition called retinopathy of prematurity.
Akinso: Dr. Brian Brooks is the chief of the National Eye Institute’s Unit on Pediatric, Developmental and Genetic Ophthalmology. He explains retinopathy of prematurity, or ROP usually develops in both eyes, and is one of the most common causes of vision loss in children.
Brooks: By definition, it affects babies that are born prematurely and is caused by a change from the baby's environment from being in utero to outside the womb. Normally, during the last weeks of gestation, the blood vessels in the back of the eye called the retina are continuing to grow and mature. When an infant is born prematurely the change in that infant's environment sometimes results in differences in changes that are abnormal in how the blood vessels are forming.
Akinso: An estimated 15,000 premature infants born each year in the United States are affected by some degree of ROP. At-risk infants generally are born before 31 weeks of the mother's pregnancy and weigh 2.75 pounds or less. Dr. Brooks says about 90 percent of infants with ROP have a mild form that does not require treatment, but those who have a more severe form can develop lifelong visual impairment, and possibly blindness.
Brooks: The Early Treatment of Retinopathy of Prematurity or ETROP study was designed to look at the question—can we identify those infants who are going to go on to develop severe retinopathy of prematurity and if we treat those infants early do we do a better job at preventing blindness.
Akinso: In 2003, the ETROP study found that early treatment improved the vision and retinal health of certain infants after nine months.
Brooks: Both the initial study and now this follow up study have confirmed that in a subset of the infants who are beginning to develop retinopathy of prematurity, but have not hit what we classically call threshold...there is a subset called type 1 infants, that did significantly benefit from treatment. Whereas if the blood vessels appeared a different way, called type 2, those babies could be just carefully monitored for the time being.
Akinso: During pregnancy, the blood vessels of the eye gradually grow to supply oxygen and essential nutrients to the light-sensitive retina. If a baby is born prematurely, growth of the blood vessels may stop before they reach the edge of the retina. In these newborns, abnormal, fragile blood vessels and retinal tissue may develop at the edges of the normal tissue. The abnormal vessels can bleed, resulting in scars that pull on the retina. The main cause of visual impairment and blindness in ROP is retinal detachment. According to Dr. Brooks, additional research is needed to identify still better methods for the prevention and treatment of severe ROP. For more information on the results of this study and eye health research, visit www.nei.nih.gov. This is Wally Akinso at the National Institutes of Health, Bethesda Maryland.
Balintfy: Coming up, the future of primary care. That’s next on NIH Research Radio.
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Advancing the Science of Effective Behavioral Treatments in Primary Care
Balintfy: Recently the NIH Office of Behavioral and Social Sciences Research sponsored and helped organize a conference designed to identify research issues and highlight a future scientific agenda regarding common approaches to behavioral aspects of primary medical care practice. In other words:
Turner: This particular conference is talking about what we call the complex patient.
Balintfy: That’s Dr. Barbara Turner. She’s a professor at the University of Pennsylvania, and Executive Deputy Editor of the Annals of Internal Medicine. She’s also a practitioner who shared her perspective at the two-day event. I asked her for some background on the conference.
Turner: Well, I think we have to set it in the context of broken primary care system in this country; that the paradigm of just having a doctor and a patient deal with all of the patient’s health care issues is pretty much gone by the way side, and we know that primary care physicians are maxed out. So, what we are trying to think about is how to evaluate and structure a health care delivery system that meets patients’ needs and uses the physician and allied health personnel in a really creative and effective way to deal with the breadth of patient issues.
Katon: I think the good news is that the medical systems are examining and trying to understand how do we better help patients where they’re at with the kind of problems that they have as opposed to building a system that is not patient-centered, which I think has largely been true in the past.
Balintfy: And that’s Dr. Wayne Katon. He’s professor and vice-chair in the Department of Psychiatry at the University of Washington Medical School. He also presented from a practitioner-perspective level at this conference.
Katon: What we are tending to find in primary care systems is many systems of care now are thinking about something called the medical home, which is a way of rebuilding primary care to not only take care of acute problems, which primary care is pretty good at. The problem primary care has had is how to take care of people with chronic problems, because it is set up more as a walk-in clinic situation and taking care of chronic problems often has to have more support for patients to change health habits, to learn to manage their chronic illnesses. And so what we have been really working on in this conference is with this change towards medical home or the things we can build into the medical home that can improve care of patients who are up against many things at once, not just one disease focus.
Balintfy: That gets back to the idea of a "complex patient"—for example, someone may need treatment for tobacco addiction, chronic depression, diabetes, chronic obstructive lung disease, and coronary disease. Again Dr. Katon:
Katon: And this conference really is focused on the fact that many patients have complex problems such as health risk behaviors that they may want to overcome, like obesity and smoking, as well as common mental health disorders, like depression and anxiety, as well as medical disorders that are chronic, like diabetes and high blood pressure and heart disease. And part of the question of the group is how do we help primary care doctors most effectively deal with patients who have some of these complex problems where all three problems may be present?
Balintfy: Having complex problems is a challenge for both the patient and the provider. Dr. Turner gave the example of a patient who has lots of medical issues that were not well controlled.
Turner: An easy way for a doc to deal with it is just give some medicines and tell the patient to change. And that really didn’t get at the patient’s problems which were much more profound, having to do with mental health and using narcotics and alcohol and being sedentary and eating chips until 2 A.M. So, there are lots of issues that we don’t deal with in primary care simply because it’s too much within 20 minutes, but it probably doesn’t get at the patient’s real issues.
Balintfy: Dr. Turner offers that the primary care environment is where patients should get the kind of care coordination assistance across all of their problems, and then use the specialists for targeted questions.
Turner: So, if you think about that being the coordinating center, you bring in all of your data, you ask—you know, these are all of my problems, how should I prioritize them? Can you help me prioritize them? And use that as your central, one-stop shopping site. Then you use the specialists as needed outside of that. And there are a lot of patients who divide themselves up into a lot of little organ systems, so they say, "Oh, I have high blood pressure; I must need a cardiologist. My knees hurt, I must need an orthopod." So, they forget that there is this possibility and important potential that primary care can be that central coordinating center for them.
Balintfy: Dr. Turner herself a primary care physician, explains this isn’t exactly a new idea.
Turner: And it got a bad name about 15 years ago with managed care, because it was like the primary care provider was tasked with preventing you from going to see specialists. In this case, the primary care provider has to help you use those resources to the best advantage, and so I spend a lot of time with my patients just helping them understand what is and is not indicated. If they come in and they have a headache, they don’t need to see a neurologist and get an MRI. There are ways that I can help them a lot and it makes their lives much easier and it also solves most of their problems. So, primary care has a lot of potential; it just it has to be structured differently than one doc, one patient.
Balintfy: Dr. Katon explains it as a team approach, which would be something to look for in a primary care practice.
Katon: Because that is what is found to be most effective, whether it is treating diabetes or heart disease or depression, if your doctor has a team that is working with you, not just the doctor. What I mean by a team could be, like, a case manager who is helping you learn as much about your illness, learning to check your blood sugars and change your diet and exercise more. So, someone who is actually helping with the things the doctor has trouble doing in a 10-minute visit, which is about what doctors have nowadays. So, asking the doctor, is there a team approach or does your system of care involve some team that could help me learn to manage my illness is an important question, because it is very hard for people to learn that in those sort of brief interactions with their doctor.
Balintfy: Dr. Katon, who is also an National Institute of Mental Health grantee, points to some research results supporting a team approach to primary care, with benefits for complex patients.
Katon: We’ve shared from our group a model of care called team care that was a grant funded by NIMH where we have screened people who are diabetic and have heart disease for poor disease control, and if they have poor medical disease control, we also screen them for depression, and if they have both, we’ve randomized them to an intervention where a nurse helps the doctor work on both their depression and their medical disease control and their health habits versus what happens in usual care, where often times it’s hard for doctors to work on all three things at once. Our data showed that we had remarkably improved outcomes on depression and their medical outcomes and the patients were much more satisfied with their care at the end of the day.
That is one example of programs that have been presented at the conference, where people are trying to come up with creative solutions to people who have complex problems. So, doctors tend to think in disease categories, but patients bring to us many problems, including problems in living and their life—you know, housing, financial problems, depression; they have struggles with controlling their product medical illness. They have financial problems that are maybe resulting from the medical and the psychological problems, and we are trying to help doctors in the systems especially with these more complex patients.
Balintfy: Dr. Katon adds that the conference is helping break new ground.
Katon: Medical home is a new model; the team care approach we have developed is a new model. But we certainly need more of this in terms of our research agenda.
Turner: Currently, we don’t have the infrastructure that we are talking about at the conference. We have scattered experiments of the so-called patient centered medical home. And we don’t yet know how patients will react to having this concept; whether they’ll feel settled with having this medical home idea, but it is where they wouldn’t just see me if they come in. If they come in and they have issues with obesity and have a behavioral educator kind of there in the office who can help them work through dietary issues. If they smoke, I will also have somebody who can help more with smoking cessation. So, a lot more of the resources for behavioral problems will have to be in the primary care practice instead of going out into the community and running around trying to find somebody to help them. So, it is an interesting and yet theoretical concept, because we really don’t have the payment structure to do that yet and primary care practices are really just subsisting right now.
Katon: You know, the medical home is kind of under testing. People are trying to define what it exactly means and there are some pilots of trying to understand how does it influence care when it’s implemented. But I think it is very important when we put in new models to really test them in a careful way, because there are both good things and sometimes unintended consequences that happen. So, really being able to understand that and understand the patient’s perspective on this is really important.
Balintfy: Important for the whole primary medical care practice. Again, Dr. Turner:
Turner: There are lots of important people who should be part of a primary care environment, and that includes nurse practitioners, nurses, licensed practical nurses, medical assistants, social workers, health educators. It actually turns out it has to be a large family of providers that are in a primary care setting because of the breadth of issues that we have to deal with in patient care, and a lot of them aren’t taken care of when it is just the doc and the patient.
And with 32 million people coming in to the health care system—happily, with health care reform—it is a disaster impending if we do not figure out a way to restructure primary care to be the center of health care in the United States. And physicians will be key, but all of these other people I described are essential to the success of that mission.
Balintfy: That’s Dr. Barbara Turner, Professor at the University of Pennsylvania and we also heard from Dr. Wayne Katon, Professor and Vice-Chair in the Department of Psychiatry at the University of Washington Medical School. They both participated in the NIH Integrated Health Improvement Strategies Workgroup: Advancing the Science of Effective Behavioral Treatments in Primary Care. For more on the conference, visit the website conferences.thehillgroup.com/obssr/integratedhealth
Balintfy: That’s it for this episode of NIH Research Radio. Please join us again on Friday, June 18 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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