May 6, 2011
NIH Podcast Episode #0133
Balintfy: Welcome to episode 133 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, and coming up in this episode we have a double-feature on complementary and alternative medicine: survey results showing its use in people over 50, and detailed information on CAM resources; also, new guidelines for research on diagnosing and treating Alzheimer’s disease; and a link between DNA damage and the immune system. But first, this news update. Here’s Craig Fritz.
Fritz: Researchers funded by the National Institute of Mental Health have found that a five-minute checklist that parents fill out in pediatrician waiting rooms may someday help in the early diagnosis of autism spectrum disorders. Identifying autism at an early age allows children to start treatment sooner, which can greatly improve their later development and learning. Researchers established a network of 137 pediatricians in California where the doctors screened all infants at their 1-year check-up using a brief questionnaire. The questionnaire asked parents about a child’s use of eye gaze, sounds, words, gestures, objects and other forms of age-appropriate communication. Any child who failed the screen was referred for further testing and was re-evaluated every six months until age 3. Following the screen, all toddlers diagnosed with autism or developmental delay and 89 percent of those with language delay were referred for behavioral therapy. On average, these children were referred for treatment around 17 months of age. This far exceeds a 2009 study using data from the CDC that found, on average, children currently receive an autism diagnosis at over 5 years of age, with treatment beginning sometime later. The researchers note that future studies should seek to further validate and refine this screening tool, track children until a much older age, and assess barriers to treatment follow up.
Scientists supported by the National Institute on Drug Abuse have found that moderate levels of secondhand smoke can deliver nicotine to the brain and may increase vulnerability to nicotine addiction. The study used pet scans to demonstrate that one hour of secondhand smoke in an enclosed space results in enough nicotine reaching the brain to bind to receptors that are normally targeted by direct exposure to tobacco smoke. This happens in the brain of both smokers and non-smokers. Previous research has shown that exposure to secondhand smoke increases the likelihood that children will become teenage smokers and makes it more difficult for adult smokers to quit. Such associations suggest that secondhand smoke acts on the brain to promote smoking behavior. Scientists note that this study gives concrete evidence to support policies that ban smoking in public places, particularly enclosed spaces and around children.
For this NIH News Update – I’m Craig Fritz
Balintfy: News updates are compiled from information at www.nih.gov/news. Coming up, experts say new Alzheimer’s disease guidelines will benefit patients and accelerate the pace of research; also damaged DNA’s link to immune responses. But first, a new survey from NCCAM and AARP finds that although many people 50 and older use complementary and alternative medicine they often do not inform their health care providers. That’s next.
(BREAK FOR PUBLIC SERVICE ANNOUNCEMENT)
Complementary and alternative medicine dialogue lacking between patients, providers
Balintfy: A recent survey looks at the use of complementary and alternative medicine (CAM) in people 50 and older.
Briggs: And the very important question of whether they talk to their health care providers.
Balintfy: Dr. Josephine Briggs is the Director of the National Center for Complementary and Alternative Medicine. She says this is the second time NCCAM and AARP have cosponsored the survey which now shows more than half of Americans over the age of 50 have used CAM at some point in their lives.
Briggs: Like the rest of Americans, people 50 and over are using complementary and alternative medicine. But the important take-home lesson of this study is that they're not consistently talking to healthcare providers about those alternative health practices.
Balintfy: CAM is a group of diverse medical and health care interventions, practices, products, or disciplines that are not generally considered part of conventional medicine. CAM includes natural products such as herbal supplements, and manual therapies and mind/body practices such as chiropractic care, massage, acupuncture, and meditation. Dr. Briggs says NCCAM-funded research into herbal and dietary supplements has shown that natural does not always mean safe. Also because older Americans do use prescriptions more than younger people:
Briggs: We are concerned that sometimes there may be interactions between dietary supplements and the prescription drugs so that's one reason to talk to health care providers. Another is that the use of manipulative therapies — massage, mind/body approaches to health — give the healthcare provider a full picture of what a person is doing to promote their health.
Balintfy: Dr. Birggs stresses the importance of a dialogue.
Briggs: We think it's important to ask and tell.
Balintfy: Meaning both healthcare providers and patients should discuss CAM use. The survey shows only one-third of older Americans discussed their CAM use, two-thirds did not. In the survey, the most frequently cited reasons for using CAM include general wellness, to help reduce pain or treat a painful condition, and to treat a specific health condition. For more information on this survey and CAM, visit www.nccam.nih.gov.
Alzheimer's diagnostic guidelines updated for first time in decades
Balintfy: For the first time in 27 years, clinical diagnostic criteria for Alzheimer's disease dementia have been revised, and research guidelines for earlier stages of the disease have been characterized to reflect a deeper understanding of the disorder.
Phelps: We've redefined Alzheimer's disease as a disease that occurs in three phases or three stages.
Balintfy: Dr. Creighton Phelps is the director of the Alzheimer's Disease Center Program at the National Institute on Aging. He says Alzheimer's disease is classically thought of in its final stage of dementia.
Phelps: However, there are stages before that, mild cognitive impairment and a pre-clinical stage that precede the development of the dementia that's associated with Alzheimer's disease.
Balintfy: The development of the new guidelines, led by the National Institutes of Health and the Alzheimer's Association, mark a major change in how experts think about and study Alzheimer's disease.
Phelps: Especially the pre-clinical phase, which is a research concept, not a clinical concept yet.
Balintfy: Dr. Phelps explains that the preclinical stage, which only applies to research, describes a phase in which brain changes may already be in process; but it is unknown what Alzheimer’s dementia risk is for these individuals.
Phelps: We're going to be able to eventually, hopefully after many more studies, be able to identify people early on who are on the road to Alzheimer's disease.
Balintfy: Research has already determined that Alzheimer's may cause changes in the brain a decade or more before symptoms appear. For example, some older people are found to have abnormal levels of amyloid plaques in the brain at autopsy yet never showed signs of dementia during life. Dr. Phelps adds that the guidelines discuss known biomarkers — signs that may be found in blood or spinal fluid – and mention others that may have future applications.
Phelps: Because if we find them early enough and we have interventions that will head off the disease, we can start the treatments early. There have been drug trials in the past that failed because we think may be the reason for the failure was it was too late. The brain was already damaged too badly and nothing they could do would correct that. However, if you catch the disease process before the brain has degenerated, then an intervention might work. Maybe some of the ones that failed earlier could even work if we do it earlier.
Balintfy: The other two distinct stages of Alzheimer's disease described in the new guidelines are Mild Cognitive Impairment and Alzheimer’s Dementia. For details on the National Institute on Aging/Alzheimer's Association Diagnostic Guidelines for Alzheimer's Disease and more information Alzheimer’s research, visit www.nia.nih.gov.
NIH investigators find link between DNA damage and immune response
Balintfy: Researchers offer the first evidence that DNA damage can lead to the regulation of inflammatory responses, the body's reaction to injury. Wally Akinso reports how proteins are involved in the regulation to help protect the body from infection.
Akinso: Researchers have found a link between DNA damage and the way the body reacts to injury.
Resnick: We know that there are a set of genes, a set of proteins that are part of what is called the innate immune system.
Akinso: Dr. Michael Resnick is the principal investigator in the Laboratory of Molecular Genetics at the National Institute of Environmental Health Sciences and author of a recent study.
Resnick: The innate immune system deals with a set of standard kinds of threats to the body and it can be bacteria, it could be viruses, it could be different kinds of fungi and so on. Now when they come into the body they represent a threat, and the innate immune system has host in humans of 10 proteins called toll-receptors.
Akinso: Toll-like receptors are proteins that play a role in the immune system by defending the body from infection. Research suggests that an injury to chromosomes changes the way toll-like receptors work. Following damage, the toll-like receptors interact with a tumor suppressor gene to regulate the amount of inflammation. Dr. Resnick explains that the tumor suppressor gene P53 helps prevent threats to the human body that can lead to cancer.
Resnick: And the way it does it, it recognizes signals in chromosomes. And it directs a set of genes to either tell cells to stop growing until they repair, tell some cells that too much damage to die.
Akinso: Healthy volunteers with informed consent donated their blood cells for the study. The scientists separated white blood cells from the samples and exposed the cells to anti-cancer agents to activate p53. They then examined toll-like receptor genes. Researchers found that p53 generally led to the activation of several toll-like-receptor genes in patients’ cells. Again Dr. Resnick.
Resnick: And what we established is that the P53 system that deals with chromosome damage and determines whether cells are going to grow or survive after DNA damage, what we find is that system that can register DNA damage can also control the innate immune system. And what we think is that may enhance the ability in some way to deal with infections or bacterial infections or viral infections.
Akinso: Dr. Resnick says that humans evolved an inflammatory response when subjected to DNA damage. He adds that the variation in toll-like-receptor activity among humans suggests that some people are more prone to inflammation following DNA damage, for example, after receiving cancer therapy. For more information on this study, visit www.niehs.nih.gov. This is Wally Akinso at the National Institutes of Health Bethesda, Maryland.
Balintfy: Coming up, more on CAM: more survey results and resources for health care providers. That’s next on NIH Research Radio.
(BREAK FOR PUBLIC SERVICE ANNOUNCEMENT)
Health Care Provider Portal
Balintfy: Welcome back. We’re talking more now with Dr. Josephine Briggs about complementary and alternative medicine. Dr. Briggs, how many people in the United States are using CAM?
Briggs: Well, we do a survey called the National Health Interview Survey that's simply implemented together with the CDC. And the data from that survey done in 2007 showed that about 40% of Americans, 12% of children are turning to some form of complementary medical or health practice either to promote their own health and wellness or to deal with a particular health condition.
People are spending a lot of money on these interventions. Our estimate is $34 billion in out-of-pocket costs. This is about a little over 1% of total healthcare expenditures and a very sizable part of the actual out-of-pocket cost. So, people are spending money on this. It's very important, therefore, that healthcare providers be able to give them accurate information about which of these modalities are safe and which may be helpful and which ones to be concerned about.
Balintfy: In the beginning of this program, we heard about a different, more recent survey. Dr. Briggs, what was most revealing about that one?
Briggs: Right. We did a recent survey together with AARP and that showed that often people are in fact not telling their healthcare providers about their use of complementary and alternative medicine. I'm particularly concerned about dietary supplement use and the fact that some dietary supplements can interact with drugs. It's also a problem, some drugs interact with other drugs, but healthcare providers, particularly those writing prescriptions for drugs, really need to know all the pills people are taking because there can be interactions that diminish the efficacy and there can also be interactions that result in greater side effects.
Balintfy: Dr. Briggs, are there specific statistics on the use of CAM from this survey?
Briggs: Well, the data was in the AARP survey, which was focusing on the Americans over the age of 50 that 2/3 had not discussed CAM with a healthcare provider. And we know that in this age group, many people are on prescription drugs. So this is one reason that this demographic group, older Americans, are particularly concerned in this area.
Balintfy: In general, what are some important reasons for health care providers to talk about CAM practices and products with their patients?
Briggs: So, the interactions between dietary supplements and herbals and conventional drugs is certainly one important reason. CAM practices are used by many Americans to promote health and it's also a valuable entry for the healthcare provider to talk about health behaviors. The advice that we need to be more active and eat a healthy diet is one that patients need to take charge of themselves and talking about their health practices, the whole range of health practices, is a very good way as a physician, and I know this from my own care patients, to begin that dialogue. So there are these two important reasons.
Some alternative practices can be risky and certainly one concern is people using an alternative practice and avoiding or failing to get an accurate diagnosis. But the other two reasons of promotion of healthy behaviors and drug interactions are two additional reasons.
Balintfy: So to help primarily health care providers, NCCAM has a new web-based resource. What is that Dr. Briggs?
Briggs: Yeah, we're very proud of it. It is called our healthcare provider portal. We feel that it's going to meet important needs of healthcare providers to provide resources both for their own continuing education, learning about the evidence based and the clinical practice guidelines, actually getting CME credits, and providing access to a wide range of information resources they can use in conversations with their patients.
Balintfy: How does this web-based resource help health care providers duscuss CAM practices and products with their patients?
Briggs: So one important aspect of this site is access to all the clinical practice guidelines that have been developed in this area, and these include guidelines developed by the American Pain Society, the American College of Physicians, and other mainstream health organizations who have evaluated systematically the evidence for safety and efficacy of these approaches. Another very valuable resource that we link to on our website is the Cochrane Collaborative, which has performed many systematic reviews. So, this access in one place to the evidence plus and minus for health impact of these interventions is one important resource.
We also have CME credits available through the website. There's a CME process for physicians and other healthcare providers to evaluate their knowledge of these. And then finally, we have a lot of resources, information and fact sheets, that we think will be helpful to docs and nurses and other healthcare providers to answer specific questions of patients about say herbs and other interventions. So we think it's got a lot of valuable information for healthcare providers.
Balintfy: How was this information developed?
Briggs: Well, we have a team who has worked on this and they use evidence base -- our key thing here is evidence base. And so they hunt through the libraries of evidence-based information including PubMed, others and do very careful searches for the information that will be helpful. We have increasingly a body of evidence-based systematic reviews that carefully, using established standards, collate all the trials that have been done and use rigorous statistical methods to draw conclusions. That's the process of evidence-based medicine and that's the process, which is the basis of our website.
Balintfy: Are there some other features you want to highlight?
Briggs: We've talked about the main ones. I just briefly mentioned the availability of literature searches. There are strategies for literature searching. So for some docs, searching PubMed in these areas is unfamiliar territory and so we have developed some resources and approaches to do those kind of literature searches. We have summaries of research studies that we've recently funded and safety and effectiveness information.
We have a toolkit there on encouraging the dialogue between patients and providers. That's called our Time to Talk toolkit and that provides sheets for example wallet cards and tip sheets that docs can give patients and then ask them to come back with the information brought into one place. So we think that there are quite a range of resources on the website that should be helpful. And we're very eager for people who use this to give us feedback as to what they would like, what's missing, and what would also be helpful.
Balintfy: Why is NCCAM providing this information?
Briggs: This is very central to our mission is providing the public with the ability to make evidence-based decisions about healthcare utilization and healthcare practices. This is really a core piece of NCCAM's mission and its part of the National Institutes of Health, our broad mission is to promote the nation's health and part of that is providing this kind of information.
Balintfy: Thank you Dr. Josie Briggs. For more information on CAM, CAM surveys and the web-portal with resources for health care providers, visit the website, www.nccam.nih.gov. And that’s it for this episode of NIH Research Radio. Please join us again on Friday, May 20 when our next edition will be available. In that episode:
“The data on older drivers is very interesting because what they actually show is that the total number of accidents and fatalities in older drivers is actually much, much smaller than we see in teenagers and people in their early 20s.”
That and much more. If you have any questions or comments about this program, or have a story suggestion of your own 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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