March 23, 2012
NIH Podcast Episode #0155
Balintfy: Welcome to episode 155 of NIH Research Radio. NIH Research Radio bringing you news and information about the ongoing medical research at the National Institutes of Health – NIH . . . Turning Discovery Into Health®. I'm your host Joe Balintfy, and coming up in this episode a common vitamin may help with a common condition in women, insight into partial-breast radiation therapies for breast cancer, and understanding rashes. But first, this news update. Here’s Craig Fritz.
Fritz: A new NIH study has found that older adults with stable coronary heart disease who underwent bypass surgery had improved long-term survival rates when compared to those who underwent stent placement to improve blood flow to the heart. In coronary heart disease, plaque builds up inside the coronary arteries that supply blood to the heart. Over time, blocked or reduce blood flow to the heart may occur, resulting in chest pain, heart attack, heart failure, or erratic heart beats. In bypass surgery, blood flow to the heart is improved by connecting a healthy artery or vein from another part of the body to bypass the blocked coronary artery. A stent intervention is a less invasive procedure in which blocked arteries are opened with a balloon. A stent, or small mesh tube, is then placed in each blocked artery to keep it open so that blood continues into the heart. While there were no survival differences between the two groups after one year, after four years there was a 21 percent increased survival advantage for the bypass group. Researchers say that in the United States, cardiologists perform over a million stent procedures a year to open blocked arteries and this study provides large-scale, national data to help doctors and patients decide between these two treatments.
NIH scientists are now one step closer to developing anti-addiction medications, thanks to new research that provides a better understanding of the properties of specific opioid receptors in the brain. The activation of this receptor counteracts the rewarding effects of addictive drugs. Unlike the other opioid receptors, the kappa opioid receptor is not associated with the development of physical dependence or the abuse potential of opiate drugs such as heroin, morphine and oxycodone. Therefore, medications that act on the kappa receptor could have broad therapeutic potential for addressing addiction, pain, and other mental disorders. Scientists say that this research could aid in the development of effective medications for the treatment of drug addiction, particularly to stimulants like cocaine, for which there are no medications currently available.
For this NIH news update – I’m Craig Fritz.
Balintfy: News updates are compiled from information at www.nih.gov/news. Coming up: one type of partial-breast radiation therapy may be outpacing the available evidence on the technique’s safety and effectiveness, info on addiction treatment options, details on dermatitis, and vitamin D and fibroids. That’s next on NIH Research Radio.
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Vitamin D shrinks fibroid tumors in rats
Balintfy: An NIH-funded study in rats suggests there may be an easy, available treatment for a common condition in women: uterine fibroids. They’re the most common noncancerous tumors in women of childbearing age.
De Paolo: They are benign tumors of the uterus, specifically the wall of the uterus. And they can be in inside the uterus, outside the uterus, but they are somehow connected to the uterine wall.
Balintfy: Dr. Louis De Paolo is chief of the Reproductive Sciences Branch at the NIH institute dealing with reproductive biology and developmental health. He explains that fibroids are associated with infertility, and that 30-percent of women 25-44 years old report fibroid-related symptoms.
De Paolo: There can be several types of symptoms. The most common is low back pain, vaginal bleeding, and painful menstrual periods. It can also be associated with infertility at times and as well as pregnancy complications.
Balintfy: Other than surgical removal of the uterus, called a hysterectomy, there are few treatment options for women experiencing severe fibroid-related symptoms. About 200,000 U.S. women have a hysterectomy each year.
De Paolo: And of course once that happens, the woman is basically sterile.
Balintfy: Now, a recent study in rats has shown that treatment with vitamin D reduces the size of fibroids.
De Paolo: In the animals that got the vitamin D, the tumor size was reduced by 75%.
Balintfy: The amount of vitamin D that the rats received each day was equivalent to a human dose of roughly 1,400 international units. The recommended amount of vitamin D for teens and adults age 70 and under is 600 units daily, although up to 4,000 units is considered safe for children over age 9, adults, and for pregnant and breastfeeding females. But Dr. De Paolo warns that this study is just the beginning.
De Paolo: Well, first of all, this work is on an animal model.
Balintfy: He explains that more study must be done to show effectiveness and safety in humans. But adds that there is enthusiasm because vitamin D is so widely available.
De Paolo: I think the real importance of this is the possibility that there could be a nonsurgical option for fibroids, a fertility sparing option. Remember that currently the only option to completely ameliorate the condition is hysterectomy.
Balintfy: A recent analysis by NIH scientists estimated that the economic cost of fibroids to the United States, in terms of health care expenses and lost productivity, may exceed $34 billion a year. Dr. De Paolo also points out that there is a disparity in the incidence of fibroids – in the general population, roughly 70% of women have a 70% chance of having fibroids.
De Paolo: In African American women, the prevalence seems to be higher, two to four times more common in African American women than in white women.
Balintfy: He adds that African American women also have lower vitamin D levels than white Caucasian women.
De Paolo: Now, that's a correlation, but there had been some preliminary reports to actually correlate the level of vitamin D in African American women with fibroid load. So in other words, one might suspect that the greater number of fibroids in a woman is correlated with lower vitamin D levels.
Balintfy: Dr. De Paolo explains that vitamin D is a steroid soluble vitamin.
De Paolo: The most common way we get vitamin D in the way that most people will get vitamin D is through the sun that acts on the skin that convert a compound into vitamin D3 which then is converted in the liver and then subsequently in the kidney to the active form of vitamin D which is 125-cholecalciferol, and this compound is approximately ten times as potent as the native vitamin D3. And of course you can take in vitamin D in fortified milk and other fruits, but then that has to be converted just like the process efforts in the skin.
Balintfy: For more on the promise of vitamin D as a treatment for fibroids, visit www.nichd.nih.gov.
Studies raise concerns about partial-breast radiation therapy
Balintfy: When it comes to treating breast cancer, the goal of doing less has been making progress. For example, a strategy of breast-conserving surgery is replacing breast removal, or mastectomy. To discuss new approaches and concerns when it comes to radiation therapy, I’m talking with Dr. Bhadrasain Vikram. He’s chief of the Clinical Radiation Oncology Branch at the National Cancer Institute here at the NIH. Dr. Virkam, what’s a good way to get an overall perspective on breast cancer treatments?
Virkam: So we start with the premise that for the last 20 years or so, lumpectomy, which is just removal of the cancerous lump in the breast, preserving the rest of the breast, followed by whole breast radiation over five to seven weeks has become the standard treatment. And what we are looking for now is to decrease that burden on women of having to come for radiation for five to seven weeks every day and also to see whether we can reduce the amount of healthy breast that we have to irradiate.
So that has led to these two approaches. One is known as hypofractionation, which means that you give the radiation over about three weeks instead of seven weeks, and the second is partial breast radiation instead of whole breast radiation. And brachytherapy and partial breast techniques in general combine both the reduction and the volume of breast being radiated and the duration for which the radiation is given. And in the case of brachytherapy, it's down to about five days. In the case of the intraoperative radiation technique, that's down to one day.
Balintfy: Again, hypofractionation is whole-breast radiation. Brachytherapy is where small radioactive seeds are temporarily implanted in the cavity left after surgery to deliver highly localized radiation for a matter of several days. Intraoperative radiation is when radiation therapy is completed during surgery. So, Dr. Vikram, how do these treatments compare?
Virkam: The three-week radiation has been head to head compared with the five to seven weeks radiation in several randomized trials in Canada and the United Kingdom, and the results are fairly consistent that the three weeks is just as effective and safe. The TARGET trial compared this one-day approach, the five-to-seven-week approach, and again concluded that the tumor control was just as good, and the toxicity was actually less, and only about 20% of women who had the intraoperative radiation on the pathological examination of the cancerous specimen two or three days later were found to have such features that warranted additional external beam radiation.
Balintfy: Dr. Vikram, what would you suggest medical professionals consider when offering options for breast cancer treatment?
Virkam: So to the medical professionals, I would encourage them to stay with what is evidence-based treatment. As I said, the gold standard for that evidence is the randomized trial and therefore either hypofractionated radiation – some of those studies were published in the New England Journal of Medicine – as well as the intraoperative option, the results of which were published in The Lancet. I think those are much more robust options in the current state of our knowledge.
The brachytherapy or other kinds of partial breast radiation options, those are still under evaluation in randomized clinical trials supported by the NCI, and I would encourage them to enroll the patients into those trials so we get the answers as soon as possible.
Balintfy: And for patients, Dr. Vikram?
Virkam: Ask questions. And I think the key question to ask is “Is this treatment you're offering me, has this been validated in a randomized clinical trial, preferably sponsored by the National Cancer Institute?”
Balintfy: Dr. Vikram emphasizes that because randomized trials have already shown excellent early results for hypofractionation and intraoperative partial-breast irradiation, where radiation therapy is completed during surgery, these may be safer options for a woman looking to avoid 7 weeks of whole-breast radiation. For more information on breast cancer treatment options, as well as breast cancer clinical trials recruiting patients, visit www.cancer.gov.
Coming up on NIH Research Radio, what’s a rash? Find out next.
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Balintfy: Welcome back to NIH Research Radio.
Katz: Skin diseases, particularly rashes, are very common.
Balintfy: That’s Dr. Steven Katz, director of the National Institute of Arthritis and Musculoskeletal and Skin Diseases here at the NIH.
Katz: People call almost anything on the skin a rash, but we in dermatology and in medicine don't consider everything to be a rash.
Balintfy: A rash is an area of irritated or swollen skin. It might be red and itchy, bumpy, scaly, crusty or blistered. Rashes are a symptom of many different medical conditions. Things that can cause a rash include other diseases, irritating substances, allergies and even your genetic makeup.
Katz: A rash is something that is usually a little bit more widespread though it doesn't have to be. So let me give you an example. If you come into contact with poison ivy just on your finger, and most people are allergic to poison ivy, you'll have a rash which will be pretty self-limited to your finger.
Balintfy: But it’s not always as simple as that explains Dr. Katz.
Katz: When you talk about rashes in skin disease terms, you're talking about an inflamed skin of one type or another. So really you're talking about a dermatitis of some type, and there's a broad spectrum of problems and diseases that can cause rashes.
Balintfy: Dr. Katz says causes range from eczema or atopic dermatitis to allergic contact dermatitis and psoriasis.
Katz: The rashes really look quite different. It can be a rash that's due to a drug that you're taking, so a drug rash. It could be a rash that's due to a virus.
Balintfy: He adds there is also a photosensitive rash where the body produces a rash when it's exposed to the sun.
Katz: There's another rash that's fairly common which is called urticaria, which is the technical term for hives. Hives is really fairly common. Usually, we can't find the reason for the cause of the hives, but sometimes there is a reason. Sometimes it's a drug. Sometimes it's a viral illness. Sometimes it's associated with other diseases, systemic diseases. So this is all a spectrum of what rashes are.
Then there are these rashes that occur due to autoimmunity. That is the body reacting against itself. There's a whole large group of what we call blistering skin diseases which are autoimmune where the treatment is very strong because patients can otherwise die from it. So some of these rashes not only occur on the skin but also in the mouth and in the upper part of the esophagus.
So there is this whole spectrum of disease. We know a lot about many of them and we know little about some of them. But most of them we do have a strong research interest in because most of these that I've talked about, except for those that are autoimmune, are fairly common.
Balintfy: And Dr. Katz points out that a dermatologist, a doctor specializing in skin, can usually diagnose those causes.
Katz: We can tell often by looking at the rash as to what the cause is, and when we don't know what that cause is, we do a biopsy.
Balintfy: A biopsy is when a small piece of tissue is removed and then checked under a microscope. But what about self diagnosing a rash?
Katz: It's complicated. Sometimes you can self-diagnose. No problem at all. But oftentimes, it's very difficult to make that diagnosis.
Balintfy: For example, he points out that if 24 hours after gardening a rash appears where your hands weren’t covered with gardening gloves, and you know there are poison ivy plants in your garden, the red bumps with intense itching and even water blisters are likely from the poison ivy.
Katz: Now some people will say, “No, it's impossible. I can't have poison ivy dermatitis because I don't do any gardening so it's impossible for me to have poison ivy dermatitis.” Well, do you have a dog? Do you have a cat? A dog and a cat can go through the poison ivy plant and carry some of the chemical that produces the dermatitis.
In fact, I'll tell you an interesting story. When I first came to NIH, one of the first patients who I saw really as a favor to somebody was somebody who had a rash all over their face where you would think, “Well, it's got to be something -- photodermatitis.” It turns out it was poison ivy dermatitis. And it was poison ivy dermatitis from the neighbor who was burning a lot of their leaves and in the silt, the pentadecylcatechol, which is the chemical, ended up on these other people.
Balintfy: Dr. Katz says another common substance that can cause rashes is nickel.
Katz: Probably the most common form of dermatitis that is seen anywhere is an allergic contact dermatitis to nickel. Why? Because of ear piercing. So for example, depending on the amount of nickel in the metal, it may be more or less allergenic, in other words, have the susceptibly to cause allergies.
Balintfy: So if someone has a rash, when is it time to see a dermatologist?
Katz: That's a very good question and that really depends on the patient and the patient's family and how much it's bothering the person. Often you're not well served by just going to the drugstore and getting some cream because often, the creams that you buy can produce problems that make the your original problem even worse and confound the problem.
Balintfy: One over the counter drug for example is 1% hydrocortisone, which Dr. Katz says is not very good for getting rid of inflammation, or swelling – for that a prescription drug is probably needed.
Katz: But if you have any significant rash, you should see a dermatologist.
Balintfy: Dermatologists and researchers working with skin diseases know a lot more than they did years ago.
Katz: When I started working here 38 years ago, the skin was thought to be a protective covering. In the intervening years we now know that the skin is an actively functioning immune organ. And the skin, despite the fact that it has this outer layer of epidermis that may be two-tenths of a millimeter or less than the thickness of cellophane wrap, it's comprised of many different types of cells. Even the main cells, which are the keratinocytes, are now known to have within them many molecules that can produce all kinds of inflammation.
Balintfy: Thanks to Dr. Steven Katz director at the NIH’s National Institute of Arthritis and Musculoskeletal and Skin Diseases. Also thanks to Leslie Earl for production assistance with this story. For more information about rashes and skin diseases, visit www.niams.nih.gov. Also, look for the story about dermatitis on the cover of the April issue of the NIH News in Health newsletter. Find that at the website: newsinhealth.nih.gov.
Balintfy: And that’s it for this episode of NIH Research Radio. Please join us again on Friday, April 6 when our next edition will be available. In that episode and on the heels of World TB Day which is Saturday, March 24:
“For the first time really in my memory we're actually talking about the elimination of tuberculosis.”
In the mean time if you have any questions or comments about this program, or have story suggestions for a future episode, please let me know. Send an email to NIHRadio@mail.nih.gov. Also, please consider following NIH Radio via Twitter @NIHRadio, or on Facebook. Until next time, I'm your host, Joe Balintfy. Thanks for listening.
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