Science, not science fiction: Two flu drugs studied at UNC

When Scott Pelley of “60 Minutes” asked HHS Secretary Katheleen Sebelius about political punditry critical of the public health response to novel H1N1, she pointedly said, “I tend to like to get my health advice from doctors and scientists.”

She’ll be getting some of her advice about treating flu from UNC. Charlie van der Horst and Christopher Hurt, from our much heralded Center for Infectious Diseases, are each leading the first studies of medications for IV treatment of influenza.

ID at UNC is known around the globe for groundbreaking work in HIV/AIDS and other  scourges. They’ve identified who’s most at risk for HIV and potential ways to prevent infection. But this is the first inpatient flu study.

“We’ve never had IV drugs (for flu) before. Ever,” says van der Horst, who ran his first clinical trial in 1983 at UNC. “Each year in the U.S. 35,000 people die from flu … We’ve had nothing to offer these people,” vdHorst says. “We’ve routinely had patients die.”

Novel H1N1 put a scare in the medical community because, Hurt and vdHorst say, it resembled “Spanish” flu that killed tens of millions of people around the world from 1918 to 1920. Both bugs started in spring and made a come-back in the fall. If you get the flu now, you can bet it’s H1N1, vdHorst says.

Late-20th century medicine gave us the anti-flu drugs Tamiflu, Relenza and peramivir. Tamiflu is taken orally; Relenza is aerosolized. They prevent the flu or shorten its duration. So it made sense to provide them in IV form, which provides a more accurate, assurable dosage that goes directly to the bloodstream in people who are hospitalized and beyond the help of chicken soup.

Hurt is studying peramivir, a medication that had not been tested until recently. It’s only available in IV form, and the criteria for receiving the drug in the study are pretty tight; prior treatment with Tamiflu eliminates a lot of people.

But viruses mutate for a living, and novel H1N1 has beefed up its resume by showing some resistance to peramivir’s close kin, Tamiflu, in an isolated instance. One of the usual seasonal flu viruses from last year had widespread resistance to Tamiflu. Both medications operate by blocking the same protein to keep the virus from spreading.

So far, novel H1N1 hasn’t shown widespread resistance to zanamivir. And to get into that trial a patient has to be sick enough to be hospitalized for five days and, basically, have the flu. It’s open to pregnant women, people on ventilators, people who have received other flu meds, etc.

As for the protection against pundits, some are more innoculated than others. VdHorst waves them off. “Vaccine and medication development in the US is based on pure science, not science fiction,” he says.

Understanding why the body goes into labor is key to controlling infant mortality

Clinton wrote this …

The National Center for Health Statistics released earlier this week a report on infant mortality.

In its analysis, the U.S. ranks 30th in the world. We deliver far more babies pre-term, before 37 weeks gestation, than most countries, and don’t do as well in keeping them alive.

National Center for Health Statistics

NPR’s Brenda Wilson delivered her usual in-depth and thoughtful news story on NPR, as did Denise Grady in the NYTimes.

I asked UNC’s John Thorp, professor of ob/gyn and deputy director of UNC’s Center for Women’s Health Research, who is passionate about correcting problems caused by preterm delivery and prematurity, his thoughts on the report. Thorp has co-authored several studies lately, including one highlighting the risks of delivering prior to 37 weeks. Here’s what he said.

Clearly prematurity is the biggest contributor to infant mortality and our high US preterm birth rates fuel our poor infant mortality results. I have spent my life trying to better understand the causes of this phenomena and it is a complex problem with preterm births having multiple causes. Our team founded the rubric of spontaneous and medically indicated preterm births as a classification system and the NY Times article delineates some of the mechanisms that we know about.

 

Socioeconomic status plays a key role and there may even be intergenerational effects – the SES of one’s maternal grandfather may be the most powerful predictor. Other contributors include our propensity for elective delivery, captioned ‘late’ preterm birth, and propensity to embrace reproductive assistance technologies that culminate in multiple babies.

 

If I were given unlimited funds I would not know how to prevent the problem, thus would strongly suggest that we invest in learning the biology that causes labor to begin. Despite all the advances in medicine in our lifetimes it is amazing that these basic biologic mechanisms are unknown. Only with that knowledge would we be able to logically intervene. Trite as it sounds, if we can put astronauts on the moon or discover that a virus causes AIDS there is no reason why we should not be able to solve this universal human health issue.

 

 

 

AIDS in the U.S.; the patient profile has changed, so should testing practices

Clinton wrote this …

There is growing sentiment, and evidence, that attention to HIV and AIDS has shifted so far abroad, to Africa and in developing countries elsewhere, that Americans have overlooked a growing epidemic in our own collective backyard.

But even in the US we’re looking through bleary eyes. This isn’t the 1980s. We need to give our eyes a good rubbing and let them focus afresh. When we do, we’ll realize the “high risk” population – IV drug users, men who pay for sex and men who have sex with other men – has changed.

The question has been who to target for testing. When a diagnosis of HIV is made early people can start receiving care sooner, probably use fewer health care $$, have a better prognosis and, hopefully, remove themselves from the sex pool.

But it’s the wrong question. Everyone needs to be tested, says Yvonne Carter, M.D., an ID fellow at UNC. Carter reviewed data for more than 200 black men and women in the rural South, where the epidemic is most rampant. They were 18-61 and denied IV drug use and male-male sex. After some fancy statistics she found that socioeconomic status, health insurance status and history of incarceration were not associated with having more advanced disease.

But there was a group whose rates of advanced HIV was twice as high as others’ – the men. Women, Carter says, usually have more interaction with a health care provider. Men, especially black men, she says, tend not to go to the doctor until they’re very sick.

“This stresses that HIV testing is important, and implies that we can’t hang our hats on this person or that person,” Carter says. She presented her study Oct. 30 at the IDSA meeting.

Carter, a black woman, was drawn to disparities research after a trip to Africa as a medical student at Maryland. She came to UNC to be mentored by Ada Adimora, one of our many top HIV/AIDS doctors. Adimora leads the Rural Health Project, which continues to provide important data, including that for Carter’s work.

In 2008 Adimora told Congress that AIDS in black men represents a national emergency. Black men account for more than half of all AIDS deaths, and about 45 percent of new diagnoses. But the question about “who” to test needs to change to “how” and “when,” as in, how soon and how can we test everyone, often.

Graduating from high school, at the hospital

Ginger wrote this…

On Oct. 23 I attended a graduation ceremony – in the NC Jaycee Burn Center at UNC Hospitals. I watched Ryan Frias, a burn patient, precess down the hospital hall, lined with staff clapping and cheering, to “Pomp and Circumstance.”

Ryan’s story is an inspiring one. He was admitted to UNC almost a year ago, on Dec. 5, 2008 after a car accident that left him with burns covering close to 80 percent of his body.  Bruce Cairns, Ryan’s doctor, described the burns, which covered his chest, neck, arms and head, as “the deepest kind you can possibly have.” Since he was admitted, Ryan has undergone nine operations. But Ryan seems to take it all in stride. “Just because I’m a little handicapped now, I’m not going to let it stop me.”

Well, it clearly hasn’t. Ryan, who is from Monroe, NC, was in the middle of his senior year at the Central Academy of Technology and Arts doing a pre-engineering concentration, when the accident put his schooling on hold – for a little while. As soon as he was able, in May, he began taking senior English (the only class he needed to graduate) with a hospital school teacher who would conduct the classes orally while he learned how to write again. He was done by September.

Ryan says he looks at his graduation as the close of a chapter. Of course, graduation always signifies the close of some chapter. But he’s referring to something different. He is merely days away from discharge and is more than ready to move forward – from the accident, from the hospital – and he’ll do it with a high school diploma. Congrats, Ryan.

Come on now (iPod) touch me, babe

Tom wrote this …

“I predict all your pagers go off … right now.”

"Trust me. I'm a doctor."

This scene, played for comic effect on the TV show House M.D., actually used to happen at UNC Hospitals all the time. All of our hospital interpreters carried pagers that were tied to the same phone number.

So, when a doctor needed an interpreter, all of the interpreters’ pagers would go off at the same time. And then all of the interpreters who weren’t already busy with a translation assignment would call the doctor back.

You can easily see how frustrating that could be for everyone involved.

Things began to get better about five years ago when the interpreters started using a Web-based dispatch management system provided by a company called ServiceHub. Under that system, doctors submitted requests for an interpreter through a Web page. Then they could see their request show up on the page, and which interpreter was assigned to it. The interpreters used cell phones to respond to requests.

But still there were problems, due to cell phone dead zones in certain parts of the hospital and the technical limitations of the cell phones themselves.

Working together to solve the problem, our interpreters and ServiceHub came up with a brilliant solution: using the Apple iPod touch through UNC Hospitals’ own house-wide WiFi system, instead of pagers and cell phones tied to an outside network.

We went live with the new system at the beginning of September. And so far it’s working smashingly well.

An iPod touch screen shot from the ServiceHub system we’re using at UNC Hospitals is shown at left. You can read about this in more detail here. And you can see our video about it here.

We’re hoping that the big shots at a certain California-based computer company are gonna like this story, too. Maybe they’ll even feature our interpreters in one of their commercials or something …

What do you say, Mr. Jobs?

Another “best” list?

Clinton wrote this …

They’re at it again. US News & World Report published online Oct. 20 a new list of “Best Hospitals” rankings based on patient satisfaction.

This is a new one. Sort of. The magazine extracted data from a list that’s already available to the public on the Hospital Compare Web site, managed by CMS, where you can scan results from patient surveys conducted by hospitals across the country.

USN&WR listed the top 17 hospitals – and ties – in three categories: overall satisfaction, satisfaction with nurses and satisfaction of pain management. It also turned the lists upside down and listed the bottom 17 in each category. Yikes.

UNC’s nurses fared best. Our patients gave UNC nurses the third-highest score in the country. We missed ranking among the top 17 in the other two categories by just 1 percentage point each. The most current data is from 2008.

So, why is USN&WR making their list, or the CMS list, available now?

In an email interview, Avery Comarow, the editor of the Best Hospitals rankings, says “pressure was building to include it in Best Hospitals somehow.” So when the Web site went through a redesign, they included a link for patient satisfaction.

Its annual Best Hospitals rankings leaves out patient satisfaction, a point that makes hospitals like UNC, who have satisfied patients, a little irritated. Comarow writes that research shows patient satisfaction is not always associated with the best care. And hospitals whose patients are the happiest tend to be small specialty facilities who do not see the most complex cases.

Mary Tonges, senior VP of nurses at UNC, points to different data.

“Research suggests that there is a significant relationship between patient satisfaction and staff satisfaction,” Tonges says. “This is a correlational rather than a causal relationship, and may be reciprocal, with each reinforcing the other. Evidence also suggests that patients cared for by satisfied staff are more likely to be compliant with their self-care regimens.”

Besides, Tonges says, it’s the right thing to do.

Comarow says his magazine will update the patient satisfaction ratings quarterly, as CMS posts the data.

Coincidentally, the first push for making hospital quality data available to the public was made by Bill Roper, M.D., dean of the UNC School of Medicine and CEO of the UNC Health Care System, in the late 1980s when he was commissioner of the Health Care Finance Administration, now CMS.

Sometimes the cure may cause a new disease

Tom wrote this …

A drawing of the digestive system from Medline Plus

Inflammatory bowel disease (IBD) is the  name given to a group of disorders, including ulcerative colitis and Crohn’s disease, that cause the intestines to become red and swollen. This inflammation typically lasts a long time and comes back again and again over time.

If you have IBD, you’re likely to suffer cramps, abdominal pain, weight loss, diarrhea or even bleeding from the intestines. And you’d probably be willing to take just about any medication that your doctor says will help.

But what if your doctor told you that a class of drugs commonly given to IBD patients could cause you to develop skin cancer?

UNC’s Dr. Millie Long presented findings this week at the American College of Gastroenterology meeting in San Diego from a study she led, which concluded that giving immunosuppressive drugs to people with IBD may increase their risk of developing non-melanoma skin cancer.

I should caution here that these are preliminary findings and additional research is needed before we can say for sure that there is a cause-and-effect relationship between immunosuppressive drugs and skin cancer.  And the study by Dr. Long, who is a Fellow in Gastroenterology and Preventive Medicine at UNC, has not yet been published in a peer-reviewed journal.

In the meantime, you can read the ACG’s press release about Dr. Long’s study here. Or you could read the media coverage about her study, including these stories published by U.S. News & World Report, MedPage Today and WebMD.

Drop a few pounds, avoid arthritis

Clinton wrote this …

Here’s another good reason to shed a few pounds: by losing just a small percentage of your body weight you could reduce the risk of developing osteoarthritis in the knee.

CDC image

The swinging hinge is the most common site of osteoarthritis, which is the most common joint disease; nearly half of all adult Americans may get it by age 85.

Thanks to a study by Lauren Abbate, a 3rd-year med student at UNC doing her research with UNC’s Thurston Arthritis Research Center, there’s now good data that showed people who were overweight and lost just 5% of their body weight reduced their risk of OA in the knee from 19% to 14%, compared to people who gained weight.

I asked Abbate if she saw a greater reduction in risk as people dropped more pounds. “We didn’t look at a linear trend, it was categorical,” she said. Because, she says, it’s clearer to communicate to a patient that they need to lose 5% of their weight instead of saying for every 1% of weight loss they reduce their risk by X%.

It’s also important for people to lose weight relative to their size, hence the data for 5% weight loss. Saying everyone needs to lose 10 pounds means different things for someone who is overweight at 180 pounds than it does for someone who is 250. You do the math.

Abbate presented her study today at the ACR conference in Philadelphia. (Apparently, Abbate, who just finished her Ph.D., is too “busy” to stay in town long enough to catch tonight’s game. She’s flying home now, then it’s on to another conference where she’ll talk about the relationship between girth and knee pain.  All work and no play, Lauren. I’m just saying.)

Expect to hear more news regularly from Thurston. Joanne Jordan has been at the helm for a couple of years and is charting new waters for the center. She’s assembling great researchers, has a new clinic and makes student and fellow education a priority.

In fact, Abbate was among of bevy of Thurston folks whose work was highlighted in Philly. Jordan received the research mentorship award. Abbate and a 2nd-year med student, Josh Knight, won student awards. And Amanda Nelson, a distinguished fellow, fittingly won a distinguished fellow award.

Appropriate surgical care: Who gets it? Who doesn’t, and why?

Tom wrote this …

Consider this: For many years now there has been a broad consensus among medical experts that far too many babies in the U.S. are being delivered by cesarean section. But repeated attempts to bring the number of c-sections down have hardly made a dent. At the same time, many morbidly obese people who might benefit from gastric bypass surgery never get it.

Clara Lee, M.D.

These are just two of several examples cited in a recent commentary on the appropriateness of surgical care written by UNC’s Clara Lee, M.D., and her UCLA colleague, Clifford Ko, M.D., which was  published in the Journal of the American Medical Association. Other examples include racial variations in surgical care (for example, blacks get many types of surgery less often than whites) and geographical variations (for example, mastectomy patients in Atlanta are more likely to get reconstructive breast surgery than similar patients in Iowa).

“This raises the question of who gets the right type of surgery at the right time, and who doesn’t, and why?” says Lee. “In our commentary we argue that more comparative effectiveness research — as opposed to the more traditional outcomes-based surgical research — is needed to answer this question and guide health care policy decisions.”

This commentary appears in a special theme issue of JAMA devoted to surgical care,  as health care reform legislation is being hotly debated in Congress. Surprisingly, the phrase “comparative effectiveness research” has even become a flashpoint in that debate. Advocates such as Dr. Lee see comparative effectiveness research as an important tool for improving health care, while some critics have derided it as a devious way to justify “rationing care.”

You can decide the issue for yourself by reading the commentary here, along with this JAMA editorial that makes reference to it.

Is there a doctor or writer in the house?

Stephanie wrote this…

It’s not all that uncommon for a person change professions mid career.  In fact, with this economy, many are having to reinvent themselves.

However, changing from one noble profession to another, makes me raise an eyebrow.  And that’s what happened when I heard about Terrence Holt.  No, not THE Terrence Holt, American football safety who was signed and (quickly) released from the Carolina Panthers.  But Terrence Holt, M.D., Assistant Professor in the UNC-Chapel Hill School of Medicine’s Department of Social Medicine and Division of Geriatrics.  Is it clicking yet?  It wasn’t for me either, until I read about THE Terrence Holt, Ph.D. and literary professor extraordinaire.  See, Dr. Holt went from shaping and influencing student minds about the great American writers of our time, to shaping the way we manage healthcare for our aging and ailing family members.

It was in Holt’s 40’s that he made the switch from Ph.D. to M.D.  And while he has no regrets, he has managed to meld his passions by recently having a collection of short stories published; In the Valley of the Kings.  The New York Times, NPR, and Wall Street Journal have taken notice.

Even today, Dr. Holt still shapes minds.  These minds are of medical students; those who look to him for guidance as they step into what could be one of many noble professions in their lifetime.