By Matt Wood

The human papillomavirus (HPV) is a strikingly common sexually transmitted disease associated with cervical cancer. More than 25 percent of women ages 14-59 are infected with HPV, but it gained greater attention in the United States in 2006 when the Food and Drug Administration (FDA) approved the first vaccine for it.

African American women and those living in low-income environments are at greatest risk for HPV infection and cervical cancer, and while some studies have looked at vaccination rates among adolescents, few have studied the unique effects of race and income level. To address this gap, a developmental psychopathologist at the University of Chicago recently studied the vaccination rates in a large, representative sample of girls 12- to 15-years old. She found that African American girls are far less likely to be vaccinated than European Americans, even when controlling for income level, exposing a significant disparity for those most at risk from HPV.

Kathryn Keenan, PhD, professor of psychiatry and behavioral neuroscience, had been working with colleagues at the University of Pittsburgh on a long-term study of the development of behavioral and emotional problems of almost 2,500 girls and their caregivers. In 2008, two years after the FDA approved the HPV vaccine, she and her colleagues took the opportunity to survey this group about initiation of the HPV vaccine.

The sample of girls in this study is unique because it is representative of the city of Pittsburgh and includes equal numbers of African Americans and European Americans. Because data had been collected annually since the study began in 2000, Keenan and her colleagues were able to identify predictors of which girls were most likely to get the vaccine.

In their latest study, published in Health Psychology, they found that about 60 percent of the girls had gotten the first of three shots for the HPV vaccine in the previous year, far below the goal of 90 percent set by the Centers for Disease Control and Prevention (CDC). African American girls were close to 40 percent less likely to have received the vaccine than European-American girls. The likelihood of vaccine uptake also increased with the level of sexual activity.

Keenan said these findings are troubling for a number of reasons. “African American women are more likely to suffer high levels of morbidity and mortality from cervical cancer than European American women,” she said. “So now we have something that in some ways should be deployed even more aggressively in that community and it’s not happening.”

The CDC recommends that all 11- or 12-year-old girls get the vaccination to protect against cervical cancer, but these recommendations have become a political issue as many parents and politicians object to the idea of protecting young children from a sexually transmitted disease. Unfortunately, this obscures the need for better education about HPV.

“Talking about sex and sexual activity when it comes to younger girls is still a huge taboo,” Keenan said. “I think we’re very uncomfortable thinking about sexual behavior in children. There are myths about how talking to children about sex gives them permission to have sex, and the data don’t support that at all.”

Keenan said that this fear overshadows the risks of HPV, because the public still has difficulty connecting it to cervical cancer. That confusion can give people the impression that there is a choice. “If you don’t have a good sense of the threat, it’s pretty easy to just say, ‘Well, it’s my choice,’” she said.  “I think we have to do a better job of making it clear that this is a real risk, and this is a real threat, because I don’t think that message is getting out.”

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By Dianna Douglas

The public health threats in Chicago aren’t just diabetes, asthma and hypertension—about 500 lives are lost every year in the city by homicide.

The University of Chicago Medicine fights the root causes of deadly violence in various ways. One recent attempt is through a partnership with CeaseFire, a group in Chicago that uses public health techniques to identify and interrupt outbreaks of violence with the same intensity as an outbreak of malaria or AIDS.

The work of CeaseFire, documented in the acclaimed 2011 film, The Interrupters, has had mixed results in lowering Chicago’s crime rate. The CeaseFire foot soldiers, called “violence interrupters,” mediate fights to try to keep them from escalating. They are hoping to change the societal norms among people who view violence as an acceptable way to solve conflict. But homicides wax and wane in the city, and the violence interrupters have had a frustrating 2012 so far, with the murder rate 60% higher than the same period last year.

The University of Chicago Medicine will host a total of 6 screenings of The Interrupters around the city this spring. Each is followed by a community discussion. The goal is to give the public some ideas on how to stop violence. Rather than seeing violence as a problem that should be addressed with crime control (more police, more incarceration), they hope that the community can view violence as a disease. The people infected by the disease need treatment and programs rather than judgment.

Below are scenes from one of these screenings and a discussion at the Rainbow PUSH coalition on April 10. Eric Whitaker, MD, MPH, executive vice president of strategic affiliations and associate dean of community-based research at the University of Chicago Medicine, served as the facilitator for the panel.

By Rob Mitchum

Brucella abortus is a particularly pesky pathogen. Frequently infecting cattle in many countries around the world, the bacterium causes the most common zoonotic infection, usually passing from animal to humans through ingestion of unpasteurized dairy products. While the infection, known as brucellosis or undulant fever, is rarely deadly, it can cause assorted flu-like symptoms including high fever, muscle pain, weight loss, and in severe cases, meningitis and encephalitis. These debilitating effects made it appealing to both the United States and Soviet Union for the development of biological weapons during the Cold War. Although these “brucella bombs” have long since been destroyed, the bacterium remains a concern around the world.

“It’s a substantial human health problem on a global level,” said Sean Crosson, assistant professor of biochemistry and molecular biology at the University of Chicago Biological Sciences. “The World Health Organization predicts that there are a half million cases annually, and it may be higher than that. It’s hard to know, because it’s more of a problem in the developing world where it’s difficult to quickly diagnose.”

Crosson’s laboratory is one of the few in the United States studying the bacterium and its surprisingly evasive behavior. The infection is very difficult to treat, requiring two different antibiotics to be taken for nearly two months — not an easy task in countries without easy access to pharmacies and the proper storage of the heat-sensitive drugs. Even when this rigorous treatment is followed under ideal conditions, the relapse rate for the disease is still high. When the Crosson lab searched through the genome of the bacterium, they found a potential reason for this resilience: a genetic poison and antidote pair usually thought of as a bacterial self-destruct mechanism.

“After treatment for brucellosis, there’s still a 15 percent chance of relapse,” said Brook Heaton, a Committee on Microbiology graduate student in Crosson’s lab. “This relapse is something that is obviously problematic, but also interesting when thinking of toxin-antitoxin systems, which are thought to play a role in persistence of infection.”

Toxin-antitoxin systems have been discovered in a variety of bacterial species, and studied primarily for their role in bacterial quality control. The tiny toxin and antitoxin genes were initially found on plasmids, small bits of bacterial DNA separate from the chromosomes. The two genes are typically transcribed together, producing both the toxin and antitoxin proteins simultaneously. Under normal conditions, the two proteins would stick together, nullifying the toxic activity like a sword in a sheath. But in this case, the antitoxin “sheath” degrades faster than the toxic “sword.” So if gene transcription stops for some reason or the cell divides and the daughter cell does not properly inherit a copy of the plasmid, then the self-destruct process begins.

But over the past decade, scientists started to find toxin-antitoxin genes on the chromosomes themselves, throwing the quality control theory into doubt.

“What exactly these things are doing is mysterious,” Crosson said. “They’ve been implicated in bacterial stress response, they get activated by certain stressors, and if they’re missing toxin-antitoxin genes then bacterial cells may not survive as well in certain environments. But the real biological function of toxin-antitoxin genes is still unclear.”

In a paper recently published by The Journal of Biological Chemistry, Heaton and her colleagues examined one toxin-antitoxin system from Brucella abortus with a wide variety of scientific techniques, from genetic manipulation and cell culture experiments carried out at the Ricketts Regional Biocontainment Laboratory at Argonne to biophysical analyses of protein structure. Functionally, when the toxin (named BrnT) was unleashed without its antitoxin (named BrnA), protein synthesis screeched to a halt and the bacterial cells stopped growing within an hour. But reports of the bacterial massacre were greatly exaggerated — subsequent activation of the antitoxin, even hours later, resurrected the cells to a normal, healthy state.

“On the surface, when you express the toxin, it looks almost like all the cells are dying,” Crosson said. “99.999% of the cells appear to die. But they’re not actually dead.”

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By Matt Wood

Video conferencing has crossed the threshold from corporate boardroom to the household in the last few years. Anyone with a Skype account or an iPhone can host their own video chats. Now, a group at the University of Chicago Medicine is using video conferencing as a way to train primary care providers in clinics throughout the South Side of Chicago.

Daniel Johnson, MD, associate professor and chief of the Section of Academic Pediatrics, has taken a telemedicine system called Project ECHO and applied it to an urban environment. Project ECHO (Extension for Community Healthcare Outcomes) was a model originally developed at the University of New Mexico to train health care providers in rural clinics using video-conferencing equipment.

“Providers in urban areas, generally speaking, work their tails off, particularly if they’re working with an under-served or under-insured population,” Johnson said. “They quite simply don’t have the time to take advantage of some of the learning opportunities that are around them. So they end up being academically isolated, intellectually isolated and in some cases socially isolated. This system provides a forum for them.”

Johnson, along with colleagues at the University of Chicago and in the community, developed a pilot program for the ECHO system to train primary care providers on resistant hypertension management. They set up the video conferencing systems at six Federally Qualified Health Centers (FQHCs) affiliated with the South Side Healthcare Collaborative and conducted 12 sessions scheduled every other week over six months.

Each session began with a 20-minute lecture by George Bakris, MD, professor of medicine and director of the University of Chicago Medicine Hypertension Center, on topics such as how and when to take blood pressure, how to make sure patients take medications properly and how to treat hypertension in the elderly. Following the lecture, medical staff from the participating clinics presented cases of patients with resistant hypertension and discussed them with the group.

At the end of the 12 sessions, the providers who participated in the ECHO training sessions scored significantly better on a knowledge test about resistant hypertension than at the beginning of the project, and better than a control group that did not participate. They also said they were much more confident in their ability to treat resistant hypertension than before they started. The results of this study were published in The Journal of Clinical Hypertension.

Johnson says this method has a number of advantages over other remote training formats such as webinars or standard video presentations. “The video conferencing has the value over most other remote formats of making you feel like you’re almost in the room with other people,” he said. The cost to equip a site with video cameras, monitors and network equipment runs from $1,500 to 3,000. While this is a high initial investment for a small clinic, it’s more cost-effective than sending a physician to a training course and losing their services for a full day or more.

The format also mimics traditional case-based rounds in which most clinicians in academic medical institutions learn. “The subject matter expert isn’t the only person providing value to the activity because the other people in the room all have experience that is valuable to each other,” Johnson said. “So there is value in the shared experience that comes from people’s sitting around learning together.”

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People are used to feeling uncomfortable at the dentist, whether its suffering the drill or trying to make conversation with a gloved finger in your mouth. Given this baseline, perhaps the dentists’ office is the perfect place for another awkward experience: testing for HIV. This intriguing proposal has been made by public health advocates since the 2004 FDA approval of the rapid saliva HIV test, which produces reliable results in less than 20 minutes. Combining that convenient test with a check-up that’s a yearly tradition for most people — one that offers no shortage of saliva — could help spot HIV cases earlier and more often. But there’s a cognitive dissonance to the idea of sexually transmitted disease testing in the dental office that’s weird for more than just the patients, as a recent survey of dentists discovered.

The medical role of the dentist has expanded in recent years, as many dentists go beyond your standard tooth-cleaning and cavity-filling to screening for oral cancers, high blood pressure, and diabetes. Would adding an HIV test to their repertoire be feasible? That’s what a team of researchers from around the country, including the University of Chicago’s Harold Pollack, asked 40 dentists in phone interviews in a paper for the American Journal of Public Health. The study found that many dentists saw the value of helping potentially infected patients discover their disease status, and thus start treatment earlier than they might have otherwise. But there were also several objections raised about offering the HIV test alongside teeth-whitening in their offices.

Surprisingly, only 1 of the 40 dentists had even heard about the rapid saliva test before the phone call. Alongside the concerns about the test’s accuracy and reimbursement for the time it takes, the dentists voiced concerns that reflect the still-touchy topic of HIV. Many said that they wouldn’t feel comfortable talking to patients about the test or its results, worrying that older or more conservative patients would be offended by even offering an HIV test. “I think most of my patients would feel insulted or that I was overstepping my bounds,” said one dentist.

If the test should come back positive, some interviewees said they were nervous about being “the bearer of bad news” in disclosing the result before referring the patient to a medical doctor. A primary care physician might be better equipped to handle both the clinical questions and emotional fallout that could result from a positive HIV test.

“This is only my opinion, but it would seem very odd for the first person to tell the patient they were HIV positive would be the dentist,” one respondent said.

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By Matt Wood

Family medicine physicians try to stay current in their fields by reading the latest medical journals and research literature, but the volume of new research can be overwhelming. To deal with this flood of information, the Family Physicians Inquiries Network created a system called Priority Updates from the Research Literature, or PURLs, in 2007 that is published in the Journal of Family Practice.

The PURLs series has covered a broad range of topics, such as when to expose children to radiation by CT examination after a fall, what medications can treat an infection in a pregnant woman without increasing the risk of birth defects and how best to control atrial fibrillation to prevent a stroke. Each month a network of physicians surveys the relevant literature for articles that might be useful in the typical family medicine setting. An editor then assigns a physician to write an article for the journal that puts the new research into context and examines its impact for family practitioners.

Nina Rogers, MD, and clinical assistant professor in the University of Chicago Department of Family Medicine, participates in this program and has written articles spanning a range of maladies, from appropriate treatment for persistent asthma to, more recently, a home remedy for a common problem that could save time and money for both patients and physicians: removing excess ear wax.

Rogers and a colleague from the University of Missouri wrote about a study published in the Annals of Family Medicine in which physicians from England found that patients can safely and effectively remove excess ear wax on their own. Patients who were given ear drops, a bulb syringe and instructions had on average 50 percent fewer office visits to remove ear wax than patients who were not encouraged to do it at home.

The relative success of home remedies like removing ear wax with a bulb syringe or treating athlete’s foot with corn starch depends on what Rogers calls “patient buy-in.” This is where close relationships earned by treating multiple generations in a family medicine practice comes in handy.

“There’s the component of physician-patient relationship, how much they trust you and how much they’ll take your advice,” Rogers said. “A lot of it is knowing your patients, what’s going to help them. Sometimes saying ’studies show that this is beneficial’ is good, whereas to others you say, ‘I recommend this to a lot of patients.’ Knowing how to present information to them definitely helps buy-in.”

Research on home remedies might seem mundane, but fewer office visits for procedures that patients can perform safely on their own can save time and money for both patients and community facilities that are often strapped for resources.

“We have barriers to how much patients can spend for medicine, so sometimes we have to come up with creative or inexpensive ways to treat an ailment,” Rogers said. “The exciting feature about this study is that there is now an evidence-based non-pharmacologic treatment we can recommend confidently.”

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Rogers N, & Stevermer JJ (2011). PURLs: Ear wax removal: help patients help themselves. The Journal of family practice, 60 (11), 671-3 PMID: 22049350

By Rob Mitchum

Arsenic is a deadly toxin, but it’s not one dose fits all. Two people exposed to the same level of the chemical can have entirely different responses, with Patient A developing the skin lesions, cancers, and respiratory conditions that are a hallmark of arsenic toxicity, while Patient B is entirely unaffected. Currently, no test exists to tell in advance who might be more vulnerable to the effects of arsenic, but scientists suspect that some clues may lie in a person’s genes. In the latest paper from Habibul Ahsan’s massive study of arsenic exposure in Bangladesh, researchers uncovered a promising genetic story that could help identify people at higher risk — and potentially help protect them from toxicity.

As discussed before on ScienceLife, Ahsan’s two studies in Bangladesh follow the victims of an almost unfathomable mass poisoning event. In the 1970’s, an international effort was put together to switch millions of Bangladeshis from disease-ridden water sources to well-water. Unfortunately, the groundwater tapped by those wells turned out to contain very high levels of arsenic…a dark fact that wasn’t discovered until some 20 years after their installation. Over those decades, some 77 million people in the country were drinking water containing arsenic concentrations as high as 27 times safe limits.

For more than a decade, Ahsan has studied the epidemiology of that long-term exposure in some 20,000 volunteers, as well as low-priced interventions to try to reduce toxicity. In his latest paper, published last week in PLoS Genetics, Ahsan’s team zoomed in on the DNA of those subjects, looking for genetic variants that predict higher arsenic toxicity in a pool of 3,000 Bangladeshi citizens from the larger studies. Using the methods of genome-wide association studies (GWAS) — one of the first such studies conducted in the developing world — the researchers found a genetic region that offers a promising and refreshingly logical story about what creates individual differences in vulnerability to arsenic.

“These results add clarity to the genetic architecture that is playing a role in arsenic toxicity and its underlying biology,” said Ahsan, Louis Block Professor of health studies, medicine and human genetics at the University of Chicago Medicine. “It’s a rare type of study for a major problem affecting millions of people around the world, and it opens up opportunities for genetic studies of other major public health problems in developing countries.”

Led by Ahsan and Brandon Pierce, assistant professor of epidemiology at the University of Chicago Medicine, the team looked for potential genetic influences on phenotypes such as arsenic metabolism and the risk of acquiring arsenic-induced skin lesions. After ingestion, the body metabolizes inorganic arsenic into first monomethylarsonic acid (MMA) and then dimethylarsinic acid (DMA). MMA is considered to be more toxic, while DMA is water-soluble and more easily excreted. Higher levels of DMA or lower levels of MMA measured from an individual’s urine are associated with lower toxicity.

A GWAS search for variants associated with high or low DMA/MMA ratios turned up several candidates in the region of a likely suspect gene: arsenite methyltransferase (As3MT), an enzyme known to be involved in arsenic metabolism. A second GWAS that compared subjects who suffered skin lesions after arsenic versus subjects who did not pointed to variants in the same region, offering more evidence for the gene’s involvement and a rare straightforward result for a genomic study.

“This makes perfect sense,” Ahsan said. “It gives us a very coherent story that we can now investigate in relation to other arsenic pathologies and in relation to a wide range of arsenic doses in this population. Many genomic signals that we see are not robust enough or do not pertain to a large population. But in this study, that is not the case. The finding is robust, and the impact is massive.”

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As another year comes to a close we’d like to look back at the fascinating research breakthroughs and inspiring patient stories from 2011. ScienceLife ran 168 posts this year, and while we wish we could highlight all of them, here are a handful of our favorites from each month.

January

Patrick Wilson found out that the H1N1 virus could end up helping us fight all types of flu. Stephen Pruett-Jones studied how some male birds mimic the sounds of predators to pick up the ladies (with an audio clip). We interviewed David Gozal about his study on the link between childhood obesity and lack of sleep, and took a look at NCAA regulations mandating sickle cell testing for athletes.

February

Harold Pollack gave a lecture on why violent crime in urban, minority communities should be considered a public health epidemic. Siri Atma Greeley studied the actual medical benefit of widespread genetic testing. Stacy Lindau wanted to know why so few women get help for sexual problems after surviving cancer. We talked to Bana Jabri about the causes of celiac disease, and Sliman Bensmaïa showed us how the brain processes the basic elements of touch very much like it handles visual information.

March

Sola Olopade educated women in Nigeria about using clean-burning stoves to prevent indoor pollution. Stefano Allesina and Jonathan Levine looked at how rock-paper-scissors helps explain evolution. Joshua Miller went to Yellowstone Park to see what stories the ghostly bones of animals can tell, and Scott Eggener questioned the wisdom of indiscriminate prostate cancer screening.

Photo by Gerald Waddell

Andrea King studied the wide range of responses to drinking alcohol, and why it can be fun for some people and a bummer for others. Cheryl Reed took a ride in a helicopter with our UCAN nurses. Kamal Sharma looked at the genes that control animals’ gait, and Ningqi Hou studied how urban environments can dictate how much exercise people get.

May

Daniel McGehee looked at the long-term effects of nicotine on the brain. Habibul Ahsan went to Bangladesh to study the health impacts of accidental exposure to arsenic in drinking water. The brain’s overlooked supporting cells got their due at a conference on neuroscience, and we remembered a landmark discovery about a once popular drug taken during pregnancy that we now know can cause cancer.

June

As we headed into summer, Diana Lauderdale used Google to track MRSA. We learned about an extraordinary transplant where a man received a new heart, liver AND kidney. Daniel Geynisman gave us the rundown on whether or not cell phones are killing us (they’re not, as long as you don’t use them in the car), and some UChicago undergrads studied what happens to gorillas on the birth control pill.

July

We spoke to Donald Jensen and Andrew Aronsohn about the new outlook for patients with hepatitis C. Igor Schneider made a time machine to find the genetic switch for limb development. Farr Curlin led a study about the benefits of addressing spiritual needs alongside medical care, and Adam Cifu looked at the phenomenon of scientific study reversals.

August

Stefano Allesina dug into the long, shady history of nepotism in academia in Italy. John Schneider talked about his work addressing sexual health and stigma in India. Michael Becker discovered a new treatment for the Royal Disease, and we had the rare chance to name check a Spiderman villain in a post.

September

Martha McClintock and Suzanne Conzen studied the connection between social isolation, stress and breast cancer. Gallego Romero traveled to India to search for the origins of lactose intolerance. Stephanie Dulawa developed a mouse model for OCD, and Paul Vezina looked at a different kind of obsession, compulsive gambling.

October

Arshiya Baig started a pilot project to help people learn about life with diabetes through pictures. Manyuan Long found that some of the youngest genes are in the brain. Jens Ludwig and Stacy Lindau published a landmark study about the connection between neighborhood poverty and health, and Issam Awad studied a rare brain disease that soon could be treated with a drug instead of surgery.

November

Cathy Pfister and Tim Wootton figured out how to use seashells to track climate change over the years. Lianne Kurina found a link between loneliness and sleep quality. Shantanu Nundy, Monica Peek and Marshall Chin developed a program to send text message reminders to people with diabetes, and Pan Chen looked at the links between childhood abuse and aggressive behavior in adults.

December

Inbal Ben-Ami Bartal, Jean Decety and Peggy Mason discovered that rats can show empathy for their fellow rats in distress. Maciej Lesniak performed a scary but amazing brain surgery on a patient who was awake. Cathryn Nagler searched for the source of food allergies within our bodies, while Stafano Guandalini uncovered the challenges in educating doctors about one of those allergies, celiac disease.

Whew. Hope you were able to click through at least a few of those. We look forward to another great year of research in 2012. We’re taking a break next week, but we’ll be back on January 5. Happy holidays!

By Dianna Douglas

The goal of World AIDS Day 2011 is not to make the public aware of the disease. That was the goal in 1988, back when the international health threat was still new, infections were rising every year, and there was no hope of a treatment in sight. This year, World AIDS Day marks the sunset of the public panic about the virus. The stated goal this year is “getting to zero” — or bringing the number of AIDS-related deaths and new HIV infections down to zero and ending all discrimination against people living with the virus.

The University of Chicago has various ways of reaching that goal here in Chicago. There’s the STI/HIV Intervention Network (SHINE) based at the School of Social Service Administration, which brings interventions to neglected groups such as men who have sex with men, people in the criminal justice system, minority youth, and young couples. There’s also the Medical Center’s Living Positively program, in which HIV-positive young people act as advocates to their peers who are at risk.

Now, in honor of World AIDS Day, the Medical Center is trying an innovative approach to this public health issue. Instead of doing what he calls the “typical academic thing for World AIDS Day” — a panel of researchers talking about AIDS in Africa in an auditorium full of other researchers — John Schneider, MD, MPH, has organized a ball. “This year, we want to collaborate and fully engage with the community,” he said. In gay culture, a ball is where people dress in drag to show off their moves, a lot like a fashion show. The community he hopes to reach with this ball is the young GLBTQ (gay, lesbian, bisexual, transgender, and queer) minorities who have the highest HIV infection rates in the city.

While the tide may have turned in the AIDS epidemic, the infection rates of several groups remain stubbornly high. Around 22,000 people in Chicago live with HIV or AIDS, and the infection rates among African Americans and gay men are particularly sobering. Since 2005, 57 percent of new HIV infections in men have been a result of men having sex with infected men. Among African Americans, the HIV infection rate since 2005 is more than double the general population’s infection rate.

A partnership with the young people striking a pose at underground balls may seem unusual, but it may also be the best way to reach Chicago’s most vulnerable populations. “We know where the epidemic is, and we have the tools to take care of it. What is needed now is hard work using traditional case-finding methods to reach these vulnerable groups with health services,” Schneider said.

The ball tradition, subject of the award-winning documentary Paris is Burning, has long been a safe place for young black gay and transgendered people to express their creativity and build communities. The World AIDS Day mini-ball will celebrate the support that the members of this subculture offered each other during the worst days of the AIDS epidemic in the 1980s and ’90s.

“These are the people most impacted by AIDS in the United States,” said Keith Green, MSW, co-director for the Chicago Black Gay Men’s Caucus and a co-sponsor for the event.

Everyone at the ball will see their peers promoting safe sex and healthy behavior.

Contestants — many of whom are gay, transgender or bisexual — will compete against one another in the lobby of the School of Social Service Administration this Friday night. Participants will display their dance skills, costumes and attitude in a variety of events, similar to a runway show. In some events, they will be judged on the “realness” of their drag. In others, on the beauty of their clothing and overall style. Each of the seven walk competition categories has a cash prize for the winner.

“Every category requires the creative integration of the AIDS ribbon, the color red, or latex,” said Matt Richards, outreach program manager for pediatric infectious diseases at the University of Chicago Medical Center.

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Texting has grown from technological fad to a primary route of communication popular around the world. With cell phones in the pockets of people of all incomes and ages, the quick, no-frills conversations enabled by texting have made almost everyone more proficient with their thumbs. Due to such impressive ubiquity, people in health care are starting to ask whether text-messaging can be harnessed as a cheap and user-friendly tool for communicating with patients outside of the clinic - particularly hard-to-reach patients in urban and low income areas.

“People are ignoring that unlike every other technology, mobile phones reverse the digital divide,” said Shantanu Nundy, clinical instructor of medicine at the University of Chicago Medical Center. “More low income patients are using phones for text messaging and internet than other groups. So shouldn’t we then be developing technology for this type of population?”

Nundy and Jonathan Dick, a Pritzker graduate now in residency at Columbia University Medical Center, arrived independently at this same idea after separate trips overseas, where they saw clinics in Uganda and India using text messages as part of their operation. With texts, physicians could follow up with patients with chronic diseases, making sure they were taking medications and doing the types of self-examinations necessary to manage diabetes or HIV - tasks that are just as challenging at home as they are abroad. In some areas of Chicago the diabetes rate is as high as 25 percent, and African-American populations have much higher rates of diabetes complications such as blindness and amputation.

“It seemed to me that we had a lot of the same problems on the South Side of Chicago, so why not try it there?,” Dick said.

To test this premise, Nundy and Dick joined efforts with Medical Center faculty Monica Peek and Marshall Chin, who recently received grants from the Alliance to Reduce Disparities in Diabetes and the National Institutes of Health to look for new ways to improve outcomes in South Side neighborhoods. For a pilot study published last month in the Journal of Diabetes, Science, and Technology, the team recruited 18 African-American diabetes patients to try out a new automated text-messaging communication system that they programmed.

The study participants were not your typical teenage texters, instead reflecting an age range (38-72) more commonly afflicted with diabetes.

“If this is going to work, we needed to look at middle aged people and people in their 60s and 70s. I’m less interested in having this as a hip thing for teenagers with diabetes,” said Peek, assistant professor of medicine. “It needs to be able to work in people I see in clinic. A 55-year-old black woman with diabetes, if it works for her, I’m interested.”

Each participant was asked at the beginning of the study what kinds of text message they would like to receive, with candidates including reminders to take diabetes medications, check blood sugar, or conduct self-examinations to detect potential complications. Participants could also customize when they received the message, and how often they came in over the one-month pilot.

Some were purely notifications (i.e. “Please take your medications now.”) while others required a text response (”How many times did you check your feet this week?”). In one early sign that the messages were reaching their targets, participants often texted back whether a response was required or not, sending an “OK” or a “Thank you” message to what they knew was an automated system. The study reports, “Many participants found that they began anticipating the text messages and readying themselves to answer the questions in an affirmative way, such as preparing the insulin syringe ahead of the expected message.” That enthusiasm was reflected in surveys of the patients after the study period ended, where all but one participant said they were very satisfied with the text reminders.

“In the context of a population that typically has very few interactions with the health care system and may have experiences that are negative or bad or fearful, it was very fulfilling for them to have positive reinforcing messages where they really felt cared for by the system in a way they hadn’t in the past,” Peek said.

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By John Easton

Even in the court of ethics and medical professionalism, there’s nothing wrong with the occasional honor or award. On day two of the conference, the Maclean Center awarded its first Prize in Clinical Ethics and Health Outcomes - at $50,000, the largest such prize in the ethics field - to John Wennberg, the Peggy Y. Thomson Professor for Evaluative Clinical Sciences at Dartmouth Medical School and founding editor of The Dartmouth Atlas of Health Care.

In 2007, the journal Health Affairs named Wennberg as “the most influential health policy researcher of the past 25 years.” Fitzhugh Mullan, former director of the Bureau of Health Professions in the U.S. Department of Health and Human Services, described Wennberg as “both the Christopher Columbus and the Johnny Appleseed of clinical variation,” meaning he not only discovered the field but also brought it to the attention of the medical and health policy communities.

“While John Wennberg is regarded as a health services researcher,” said Mark Siegler, MD, director of the MacLean Center, “his fundamental work on patient preferences and shared decision making highlight his contributions to the field of clinical medical ethics.”

The Dartmouth Atlas examines the patterns of medical resource intensity and utilization in the United States, with special emphasis on end-of-life care, inequities in the Medicare reimbursement system and the under-use of preventive care.

From the start, it has brought surprises, according to Kenneth Polonsky, dean of the Division of the Biological Sciences and the Pritzker School of Medicine at the University of Chicago, who introduced Wennberg. The report comprehensively documented the “striking differences” in the amount of health care provided in different regions, adding the provocative observation that the amount or cost of care delivered did not correlate with good outcomes.

Joking that “when you get paid so much to give a lecture, you get a little nervous,” Wennberg spoke about the early days of the Atlas and how their studies of practice variation in the mid-1970s “challenged the notion that science was driving utilization.” Instead, decisions about surgical treatment for benign prostate hyperplasia revealed what the researchers called “surgical signatures,” patterns of practice based on the beliefs of individual surgeons.

When Wennberg’s team developed short, balanced videos to show to patients, explaining the risks and benefits of surgical treatment and showing taped interviews with two physicians who had made different decisions, patients were much less likely to choose surgery. “This was the first evidence,” he said, “that engagement of patients could lead to the right utilization rate.”

However, only about 25 percent of medical care turns out to be so “preference-sensitive,” forming what Wennberg calls “little islands of rationality.” Studies of end-of-life care found a far more limited role for shared decision making between patients and their caregivers. Instead, demand for resources appears to be driven by supply. Empty hospital beds and unused capacity strongly correlate with increased medical care late in life. For example, more than twice as many patients were admitted to an intensive care unit in the last six months of life at UCLA compared to Dartmouth.

Wennberg described the four goals of the Atlas’s end-of-life team for the next five years: to better inform patient choices, improve the science behind these decisions, promote organized care and constrain undisciplined capacity spending. At this point, he said, “we don’t need more research, we need more action.”

Another session at the conference focused on a very different book, not an atlas but a historical novel, based on true events and real people. Open Wound: The Tragic Obsession of Dr. William Beaumont, by former ethics fellow Jason Karlawish, a professor of medicine and medical ethics at the University of Pennsylvania, examines the professional and ethical issues raised by William Beaumont, a 19th-century surgeon who cared for - and experimented on - a patient with a shotgun-blast-induced hole in his stomach. Beaumont saved the patient’s life, but then used this wound, which never quite healed, as a window to decipher the mysteries of digestion.

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Almost everyone has experienced the boredom of sitting through someone’s vacation photos, forcing a wan smile as a friend hands you picture after picture of beaches, museums, and old buildings. But if you’ve been to the same destination as your friend, there’s an allure to seeing how their experience of a particular place compares to your own. Discussing a gelato stand you both visited outside the Uffizi gallery in Florence or debating the merits of ocean-side vs. sound-side in the Outer Banks can bring a friendship closer. But can that communal photo-sharing power be captured and channeled into improving people’s health?

That concept is a novel component of assistant professor of medicine Arshiya Baig’s pilot project to improve diabetes outcomes in the Chicago Latino community, Picture Good Health/Imagínate una Buena Salud. Designed in cooperation with churches in the predominantly Mexican neighborhood of Little Village, Baig’s program offers focus group classes with Latinos diagnosed with diabetes, seeking to improve their diet, exercise, and disease control. At each of the eight weekly sessions, participants go through education, counseling, and activities to help manage their diabetes. But each meeting begins with a novel concept, called “photovoice,” that puts the storytelling potential of photography to use as a stimulant of healthy discussion.

“We thought we would do something fun, so we are giving disposable cameras to everyone in the intervention group, and they get to take photos of their life with diabetes,” Baig said. “Then each class starts off with a conversation around those photos. People can share stories, they can problem solve, and our class leader is trained to facilitate a conversation. It’s probably the most innovative part of the study.”

The concept of photovoice was not created by Baig, but it is typically used by researchers for different purposes. Typically, the idea of giving subjects cameras and asking them to document their situation is used as a “needs assessment” to help design an intervention. For example, one project asked teenagers in an urban area to photograph negative elements in their daily life and community. Researchers or policy makers could then look at those photos to find places where an intervention could make the largest impact, such as cleaning up abandoned buildings or providing more supervision during walks to school.

However, in Picture Good Health, the photovoice method is the intervention. Participants are told only to document things in their life that are relevant to living with diabetes. After the photos are developed, they can choose which ones to share with the group during the first half-hour of each week’s session. The photographer explains what the photo means to him or her, and then the group discusses from there.

Second-year Pritzker medical student Matthew Stutz joined Baig’s project this summer to start analyzing the photovoice component of the focus groups. He found that the participant’s photos covered a wide range of topics, from the obvious (food, diabetes medications) to more general influences such as their home, workplace, neighborhood, and family. A photo of loaves of white and wheat bread might kick off a group discussion of health grocery choices, or a picture of an ashtray could trigger participants to talk about the methods they have used to try and quit smoking. One man shared a picture of a park and said it reminded him of his deceased daughter, inspiring the other participants to talk about family members they had lost - a topic that wouldn’t typically be on the agenda for a diabetes intervention.

“I think of photovoice as an easy mechanism for someone to convey emotions, experiences, losses, gains, without having to verbalize it,” Stutz said. “By having a prop or a mechanism to share, I feel we can gain a lot more ground and depth and conversation.”

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By Dianna Douglas

The Affordable Care Act is nearly one and a half years old, but the complexity of its reforms and their gradual roll-out have made it difficult to grade. Different disciplines are still parsing the legislation, attempting to figure out how it will change the future of their field. Experts in the field of Family Planning and Contraceptive Research has been puzzling over an enormous and perhaps unanswerable question: How will health care reform affect the reproductive lives of women and girls?

That was the primary question at the section’s spring conference, “Reproductive Justice and Health Care Reform: the Impact of Reform on the Reproductive Health of Underserved Women and Youth.” The phrase “reproductive justice” connotes the activism to give women and girls of all races and incomes the access to the same choices and education for controlling their reproduction. Panelists argued that some aspects of the bill, particularly the expansion of insurance coverage, would benefit this cause. But there were also warnings about the political resistance, exemplified by Representative John Boehner’s statement that he doesn’t think reproductive health care services are the business of the federal government: “How can you spend hundreds of millions of dollars on contraceptives? How does that stimulate the economy?” he asked in 2009.

Speakers at the conference, which was co-sponsored by UChicago’s Center for the Study of Race, Politics and Culture, posed many unanswered questions about how the Affordable Care Act will affect women and girls in America. Some expressed hope that it could close the gap between black and white and rich and poor in all areas of maternal health, unintended pregnancy, intimate partner violence, and infant mortality.

But Harold Pollack, PhD, professor at the School of Social Service Administration, gave both sides of the story. He argued that the Affordable Care Act is not only health care policy, but it is the defining document of America’s public policy on reproductive health care.

“Near-universal health insurance coverage will reduce disparities in health,” Pollack said. One of the goals of the Affordable Care Act, passed by Congress and enacted by President Obama in 2010, was to stop people from skimping on health care when they couldn’t afford it. If enacted properly, the health care plan would extend reproductive health care to millions of women.

Under the law, Pollack said, insurers can no longer require a referral to see an obstetrician or gynecologist, and must offer women direct access to these specialists. They are required to pay for some preventative services, like screenings for breast and cervical cancers and sexually transmitted infections. Insurers are required to pay for certain vaccines for women. They have to pay for preventive care for children and adolescents, including screenings for pregnancy. And, insurers may be required to pay for contraception and other family planning services.

All of these requirements were designed to improve women’s health across income levels, but basic access to physicians is the key. “When you visit a doctor because your knee hurts, the truth is that she probably won’t do very much for your knee. But you’ll get your blood pressure taken. She’ll ask you about your diet. And she’ll recommend you for other screenings and lifestyle adjustments,” he said. Oregon recently found that poor people with health insurance were healthier than poor people without it.

Pollack’s keynote address was not uniformly cheerful, however. “The bill is vulnerable, and reform is a risk,” he said. The politics around health care reform have become poisonous, he said, and some of the best public policies in the bill are the most under attack.

Pollack lamented that the great benefits of health care reform won’t be enacted for a few years, during which time public opinion on health care reform could sour more dramatically. “Backloading was the sin of this bill,” Pollack said. It takes time for reforms to embed in society, he said and the legal challenges to the bill may stop the process before it can begin.

To keep the Affordable Care Act on track and make the reforms sustainable, Pollack suggested that the people who support the bill should put a human face on it. “Americans are deeply ambivalent about sexuality and reproductive health,” he said. “But even people who disagree with abortion are uncomfortable with making a poor woman carry a baby to term after a rape or if the pregnancy will seriously damage her health.”  The more human and less theoretical the reforms can become, the more likely they are to survive the next few years of budget cutting.

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It has been a couple months since the end of the spring quarter, and the with it the end of many of the Medical Center’s weekly lecture series. But a recent batch of videos posted to the website of the MacLean Center for Medical Ethics brought a whiff of the school year to the dog days of summer. The videos feature a selection of the lectures from the third and final segment of the 2010-2011 theme, “Health Disparities: Local, National, Global,” [pdf] and run the gamut of expert perspectives from libertarian law and the insurance industry to black history and medical education. If you are going through lecture withdrawal or want to get excited for next year’s MacLean Center series (“Medical Professionalism and the Future of American Medicine” [pdf]) beginning in late September, enjoy these videos.

The Case for Health Disparities - Richard Epstein, University of Chicago

Richard Epstein’s annual contribution to the seminar series is always a combustible reaction, where the classically conservative law professor’s market economics conflict with the more liberal lean of the regular audience. This year’s topic was especially flammable - after a couple dozen lectures on the struggle to reduce the health care gap in the United States and around the world, here was Epstein arguing for preserving those very same inequities. Beyond the deliberately provocative title, Epstein’s characteristically off-the-cuff speech recommended that health care reformers should choose a different target - instead of minimizing the health care differences between top and bottom, push policies that support growth and innovation for all patients, rich or poor, while encouraging charity instead of coercive giving.

Future Directions for Health Equity - Anne Beal, Aetna Foundation

The Aetna Corporation is in the business of providing health insurance to Americans. The Aetna Foundation is the charitable arm of that company, dispensing grants and funds to research ways of improving the health care system and reducing costs. Researcher and author Anne Beal is the current president of the Aetna Foundation, and focused her talk on reducing costs and inequalities via improving the quality of health care in America. “Giving people the right care at the right time and preventing disease is an amazing way for us to really rein back a lot of these health care costs,” Beal said. [Original Article]

“Without Health and Long Life All Else Fails”: African-Americans and the History of the Elimination of Racial Disparities in Health and Health Care - Vanessa Northington Gamble, George Washington University

Obviously, racial disparities in health care are not a new phenomenon. Efforts to improve the health of African-Americans also didn’t begin with the civil rights movement, though the strategies employed by the disparity-fighters of the segregation era were very different from today.

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Being a parent these days is anxious business, with an onslaught of news reports telling you what might be good or bad for your child’s health and development. In many cases, these claims are based on scientific evidence that is preliminary at best, studied only in small subject pools or retrospectively. To comprehensively confirm a link between, say, breast-feeding and body weight or living near a smokestack and asthma, a large epidemiological study that tracks thousands of children from before birth to adulthood is necessary. But that kind of study is very expensive, thanks to costs associated with recruitment, data collection, and analysis over decades of time.

As such, it’s better to do one enormous study of many factors that potentially influence child health rather than several independent and costly experiments. Enter the $5 billion National Children’s Study, a federally-funded project that hopes to track over 100,000 American children from their mother’s womb to age 21 in order to test possible influences - genetic and environmental, positive and negative - to their health. Already 11 years in the making, the study is just completing its warm-up phase, hoping to start the main event in April 2012. But as Daniel Johnson and Angela DeBello presented at the University of Chicago Medical Center Pediatric Grand Rounds earlier this month, the study is already teaching researchers valuable lessons.

“We have a very ambitious agenda,” said Johnson, an associate professor of pediatrics at the Medical Center involved in the Chicago branch of the study. “We’re kind of learning how to do this as we’re going along.”

The Children’s Health Study was authorized as part of the Children’s Health Act of 2000, alongside improvements to child mental health care, anti-violence programs, and day care provider training. While many of the other initiatives have long been implemented, the CHS has taken more time to reach the launchpad due to the mind-boggling logistics involved. In order to break down the roughly 4 million U.S. births each year into a manageable study cohort, the project will collect medical and survey data on growing kids from 105 different counties reflecting almost every region of the country.

It’s a beautiful plan on paper, but executing the recruitment and retention of 100,000 children around the country is immensely difficult. Debello, the vice president and associate director of public health research at the National Opinion Research Center (one of the organizations charged with administering the CHS), said that pilot studies have revealed just how difficult it is to even find pregnant mothers eligible for the study. Researchers have tried surveying homes for women expecting children or trying to have children, working with medical providers who can direct eligible women to the study, and mailed surveys to try and find the right subjects. But the up-to-date numbers presented at grand rounds indicated the low hit rate of this full court press: of 28,000 households originally contacted in Cook County, only 67 women were found to be eligible for the study (and only 49 provided consent to participate).

“It’s pretty overwhelming…the numbers are going to get big very quickly as this study progresses,” DeBello said. “Not surprisingly, it was far more expensive than we expected it to be.”

Hence that large price tag, which Johnson admitted is high, while also suggesting that it could be a bargain in the end. Any costs spent on conducting the study should be weighed against the potential health care costs saved with the information it collects. There’s a lot of room to work with in child health costs, he pointed out - a study in the journal Health Affairs calculated that environmentally-mediated diseases caused by lead exposure, air pollution, and other toxins produced $76 billion in medical costs in 2008 alone. Johnson also pointed out that the results of a similarly large project, the Framingham Heart Study, has prevented an estimated 800,000 deaths despite only being 1/20th the size of the CHS.

“It’s still not clear how successful this study will be,” Johnson said. “But we think that the goals and aspirations are certainly strong reasons to drive us forward.”

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