Tropical Diseases Add to Burden Among the Poor in the U.S.

By DONALD G. McNEIL JR

Ailments of poverty, including some tropical diseases much more common in poor countries, are a burden in several regions of the United States, a new analysis finds.

The diseases affect thousands of the poor concentrated in the Mississippi Delta, Appalachia, the borderlands with Mexico, poor urban neighborhoods and tribal reservations, says the report, which appears this week in Neglected Tropical Diseases, a journal of the Public Library of Science. Many are insidious and disabling; some may be transmitted at birth.

That they are not higher on the public health agenda “is a national disgrace,” said the author, Dr. Peter J. Hotez, chairman of the tropical disease department at George Washington University.

The prevalent diseases include Chagas, spread by blood-sucking insects; cysticercosis, spread by tapeworm eggs in dirty drinking water; and worm diseases often spread through soil near houses where pets have not been dewormed, or in urban playgrounds.

Other potentially dangerous infections include dengue fever, spread by mosquitoes; syphilis, which is spread by sexual contact and which may be transmitted to infants; and cytomegalovirus, which is dangerous to an infant if a mother acquires it in pregnancy.

Immigrants from refugee camps in Africa or from Mexico and Central America often have high rates of worm infections or insect-borne diseases. Inuits in Alaska are susceptible to parasites carried in the meat of seals, polar bears and caribou.

Dr. Hotez recommended more surveys of such illnesses, particularly more newborn screening and more collection of fecal samples to check for worm diseases.

Drug-Resistant High Blood Pressure on the Rise

By BRENDA GOODMAN

High blood pressure, the most commonly diagnosed condition in the United States, is becoming increasingly resistant to drugs that lower it, according to a panel of experts assembled by the American Heart Association.

“It’s becoming more difficult to treat and it’s requiring more and more medications to do so,” said the panel chairman, Dr. David A. Calhoun, a hypertension specialist at the University of Alabama at Birmingham.

The problem is not that the medications have stopped working, said the report, published this month in the journal Hypertension. Instead, many blood-pressure patients are sicker to begin with and require more drugs, at greater dosages, to manage their conditions.

The doctors say this is especially worrisome because recent surveys estimate that one in three Americans have hypertension, an underlying cause of heart attacks, strokes, kidney disease and heart failure.

Starting at a blood pressure of 115/80, research shows that the risk of a heart attack or stroke doubles with every 20-point increase of systolic pressure, the top number, or 10-point increase of diastolic pressure, the bottom number.

“High blood pressure is currently the biggest single contributor to death around the world because it is so common,” said Dr. Neil R. Poulter of the International Center for Circulatory Health at Imperial College London. In the United States, it is particularly common among blacks, with 41 percent found to have it in a 2005 study, compared with 27 percent of whites.

Resistant hypertension is defined as blood pressure that remains above clinical goals, even after a patient has been put on three or more different classes of medications. Additionally, patients whose blood pressure can be lowered to normal on four or more drugs should be considered resistant and should be closely monitored, the panel said.

After reviewing the available research on drug-resistant hypertension, a phenomenon first described in the 1970s, the panel found that it became more likely with advanced age, weight gain, a diet high in sodium, sleep apnea or chronic kidney disease.

Living in the Southeast, a region long recognized as the “stroke belt” of the United States, is also a risk factor for blacks and whites, though researchers are not sure why. An author of the new paper, Dr. William C. Cushman, chief of preventive medicine at the Veterans Affairs Medical Center in Memphis, said he suspected factors like inactivity, obesity and diets high in salt and fat.

Pat J. Dixon, 58, a nurse in Atlanta, takes five medications to lower her blood pressure. In many ways, Ms. Dixon is typical of a patient who develops resistant hypertension. At 5 feet and 172 pounds, she is obese, and her weight gain has caused mild Type 2 diabetes, for which she takes yet another drug. The diabetes is an extra strain on the kidneys, in turn worsening her blood pressure.

Ms. Dixon said that she did not use much salt when she cooked but that she did like to snack on potato chips.

“My doctor tells me about every week that I’m going to eat myself to death,” she said. “You do kind of get worn out and depressed every morning that you have to take five or six pills.”

The new report is one of the first to help doctors recognize and manage this growing group of difficult cases. Because so few studies have focused on resistance, the authors say, the number of drug-resistant patients is unclear.

By reviewing studies of patients with at least some hypertension, the panel estimated that 20 to 30 percent could not control their blood pressure with three or more drugs, even when taking them exactly as prescribed. The 20 to 30 percent cohort appears to be growing. A large study in 2006 from Stanford found that the number of blood-pressure patients who were prescribed three or more drugs had increased over 12 years, to 24 percent from 14 percent.

If patients need that many drugs, experts say, they are likely to be at greater risk for illness even if they lower their blood pressure to normal. These patients have usually had high blood pressure for some time and, as a result, have more organ damage.

“It’s a critically important issue,” said Dr. Sheldon Hirsch, chief of nephrology at Michael Reese Hospital in Chicago. “One of the biggest failings in medicine is that as we increasingly realize the importance of treating hypertension, that lower numbers are better than higher numbers, we have increasing trouble reaching those goals.”

An Alzheimer's Minibreakthrough


By: Heather J. Chin , The Bulletin

The dementia and loss of mental faculties resulting from Alzheimer's disease has long been recognized, but the exact cause has remained elusive, until perhaps now.
New research suggests that one form of beta-amyloid protein - which clumps around an afflicted brain's neurons and forms plaque that inhibits and destroys neurons needed for daily functions and memories - causes symptoms of Alzheimer's.
Previous research had been unable to determine whether the beta-amyloid plaque was a cause or a side effect of Alzheimer's disease.
In the new study, researchers caused Alzheimer's symptoms of impaired memory function in rats by injecting them with a two-molecule soluble form of beta-amyloid protein.
One-molecule and three-molecule forms of both soluble and insoluble proteins did not trigger illness in the rats, which researchers say may explain why some people with beta-amyloid plaque don't exhibit such symptoms.
Dr. Ganesh M. Shankar and Dr. Dennis J. Selkoe of Harvard Medical School published their findings in Sunday's online edition of the journal Nature Medicine. In the report, they noted that when studies were also conducted on mice, the brain cell density was reduced by 47 percent, and affected the synapses, or connections between cells that are necessary for cell communication.
Beta-amyloid extracts were taken from the brains of people who had donated their bodies to medical research.
This is the first time that research has showed the effect of a particular type of beta-amyloid in the brain, said Dr. Marcello Morrison-Bogorad, director of the division of neuroscience at the National Institute on Aging, to the Associated Press.
He added that the revelation that only one of three types of the proteins had a damaging effect on the brain is important because doctors have long wondered why they find some plaque-covered brains in autopsy that belong to a person who didn't have Alzheimer's.
"A lot of work needs to be done," stated Dr. Morrison-Bogorad, as to why one protein has a damaging effect and not others. "Nature keeps sending us down paths that look straight at the beginning, but there are a lot of curves before we get to the end."
The Harvard study was funded by the National Institute on Aging, Science Foundation Ireland, Wellcome Trust, the McKnight and Ellison foundations and the Lefler Small Grant Fund.
In a separate study out of the Feinstein Institute of Medical Research in New York, Dr. Yousef al-Abed, chief of medicinal chemistry, and his colleagues Michael Bacher and Richard Dodel of Marburg University in Germany created and tested an experimental drug that they say might neutralize or reduce the effects of the beta-amyloid plaques in the patient's brain.
Published in the Journal of Experimental Medicine, the study's results describe an experimental medicine, CNI-1493, already being tested as a medicine for the bowel affliction called Crohn's disease, that targets and transforms amyloid in the brain so that it does not clump and form plaque and also loses its toxicity.
Their results show a 70 to 85 percent reduction of amyloid buildup in the cortex and the hippocampus - the two areas of the brain most affected in Alzheimer's patients and which affect memory, attention, perceptual awareness, language, consciousness and the regulation of emotion.
Heather Chin can be reached at heather.jean.chin@gmail.com

Hopkins neurosurgeon Carson says he's 'humbled' by appearing at White House for Medal of Freedom


From poverty to top U.S. honors


By David Nitkin

Sun reporter

7:30 PM EDT, June 19, 2008

WASHINGTON

Baltimore neurosurgeon Benjamin S. Carson said he was "humbled" when President Bush draped the nation's highest civilian award, the Presidential Medal of Freedom, around his neck Thursday.

But such accolades are routine for the doctor who persevered through a childhood of poverty and urban violence to become the youngest department head at the Johns Hopkins Hospital and a benefactor distributing thousands of scholarship dollars each year.

Four months ago, Carson was at the White House to receive a Ford's Theatre Lincoln Medal, awarded to individuals who exemplify the spirit of the 16th president. Last month, Hopkins announced an endowed professorship that will link Carson's name with the university's. "I'm still coming down off of that," he said.

There is undeniable cachet, however, in an award created during the administration of President John F. Kennedy to recognize lifetime achievement and distributed sparingly enough that its value persists.

"I was just very grateful that people are starting to recognize some of the work I am trying to do," Carson, 56, said in an interview after the ceremony, referring to his promotion of reading programs and college education for at-risk high school students. He called high school dropout rates an "epidemic," and said, "Sometimes I feel people aren't paying attention."

Born in Detroit to a barely literate mother who married at age 13 and soon left her husband to raise two sons alone, Carson overcame what he has described as a temper problem as a teen and went on to attend Yale University and the University of Michigan medical school. He gained fame as a pediatric neurosurgeon for, among other things, leading the separations of five sets of twins conjoined at the head between 1987 and 2004. He is also skilled in hemispherectomies, a procedure to remove half the brain to prevent seizures.

3,400 scholarships

The Carson Scholars Fund, founded with his wife, Candy, has given more than 3,400 scholarships to high school students over the past 14 years.

Carson's mother, Sonya, was in the audience at the White House ceremony, and Bush singled her out as he summed up the doctor's life to an invited audience of several hundred.

The president praised her doggedness in insuring that her children took their education seriously.

'Forces of nature'

"Some moms are simply forces of nature who never take no for an answer," Bush said. "I understand," he added, drawing laughter for the allusion to his own mother.

"Every week the boys would have to check out library books and write reports on them," Bush said. "She would hand them back with check marks, as though she had reviewed them -- never letting on that she couldn't read them."

When Bush said "Welcome to the White House," Sonya Carson stood and waved to a round of applause in the East Room, where she sat near Supreme Court Justice Antonin Scalia, former Sen. Bob Dole and the actor Cuba Gooding Jr. -- who will portray Carson in an upcoming film.

A false start

Bush read a detailed account of Carson's life and achievements, and the doctor took a few steps forward to receive the medal. However, he was supposed to wait for the president to talk about the five other winners.

The premature timing drew a good-natured rebuke from Bush, who looked Carson back to his seat near a massive portrait of Martha Washington and chided: "The bestowing part will take place a little later, Ben."

Upon completion of the six introductions and the formal reading of a citation by a military officer, Bush smiled broadly at Carson and summoned him closer, so the president could clasp a blue ribbon bearing the medal around the doctor's neck.

Carson joins a notable list of Medal of Freedom winners in the medical field, including Jonas Salk, who developed a vaccine for polio, and Denton Cooley, a pioneer in cardiovascular surgery who received his surgical training at Hopkins. Dr. Anthony S. Fauci, the top AIDS research official at the National Institutes of Health in Bethesda, was also honored Thursday.

Others in the latest group of Medal of Freedom recipients include retired Marine Gen. Peter Pace, former chairman of the Joint Chiefs of Staff; Donna E. Shalala, president of the University of Miami and secretary of health and human services in the Clinton administration; Laurence H. Silberman, a senior judge on the U.S. Court of Appeals for the District of Columbia and co-chairman of the Iraq Intelligence Commission; and the late Rep. Tom Lantos of California, the only Holocaust survivor to serve in Congress

Carson is "such a role model," said Rep. C.A. Dutch Ruppersberger, who attended the ceremony.

The White House visit gave Carson a chance to chat privately with Bush about non-medical topics, including off-shore oil exploration. Carson said he told Bush, a former oilman, that it would be difficult to convince the public that drilling has become more environmentally sound today than it was 30 years ago.

"He said 'You are absolutely right,'" Carson said.

david.nitkin@baltsun.com

Dr. Denton Cooley was incorrectly credited with performing the world's first heart transplant when this article was published in the print edition. The Sun regrets the error.

Guidelines Seek to Reduce Medication Errors Involving Kids

By Amanda Gardner, HealthDay Reporter

FRIDAY, April 11 (HealthDay News) -- The group that accredits most U.S. hospitals issued guidelines Friday to help prevent medication errors in hospitalized children.

Among the recommendations: Children should be weighed in kilograms -- the global standard and the standard for medication dosing -- when they are admitted to a hospital.

"The vast majority of countries utilize the metric system, and the recommendations for pediatric medication use are based on the metric system," said Dr. Peter Angood, vice president and chief patient safety officer for The Joint Commission, which announced the "Sentinel Event Alert" at a teleconference.

"Sadly, there seems to be a lack of widespread appreciation even among health-care providers that children have unique safety and medication needs," said Dr. Matthew Scanlon, assistant professor of pediatrics-critical care at the Medical College of Wisconsin and a member of the Joint Commission's Sentinel Event Advisory Group. "The issues of having to adapt products -- be it technology or medications -- that were created for adults and apply those to pediatric patients is terribly problematic and really is the source of a great deal of work that has to be performed on a daily basis among pediatric health-care providers."

Added Catherine Tom-Revzon, clinical pharmacy manager at Children's Hospital at Montefiore in New York City: "This is definitely increasing the public awareness that at least something's being done to address the medication errors that occur in children."

The alert follows publication this week of a study that found that medication errors, including accidental overdoses and adverse reactions, affect about one of 15 -- or 7 percent -- of hospitalized children. The study was published in the April issue of the journal Pediatrics.

That 7 percent figure is much higher than previous estimates. And it underscores growing concerns about medical errors involving hospitalized children -- an issue that generated headlines in November when actor Dennis Quaid's newborn twins were accidentally given life-threatening overdoses of a blood thinner.

What's to blame for the problem? According to Angood, most medications are made and packaged for adults, and most health-care facilities are built and organized around the needs of adults, not children. Also, process issues -- including miscommunication, lack of standards for labeling and packaging, and the misidentification of medications -- are at fault, he said.

Even recent innovations in technology often don't help the pediatric population. A system for computer order entry of medications implemented by Scanlon's hospital did not have weight-based dosing. "Pediatric providers were left to cobble together weight-based dosing," he said.

Similarly, bar coding of medications is sometimes not readable for children because of the range of size.

"Technology holds great promise," Scanlon said. "Unfortunately, today, that hasn't been realized and lack of explicit attention to the needs of children certainly has not helped that matter."

Perhaps the simplest solution proposed by the commission is for hospitals and health-care providers to weigh children in kilograms to arrive at the proper dosing.

"This should become the standard of recording pediatric patient weights," Angood said.

The commission is also suggesting that caregivers who prescribe medications to children be required to write out and document how they arrived at particular doses. "In other words, show the math," Angood said. "This means nurses or doctors can easily double-check the calculations of any medications administered."

The family and, if possible, the child should also be involved in the medication management process, and should be asked to repeat back any medication-related instructions, according to the guidelines.

"What's really important from the patient's or parents' perspective is not only know the child's weight [in kilograms] but also maintain a current list of a child's medications -- whether they be prescription, over-the-counter or both," Tom-Revzon said. "Also, as part of that list, it should include any allergies to medication or foods, so that even if the child doesn't end up going to the hospital, even if they go to the emergency [room] or to a different doctor, that list will help prevent potential drug interactions and duplications."

Angood added: "We can and we're obligated to do better. We really do owe it to those patients who depend on us."

Health Tip: Before Getting Plastic Surgery


(HealthDay News) -- You should do your homework before you elect to have plastic surgery.

Here are suggestions on how to prepare for the procedure, courtesy of the American Society of Plastic Surgeons:

  • Research the surgery until you fully understand its possible benefits and risks.
  • Talk to your doctor about what to expect after the surgery, including likely results, how much time it may take you to recover, and what the recovery period will feel like.
  • Talk to other people who have had the procedure to gain their insight.
  • Don't be afraid to discuss any questions or concerns with your doctor. Be sure the physician knows your complete medical history.
  • Make sure the surgeon you select is qualified, properly trained, and certified to perform the procedure.

-- Diana Kohnle

Life Expectancy Tied to Education

Initiatives that target health disparities are always welcome, but they may not go far enough if they don't relieve underlying discrepancies in educational or economic status, Katz said.  © istockphoto.com/David H. Lewis
Initiatives that target health disparities are always welcome, but they may not go far enough if they don't relieve underlying discrepancies in educational or economic status, Katz said. © istockphoto.com/David H. Lewis

By Steven Reinberg, HealthDay Reporter

TUESDAY, March 11 (HealthDay News) -- Life expectancy in the United States is on the increase, but only among people with more than 12 years of education, a new study finds.

In fact, those with more than 12 years of education -- more than a high school diploma -- can expect to live to 82; for those with 12 or fewer years of education, life expectancy is 75.

"If you look in recent decades, you will find that life expectancy has been increasing, which is good, but when you split this out by better-educated groups, the life expectancy gained is really occurring much more so in the better-educated groups," said lead researcher Ellen R. Meara, an assistant professor of health care policy at Harvard Medical School.

"The puzzle is why we have been successful in extending life span for some groups. Why haven't we been successful in getting that for less advantaged groups?" Meara said.

The answer may lie with tobacco, the study found.

About one-fifth of the difference in mortality between well-educated and less-educated groups can be accounted for by smoking-related diseases such as lung cancer and emphysema, Meara said.

But the disparity in life expectancy is not only a function of education, Meara said. "Those with less education are likely to have lower income. They're likely to live in areas that have their own health threats, either through crime or poor housing conditions. In addition, they may have worse access to health insurance coverage and health services," she said.

The study was published in the March/April issue of Health Affairs.

For the study, Meara's team collected data on people who took part in the National Longitudinal Mortality Study. The researchers used death certificates, plus estimates from Census data, to create two datasets -- one covering 1981 to 1988 and the other from 1990 to 2000.

The researchers found that in both datasets, life expectancy rose but only for people with more than 12 years of education. For those with 12 years of education or less, life expectancy remained flat through the periods.

When the researchers compared data from the 1980s to data from the 1990s, people with more education had almost a year and half of increased life expectancy. But, for people with less education, life expectancy increased by only six months.

In the period of 1990 to 2000, the better educated saw their life expectancy increase by 1.6 years. For the less educated, life expectancy didn't increase in all.

When the researchers looked at gender differences, they found that less-educated women actually had a decline in life expectancy. In 2000, those women with more than 12 years of education by age 25 could expect to live five years longer than less-educated women, the study found.

The challenge, Meara said, is to figure out ways to extend life expectancy of all groups in U.S society. "We need to get a better understanding of how we can extend these great things we're learning about how to lead healthier lives into these groups," she said.

Dr. David L. Katz, director of the Yale University School of Medicine's Prevention Research Center, thinks fighting poverty and improving education are key to increasing life expectancy among less-advantaged Americans.

"Disparities in health are a major challenge in the United States," he said. "The less affluent and less educated are also, invariably, less healthy."

Initiatives that target health disparities are always welcome, but they may not go far enough if they don't relieve underlying discrepancies in educational or economic status, Katz said.

"Despite efforts throughout the 1980s and 1990s to reduce the disproportionate mortality and morbidity burden experienced by ethnic minorities and the socio-economically disadvantaged, those burdens have persisted," Katz said. "And the gap in life expectancy between the more educated and the less has actually widened."

The take-home message is to redouble efforts to eliminate health disparities, Katz said. "Health is not a product of health care per se, but of one's life course and opportunities. Poverty and limited education are enemies to both opportunity and health. Public health efforts must strive against them as earnestly as against the diseases they drag in their wake."

In another report in the same journal issue, Rachel Kimbro, a sociology professor at Rice University, and colleagues found that immigrants with low levels of education fared better in health outcomes compared with native-born Americans, regardless of race or ethnicity.

The researchers said these differences should be taken into account when targeting programs to reach specific groups of people.

Doctors Slow to Embrace Electronic Medical Records

By Steven Reinberg, HealthDay Reporter

WEDNESDAY, June 18 (HealthDay News) -- Electronic medical record systems are being touted as the wave of the future in health care and communication, but only 17 percent of U.S. doctors have embraced the technology, a new survey finds.

"When you use a good definition of what a record system is, very few physicians appear to have one," said lead study author Catherine M. DesRoches, at Massachusetts General Hospital's Institute for Health Policy, in Boston.

The definition of a fully functional electronic medical record system includes a patient's complete medical records, medication lists, problems, and clinical notes from past visits. The doctor can also order prescriptions, laboratory tests and radiology tests electronically, DesRoches said.

In addition, the doctor can review lab results and view X-rays, MRIs or other scans on the computer, DesRoches noted. There are also warnings about inappropriate prescriptions or abnormal lab results. And the systems remind the doctor when lab or screening tests are needed.

For the survey, DesRoches and her colleagues surveyed 2,758 doctors nationwide about their use of electronic medical record systems. The researchers found that 4 percent reported having a fully functional system. An additional 13 percent said they had a basic system.

The survey also found that primary care doctors and doctors with large practices or those in hospitals or medical centers were more likely to have electronic medical record systems. In addition, doctors in the western region of the United States were more likely to have such systems.

The findings, published online Wednesday, were expected to be published in the July 3 edition of the New England Journal of Medicine.

Doctors cited a number of barriers for not adopting an electronic medical record system, including concern about cost and return on investment, DesRoches said.

"They also worry about their system becoming obsolete," she said. "They also worry that the system is going to go down, and they will have a waiting room full of patients, and they can't get to anyone's record."

But, she added, doctors who have these systems are very satisfied with them. "It makes care more effective and efficient," she said.

DesRoches thinks that eventually, most doctors will adopt an electronic system. In fact, the survey found that 40 percent of those physicians who did not have an operational system said they had purchased one but hadn't started to use it, or they planned to buy one, she said.

Both Medicare and private insurance companies are pushing doctors to adopt electronic medical record systems as a way of monitoring quality of care, which will be a basis for reimbursement levels, DesRoches noted.

One electronic medical records expert doesn't think this survey truly reflects which physicians are using electronic systems or takes into account the ultimate goal of computerized medical care.

"What we are talking about is moving physicians into the computer age," said C. Peter Waegemann, chief executive officer of the Boston-based Medical Records Institute, which promotes the use of electronic medical records. "We are changing the way physicians practice medicine, from an intuitive art to a computer-guided, computer-based care system."

Waegemann said that while only about 20 percent of doctors have electronic record systems, the number varies by specialty and region of the country.

"About 50 percent of family practitioners have electronic health record systems. Among pediatricians, 40 to 50 percent have systems," Waegemann said. "In states such as Massachusetts, New York and California, you have maybe 40 to 50 percent implementation. When you get to Mississippi and Idaho, you have maybe 4 percent."

Electronic medical records are coming rapidly, Waegemann predicted. Forces pushing their adoption include patient demand, younger doctors who were trained with such systems and pressures from the insurance industry.

Electronic records also make it easy for patients to send their medical records directly to doctors and specialists, Waegemann said, adding, "If physicians don't have such systems, patients will go elsewhere."

Nurses Rally For Smaller, Safer Ratios


COLUMBUS, Ohio -- Ohio nurses and patients called for legislative action Tuesday in hopes of making the state's hospitals safer for patients.

A House bill will be introduced that will require limits on how many patients a nurse could have on her floor at one time, NBC 4's Mike Bowersock reported.

Nurses rallied at the Statehouse for smaller nurse-to-patient ratios.

They claimed that in some units, the nurse-to-patient ratio was 14:1. They said a safe ratio is more like a quarter of that.

"In order for patients to enter the hospital setting safely and exit safely, there needs to a 1:4 or less of nursing care assigned to a patient clientele," said Adrienne Zurub with National Nurses Organizing Committee.

"The demographic is usually of high acuity. It is even more important for the sake of patients and for the sake of nurses to do their direct care to ensure those ratios are met."

One patient in attendance claimed to have suffered through nine days without having a wound dressed, Bowersock reported.

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