North Carolina

Docs, Guns, and Smokes.

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Family doc/tobacco researcher spearheads physicians’ role in gun safety research.

  • by Jennifer Ferris
    North Carolina Health News/MedPage Today

CHAPEL HILL, N.C. — One day in clinic, 2 years ago, a patient handed Adam Goldstein, MD, MPH, a request for a concealed weapon permit, soliciting his signature.

The family physician didn’t know what to do. “What do you mean fill this out on a patient? First off, what do I know about guns and safety? And second, what do I know about that patient?” Goldstein didn’t sign that form, nor has he signed any others that have come into his office since.

At the time, Goldstein didn’t know anything about gun safety issues, but he’s no stranger to public health. For nearly 20 years, he’s been the guy showing the world how tobacco use in the media turns kids onto smoking and dipping. This research, conducted in the heart of tobacco country, has changed U.S. policy. And teen smoking rates have dropped by nearly half since he began.

Now, prompted by the patient encounter from 2 years ago, the physician says he has embarked on a new research topic: physicians’ role in gun safety.

This hybrid career of clinical practice and research is the right fit for Goldstein, who says he originally set out to work in public health full time, but then found great personal satisfaction in treating patients. “Seeing patients is the great equalizer in academics. If you don’t see patients you don’t get much respect among your peers. The more you do that, the more respect you have. For me it’s always been a dual track,” he said.

Fueled by the concerns of his colleagues facing questions of gun violence, and tragedies like Sandy Hook Elementary School, Goldstein is beginning to publish the first bits of research on family medicine and firearm safety.

Early Career: Forging a Hybrid Path

As an undergraduate at Tufts, Goldstein focused on the sociology of healthcare. He says he found large-scale public health fascinating. But when it came time to choose a career path, he set his sights solely on Augusta State University Medical School, now part ofGeorgia Regents University, with a career goal of working in a public health department.

In medical school, Goldstein took his first steps toward working in public health with preventive medicine community service projects, and by joining Doctors Ought to Care, a physicians’ organization that connects doctors and patients with media literacy tools. But, Goldstein reflects on his clinical rotation, “I realized that I really loved the individual patient care element. Even more so than the public health movement.”

After graduating in 1987, Goldstein decided on a residency at UNC Family Medicine to pursue a career in both academic research and patient care. “I was probably a bit of a pariah” Goldstein says. “Because I wasn’t taking the same path and I didn’t want to go out to a rural practice.” Most of Goldstein’s peers went into rural care.

“I wanted to be in an academic health center: teaching, researching, doing care,” he says.

Tobacco Research Pioneer

That same year, Goldstein published the first study addressing media influence on teen smoking habits. After that initial success, Goldstein says he was under a lot of pressure by his peers in research to forgo practicing family medicine and focus on his funded tobacco investigations.

Instead, Goldstein chose to let go of committee work and other distractions in favor of continuing with both of his passions: patient care and academic research. Goldstein also makes a little time for his creative outlet — poetry, which is mostly about practicing medicine.

After publishing his initial findings, Goldstein expanded this research, and proved that a group of 3-year old kids were just as likely to identify Joe Camel as Mickey Mouse.

“We showed that the more kids recognize tobacco advertising, the more likely they are to become smokers,” Goldstein says. At the time, he remembers, the causal link between advertising and adolescent smoking was controversial.

By 1999, Goldstein had published 15 tobacco research papers. One such paper, published in JAMA, found that 68% of G-rated films produced by five of the big movie production companies in the U.S. included at least one episode of cigarette smoking or other tobacco use.

Jonathan Polansky is a consultant with the UCSF Center for Tobacco Control Research and Education. He says that Goldstein’s early research was among the factors that pressured movie studios into nearly eliminating smoking from modern G- and PG-rated movies.

“Adam played a very important early role in establishing how much smoking was appearing in the movies,” Polansky says. “Over the ages there were bouts of concern about incidents of smoking in the movies with a common sense belief that seeing it caused children to smoke. We now have research that shows a definitive causal relationship between seeing acts of smoking and teenagers’ future smoking behaviors.”

Since Goldstein’s work began, teen smoking has dropped. According to the CDC, in the early 1990s more than 30% of high school students used tobacco. Today, that number is down to 18%.

Goldstein’s work resonates within academia, with 18 of his papers having been cited at least a dozen times by other researchers.

Goldstein brought his mission to change the culture of smoking to his home state, as well. When he first began his research in the 1980s, tobacco farming and smoking were a cornerstone of life in much of the state. Even today, as the industry is beginning to lag, the North Carolina Department of Revenue reports that the Tarheel state still relies on the “bright leaf” for more than 255,000 jobs and $500 million in revenue.

At his own place of work, UNC, in 1998, Goldstein founded a nicotine dependence program to help employees and patients kick the habit and a wellness program that led to the prohibition of smoking on hospital grounds and outside building entrances.

“No one person does anything on their own,” Goldstein says. “But we have changed how people in North Carolina, in the Southeast, and across the country, look at nicotine addiction and tobacco policy. I know that.”

Docs and Guns

On his public health path, Goldstein says his work in tobacco cessation may never be complete. But in the last few years his attention has shifted to what he sees as a new threat to the wellness of his patients: firearm safety.

After being handed the concealed handgun waiver by his patient, Goldstein says he began to wonder about what a doctor’s role in keeping patients and their families safe from gun violence actually is.

The role of doctors in vetting gun safety is an emerging issue in medical societies and courtrooms.

In April 2014, the American College of Physicianspublished policy recommendations on the topic. A 2014 Florida Court of Appeals ruling upheld a law that limits doctors’ ability to discuss gun safety with patients. The American Academy of Pediatrics called the decision a violation of First Amendment rights and is appealing the ruling.

Goldstein says that doctors must be given the tools they need to help guide patients to gun safety before they are tasked with vetting gun owners for licenses.

“I am not a gun researcher,” he says, “Medical boards need to get involved and we need to start developing criteria to help physicians make these types of assessments that have some kind of validity.”

Finding a lack of published research on the topic, Goldstein has been pursuing the issue. Along with several colleagues, he wrote a Perspective for the New England Journal of Medicine questioning physicians’ roles in assessing competency for weapons ownership.

In a preliminary local survey, doctors in North Carolina said they wanted more information and more policy on this topic. Goldstein says he’s engaged an intern to pursue further research and that he’s working on writing more papers and beginning to travel to conferences to speak on this controversial subject.

Taking Over the Airwaves

Several years ago, Goldstein found an intersection between patient care and public health in hosting a radio show. His show, “Your Health Radio,” is a platform for medical research discussions, which he makes accessible to both medical professionals and the general public with his co-host Cristy Page, MD, MPH.

Together, they take calls from the audience and deliver advice on anything from folk remedies to vaccinations.

One day in September of 2014, Goldstein starts to sweat a little before his first-ever live audience.

Dozens of residents and fellows from UNC medical school, eager to hear him interviewMyron Cohen, MD, director of UNC’s Global Health and Infectious Disease department, squeeze into a conference room crammed with microphones, speakers, and a host of recording equipment — thanks to the show’s host station WCHL.

Goldstein questions Cohen about the Ebola epidemic. Attempting to keep the conversation accessible, with a minimum of technical terms, Goldstein says to his guest, “Let me ask you a quick question here. The early symptoms of Ebola — we’re about to be in flu season and it appears to me the symptoms overlap with flu.”

Cohen quickly took advantage of Goldstein’s prompt, explaining the difference between influenza, stomach flu, and Ebola. Guiding his speaker to the explanation was his way of reaching worried listeners in Idaho, rural North Carolina, and further away, for reassurance.

Goldstein spends a half hour after the radio show answering questions from the white-coats in the audience. Later, he reflects on his career and the harmony he has found among supervising students, helping patients, and furthering the course of global health.

“Every physician wonders about whether they are succeeding,” he says. “Every person wonders about trying to do the best they can. I think each and every day is a challenge. The opportunity is there to do well and to do mistakes. I try to improve the ‘do well’ part, and I try to limit my mistakes.”

Fracking Waste Could Increase Carcinogens in NC Drinking Water.

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Chemicals in water from deep underground in hydraulic fracturing wells have caused problems as they get to water treatment plants in other states. It’s a potential problem to consider as North Carolina moves closer to allowing fracking.

Allegheny river

It began as a routine test of drinking-water quality.

In 2010, the Pittsburgh Water and Sewer Authority was taking samples from its distribution system. When the lab results came back, PWSA’s staff was surprised.

“All of a sudden we saw very high – very high – [trihalomethane] levels in the distribution system,” said Stanley States, PWSA’s former director of water quality and production.

Trihalomethanes are byproducts of the process used to disinfect water. Research has linked the chemicals to several health problems, including bladder cancer. The federal government sets limits on their concentration in drinking water.

Allegheny river
The Allegheny River, which runs through Pennsylvania. Wastewater treatment plants failed to remove bromides from fracking waste, allowing bromides to flow freely into the Allegheny, Pittsburgh’s source of drinking water. Photo by David Fulmer, courtesy Wikimedia Commons
The concentration of trihalomethanes was unusually high in PWSA’s drinking water. So the utility’s staff began to look for the problem’s source. PWSA teamed up with engineering researchers at the University of Pittsburgh, and throughout 2011 and 2012 the group took monthly water samples from along the Allegheny River, the source of Pittsburgh’s drinking water.

Eventually, the team identified a culprit: industrial wastewater plants that were treating water from hydraulically fractured gas wells.

These plants were ill-equipped to treat the wastewater, the team found, and were releasing drilling byproducts into the Allegheny. Those byproducts were then flowing downstream and causing trihalomethanes to form in Pittsburgh’s drinking water.

Pennsylvania’s experience points to the numerous, unforeseeable challenges associated with processing the waste from hydraulic fracturing. These are challenges that North Carolina will face, as it prepares for its own industry of natural-gas drilling.

After Pennsylvania’s environment agency learned about this problem, it urged drillers to stop taking their water to the wastewater plants, according to Victoria Binetti, the U.S. Environmental Protection Agency’s associate director of its water-protection division, in Region 3 of the agency.

The request was not legally binding, but drillers appeared to change their practices.

“To their credit, most of them complied,” she said.

The story in Pennsylvania raises a question: whether, as in the past, North Carolina’s regulators will react after the fact to control trihalomethanes caused by an energy industry, or whether regulators will set rules to prevent the chemicals from forming.

The brine trapped in shale

Water plays a crucial role in hydraulic fracturing, as the name suggests. Hydraulic fracturing, or fracking, is a process in which water, sand and chemicals are pumped into wells at high pressures. This causes fissures in deep shale deposits, releasing natural gas and oil from the dense rock.
A drilling rig in the Marcellus Shale. Hydraulically fractured wells produce large amounts of wastewater, which drillers must eventually dispose of. Photo courtesy U.S. Geological Survey
But shale contains more than just gas and oil. It also stores water. Fracking releases this water too, which drillers call “produced water.” Produced water flows to the surface after “flowback,” portions of the water originally pumped into the well.

Like flowback, produced water must eventually be dealt with.

In Pennsylvania, drillers often sent their wastewater to industrial treatment plants and municipal wastewater plants – the kind that treat, say, apartment buildings’ sewage. But neither type of plant was designed to treat fracking waste, according to PWSA’s States. Both types of plants treated the water as best they could, then released it into state rivers, as permitted by federal and state laws.

Whenever – and if ever – drilling begins in North Carolina, energy developers will be much more constrained.

The N.C. Mining and Energy Commission is developing rules for fracking, including rules that govern fracking’s wastewater. Commission members have learned from states like Pennsylvania. Under rules the commission has tentatively approved, drillers will not be able to send their waste to municipal plants.

“The mistake that they made in Pennsylvania was, these things were sent to [municipal plants], as if it was just normal waste, and it’s not,” said Vikram Rao, a member of the M.E.C. and chairman of the committee that developed the wastewater rules.

But drillers will be allowed to send their wastewater to commercial plants, he said. These plants must be designed specifically to treat fracking wastewater.

But no such plants currently exist in North Carolina.

Drillers will also be allowed to haul their waste out of state and to use onsite technology to treat their water.

Yet even with onsite treatment or a specially designed wastewater plant, concentrations of one chemical class may still find their way into state waters.
Chemical diagram of bromoform, a brominated trihalomethane. The U.S. EPA says that exposure to bromoform can cause injuries to livers, kidneys, and central nervous systems, and the agency lists the chemical as a probable carcinogen. Graphic courtesy Wikimedia Commons
Those chemicals are bromides, the catalysts for trihalomethanes in Pittsburgh’s drinking water, and, according to States, a particularly difficult chemical to filter out of fracking water.

“To remove dissolved solids like bromides is very difficult,” he said. “Typically, you have to use ion exchange and reverse osmosis. Very expensive.”

How fracking water catalyzes trihalomethanes

Produced water can be highly saline, and can contain a number of minerals, owing to its former presence within shale.

“If it’s highly saline, it’s got a lot of chloride and a lot of bromide,” said Philip Singer, a professor emeritus of environmental engineering at the University of North Carolina-Chapel Hill.

If wastewater-treatment systems fail to remove bromides before re-releasing the water, the chemicals simply flow downstream. There, drinking water-plant intakes slurp up the chemical-laden water from rivers, as happened at the water-treatment plant that serves Eden.

Drinking-water plant operators then often treat the river water with chlorine; this kills harmful bacteria.

But chlorine and bromides don’t play well together.

When bromides mix with chlorine and decaying matter – tree leaves, river grasses – drinking-water plants can begin to form high levels of trihalomethanes.

According to Singer, one type of trihalomethane, chloroform, forms without the presence of bromides.

But, he said, the brominated trihalomethanes – the ones that require bromides – have more harmful health effects.

Health researchers have linked bladder cancer to long-term exposure to trihalomethanes, and the EPA warns that trihalomethane exposure over the long term can harm kidneys, livers and central nervous systems.

According to the American Water Works Association, one brominated trihalomethane, dibromochloromethane, is about 17 times more carcinogenic than chloroform.

A lack of data

It’s hard to say whether hydraulic fracturing will increase bromide concentrations in North Carolina’s rivers.

For one, North Carolina’s shale is different from Pennsylvania’s, according to the MEC’s Rao.

North Carolina’s shale formed “in inland water, not in ocean beds,” like Pennsylvania’s Marcellus Shale formation, he said.

Bromide occurs naturally in seawater. And without a marine origin, North Carolina’s shale water might have a lower level of bromides, according to Detlef Knappe, a professor of environmental engineering at North Carolina State University.

Yet, without actual measurements, assessing bromide levels in shale water is difficult, he said.

The N.C. Department of Environment and Natural Resources does have some data [see documents below] on the state’s shale water, from a test well drilled in 1998.

Photo of the type of tank that would hold fracking water.
A storage tank holding produced water from Marcellus Shale drilling. Hydraulic fracturing brings this saline, bromidic water to the surface. Photo courtesy U.S. Geological Survey
State geologist Kenneth Taylor said that the water in this sample showed a low level of salinity.

But a low level of salinity does not necessarily point to low levels of bromides, according to Knappe.

As a study by DENR said, “It may not be possible to fully characterize flowback waters from shale gas operations in North Carolina until there is actual wastewater from a North Carolina hydraulic fracturing operation.”

Knappe acknowledges that fracking wastewater in North Carolina could cause problems with trihalomethanes. But, he said, there’s a broader issue at hand.

“If indeed discharge to sewers and eventually surface waters is allowed, then the question of what chemicals are being used altogether in this process is something that needs a lot more scrutiny,” he said.

Knappe noted that drillers will be able to keep secret some of the chemicals they use to fracture wells.

“What is it that could potentially end up in our drinking-water sources?” he asked. “And is it permitted?”

These documents show the the constituents of deep, geologic water from two test wells that were drilled in North Carolina in 1998. This water is known as “produced water,” the unadulterated ground water that contains chemicals similar to those that would be found in a fracked well.

According to by Kenneth Taylor, North Carolina’s State Geologist, employed by DENR, this is some of the only data available on produced water in North Carolina shale formations. However, the water’s bromide levels were not measured.

During the fracking process, between three and five million gallons of water are injected underground. 10-35 percent of that wastewater comes back to the surface; that water is called “flowback,” and can commingle with the produced water. The produced water, a much smaller volume of wastewater, returns to the surface continuously, as long as the well remains active.

This sort of brine water caused problems in PA, because it can have high levels of bromides in it. Wastewater plants that treated the produced water did not effectively remove the bromides before re-releasing the water into rivers. That bromide-laced water then mixed with rivers, and found its way into drinking-water plants downstream, where it catalyzed the formation of trihalomethanes.

Induced or Augmented Labor Linked to Higher Autism Risk.

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Children whose mothers had induced or augmented labor show increased risk for autism spectrum disorders, according to a JAMA Pediatrics study.

Researchers matched birth and public education records for some 625,000 North Carolina children, including 5500 with documented autism. Compared with children delivered without labor induction or augmentation, children of induced or augmented deliveries faced between a 10% and 25% increased risk for an autism diagnosis. The effect was stronger in boys.

The authors speculate that the effect may be due to exposure to exogenous oxytocin. They remind readers of the benefits of labor induction, especially with regard to preventing meconium aspiration syndrome. They also assert that their findings should not change care standards until more data become available.

Source: JAMA 

Scientists discover true function of appendix organ.

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It has long been regarded as a potentially troublesome, redundant organ, but American researchers say they have discovered the true function of the appendix.

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The researchers say it acts as a safe house for good bacteria, which can be used to effectively reboot the gut following a bout of dysentery or cholera.

The conventional wisdom is that the small pouch protruding from the first part of the large intestine is redundant and many people have their appendix removed and appear none the worse for it.

Scientists from the Duke University Medical Centre in North Carolina say following a severe bout of cholera or dysentery, which can purge the gut of bacteria essential for digestion, the reserve good bacteria emerge from the appendix to take up the role.

But Professor Bill Parker says the finding does not mean we should cling onto our appendices at all costs.

“It’s very important for people to understand that if their appendix gets inflamed, just because it has a function it does not mean they should try to keep it in,” he said.

“So it’s sort of a fun thing that we’ve found, but we don’t want it to cause any harm, we don’t want people to say, “oh, my appendix has a function”, so I’m not going to go to the doctor, I’m going to try to hang onto it.”

Attractive theory

Nicholas Vardaxis, an associate professor in the Department of Medical Sciences at RMIT University, says the theory put forward by the Duke University scientists makes sense.

“As an idea it’s an attractive one, that perhaps it would be a nice place for these little bacteria to localise in, a little cul-de-sac away from everything else,” he said.

“The thing is that if we observe what’s been happening through evolution, the higher on the evolutionary scale we are and the more omnivorous animals become, then the smaller and less important the appendix becomes and humans are a good example of that.

“The actual normal flora bacteria within the appendix, as well within our gut, are the same, so we’ve lost all of those specialised bacteria.

“So it doesn’t have that safe house type of function anymore, I don’t think.

“It’s a vestige of something that was there in previous incarnations, if you like.”

Koala appendix

Unlike the human, the koala is famous for having a very long appendix.

It is thought to aid digestion on a diet made up exclusively of eucalyptus leaves.

Professor Vardaxis says that is not likely to change any time soon.

“Unless of course we have a massive blight and we get the eucalypt on which the koala thrives dying, then we may find some mutant koalas out there perhaps that will start eating other things, and as they start to eat other things, then over generations and hundreds of thousands of years of time, then surely, yes, the koala’s appendix will shrink as well,” he said.

Professor Vardaxis says it is possible that at that point, koalas might be afflicted by appendicitis and have to have it taken out at times.

 

Asthma genetic risk research could lead to future test

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Research into the genetic risks for asthma could lead to a test which predicts which children will never grow out of it, says a study in The Lancet.

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Scientists found that those at higher genetic risk of asthma were 36% more likely to develop serious, life-long asthma than those with lower risk.

But they said it was too soon to be used as a reliable clinical test.

Asthma UK says the findings could help identify people whose asthma could become severe.

Earlier studies had linked several genes to small increases in asthma risk.

This study, led by researchers from Duke University in North Carolina, identified 15 separate locations in the human genome which are associated with asthma.

Using this knowledge combined with data from a major New Zealand health study of more than 1,000 people since birth, the researchers were able to calculate the genetic risk score for 880 individuals.

They then tracked the development and progression of their asthma from early childhood through to their late 30s.

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Genetic risk prediction for asthma is still in its infancy.”

Dr Daniel BelskyDuke University

Those with higher genetic risk scores were more likely to have severe asthma which continued into adulthood, and they more often developed problems with lung function.

They were also more likely to miss school or work and to be admitted to hospital because of their asthma.

At present, there are no tests that can predict which children will recover as they grow older.

Dr Daniel Belsky, a post-doctoral fellow at the Duke Institute for Genome Sciences and Policy, said it was too early to talk about a predictive test for severe asthma.

“Although our study revealed that genetic risks can help to predict which childhood-onset asthma cases remit and which become life-course-persistent, genetic risk prediction for asthma is still in its infancy.

“As additional risk genes are discovered, the value of genetic assessments is likely to improve.”

He said there was still a long way to go before genetic risk scores could be used routinely in medical practice.

But the study could lead to a better understanding of asthma and how to treat it, he said.

Leanne Reynolds, from the charity Asthma UK, said it was misleading to assume that some children ‘grow out’ of the condition.

“We know that some children with asthma no longer experience symptoms when they reach adulthood, however… the underlying tendency still remains and so symptoms can still return in later life.”

However, she said further research in this area would be welcomed.

“This could mean that in the future we’re able to identify those people whose asthma will put them at greatest risk so we can ensure they get the support they need.”

Source: BBC

 

 

Lab-grown bladders ‘a milestone’.

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US scientists have successfully implanted bladders grown in the laboratory from patients‘ own cells into people with bladder disease.

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The researchers, from North Carolina’s Wake Forest University, have carried out seven transplants, and in some the organ is working well years later.

The achievement, details of which have been published online by The Lancet, is being described as a “milestone”.

The team is now working to grow organs including hearts using the technique.

Bladder disease can raise pressure in the bladder leading to kidney problems.

It is usually treated by reconstructive surgery but this can lead to complications.

Standard reconstructive surgery uses tissue grafts from a section of the small intestine or stomach to build up the damaged bladder.

The technique has been shown to protect kidney function and ease problems with incontinence.

But because the intestine is designed to absorb nutrients and a bladder is designed to excrete, patients who have the procedure are prone to problems such as osteoporosis, increased risk of cancer and kidney stone formation.

The Wake Forest team identified seven young patients with a congenital condition called myelomeningocele which causes a weak bladder.

Lead researcher Dr Anthony Atala said: “This is one small step in our ability to go forward in replacing damaged tissues and organs.

“It is rewarding when you can see the improved quality of life in these patients.

“We wanted to go slowly and carefully and make sure we did it the right way.

“This is a small, limited experience, but it has enough follow-up to show us that tissue engineering is a viable tool that will allow us to tackle problems of similar magnitude.”

In a commentary, Dr Steve Chung, of the Advanced Urology Institute of Illinois, described the work as a “milestone”.

He said it could prove to be particularly useful for people with bladder cancer.

However, he warned that longer term follow-up was needed to ensure the technique was safe and effective.

Dr Richard Horton, editor of The Lancet, the journal which published details of the new research, said the science of growing organs was still at an early stage.

But he added: “This is a milestone. A lot more work needs to go into this, but over the next ten years or so we are going to see a revolution in transplantation.”

Source: BBC

 

 

Will we ever grow replacement hands?

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It might seem unbelievable, but researchers can grow organs in the laboratory. There are patients walking around with body parts which have been designed and built by doctors out of a patient’s own cells.

hand

Over the past few weeks on the BBC News website we have looked at the potential for bionic body parts and artificial organs to repair the human body. Now we take a look at “growing-your-own”.

There is a pressing need. A shortage of available organs means many die on waiting lists and those that get an organ must spend a lifetime on immunosuppressant drugs to avoid rejection.

The idea is that using a patient’s own stem cells to grow new body parts avoids the whole issue of rejection as well as waiting for a donor.

Dr Anthony Atala, director of the Institute for Regenerative Medicine at the Wake Forest Baptist Medical Center in North Carolina, US, has made breakthroughs in building bladders and urethras.

He breaks tissue-building into four levels of complexity.

  • Flat structures, such as the skin, are the simplest to engineer as they are generally made up of just the one type of cell.
  • Tubes, such as blood vessels and urethras, which have two types of cells and act as a conduit.
  • Hollow non-tubular organs like the bladder and the stomach, which have more complex structures and functions.
  • Solid organs, such as the kidney, heart and liver, are the most complex to engineer. They are exponentially more complex, have many different cell types, and more challenges in the blood supply.

“We’ve been able to implant the first three in humans. We don’t have any examples yet of solid organs in humans because its much more complex,” Dr Atala told the BBC.

Bladder builders

His technique for growing bladders starts with taking a tissue sample, about half the size of a postage stamp, from the bladder that is being repaired.

Over about a month, the cells are grown in the laboratory in large quantities. Meanwhile a scaffold in the shape of the organ, or part of the organ, being replaced is built.

“We coat the scaffold, basically like creating a layer cake. We place the cells on the structure one layer at a time with the cells in the correct positions,” Dr Atala said.

The cake is then “baked” for a two weeks in an oven, which has the same conditions as the inside of the human body. The new bladder is then ready to be implanted back into the body.

Eventually the scaffold is absorbed by the body, leaving the cells in place.

Building a scaffold for the bladder is one thing, building one for the heart is far more complicated. One of the problems when you move to larger organs is the getting the blood supply to work, connecting arteries, capillaries and veins to keep the organ alive.

It is why some researchers are investigating “decellularisation” – taking an existing donated organ, stripping out the original cells and replacing them with new cells from the patient who will receive the organ.

Prof Martin Birchall, a surgeon at University College London, has been involved in a number of windpipe transplants performed in this way.

The technique starts with a donor windpipe which is then effectively put through a washing machine. Repeated cycles of enzymes and detergents break down and wash away the host cells.

What is left behind is a web of proteins, mostly collagens and elastins, which give the windpipe its structure. It would look and feel like a windpipe, just without cells – a natural scaffold.

The next steps are very similar to those for making the bladder. Stem cells are taken, this time from bone marrow, and grown in a lab before being layered onto the scaffold.

The first patient was fitted with one of these windpipes in Spain in 2008.

Prof Birchall said: “We’ve made some inroads by starting with the windpipe. We’re looking at some other tissues now like the oesophagus and diaphragm and overseas the big breakthroughs have been in building the bladder and urethra.

“Those are the areas in which immediate breakthroughs have occurred, but I see a raft of further first-in-man studies in other organs happening in the next five years.”

Heartbeat

There are already strong hints of what the next steps could be.

Five routes to a solid organ

  • Build it on a scaffold
  • Strip an old organ of cells and put new ones in their place
  • Use a “bioprinter” to built an organ layer by layer
  • Inject cells into a living organ to repair
  • Use chemicals to trigger an organ to repair itself

Dr Doris Taylor, who is about to move to the Texas Heart Institute, has used the decellurisation technique on rats’ hearts andproduced beating organs.

The cells were stripped away leaving a “ghost heart” and were then injected with heart cells. Eight days later the heart was beating, albeit at just 2% of normal heart function.

She said the technique could “absolutely” be used on any organ that had a blood supply.

She told the BBC: “It’s not science fiction any more, but moving that to more complex organs is the challenge ahead of us.”

Other groups have also produced miniature organs or “organoids”. They are not the full-blown thing, but they perform the same functions at a smaller scale.

Wake Forest researchers have produced liver organoids which can break down drugs.

Dr Atala said: “The challenge for us is – how do we scale up?”

Bioprinting, just like an office printer except it “prints” cells layer by layer, has been used to “print” a kidney.

While these findings are a very long way from making it into hospitals, if indeed they ever do, the scientists involved are convinced these techniques will come good.

“The vision has to be tempered by the past and the number of false dawns that have occurred,” Prof Birchall said.

“But I genuinely do believe stem-cell technologies and tissue engineering is going to completely transform healthcare delivery in the future.

“I see it incrementally reaching out to replace transplantation. The writing is on the wall for it to do wonderful things.”

Dr Atala said: “The strategies are out there to someday be able to target every organ in the body we are not there yet. We are nowhere near there yet.

“But the goal of the field is to keep on advancing the number of tissues that we can target.”

Of course growing a hand is even more challenging than anything being tried in laboratories so far. Will it ever be possible?

“You never say never, but certainly it’s something I will most likely not see in my lifetime,” Dr Atala concluded.

Source: BBC

Rapid pediatric weight gain beneficial in low-income countries .

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Previous studies have suggested that rapid weight gain during the first 2 years of life is associated with an increased risk for obesity and insulin resistance later in life. However, a new study with an emphasis on countries with low or middle income suggests that higher birth weight and early growth during the first 2 years of life led to improvements in height and levels of education.

“Our results challenge several programs in countries of low and middle income. … Traditional school feeding programs that increase BMI with little effect on height might be doing more harm than good in terms of future health,” researcher Linda S. Adair, PhD, of the Gillings School of Global Public Health at the University of North Carolina at Chapel Hill, said in a press release.

The researchers collected data for 8,362 patients from five prospective birth cohort studies from Brazil, Guatemala, India, the Philippines and South Africa who had at least one adult outcome of interest.

They wrote that a higher birth weight was consistently related to an adult BMI of >25 kg/m2 (OR=1.28; 95% CI, 1.21-1.35) and a reduced tendency for short adult stature (OR=0.49; 95% CI, 0.44-0.54) and of not completing secondary school (OR=0.82; 95% CI, 0.78-0.87).

Additional data indicate that faster linear growth at age 2 years (OR=0.23; 95% CI, 0.20-0.52) and mid-childhood (OR=0.39; 95% CI, 0.36-0.43) was associated with a reduced risk for short adult stature and of not completing secondary school at age 2 years (OR=0.74; 95% CI, 0.67-0.78) and mid-childhood (OR=0.87; 95% CI, 0.83-0.92).

However, faster linear growth increased the likelihood for children being overweight at age 2 years (OR=1.24; 95% CI, 1.17-1.31) and mid-childhood (OR=1.12; 95% CI, 1.06-1.18), in addition to elevated BP at age 2 years (OR=1.12; 95% CI, 1.06-1.19) and mid-childhood (OR=1.07; 95% CI, 1.01-1.13), researchers wrote.

Moreover, faster relative weight gain was associated with an increased risk for adult overweight status at age 2 years (OR=1.51; 95% CI, 1.43-1.60) and mid-childhood (OR=1.76; 95% CI, 1.69-1.91), in addition to elevated BP at age 2 years (OR=1.07; 95% CI, 1.01-1.13) and mid-childhood (OR=1.22; 95% CI, 1.15-1.30), they wrote.

Linear growth and relative weight gain were not linked to dysglycemia. However, higher birth weight was related to a decreased risk for the disorder (OR=0.89; 95% CI, 0.81-0.98), according to data.

In an accompanying commentary, Zulfiqar A. Bhutta, MBBS, PhD, of the division of women and child health at Aga Khan University in Karachi, Pakistan, wrote that aside from study limitations, Adair and colleagues’ findings have clear implications.

“As shown by an analysis of evidence-based interventions, a focus on improvements in nutrition in pregnancy and linear growth in the first 2 years of life could lead to substantial reductions in stunting and improved survival,” Bhutta wrote.

According to Bhutta, there should be well-designed prospective studies with appropriate interventions and follow-up, including elements of child development, education, employment and earnings, as outcomes.

For more information:

Adair LS. Lancet. 2013;doi:10.1016/S0140-6736(13)60103-8.

Bhutta ZA. Lancet. 2013;doi:10.1016/S0140-6736(13)60716-3.

Source: http://www.healio.com

Normalization of Vital Signs Does Not Reduce Risk for Acute Pulmonary Embolism.

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Up to one third of patients whose abnormal triage vital signs reverted to normal values had PE.

In a prospective single-center study, researchers evaluated whether normalization of vital signs in patients who present with symptoms of pulmonary embolism (PE) reduces the probability of the disease. Patients at an urban academic emergency department (ED) in North Carolina were enrolled if they were older than 17 years and had at least one predefined sign or symptom and one risk factor for PE.

Of 192 patients, 35 (18%) were diagnosed with PE by computed tomography in the ED. In patients whose abnormal triage vital signs normalized at any time during their ED visit, incidence of PE was not lower than for patients whose vital signs did not normalize. The incidence of PE for patients with abnormal pulse rate, respiratory rate, shock index, or pulse oximetry at triage that subsequently normalized was 18%, 14%, 19%, and 33%, respectively.

Comment: Just as a normal blood gas value does not rule out acute pulmonary embolism, this study shows that normalization of initially abnormal vital signs also does not reduce the likelihood of PE. The best approach for patients presenting with signs and symptoms of PE is to note abnormal vital signs occurring at any time after symptom onset and use these vital sign numbers in the determination of pretest probability of PE, even if they subsequently normalized.

Source:Journal Watch Emergency Medicine

 

Aspergillus Meningitis Linked to Steroid Injections Sickens 26, Kills 4 .

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Twenty-six patients have contracted fungal meningitis after receiving spinal steroid injections for back pain, CNN reports. Four of the patients have died.

The majority of cases — 18 — have occurred in Tennessee; the rest are divided among Florida, Maryland, North Carolina, and Virginia.

Clinicians suspect that the steroid, preservative-free methylprednisolone acetate, was contaminated with the fungus Aspergillus. All patients received injections between July 1 and September 20, and with the incubation period lasting as long as 4 weeks, more cases may still be identified.

The New England Compounding Center, which has been implicated in the outbreak, has recalled three lots of methylprednisolone acetate: #05212012@68, #06292012@26, and #08102012@51.

Asked to comment, Journal Watch‘s Paul Sax said: “What makes this [outbreak] notable is both the severity and the rarity of the condition, Aspergillus meningitis. Needless to say, consultation with a specialist in infectious diseases would be highly recommended for any clinician encountering such a case.”

Source: CNN