University Times

Grants awarded to researchers

David Axelson of the medical school’s psychiatry department has received a $422,858 grant from the National Institute of Mental Health to study the effectiveness of medications in treating mania in children and adolescents.

The Alfred P. Sloan Foundation has granted $256,000 to Frank Giarratani of economics to help build an academic community around the Sloan Industry Centers, which foster research and education in business and government policy.

Bambang Parmanto of the School of Health and Rehabilitation Sciences has received a $490,000 grant from the National Telecommunications and Information Administration for a project aimed at making the Internet more accessible to people with visual impairments.

The U.S. Department of Education has awarded $498,903 to Charles Perfetti of the Learning Research and Development Center for classroom and laboratory studies of word learning (vocabulary acquisition and comprehension).

Stephen Thomas, director of the Graduate School of Public Health’s Center for Minority Health, has been awarded $873,216 by the National Center on Minority Health and Health Disparities. The grant will fund the Pitt center’s Project EXPORT, aimed at increasing the African American community’s capacity to participate in health promotion and disease prevention research and interventions.

The National Institute of Child Health and Human Development has awarded $383,178 to the medical school’s Ross Zafonte to fund participation by the University of Pittsburgh Brain Injury System in a traumatic brain injury clinical trials network.

************

Migraines often not diagnosed correctly, researcher says

Migraine headaches, suffered by millions of Americans and debilitating for many, are significantly under-diagnosed by physicians, according to a Pitt neurologist writing in the March 19 issue of the Journal of the American Medical Association.

“A review of a number of studies suggests that far more people actually suffer migraine headaches than popularly thought,” said Robert Kaniecki, assistant professor and director of the Headache Center at the University of Pittsburgh Medical Center. “Many people who are diagnosed as having ‘tension’ or ‘sinus’ headaches are, in fact, suffering migraines.”

Migraine is a significant public health problem, with more than 28 million sufferers in the United States. More women than men have migraines, as 18 percent of women and 6 percent of men report having a migraine at some point. The cost to the U.S. economy is approximately $17 billion annually in health care and lost labor costs.

Treatments for acute attacks can include the use of high doses of non-steroidal and anti-inflammatory drugs such as aspirin, ibuprofen, naproxen, tolfenamic acid or a combination of acetaminophen, aspirin and caffeine. Also, migraine-specific medications such as those from a family of drugs known as triptans also are frequently used and are considered to be the most effective products on the market.

According to Kaniecki, prescription and non-prescription products are used by 9 percent of the population to treat headaches each week, matching hypertension as the most-treated medical condition.

One of the most over-diagnosed forms of headache, Kaniecki said, is the sinus headache, which he says exists only in theory. Recent research has shown that the majority of patients diagnosed with sinus headache actually have headaches meeting criteria for migraine.

“The United States is the only country in the world to have such a thing as ‘sinus headache.’ A study done in 2002 showed that of 3,038 people who reported that they had sinus headaches, only eight actually had sinus infections,” Kaniecki said. “Over 50 percent of patients with migraine are undiagnosed, and in this group, 42 percent carry the label of ‘sinus headache’ and 32 percent the diagnosis of ‘tension headache.’”

The result of the over-diagnosis of sinus headaches is an excessive number of prescriptions written to treat the phantom sinus infection, including mass doses of antibiotics and decongestants. This, he said, may be a major contributor to antibiotic resistance.

A primary reason for the under-diagnosis is a lack of physician education, he said.

The tools for assessing headache are most important so that the physician and patient can work together to determine the best diagnosis and treatment.

“The first step is to find out if there are secondary origins of headache, such as a brain tumor or aneurysm. We then assess the patient for a primary headache subtype such as migraine, tension, or cluster,” Kaniecki said.

“Once that step is complete, we assess the frequency of episodes to determine whether the patient has an episodic or chronic form of this headache,” he added.

The International Headache Society defines chronic headache as attacks that occur more frequently than 15 days a month for more than 6 months. More than 4 percent of adults in the U.S. suffer from chronic headaches that are daily or near-daily.

“Episodic tension-type headache annually affects some 38 percent of U.S. adults, yet rarely requires medical attention given the typical absence of disability or concerning symptoms,” Kaniecki said. The pain is generally mild to moderate, usually bilateral, and non-throbbing, with stress as the most common trigger.

“Migraine symptoms may be quite variable,” he said. Although typically seen as a one-sided throbbing headache associated with nausea and sensitivities to light and noise, migraine also may be associated with neck pain or sinus drainage and congestion.

“If one has a stable pattern of disabling headache occurring as episodes over months to years, it almost always represents migraine,” Kaniecki said.

************

Can cardiac arrest victims be aided by vasopressin?

More than 350 people in cardiac arrest are treated by City of Pittsburgh paramedics each year, according to statistics from researchers in the Department of Emergency Medicine at Pitt’s School of Medicine.

Can survival for patients who suffer out-of-hospital cardiac arrest be improved by using a generic drug called vasopressin?

Emergency medicine researchers are participating in a local, one-year research study known as the Vasopressin in Cardiac Arrest Research Project. Researchers will collaborate with City of Pittsburgh paramedics, who will administer the drug.

Pittsburgh paramedic crews will be asked to carry research vials. Half of the paramedics will receive vials containing vasopressin and half of the paramedics will receive vials containing saline (salt water). None of the paramedics will know whether the vials contain the active drug or the saline.

The paramedics will perform their current standard of care for cardiac arrest, including giving adrenaline (epinephrine) and, additionally, will administer the contents of the research vial. It is expected that one-half of patients in cardiac arrest will receive vasopressin in addition to their regular treatment. The researchers hope to give vasopressin to 162 patients in cardiac arrest. A total of 324 people may participate in the study.

When paramedics are called to the scene of a patient in cardiac arrest, they typically provide advanced tools to help the patient breathe and administer drugs like epinephrine to help promote blood flow to the heart, making it more likely to resume beating. Currently, the only blood flow-promoting drug approved for use by paramedics is epinephrine.

During the vasopressin study, an emergency medicine physician from Pitt will ride with paramedics in the ambulance. It is part of the required training for emergency medicine residents at Pitt.

Information gathered during the study will enable researchers to examine whether there is any change in the proportion of victims whose hearts restart after receiving the vasopressin.

“If results of this study show a significant increase in resuscitation from sudden cardiac arrest, vasopressin may eventually win approval for use by all paramedics,” said Clifton W. Callaway, assistant professor of emergency medicine at Pitt’s School of Medicine and principal investigator of the vasopressin study. “It is necessary to conduct this study in the out-of-hospital setting because victims of cardiac arrest often arrive at the hospital too late for the drug to do any good.”

Recent studies in Canada and Europe have shown that vasopressin was equivalent or superior to adrenaline when used as a treatment for cardiac arrest. Based on these studies, the American Heart Association recommends vasopressin as the drug to be considered for the treatment of cardiac arrest. However, it is unknown whether vasopressin is helpful when used for victims of cardiac arrest under conditions like those encountered by paramedics in the United States.

According to federal law and Pitt policy, those who participate in clinical research must provide informed consent. Because of the nature of this trial, it is impossible to obtain consent at the time of cardiac arrest. Researchers are notifying the public that informed consent will be waived and will make every attempt to contact family members and, if possible, the cardiac arrest patient to obtain consent at a later time.

************

Acupuncture for end-stage colorectal cancer patients studied

Colorectal cancer patients with end-stage disease often suffer from physical and psychological symptoms that negatively affect their quality of life and require frequent hospital stays. The intensity of these symptoms can prevent patients from taking full advantage of their limited time with family and friends.

Investigators at the University of Pittsburgh Cancer Institute (UPCI) are testing the use of acupuncture in alleviating symptom distress in people with advanced colon cancer. The study is supported by a $1.2 million grant from the National Institutes of Health. In order to determine whether acupuncture helps people with colon cancer, some study participants receive acupuncture and others do not.

“For many terminally ill colorectal cancer patients, their final months are marred by distressing physical symptoms,” said Ellen M. Redinbaugh, principal investigator of the study and assistant professor of medicine in Pitt’s Department of Behavioral Medicine. “These symptoms can be overwhelming for the more than 50,000 colorectal cancer patients who die every year in the United States. Their alarmingly high rates of hospitalization for symptom management near the end of life indicate a clear need for new interventions to ameliorate their distress and promote their quality of life.”

Acupuncture has been used in traditional Chinese medicine for 2,500 years to prevent and treat illness. It is widely practiced in the United States as a therapeutic intervention for a variety of health conditions. The theoretical basis for acupuncture is that disruptions in energy flow (Qi) cause illness and disease, or an imbalance between the complementary life energies, Yin and Yang. Acupuncture is said to correct the imbalances of energy flow and promote optimal health. It relies on the insertion of thin surgical needles into specific points close to the surface of the skin (acupoints) to stimulate energy flow.

“Acupuncture has been used successfully to reduce pain, but there is a lack of well-designed studies that compare it to other treatment modalities in this patient population,” commented Andrew Baum, professor of psychiatry and psychology and UPCI’s deputy director for cancer control and population sciences.

The current study will evaluate the efficacy of acupuncture to improve quality of life, promote emotional well-being and decrease physical symptom distress among colorectal patients with a life expectancy of six months or less. One hundred and seventy patients with metastatic colorectal cancer will be recruited for the study through the UPCI’s gastrointestinal oncology department.

Patients will be randomly assigned to one of three groups. The first group will receive “true” acupuncture in which needles will be inserted at acupoints. A second group will receive “sham” acupuncture, or the insertion of needles at locations on the body that do not represent actual acupoints. The final group will receive usual care without acupuncture.

Colorectal cancer is second only to lung cancer in numbers of cancer-related deaths in the United States. If detected early, it is highly curable.

************

UPMC studies headaches in evaluating concussion recovery in high school athletes

Any degree of post-concussion headache in high school athletes even one week after injury likely is associated with incomplete recovery, indicating the need to keep the athlete from returning to contact play until headache and all other post-concussion symptoms resolve, according to a study by the University of Pittsburgh Medical Center (UPMC) Sports Medicine Concussion Program published in the March-April 2003 issue of The American Journal of Sports Medicine.

In the study, concussed high school athletes with any degree of headache at one week post-injury also had significantly more other post-concussion symptoms and performed more poorly on neurocognitive tests measuring reaction time and memory than concussed athletes who reported no headache at one week post-injury.

Athletes with headaches one week post-injury also were four times more likely to have experienced memory loss and other symptoms on the playing field immediately after the injury, and were five times more likely to experience on-the-field symptoms that lasted longer than five minutes. Thus, the presence of headache also was associated with more severe concussion.

“Our study results suggest that headaches in concussed high school athletes be taken seriously,” said principal investigator Michael W. Collins, a neuropsychologist and assistant director of UPMC Sports Medicine Concussion Program. “An athlete with post-concussion headache should receive further evaluation before being allowed to return to play. Headache certainly appears to be associated with lingering problems and incomplete brain recovery following concussion.”

“The significance of headache after sports-related concussion is often questioned because of the high frequency of headaches among athletes who have not sustained concussions,” said Melvin Field, study investigator and chief resident in UPMC’s Department of Neurological Surgery. “Even though as many as 86 percent of athletes with concussion report post-injury headache, until this study there has been no published study examining whether post-concussion headache is associated with neurocognitive impairment and other symptoms, thus suggestive of incomplete recovery.”

“We are concerned about returning a concussed athlete to play before the brain has had time to heal, given that the effects of a second concussion may be more harmful and serious,” said Mark R. Lovell, study investigator and director of UPMC’s concussion program. “Most athletes who sustain an initial concussion can recover completely as long as they are not returned to contact sports too soon.

“The problem is that concussion symptoms are not always straightforward and not always reported by the athlete. Evaluation of the injury’s effects and knowing when it is safe to return the athlete to play can be difficult to measure objectively,” Lovell added.

An estimated 63,000 high school athletes sustain a concussion each year. A concussion occurs when the brain is violently rocked back and forth inside the skull due to a blow to the head or upper body, much like an egg yolk inside an eggshell. Concussion is a trauma-induced alteration of mental status that may or may not result in loss of consciousness. Other symptoms may include headache, disorientation, confusion, dizziness, amnesia and uncoordinated hand-eye movements.

The UPMC researchers reviewed the cases of 109 high school athletes who sustained concussions during the 2000-2001 school year. The athletes were divided into two groups on the basis of self-reported headache at one week post-injury evaluation. Seventy-three of the athletes reported no headache while 36 athletes reported various degrees of headache. At that time a neurocognitive function test was administered to all study participants to compare headache presence to objective neurocognitive function data. Athletes with postconcussion headaches had significantly slower reaction times and reduced memory performance as measured by the neurocognitive test scores.

The test used in the evaluation was ImPACT (Immediate Post-concussion Assessment and Cognitive Testing), a 20-minute computer assessment tool developed by the UPMC sports concussion researchers. ImPACT includes tests of mental function such as attention, memory, reaction time and information processing speed. Some 250 high schools use ImPACT to objectively evaluate the effects of concussion and more accurately determine when it is safe for an athlete to return to contact play.

The athletes in the study were from 20 high schools in Pennsylvania, Michigan, Illinois, Oregon and Maine. The majority were football players, while the rest represented basketball, soccer, hockey, lacrosse, softball, track, volleyball and wrestling.