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April 3, 2014

Research Notes

Falls among elderly reduced by PA program

A low-cost program reduced falls in the elderly by 17 percent statewide, illustrating the value and effectiveness of using existing aging services, such as senior centers, in preventing falls, a Graduate School of Public Health study determined.

Researchers followed nearly 2,000 older Pennsylvanians between 2010 and 2011 to determine the effectiveness of the state’s Healthy Steps for Older Adults, a voluntary fall-prevention program. Results of the study, funded by the U.S. Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH), will be published in the May issue of the American Journal of Public Health and now are available online.

Healthy Steps for Older Adults, run by the Pennsylvania Department of Aging, offers risk screening for falls and educational information regarding fall prevention for adults 50 years and older. Participants who are identified as high risk for falls are referred to primary care providers and encouraged to complete home safety assessments, which identify modification — including banisters and grab bars — to reduce hazards in their homes that might put them at greater risk for falls.

The program is designed to be administered by volunteers at senior centers to keep costs low. Between 2010 and 2011, the state reimbursed the centers $70 per person for delivering the program, allocating $1.2 million to the program as a whole.

Lead author Steven Albert, a faculty member in the Department of Behavioral and Community Health Sciences, and his co-authors recruited 814 older adults at senior centers statewide to complete the program, and compared them to 1,019 counterparts who did not. The average age of study participants was 75.4 years. Of those who completed the program and were informed they were at high risk for falls, 21.5 percent followed up with physicians. More than three-quarters of program participants at high risk conducted home safety assessments, and a third went on to reduce home hazards.


Older age at onset of Type 1 diabetes associated with lower brain connectivity later in life

Children and adolescents who were older than 8 at the onset of Type 1 diabetes had weaker brain connectivity when tested later in life relative to those who were diagnosed at a younger age,  Pitt Schools of the Health Sciences researchers discovered.

The findings were made by analyzing the brain scans of 44 middle-age adults diagnosed with Type 1 diabetes as children.

“Adolescence is a time when the brain matures and makes connections in networks responsible for different functions,” said John Ryan, a faculty member in the Department of Psychiatry. “Further study is needed to determine if and how the onset of Type 1 diabetes shortly before or during puberty affects brain function and how better control of the disease at that important time could yield changes in brain function later in life.”

Half the study participants had onset of Type 1 diabetes before age 8 and were matched with participants of the same sex and age who were diagnosed after age 8, but before age 17.

Type 1 diabetes is usually diagnosed in children and young adults and happens when the body does not produce insulin, a hormone that is needed to convert sugar into energy, and can lead to nerve and organ damage. With insulin therapy and other treatments, the condition can be controlled.

Ryan noted that his findings were a “snapshot” of scans and tests from one time point, and repeated scans and tests over the next five-10 years will be critical to determine if the weaker brain connectivity might be linked to cognitive function, and if any predictive markers could be found in the brain scans that might warn of future cognitive impairment.


Accepted sepsis treatment challenged

A structured, standardized approach to diagnose and treat sepsis in its early stages did not change survival chances for people who develop this deadly condition, according to a national, randomized trial led by researchers at the School of Medicine.

Their findings, available online and published in the May 1 edition of the New England Journal of  Medicine, could change the way sepsis is diagnosed and treated. Each year, sepsis, the body’s response to severe infections, kills more people than breast cancer, prostate cancer and HIV/AIDS combined.

“We found no overall differences in two protocolized approaches when compared to conventional treatment,” said Derek C. Angus, a faculty member in the Department of Critical Care Medicine and an investigator on the study.

The five-year, multicenter study, called “Protocolized Care for Early Septic Shock” or ProCESS, was sponsored by an $8.4 million grant from the National Institute of General Medical Sciences.

“More than 750,000 cases of severe sepsis and septic shock occur in the U.S. each year, most receiving care initially in an emergency department. We’ve found that if early recognition and treatment happen, one approach to supporting circulation while giving antibiotics is not better than another,” said Donald M. Yealy, a ProCESS investigator and faculty member in emergency medicine.

A 2001 study in a Detroit hospital suggested that early, goal-directed therapy (EGDT), a treatment protocol that includes placing a catheter called a central line in the jugular vein to monitor blood pressure and oxygen levels, as well as delivery of drugs, fluids and blood transfusions according to target levels, reduced mortality by 16 percent.

ProCESS tested whether EGDT was superior to either protocolized standard care (PSC), a simpler strategy that still requires vein access but no central catheter, or the usual care in hospitals across the country, in which the bedside physician directs the course of treatment. All patients in ProCESS were diagnosed quickly and received prompt intravenous antibiotics and fluid resuscitation, but only EGDT required central venous catheterization, sophisticated monitoring and blood transfusions.

Between March 2008 and May 2013, 1,351 patients with septic shock at 31 U.S. hospital emergency departments were enrolled in the trial. They were chosen randomly to receive EGDT, PSC or the usual care for the first six hours of resuscitation.

The researchers found no difference in outcomes among the three interventions. At 60 days post-intervention, 21 percent of the EGDT group, 18.2 percent of the PSC group and 18.9 percent of the standard care group had died in the hospital. There also were no differences in mortality after 90 days or one year.


Stem cells from muscle can repair nerve damage

Stem cells derived from human muscle tissue were able to repair nerve damage and restore function in an animal model of sciatic nerve injury, according to researchers at the School of Medicine. The findings, published online in the Journal of Clinical Investigation, suggest that cell therapy of certain nerve diseases, such as multiple sclerosis, might one day be feasible.

To date, treatments for damage to peripheral nerves, which are the nerves outside the brain and spinal cord, have not been very successful, often leaving patients with impaired muscle control and sensation along with pain and decreased function, said senior author Johnny Huard, the Henry J. Mankin Chair in Orthopaedic Surgery Research at the School of Medicine and deputy director for cellular therapy at the McGowan Institute for Regenerative Medicine.

“This study indicates that placing adult, human muscle-derived stem cells at the site of peripheral nerve injury can help heal the lesion,” Huard said. “The stem cells were able to make non-neuronal support cells to promote regeneration of the damaged nerve fiber.”

The researchers, led by Huard and first author Mitra Lavasani, faculty member in orthopaedic surgery, cultured human muscle-derived stem/progenitor cells in a growth medium suitable for nerve cells. They found that, with prompting from specific nerve-growth factors, the stem cells could differentiate into neurons and glial support cells, including Schwann cells that form the myelin sheath around the axons of neurons to improve conduction of nerve impulses.

In mouse studies, the researchers injected human muscle-derived stem/progenitor cells into a quarter-inch defect they surgically created in the right sciatic nerve, which controls right leg movement. Six weeks later, the nerve had fully regenerated in stem-cell treated mice, while the untreated group had limited nerve regrowth and functionality. Twelve weeks later, treated mice were able to keep their treated and untreated legs balanced at the same level while being held vertically by their tails. When the treated mice ran through a special maze, analyses of their paw prints showed eventual restoration of gait. Treated and untreated mice experienced muscle atrophy, or loss, after nerve injury, but only the stem cell-treated animals had regained normal muscle mass by 72 weeks post-surgery.

The researchers now are trying to understand how the human muscle-derived stem/progenitor cells triggered injury repair, as well as developing delivery systems, such as gels, that could hold the cells in place at larger injury sites.


Integrating mental health services in pediatric practices is effective

Brief behavioral and mental health programs for children can be provided effectively within pediatric practices as an alternative to being referred to a community specialist, Pitt researchers found in an NIH trial.

Behavioral health treatment provided in the pediatrician’s office resulted in improved access to care, greater participation by both the child and caregiver in treatment programs and higher rates of treatment completion, without burdening the pediatric practice, researchers report in the April issue of the journal Pediatrics.

Lead author and Department of Psychiatry faculty member David Kolko and his colleagues recruited more than 300 children and their caregivers at eight community pediatric practices affiliated with Children’s Hospital who had been referred for treatment of behavioral problems; many also had attention-deficit/hyperactivity disorder (ADHD) or anxiety.

Half the children received “doctor office collaborative care,” where a trained behavioral health clinician, known as a care manager, collaborated with the child’s pediatrician to deliver mental health services in the pediatrician’s office. The other half received “enhanced usual care,” where the patients received educational materials and were referred to a local mental health specialist outside the pediatrician’s office who accepted the child’s health insurance.

The participants were 8 years old on average and two-thirds were boys. Most had a primary diagnosis of ADHD, followed by disruptive behavior disorder and anxiety disorder. Only 10 percent previously had received ADHD medication.

In the program at the pediatrician’s office, the child and caregiver participated in six-12 individual or family sessions within six months where the mental health clinician worked on individualized goals to address the behavioral health issue and reviewed educational materials to help achieve those goals. The clinician communicated with the pediatrician in regular meetings and through progress notes.

In both the in-office and outside specialist programs, the pediatrician was updated on the patient’s care and could prescribe medication when necessary. Of the participants assigned to the care manager at the pediatrician’s office, 99.4 percent began treatment programs and 76.6 percent completed them. Of those assigned to a specialist outside the office, 54.2 percent began treatment and 11.6 percent completed it.

The program in the pediatrician’s office also was associated with higher rates of improvement in behavioral and hyperactivity problems, lowered parental stress, better treatment response and consumer satisfaction. Pediatricians whose offices received the in-office program reported greater efficacy and more confidence in their skills to treat ADHD.


Lifestyle interventions can prevent major depression in older adults with mild symptoms

According to researchers at Pitt and the University of Maryland, discussions with a dietary coach to learn about healthy eating were as effective as meeting with a counselor for problem-solving or “talk” therapy in preventing major depression among older adults with mild symptoms of the mood disorder. Their findings were published online in Psychiatric Services.

Senior author Charles F. Reynolds III, a faculty member in psychiatry, said: “Sadness, fatigue and disinterest in activities that used to bring pleasure can leave patients isolated and unable to care for themselves.”

The team assessed whether problem-solving therapy for primary care (PST-PC), a scientifically proven seven-step approach delivered by non-mental-health professionals to help patients resolve difficulties and thus improve coping skills and confidence, could prevent elderly adults who have mild symptoms of depression from developing full-blown disease.

Instead of comparing the PST-PC participants to those who received “usual care,” which would most likely mean receiving no intervention, the team took the approach of comparing the PST-PC group to participants who underwent a program of dietary coaching at a similar visit interval for the same number of hours.

In a new project, the researchers will examine whether PST-PC can be administered effectively by lay health counselors in low- and middle-income countries such as India.


Can texting lead to better monitoring of concussion treatment?

Is text messaging a more effective way to get patients to help monitor their own concussion treatments? That’s what Stephanie Huang from Rutgers’ Robert Wood Johnson Medical School plans to find out under the tutelage of Brian Suffoletto, a faculty member in Pitt’s Department of Emergency Medicine. A better understanding of the effects of cognitive and physical activity on concussion recovery is necessary to determine the best method to treat post-concussive symptoms.

Thanks to a grant from the Pittsburgh Emergency Medicine Foundation, Huang will begin a study that builds upon a pilot study by Suffoletto that successfully used text messaging to track symptoms and influence self-management of patients with concussions.

According to the Brain Injury Journal, although most patients with concussions can expect a full recovery, as many as 25- 35 percent of patients with concussions in the United States report unrelenting complaints three- six months after the injury. Meanwhile, 5-15 percent continue to have persistent disability and dysfunction.

Huang’s study will be the first prospective and observational study to gain a better understanding of the variability in cognitive and physical activity post-concussion. Furthermore, her study will explore the effects of symptom exacerbations due to cognitive and physical activity during the initial recovery period from an acute concussion.


Does treatment for depression benefit heart failure patients?

Equipped with a new five-year, $7.3 million grant from the National Heart, Lung and Blood Institute, Pitt researchers are investigating whether treating depression in patients with heart failure can help them live longer.

According to government estimates, nearly six million Americans live with heart failure, and studies confirm about a quarter of them suffer from depression.

Previous research by Bruce L. Rollman, a faculty member in the Department of Medicine, and his colleagues found that patients hospitalized for heart failure who screened positive with depressive symptoms experienced a 20 percent mortality rate at one year following discharge, compared to just 8 percent among similar heart failure patients who screened negative for depression. After they adjusted for age, gender and other health variables, depression still was associated with a three-fold increase in mortality.

The study will include 750 participants recruited from several UPMC hospitals who meet severity criteria for heart failure and screen positive for depression both in the hospital and at two weeks after discharge over a three-year period.

Patients will be assigned randomly to receive either one year of a nurse-provided and telephone-delivered “blended” collaborative care intervention for treating both depression and heart failure, provided in coordination with patients’ cardiologists and primary care physicians (a similar collaborative care intervention that addresses only their heart failure) or to their doctors’ usual care for these conditions.

“If proven effective and cost-effective, the potentially more powerful and accessible blended care approach for treating heart failure and co-morbid depression could have profound implications for improving chronic illness care and stimulate development of similar interventions for integrating behavioral health into routine clinical care,” Rollman said.

—Compiled by Alex Oltmanns


The University Times Research Notes column reports on funding awarded to Pitt researchers as well as findings arising from University research.

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