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March 17, 2016

Research Notes

Mindfulness meditation can lead to back pain relief

Mindfulness meditation programs can help reduce severe pain and increase function for older adults with chronic low-back pain, according to research led by the School of Medicine.

After an eight-week mind-body program, people with chronic low-back pain noted an improvement in their physical function and a decrease in their most severe pain. The research was supported by National Institutes of Health’s (NIH) National Institute on Aging and published in JAMA Internal Medicine.

Said lead investigator Natalia Morone, medicine faculty member in the School of Medicine: “Since effective treatments for chronic lower back pain are limited, complementary medical therapies are a welcome addition to conventional treatments.”

Mindfulness meditation is a mind-body method described as paying attention on purpose and staying in the present moment to experience each unfolding event. The study assessed the effects of mindfulness on 282 adults age 65 and older who experienced chronic lower back pain daily or almost every day. Participants were taught three mindfulness meditation methods they practiced alone and in group sessions for eight weeks: self-examination in which the participant lies down and focuses attention non-judgmentally on each area of the body; sitting practice, which focuses on breathing while seated; and walking meditation, which is mindful, slow walking with focused attention on how the body feels.

Backache concept bending over in pain with hands holding lower back

Participants were assessed on measures of pain, physical function, self-efficacy and quality of life before the program began, at the end of the program and at a six-month follow-up.

The study found that the mind-body program helped with pain management even six months after the program, indicating there is a long-term benefit of coping with pain. However, while patient function immediately was improved after the eight-week program, at the six-month follow-up the impact of the program on function was not significant. At six months, 76 percent of participants still noted improvement in their back pain symptoms and their ability to cope with pain as a result of the mind-body program.

“Mindfulness meditation focuses on letting go of struggle and accepting one’s condition without judgment,” said Morone. “The mind-body program teaches patients how to be more aware of their thoughts, emotions, sensations and behaviors. As patients learn to do this, they can become more aware of behaviors or even thoughts and feelings about pain that make it worse, or more difficult for them to do activities.”

Other Pitt researchers were Carol M. Greco, Bruce L. Rollman, Bridget Lane, Lisa A. Morrow, Nancy W. Glynn and Debra K. Weiner. A colleague from Carolinas HealthCare System also participated.

New placenta model for infection crossing

Researchers at the School of Medicine and Magee-Womens Research Institute (MWRI) have devised a cell-based model of the human placenta that could help explain how pathogens that cause birth defects, such as Zika virus, cross from mother to unborn child. The findings were published in Science Advances.

The placenta is a complex and poorly understood organ that anchors the developing fetus to the uterus, nourishes the fetus and provides a barrier to the spread of microorganisms from an infected mother to the fetus.

Said senior investigator Carolyn Coyne, faculty member in microbiology and molecular genetics in the School of Medicine and a member of the MWRI: “The human placenta is unique and unlike that of many other placental mammals. With our new model in the research toolkit, we and other scientists hope to advance our knowledge of the placenta, examine its function and learn how it can prevent most, but not all, maternal infections from causing problems for the baby.”

Researchers currently can obtain and study placental cell lines, but such cells do not fuse spontaneously to form the characteristic structure of the human organ. Some scientists study cells, called primary human trophoblasts, that are isolated from placentas obtained after childbirth, but such cells do not divide, can be more difficult to obtain and are more difficult to genetically manipulate to learn about biochemical pathways that have a role in placental function, Coyne said.

Her team took a different approach: They cultured a human placental trophoblast cell line in a microgravity bioreactor system developed by NASA. The trophoblasts, along with blood vessel cells, were added to small dextran beads that were then spun around in a container filled with cell culture fluid, creating shear stress and rotational forces to better mimic the environment at the maternal-fetal interface than static cell-culture systems.

As a result, the cells fused to form syncytiotrophoblasts, and thus more closely resemble the primary cells lining the outermost layer of the tree-like or villous structure of the human placental tissue. Next, the researchers tested the functional properties of their model by exposing it to a virus and to Toxoplasma gondii, a parasite found in cat feces that can lead to fetal infection, causing miscarriage, congenital disease and/or disability later in life.

Said co-investigator Jon P. Boyle, biological sciences faculty member in the Dietrich School of Arts and Sciences: “We found that the syncytiotrophoblasts formed in our system recapitulated the barrier properties of the naturally occurring cells and they resisted infection by a model virus and three genetically different strains of Toxoplasma. With this model, we can experiment with different biological factors to see what might allow an infectious agent to get through the placental barrier to the fetus.”

Understanding the placenta might one day lead to ways to prevent fetal damage from the so-called TORCH infections: toxoplasmosis, rubella, cytomegalovirus, herpes and HIV, he added.

The researchers are beginning to use their model to test whether Zika virus, and other pathogens associated with congenital disease, can infect placental cells and/or cross the placental barrier.

Pitt research team members include Cameron McConkey, Elizabeth Delorme-Axford and Yoel Sadovsky. Colleagues from Arizona State University and Johns Hopkins University also contributed.

The project was funded by NIH and the Burroughs Wellcome Fund.

Binge drinking lower in better LGBTQ school climates

Empty brown beer bottle standing in a row

Both heterosexual and gay/lesbian students report less binge alcohol consumption when living in states or cities that have greater proportions of schools with programs and policies that support lesbian, gay, bisexual, transgender and questioning (LGBTQ) youth, according to research from the Graduate School of Public Health.

These findings, published in Drug and Alcohol Dependence, suggest that LGBTQ-affirmative schools are associated with lower binge-drinking frequency for nearly all adolescents, irrespective of their sexual identity.

Data were collected with assistance from the Centers for Disease Control and Prevention (CDC) Division of Adolescent and School Health.

Said lead author Robert W.S. Coulter, a doctoral student in the Department of Behavioral and Community Health Sciences: “School environments have a powerful influence on adolescents’ health. In particular, schools that are more affirming of LGBTQ students may be less stressful environments or foster healthy emotional resilience for all students, thereby making them less likely to turn to alcohol as a coping mechanism.”

Coulter and his colleagues analyzed data collected from the Youth Risk Behavior Survey from more than 50,000 students in eight states or cities nationwide. Students were asked about how many days in the past month they had at least one alcoholic drink and how many days they had at least one drink on school property. The questionnaire also assessed binge drinking by asking how many days in the past month the students had five or more drinks in a row, within a couple of hours.

The team determined each jurisdiction’s overall school climate toward LGBTQ students using the School Health Profile Survey.

Jurisdictions were considered more affirmative of LGBTQ students if they had greater proportions of schools that have gay-straight alliances or similar student clubs and “safe spaces” for LGBTQ adolescents; prohibit harassment based on real or perceived sexual orientation; encourage staff to attend professional development activities about safe and supportive school environments for LGBTQ adolescents; provide LGBTQ-inclusive sexual health curricula; facilitate access to LGBTQ-competent health services outside of school; and facilitate access to LGBTQ-competent social and psychological services outside of school.

Living in jurisdictions with more affirmative LGBTQ school climates was associated with significantly fewer binge drinking days for gay/lesbian and heterosexual students, compared with living in jurisdictions with less LGBTQ-affirmative school climates.

Living in jurisdictions with more affirmative LGBTQ school climates also was significantly associated with fewer drinking days at school for adolescents unsure of their sexual orientation.

“By nurturing LGBTQ-affirmative school climates through inclusive policies and programming, schools may reduce certain alcohol use behaviors for gay/lesbian students, heterosexual students and students unsure of their sexual orientation,” said Coulter.

However, LGBTQ-affirmative school climates were not associated with reduced binge and other alcohol drinking behaviors for bisexual adolescents.

“One potential explanation for this finding is that LGBTQ-affirmative school policies and programs may not adequately address the needs of bisexual students as much as they do for gay/lesbian students,” Coulter said. “This is concerning because bisexual adolescents had the greatest number of drinking and binge drinking days when compared to other sexual-orientation subgroups, and bisexuals composed a larger segment of the population than gay/lesbian adolescents or adolescents unsure of their sexual orientation.

“Future studies should explore how school climates can be more affirmative of bisexual adolescents, and public health researchers and practitioners should design, implement and evaluate interventions specifically aimed at preventing and reducing alcohol use for bisexual adolescents.”

Additional authors on this research were Ron D. Stall of Pitt and colleagues from Northwestern University, San Diego State University and Columbia University.

The research was funded by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institute on Drug Abuse and the IMPACT LGBT health and development program at Northwestern University.

RAVEN initiative cuts hospitalizations, costs in skilled nursing facilities

A report commissioned by Centers for Medicare and Medicaid Services (CMS) finds that UPMC and its community partners are achieving reductions in avoidable hospitalizations and costs in the third year of a comprehensive initiative to improve care in skilled nursing facilities across western Pennsylvania.

Nearly two-thirds of nursing facility residents are enrolled in Medicaid, and most also are enrolled in Medicare, making this population among the most fragile and chronically ill served by these programs. CMS estimates that as many as 45 percent of hospitalizations could be avoided among Medicaid and Medicare enrollees receiving care at Medicare-regulated skilled nursing facilities.

In 2012, UPMC was one of seven organizations awarded a grant from CMS to reduce potentially avoidable hospitalizations. While all sites showed a general reduction in Medicare expenditures, the year-three evaluation report found the UPMC program, called RAVEN (Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents), was one of two programs that significantly reduced avoidable hospitalizations and costs.

UPMC Community Provider Services and its Aging Institute and Palliative and Supportive Care Institute partnered with Excela Health, Heritage Valley Health System, Jewish Healthcare Foundation and Robert Morris University to collaborate on this initiative.

In western Pennsylvania, potentially avoidable hospitalizations were reduced nearly 25 percent, while potentially avoidable emergency department visits were reduced more than 40 percent. The reduction in health care utilization led to a net savings to CMS of more than $5 million.

In western Pennsylvania, 18 nursing facilities have committed to making changes to improve care and reduce potentially avoidable hospitalizations. Those changes include on-site enhanced care staff, specifically nurse practitioners and enhanced registered nurses who work with facility nursing staff to provide preventive services, improve the assessment and management of residents’ medical conditions and provide advance-care planning, support and treatment for those who choose palliative care as end of life approaches.

Other interventions include educating clinical staff about customized tools to help improve communication about residents’ changing medical conditions; expert training about special health needs of the elderly, palliative care and advance-care planning; improved management of residents’ prescription drugs to reduce the risk of medication-related complications; and telemedicine to manage any worsening of a medical condition experienced by a resident after hours.

UPMC has applied for a subsequent round of CMS funding to launch RAVEN’s second phase. If funded, RAVEN will explore whether a new payment model for nursing facilities and practitioners will improve quality of care by further reducing potentially avoidable hospitalizations, while lowering combined Medicare and Medicaid spending.

The seven organizations involved in this CMS Innovation project are Alabama Quality Assurance Foundation, Alegent Health, the Curators of the University of Missouri, Greater New York Hospital Foundation Inc., HealthInsight of Nevada, Indiana University and UPMC. All the groups collaborate with the CMS Medicare-Medicaid Coordination Office and the Center for Medicare and Medicaid Innovation, both created by the Affordable Care Act to improve health care quality and reduce costs in the Medicare and Medicaid programs.

Burn more calories, reduce Alzheimer’s disease risk

Whether they jog, swim, garden or dance, physically active older persons have larger gray matter volume in key brain areas responsible for memory and cognition, according to a new study.

Two Mature Male Cyclists Riding Bikes Along Path

The findings, published in the Journal of Alzheimer’s Disease, showed also that people who had Alzheimer’s disease or mild cognitive impairment experienced less gray matter volume reduction over time if their exercise-associated calorie burn was high.

A growing number of studies indicate physical activity can help protect the brain from cognitive decline, said investigator James T. Becker, faculty member in the school’s psychiatry department. But typically people are more sedentary as they get older, which also is when the risk for developing Alzheimer’s disease and other dementias increases.

Said Becker: “Our current treatments for dementia are limited in their effectiveness, so developing approaches to prevent or slow these disorders is crucial. Our study is one of the largest to examine the relationship between physical activity and cognitive decline, and the results strongly support the notion that staying active maintains brain health.”

Led by Cyrus Raji, formerly a Pitt School of Medicine student and now a senior radiology resident at UCLA, the team examined data obtained over five years from 876 people 65 or older participating in the multicenter cardiovascular health study. All participants had brain scans and periodic cognitive assessments. They also were surveyed about how frequently they engaged in physical activities, such as walking, tennis, dancing and golfing, to assess their calorie expenditure or energy output per week.

Using mathematical modeling, the researchers found that the individuals who burned the most calories had larger gray matter volumes in the frontal, temporal and parietal lobes of the brain, areas that are associated with memory, learning and performing complex cognitive tasks. In a subset of more than 300 participants at the Pitt site, those with the highest energy expenditure had larger gray matter volumes in key areas on initial brain scans and were half as likely to have developed Alzheimer’s disease five years later.

Said Raji: “Gray matter houses all of the neurons in your brain, so its volume can reflect neuronal health. We also noted that these volumes increased if people became more active over five years leading up to their brain MRI.”

He added that advancements in technology might soon make it feasible to conduct baseline neuroimaging studies of people who already have mild cognitive impairment or who are at risk for a dementia disorder, with the aim of prescribing lifestyle approaches such as physical activity to prevent further memory deterioration.

“Rather than wait for memory loss, we might consider putting the patient on an exercise program and then rescan later to see if there are any changes in the brain,” Raji said.

Other Pitt members of the research team were Kirk I. Erickson, Oscar L. Lopez, H. Michael Gachi and Lewis Kuller. Colleagues from UCLA, University of California-Davis and the University of Washington also contributed.

The research was supported by the National Heart, Lung and Blood Institute and the National Institute of Neurological Disorders and Stroke.

Flu shot laws boost health care workers’ vaccination rates

State laws mandating influenza immunization for health care workers increase their vaccination rates, according to research led by the School of Medicine.

The analysis, published in the Journal of the National Medical Association and funded by the Robert Wood Johnson Foundation, looked at 2000-11 influenza immunization rates, a timespan in which states with flu vaccination laws aimed at health care workers climbed from two to 19.

Said lead author Chyongchiou Jeng Lin, faculty member in the school’s Department of Family Medicine: “Flu vaccination for all health care workers has long been recommended as one of the most effective ways to avoid infecting vulnerable patients with influenza, which kills thousands of people every year.

“State laws mandating that health care workers get flu vaccinations are an effective method to potentially save lives.”

From 2000 to 2005, only Maine and New Hampshire had flu vaccine requirement laws for health care workers. During that period, the average flu vaccination rate for health care workers was 22.5 percent. From 2006 to 2011, when 19 other states, including Pennsylvania, passed similar laws, the average vaccination rate for health care workers increased to 50.9 percent.

The states do not have equal vaccine laws. Some mandate that health care employers pay for the vaccines; some require formal documentation, and others, like Pennsylvania, require only that certain health care workers — such as those in long-term care facilities — get vaccines.

To do their analysis, Lin and her team assigned scores to each state based on the rigor of its law.

“We’re finding that the higher the score — meaning the state has a law and includes components like a mandate or education — the greater the probability that the vaccination rate among health care workers will be higher,” said Lin.

Advisory committees and health care organizations recommend that all health care workers receive an annual flu vaccine to reduce the spread of flu among staff and patients, and to decrease staff absenteeism.

In a previous study, Lin and her colleagues found that individual hospital policies that mandate influenza vaccination can nearly double vaccination rates. When coupled with a state law mandating health care worker flu immunization, those rates nearly triple.

UPMC is on the Immunization Action Coalition’s honor roll due to its systemwide policy that requires employees in clinical settings receive the influenza vaccine, unless they have an exemption. Exempted employees must wear a mask throughout flu season.

Said senior author Richard Zimmerman, faculty member in the school’s Department of Family Medicine and in public health: “By getting immunized against the flu, the health care worker is, in essence, building a fence to protect patients who perhaps can’t get immunized or whose immune systems are so compromised that the vaccine isn’t as effective.”

Since the study, several more states have added laws that address flu vaccine requirements for health care workers, bringing the total to 33 states. Flu vaccination rates among health care workers also increased to 66.9 percent in the 2012-13 season.

Additional Pitt authors on this research were Mary Patricia Nowalk, Mahlon Raymund and Patricia M. Sweeney.

—Compiled by Marty Levine

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