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The first evidence of a distinctive protein signature that could help to transform the diagnosis and improve the monitoring of the devastating lung disease idiopathic pulmonary fibrosis (IPF) is being reported by University of Pittsburgh School of Medicine researchers in this month's edition of PLoS Medicine, an open-access journal of the Public Library of Science.

In the paper, Naftali Kaminski, M.D., director of the Dorothy P. & Richard P. Simmons Center for Interstitial Lung Disease in the Division of Pulmonary, Allergy and Critical Medicine at the University of Pittsburgh School of Medicine, and his colleagues describe a unique combination of blood proteins that appears to distinguish IPF patients from normal controls with extraordinary sensitivity and precision.

"Our findings suggest that we may be able to monitor what is happening in the lungs by measuring certain proteins in the peripheral blood," explains senior author Dr. Kaminski, who also is associate professor of medicine. "More study is needed to confirm whether these biomarkers might be useful as a clinical blood test to detect lung fibrosis. But right now, there is no straightforward test for IPF. The lung is not highly accessible; biopsy procedures carry risk, and while imaging is good, it can't follow the disease biologically."

IPF is a degenerative illness distinguished by progressive lung scarring and diminished breathing capacity, typically leading to death within about five years of diagnosis. It is estimated that 5 million people worldwide and 130,000 in the United States are affected by pulmonary fibrosis and about 30,000 people die of the disease every year.

For this study, researchers analyzed the concentrations of 49 proteins in the plasma of 74 patients with IPF and 53 normal controls. A combination of five proteins related to normal tissue breakdown and remodeling and certain disease processes, including arthritis and cancer, was found to be highly indicative of IPF.

Increases in two of the five, matrix metalloproteinases (MMP) 7 and 1, also were observed in tissue and fluid taken from the lungs of IPF patients. Other proteins in the IPF signature are matrix metalloproteinase 8, insulin-like growth factor binding protein 1 and tumor necrosis factor receptor superfamily member 1A.

"These proteins were increased in IPF patients, but not in patients with lung illnesses such as chronic obstructive pulmonary disease," says Ivan O. Rosas, M.D., first author on the study and assistant professor of medicine, University of Pittsburgh School of Medicine. Elevated MMP1 and MMP7 also distinguished IPF when compared to levels associated with another disease that closely mimics IPF, called subacute/chronic hypersensitivity pneumonia. In particular, increased concentrations of MMP7 "may be indicative of asymptomatic lung disease and perhaps reflect disease progression," Dr. Rosas says.

"One of the challenges is to know whether a blood protein actually reflects the situation in the lung," notes Thomas J. Richards, Ph.D., study co-first author and research assistant professor in the Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine. The team evaluated all the genes expressed in IPF-affected lung tissue to determine the proteins in the peripheral blood on which they should focus. Based on their detailed analysis, the team believes that increased levels of these five proteins probably are reflective of the disease.

"IPF can have a slow progression, so drug companies may wait a long time to see whether a particular drug is having any effect," says Dr. Kaminski. "But a blood biomarker could indicate whether a drug is working earlier. The biomarkers also might be used for risk assessment and for evaluation of disease progression."

Some known causes of pulmonary fibrosis include occupational and environmental exposure to asbestos, metal dust, farming chemicals and mold, an inflammatory disease called sarcoidosis, radiation, drug reactions, autoimmune disorders and possibly a genetic predisposition, according to the American Lung Association.

Most cases are considered to be idiopathic, or of unknown origin. There is no proven effective therapy for IPF, and most drug interventions are considered experimental. Long-term benefit may be possible with lung transplantation, a radical approach dependent upon a limited number of donated organs.

http://www.upmc.com/

The overall amputation rate in northern Illinois is declining due to improved care for diabetes and peripheral vascular disease, new research shows.

But not everyone is reaping the benefits.

A new study from Northwestern University's Feinberg School of Medicine has found people in African American communities on Chicago's South and West Side have a five times higher rate of lower limb amputations than people in the predominantly white suburbs and exurbs.

"Amputations are the canary in the coal mine for quality of care," said Joe Feinglass, lead author and research professor of medicine at the Feinberg School. "Many amputations are preventable. This means the primary care for minority people may not be very good. "

Feinglass said the high rate of amputations means people are not being closely monitored. "They come in with gangrene or a skin ulcer that comes to the attention of a doctor really late and nothing can be done," he said. "They have to take their leg off."

This is the first longitudinal study -- nationally or locally -- to examine amputation trends over nearly 20 years. Most studies of amputation rates look at one point in time.

The study will be published in the May issue of the Journal of Vascular Surgery.

The high amputation rate for minorities in Chicago likely reflects other racial disparities in healthcare, Feinglass said. "Diabetes is a condition that is highly susceptible to quality of care. Amputation rates give you a basic idea of how the system is performing."

It was known in the late 1990's that African Americans were more likely to have an amputation than whites. But as the national trend of amputations declined in the early 2000's, Feinglass wanted to see if the gap closed or at least narrowed.

The study examined hospital discharge data from the Illinois Department of Public Health for nine counties in northern Illinois encompassing more than eight million people. Feinglass then broke the statistics into three rings of the metropolitan area based on their zip codes.

He found that amputations in the suburban and exurban areas with a primarily white population dropped to 12 per 100,000 in 2004 from 14 in 1987. The largely African American area on the South and West Side actually increased to 63 amputations from 60. The inner suburbs and other areas of Chicago, with between 10 and 50 percent African American population and a large Hispanic population, held fairly steady at 20 amputations per 100,000.

About half of the people who have amputations are diabetic patients with decreased circulation to the feet. Almost all who have amputations are smokers, a habit that can cause hardening of the arteries and clots in the legs.

"These people get sores on their feet that don't heal," Feinglass said. "They develop an ulcer that can often turn into something worse if it's not treated right away."

The high amputation rate is linked to lack of access to primary care and specialty care for diabetic patients and patients with vascular disease. In addition, patients without diabetes may not get a screening for peripheral arterial disease, an inexpensive test to indicate risk factors for circulation problems.

To address these problems, Feinglass said communities need diabetes management programs with nurses to help people control their blood sugar.

"Those are the kinds of programs we know would pay off in the inner city. When blood sugar is lower, there is a lower amputation rate," Feinglass said. Vascular surgeons and podiatrists are also needed in these areas.

"An amputation is a horrible thing to have anybody go through," Feinglass said. "We have to do better at preventing these."

http://www.northwestern.edu/

The inability to manage weight gain and weight regain throughout life is helping to fuel the obesity epidemic in adults and children throughout Europe. However, the successful participation of more than 400 families in 8 countries in the largest European dietary intervention study, co-ordinated by the EC funded Diogenes project and headed by Professor Arne Astrup from the Faculty of Life Sciences at University of Copenhagen, is helping to address this vital issue.

The key focus of the Diogenes study is to identify the most effective diet to help adults stop regaining weight after initial successful weight loss.

To participate in the Diogenes study, adult family members were required to lose at least 8% of their body weight, before the whole family was admitted to the 'dietary intervention' part of the study and randomised to one of five diets.

763 participating adults were successful, losing between them a total of 8500 kg, equivalent to the weight of 4 fully grown bull elephants and 11.2kg on average for each person. (see Notes below for copyright free illustration)

After this successful weight loss phase, 565 families (763 adults and 787 children) were randomly chosen to follow a diet either high or low in protein or high or low in glyceamic index foods. The fifth diet, the control diet, was based on the family's usual diet but with additional advice on the inclusion of healthy foods.

In two centres (Copenhagen and Maastricht) supermarkets set up for the study provided families with free food for 6 months, followed by 6 months of dietary advice and support. The other 6 centres (UK, Bulgaria, Crete, Czech Republic, Germany & Spain) provided families with 6 months of dietary advice and support only.

"The real target in this Diogenes research study is the prevention of weight regain after initial weight loss," states Professor Arne Astrup, from the Faculty of Life Sciences at University of Copenhagen and co-ordinator of the 8-country dietary intervention study, one of the five research lines organised by Diogenes. "Most of us can lose weight if we set our minds to it - but we are not so good at keeping it off."

Professor Astrup continues: "The data now being collated and analysed from the Diogenes study on how successful each diet has been in preventing weight regain in each country will provide clearer answers to European consumers on which diet is likely to be most successful."

Professor Wim Saris, Executive Director of the entire Diogenes project concludes: "Preliminary results from the Diogenes dietary intervention study will be disclosed at the European Congress of Obesity (ECO) (14 May 2008) with results of the entire project being presented at the Diogenes satellite on 5/6 May 2009 as part of ECO."

http://www.ku.dk/English/

Growing pains can mean one thing for a typical adolescent and quite another to an older teen with cerebral palsy attempting independence in an adult world. A unique program, the Indiana University School of Medicine Center for Youth and Adults with Conditions of Childhood (CYACC) is helping these youths spread their wings and live more independently.

IU pediatricians at Riley Hospital for Children have been at the forefront of innovative care for patients, including advances that over the past three decades have created new challenges for patients with special needs and their caregivers. Now, Riley physicians are leading the way to providing a solution.

CYACC provides interdisciplinary consultation in a health-care setting to specifically address transition and adult life issues regardless of the youth or adult's diagnosis.

"Twenty to 30 years ago it was not unusual for children with serious congenital or developmental conditions to die before reaching adult life," said Mary Ciccarelli, M.D., an assistant professor of clinical medicine and pediatrics at the IU School of Medicine and medical director of CYACC. "Today, the life expectancy of many of these children reaches well into adulthood yet there are few programs available to help them transition to independent lives with both the best health status and the fullest participation in their communities."

Nationally, there are only a handful of programs that are beginning to address the need, Dr. Ciccarelli said.

It is estimated that 4,000 Indiana youth with special health-care needs experience transition into adult life each year. CYACC patients, who are between the ages of 11 and 22 years, are seen at the Wishard Primary Care Center on the IU Medical Center campus. Frequent diagnoses of patients served by the CYACC team are cerebral palsy, Down syndrome, autism, diabetes, rheumatologic disorders and spina bifida. Resources in many specialties and disciplines are involved to successfully integrating youth with chronic conditions into the adult world.

Psychosocial, educational, vocational and medical needs of the adolescents are addressed by the interdisciplinary team of physicians, nurses, social workers and community organization liaisons. Health-care coverage options and applications are made available. Family support and education are provided. While increasing numbers of community programs provide resources or accommodations for those with disabilities, many families are not aware of these opportunities in their communities. Collaboration is tailored for each individual with schools, employers, and agencies that can provide services for youth and their families.

Coordination of medical care also is one of the key issues the team addresses. With more than 300 unusual chronic conditions with onset in childhood, adult practitioners often have never provided care for individuals with the majority of these conditions. Pediatric doctors are trained to care for youth with childhood diseases but are not routinely familiar with addressing issues such as reproduction and other health issues common in adult life.

The team approach provides hands-on learning opportunities for IU School of Medicine physician residents in training. By involving the young physicians, CYACC extends its mission; these residents will take with them an awareness of the comprehensive medical, social and educational needs of this group of patients as they begin their careers in Indiana or elsewhere.

CYACC is currently funded by the Indiana State Department of Health and the Indiana State Division of Disability, Aging and Rehabilitative Services.

http://www.iupui.edu

Presidential candidates Sens. Hillary Rodham Clinton (D-N.Y.), John McCain (R-Ariz.) and Barack Obama (D-Ill.) each have announced proposals that seek to reduce health care costs, but "it is unclear how many of the candidates' ideas could actually make a dent in the rising cost of care," the Wall Street Journal reports.

According to the Journal, the candidates have proposed similar initiatives to address health care costs, including: providing consumers with more information to allow them to consider the cost and quality of medical treatments when they make health care decisions; promoting the use of generic medications and health care information technology to help reduce costs; and some form of medical liability reform.

McCain also has proposed to replace a tax break for employees who receive health insurance from employers with a refundable tax credit for the purchase of private coverage and to allow the purchase of health insurance across state lines -- both of which he maintains would promote competition among health insurers and reduce costs.

Gail Wilensky, an adviser to McCain, said, "The real answer is we don't know" whether the proposals from the candidates would reduce health care costs. She added that the alternatives include price controls and controlling the spread of new technology, which "gets real ugly real fast." Robert Reischauer, president of the Urban Institute, added, "Everybody is talking about the same kinds of things, but they are very difficult to do," adding, "If we started on the campaign trail right now, you'd be lucky to see the product of that in seven to 10 years, if everything was meshing right" (Meckler, Wall Street Journal, 4/28).

Cost of Proposals

Health care and other proposals from each of the candidates could "significantly swell the budget deficit and increase the national debt by trillions of dollars," the New York Times reports.

According to the Times, Clinton and Obama have acknowledged that their proposals "would be costly but have outlined how to pay for them," although "some fiscal monitors say they may be relying on overly rosy projections of how much savings their proposals would actually yield." Clinton has estimated that her health care proposal would cost about $110 billion annually, and Obama has estimated that his plan would cost as much as $65 billion annually.

McCain has "spoken vaguely about making entitlement programs like Social Security and Medicare less costly for the government" to help finance his health care and other proposals, the Times reports (Rohter/Cooper, Times, 4/27).

Forum

Health care advisers to each of the candidates on Thursday at a forum hosted by the National Federation of Independent Business discussed proposals by the candidates to expand health insurance to more residents and reduce costs, CQ HealthBeat reports.

Douglas Holtz-Eakin, a policy adviser for McCain, said, "Rising spending on health care has been the biggest threat to the system. ... It is the reason we find employers dropping coverage" (Cooley, CQ HealthBeat, 4/25). He added, "We are paying far too much for the outcomes we get" (Wall Street Journal, 4/28).

Katherine Hayes of the Clinton campaign said, "It's really heard to get a handle on cost without addressing coverage," adding, "You can't open up the door (to tell) insurance companies that they have to take everybody ... if some people can wait until they're sick to enter the health care system."

Kavita Patel, an adviser to Obama, said that Obama and Clinton have "very similar" health care proposals, although the Obama plan would not require all residents to obtain health insurance (CQ HealthBeat, 4/25).

A webcast of the forum is available online at kaisernetwork.org.

McCain To Deliver Health Care Speech

McCain on Tuesday plans to deliver a major policy speech on health care at the H. Lee Moffitt Cancer Center & Research Institute in Tampa, Fla., according to his campaign, the Tampa Tribune reports. McCain spokesperson Jeff Sadosky said the speech will focus on the cost of health insurance, "which Sen. McCain feels is the root issue for the health care crisis as a whole," as well as the need to focus on preventive care and other issues (March, Tampa Tribune, 4/26).

Opinion Piece

"For the last month, news media attention was focused" on the Pennsylvania Democratic primary, but, "as in the rest of the country this political season," information "about the candidates' priorities, policies and principles" on health care and other issues "too often did not make the cut," Elizabeth Edwards, wife of former Democratic presidential candidate and former Sen. John Edwards (N.C.), writes in a New York Times opinion piece. She writes, "Did you, for example, ever know a single fact about Joe Biden's health care plan?" adding, "But let me guess, you know Barack Obama's bowling score."

According to Edwards, "[I]t's not as if people didn't want this information," but few "people even had the chance to find out about Joe Biden's health care plan before he was literally forced from the race by the news blackout that depressed his poll numbers, which in turn depressed his fundraising." Such "shallow news coverage" allows residents to "ignore issues and concentrate on things that don't matter," Edwards writes, adding, "If voters want a vibrant, vigorous press, apparently we have to demand it" by "talking calmly, repeatedly, constantly in the ears of those in whom we have entrusted this enormous responsibility" (Edwards, New York Times, 4/27).