Medicine's new waves

What will surface in the next wave of medical research?

from Scope Magazine, fall 2012

As “Obamacare” reforms start to move ahead, questions are boiling about their implementation and impacts. Many critics say the current health care system is broken; some call it more of a “health scare system.” Statistics show the US spends twice as much on health care per capita as other developed nations but ranks lower in many measures of health and wellness. In a recent Physicians Foundation survey, 57 percent of young doctors say they’re pessimistic about US health care, citing especially its red tape and insurance costs.

   Illustration by Brucie Rosch

While health care policies and finances wend tortuously through new rules, an ongoing rush of research could turn the legal evolution into a clinical revolution. The CEO of the Eli Lilly pharmaceutical company recently told a national health and life-sciences conference, “Time and time again, medical innovation has reset the standard for what we can expect from the health care system and from human life.” He declared, “We are only at the beginning of what will be known as the biomedical century.”

Several Skidmore professors are doing fascinating work with potentially profound medical implications, so Scope asked six of them to share a prediction about America’s health care future.

Think a cancer walk means fundraising? Think again. Chris Repka says walking, lifting weights, cycling, and other exercise should and will be a standard treatment in cancer care and re­habilitation. Certainly physical therapy helps patients regain strength and flexibility after surgery. But his research shows that aerobic, cardiovascular exercise after and even during chemotherapy and radiation is especially valuable as well.

“Radiation and chemo kill cancer cells by causing them severe oxidative stress,” Repka says, “and exercise helps healthy cells recover from just that kind of damage.” Post-treatment anemia is a common problem, but exercise speeds the body’s generation of red blood cells. Cancer survivors often talk of “chemo brain—forgetfulness or fuzzy thinking that can linger for years afterward. We know that exercise stimulates not just blood flow to the brain but actual neuronal development.” One common and effective chemo drug is known to be so cardiotoxic that it can permanently weaken patients’ hearts. Repka’s lab rats show significantly reduced heart damage when they do even a little bit of exercise before, during, or after being dosed with this drug. His conclusion: “Exercise is a way of treating the treatment.”

Just as patients used to be told to take it easy after a heart attack but are now given exercise programs, cancer patients may soon find exercise among their prescriptions. “Cancer exercise is growing but is still years behind cardiac rehab, in that it’s not part of the oncologist’s or surgeon’s or primary-care doctor’s standard protocol and it’s not covered by insurance. But it should be,” Repka says. The American College of Sports Medicine just created an official “cancer exercise specialist” certification.

As cancer treatments keep improving, more and more people are living long-term with the aftereffects. “That’s a huge population that can benefit from cancer exercise rehab.”

Our “Prozac nation” is a failed state, according to “extensive research showing that psychotropic drugs like antidepressants are often no more effective than placebos,” says Andy Molteni. Studies are reviving the reputation of “talk therapy” as more efficacious than mood-altering pills. Molteni also points to “alarming research about the dangers of such drugs for children.” (He cites the too-frequent practice, when attention-deficit meds don’t work, of “rediagnosing the kids and switching them onto antipsychotic drugs, which have serious long-term risks.”)

Reacting to the research, pharmaceutical companies aren’t  investing as much in new depression and anxiety drugs lately, Molteni says. He adds that as more states pass mental-health parity laws, more insurance companies will be required to cover psychological treatment costs as thoroughly as physical ones. He predicts, “We’ll be returning to more behavioral and cognitive therapies, in offices and clinics as well as through exercises that patients can do on their own on smartphones and computers.”

He sees this trend as crucial in addressing pediatric obesity. “Being told to follow a new diet regimen isn’t enough. There are strong underlying reasons why people don’t stop certain behaviors. People negotiate and embrace change differently and need different psychological supports during the process. There’s interesting research trying to identify interventions that best match the stages of thinking that kids and their families go through in changing their eating habits.” He adds that insurance plans are seeing the value of covering psychological support in pediatric obesity, because the cost of covering lifelong adult obesity is far higher.

Big Brother could save your life. From blood-pressure cuffs to EKGs, more and more equipment can send health data directly to a doctor’s computer or cell phone. This mobile e-medicine may be “the most exciting development in health care,” Denise Smith says.

Consider chronic congestive heart disease. Blood pressure is crucial to manage, but it fluctuates frequently, so occasional readings in a doctor’s office (where it commonly rises anyway) aren’t as informative as daily monitoring at home, to watch for trends and responses to medications. With a wireless link, a home blood-pressure gauge can transmit readings directly to a doctor’s office.

In her research on cardiovascular stress in firefighters, Smith says, “we’ve helped develop a T-shirt with a sensor that monitors heart rate, breathing, and temperature.” As the little gizmo transmits over Bluetooth wireless, “we integrate the data to get  a good overview of how the firefighter is recovering after working.” Future firehouses could have baseline stats for each crew member on file, and then during or after a fire the shirt-sensor data could be collated and compared to track each firefighter’s cool-down and return to normal heart rate.
The more telehealth can keep people out of hospitals, the more health costs can drop. So Smith says, “Companies are investing heavily in these technologies, and health care reform will drive this even more.” She predicts it’ll happen fast: “Once you figure out and devise a system, it’s relatively easy to expand it. For e-medicine, it’s just different sensors or diagnostics.”

She sees this as a “monumental change, because it’s not just for one condition or injury. It can change our whole approach to doctor’s visits, hospitalizations, home care—it’s a new paradigm for health care across the board.”

What color is your body fat? That question may be “an important watershed for developing really novel therapies for obesity,” predicts T. H. Reynolds. Using PET scans and then biopsying the hot areas, Dana Farber Institute researchers have found that adults retain some adipose tissue that resembles the “brown fat” that babies have. Brown fat’s role is not to store energy, as regular white fat does; instead, it burns energy to generate heat and keep the body warm.

“What if we could increase the amount or thermogenic activity of a patient’s brown fat?” Reynolds asks. In theory, the patient would burn off much of the energy stored in white fat cells, so those fat cells would shrink and the person would lose weight.

He also points to related research identifying one of the substances generated by muscle contractions as a hormonelike protein called irisin, which “can make white fat ‘browner’—that is, more metabolically active, more thermogenic.” Certainly exercising is healthy and burns calories, but Reynolds says muscle use produces a wide range of effects—often including increased appetite—that may balance or counteract the irisin release. Extracted irisin could turn out to be useful in, or as, a future anti-obesity medication.

Yet another avenue is stem-cell therapy. Since brown fat cells begin as the same stem cells that produce muscles but then differentiate during embryonic development, Reynolds explains, “we could potentially figure out how to culture these stem cells to become brown fat cells and then inject them into a patient.”

As with any really safe, really effective obesity treatment, of course, “the implications for health, and for health care costs, would be huge.”

“Care coordination has got to improve, and I’m optimistic that it will,” Crystal Moore declares. Specialists who don’t communicate with each other, family care-givers left out of the loop, factors that medical personnel don’t even know about—these are big issues in geriatrics especially. And geriatrics itself is big, because the number of US citizens over the age of 65, now at 40 million, will explode to 72 million by 2030, Moore reports.

An office visit with an elderly patient typically takes longer and may involve fewer reimbursable procedures. If the geriatrician wants to talk with one or two of the patient’s specialists, that phone time isn’t billable. At the same time, Moore cites studies showing that several key factors in older adults’ hospital readmission rates aren’t even medical—such as marital status, race, and income.

This is where comprehensive care teams show real promise, she says. When care is planned and delivered by a group including, say, a visiting nurse, a social worker, a physical therapist, and a geriatrician, health and wellness improve and costs decline. Her research finds that elderly patients at Veterans Administration clinics using such coordinated care strategies do not have different readmission rates according to race or class; the integrated approach is more equitable, and communications are better with the VA’s “incredibly good electronic medical-records system.” When  a team gets pay incentives for good outcomes rather than reimbursements for each test or procedure, she adds, everybody wins.

Moore says, “America is  finally waking up to the fact that health care is a scarce  resource. And the baby boomers who will be its main consumers tend to have high expectations and demands. Today’s fragmented fee-for-service health care marketplace won’t be sustainable much longer.”

Home pregnancy tests are so yesterday. Coming soon are far smaller kits for far more complex biomedical testing; in fact, such lab-on-a-chip technology is already in use. Kim Frederick and her peers around the world have been developing plastic chips, smaller than credit cards, and etching into them thinner-than-hair channels and tiny wells to hold droplets of blood, urine, or other liquid. The researchers are also optimizing concentration and filtering methods and fine-tuning ways of stimulating the fluids to flow through the etched capillaries into the testing stations laid out on each chip.

In disaster zones or other unequipped locations, as well as in kitchens and bathrooms, a wide array of tests—say, for air- or food-borne toxins or for any number of medical conditions—are now and will be increasingly doable on chips. One application of this technology is for diagnosing malaria: instead of a microscopist peering at a blood smear on a slide to look for malaria parasites after the patient is already dangerously sick, Frederick says, a chip device can quickly identify d-lactate, which is produced by the parasites and is detectable very early in the infection.

Frederick’s own lab is working on food-allergy screening. “Life-threatening food allergies have increased dramatically in recent years,” she says, and “unfortunately, the best tests still involve taking multiple vials of blood from a screaming child.” But soon multiple allergy screenings could be done with just one drop of blood in a little plastic chip.

Analytical chemistry labs like Frederick’s are working on improvements (some are even trying waxed paper instead of plastic for affordability) that could revolutionize medical testing and enhance health care both here and abroad.