In the Jan. 10, 2011, issue of the Journal of Experimental Medicine, researchers from the University of Chicago and Emory University report that people who were infected with pandemic H1N1 and recovered had an extraordinary immune response, producing antibodies that are protective against a variety of flu strains.

The 2009 H1N1 virus matched typical influenza strains only in the components that are absolutely critical for the virus to function.  It induced an immune response to the virus’ most essential molecules. Consolidating those defenses into a vaccine could put an end to the yearly scramble to predict coming flu strains and quickly mass produce a different vaccine each fall.

The result is something like the Holy Grail for flu-vaccine research, said study author Patrick Wilson, assistant professor of medicine at the University of Chicago. “It demonstrates how to make a single vaccine that could potentially provide immunity to all influenza. The surprise was that such a very different influenza strain, as opposed to the most common strains, could lead us to something so widely applicable.”

Our data show that infection with the 2009 pandemic influenza strain could induce broadly protective antibodies that are only very rarely seen after seasonal flu infections or flu shots,” said first author of the study, Jens Wrammert, assistant professor of microbiology and immunology at Emory University School of Medicine and the Emory Vaccine Center. “These findings show that these types of antibodies can be induced in humans, if the immune system has the right stimulation.”

The team began by analyzing antibody responses from nine patients who contracted and recovered from the illness.  The team identified white blood cells from the patients that made antibodies against the virus, then isolated antibody genes from individual cells. They used the genes to produce antibodies—a total of 86 varieties—and then tested which flu strains the antibodies reacted against.
Five antibodies isolated by the team could bind all the seasonal H1N1 flu strains from the last decade, the devastating “Spanish flu” strain from 1918, plus a potentially lethal H5N1 avian flu strain.

This indicated that while the flu changes from year to year, some core elements have been consistent for nearly a century,” said Wilson.
The cross-reactive antibodies were produced by highly mutated antibody genes. These antibodies appear to have been produced by white blood cells that had been exposed to influenza in previous years and were reactivated by a new viral infection. As the antibody genes, developed to combat one strain, adapted to a new infection, they continued to mutate, increasing their affinity for certain key targets present on both strains.

Half of the cross-reactive antibodies the team identified attached to the virus’ “stalk” region, a sort of biochemical drill-bit the virus uses to enter cells. Because this part of the virus doesn’t change as much as other regions, scientists have proposed to make it the basis for a vaccine that could provide broader protection.

Previously, this type of broadly protective, stalk-reactive antibody was thought to be very rare,” Wrammert said. “In contrast, in the patients we studied, these stalk-reactive antibodies were surprisingly abundant.”

The team tested whether three of their cross-reactive antibodies could protect mice against the 2009 strain or two other common lab strains. Two antibodies protected mice against an otherwise lethal dose of any of the three strains, even when the antibody was given 60 hours after infection.
One antibody, from the patient with the most severe illness, only protected against the 2009 H1N1 strain. The antibody genes from that patient suggest that the patient had a complete lack of preexisting immunity to H1N1 viruses. In cases where patients experienced a milder illness, it appears that immune cells that developed in response to previous seasonal flu shots or infections formed a foundation of response to 2009 H1N1 strain.

Although relatively few patients could be analyzed in detail at the antibody level, the authors concluded that “with the proper immunogen, the long-sought development of a pan-influenza vaccine might be possible.”

Next, the research team is planning to examine the immune responses of people who were vaccinated against the 2009 H1N1 strain but did not get sick to see if they also produce antibodies that protect against many influenza strains.

Funded by the National Institute of Allergy and Infectious Diseases, part of the National Institutes of Health, and by the American Recovery and Reinvestment Act of 2009, the research comes from a collaboration between the laboratories of Rafi Ahmed, director of the and Patrick Wilson, at the University of Chicago’s Knapp Center for Lupus and Immunology Research. Ahmed, Wrammert and Wilson, and Emory University and the University of Chicago, are entitled to royalties derived from the sale of products related to the research described in this paper. This study could affect their personal financial status.

Additional authors include Michael Morrissey, Nai-Ying Zheng, Jane-Hwei Lee, Min Huang, Zahida Ali, Kaval Kaur, and Sara Andrews from the University of Chicago; Dimitrios Koputsananos, Gui-Mei Li, Srilatha Edupuganti, Megan McCausland, Ionna Slountzou, Behzag Razavi. Carlos Del Rio, Rama Rao Amara, Youliang Wang, Mark Mulligan, Richard Compans, and Aneesh Mehta of Emory University; Mady Hornig and Ian Lipkin of Columbia University; Jinhua Sui and Wayne Marasco of Harvard Medical School; Suman Das, Christopher O’Donnell, Jon Yewdell and Kanta Subbarao of the National Institutes of Health.

Eight percent of the U.S. population has diabetes, but nearly six million people remain undiagnosed. According to the American Podiatric Medical Association (APMA), foot problems can help doctors discover diabetes. Diabetes can cause nerve damage in people’s feet, which can easily lead to amputation.

In the U.S., more than 60 percent of the patients who receive non-traumatic lower-limb amputations have diabetes. In 2004, almost 71,000 American diabetics needed amputations. Luckily, most diabetic amputations can be prevented through vigilant footcare.

”Diabetes can cause patients to lose sensation in their extremities, therefore a person with diabetes might not notice injuries to their feet until serious infection occurs,” said Ross Taubman, D.P.M., president of APMA. ”In most cases, patients can avoid amputation by working regularly with a podiatrist.”

Once diagnosed, patients with diabetes can prevent amputation by creating a footcare plan. Plans should include annual checkups with a podiatrist and daily foot inspections. Diagnosed diabetics need to be especially careful about footcare and should work with a podiatrist to determine the best preventative treatments.

Early diagnosis helps prevent severe nerve damage. For patients at risk for developing diabetes, foot conditions can be an early warning sign. According to the APMA, patients should see a podiatrist if they notice the following conditions:

• Calluses, blisters, or dry and cracked skin anywhere on the foot can imply poor circulation or foot health, especially if you don’t feel them or they take two or more weeks to heal.
• Look for thin, fragile, shiny or hairless skin, which can denote decreased circulation to the foot.
• Check shoes for torn linings or foreign objects. If they don’t irritate you when you walk, you might have nerve damage. Other warning signs include foot deformities like hammertoes, a past history of foot ulcers, or lower leg or thigh pain when walking.

For more information on preventing diabetes complications to the feet, visit the APMA’s website at www.apma.org.

The number of emergency rooms has been falling in recent years, as the number of people heading into the ER has been climbing.

Urgent care centers — doc-in-a-box outfits that handle urgent health problems that aren’t life-threatening — have been growing to take up some of the slack.

But, this morning’s WSJ notes, urgent care has remained largely unregulated. Urgent care doctors and nurses do have to be licensed the same as health care providers anywhere else, but there are no national standards for what urgent care centers should offer, or what quality measures they should meet.

That looks likely to change. The Urgent Care Association of America recently made a deal with the Joint Commission, the group that accredits the nation’s hospitals, to accredit urgent care centers and publish national quality standards by 2010.

While many insurers already pay for some urgent care services, accreditation could lead to better reimbursements. “We’d look far more favorably at an urgent-care clinic that was accredited than one that wasn’t,” Troy Brennan, chief medical officer at Aetna, tells the WSJ. “[I]t means an organization is taking a hard look at a variety of safety issues that should be involved in caring for someone who is acutely ill.”

Health-Care Costs Easing
Workplace wellness programs may be reining in rising costs, a survey finds.
From: Inc.com | August 13, 2008 By: Michael Gadd

Employer health-care costs are expected to rise at a slower pace in the year ahead, as more workplaces offer wellness programs and consumer-driven coverage options, according to Aon Consulting.

Based on a survey of more than 70 health-care insurers, the Chicago-based consulting firm estimates that that health-care costs will increase by 10.6 percent over the next 12 months, a 0.3 percent drop from last year and the lowest rate since the study was launched in 2001.

Rising prescription drug costs are also expected to ease, dropping by 0.3 percent for last year to 9.2 percent.

The study attributes the lower costs to an upturn in workplace wellness programs and consumer-driven coverage.

According to John Zern, the firm’s health and benefits director, employers could be doing more to combat rising health-care costs, in addition to wellness programs.

“This includes greater senior management support for these programs, better employee communications and more consistent cooperation from the medical community,” he said in a statement.

Talking Points: Making the Most Of Doctor Visits
October 31, 2007; Page D1

When her sister Kelly Rooney was battling breast cancer, Erin Dugery went along to doctors’ appointments to help make sense of the treatment options. But the medical jargon was often hard to understand, and she often felt she had forgotten important questions her sister needed answered. “On the drive to the appointment, you think of a million things you want to ask, but when you finally have the attention of the doctor it’s almost like getting stage fright,” says the Philadelphia mother of four.

Ms. Rooney died 15 months ago at age 43, but Ms. Dugery says she learned valuable lessons during her sister’s illness — such as writing down important questions beforehand and not being afraid to ask the doctor to explain things. Much of this advice came from an unusual source: “Doctor, Doctor, Lend Me Your Ear,” a one-woman skit the sisters saw performed in Florida by Ms. Rooney’s radiation oncologist, Marisa Weiss. Dr. Weiss, who strips off her white coat and clothes on stage to reveal a hospital gown, uses humorous examples from her own experience to convey lessons on how to talk to — and listen to — your doctor. (See video of Dr. Weiss’s speech)

Dr. Weiss, who has turned the lessons from the skit into a new book, is one of a growing number of medical professionals and health-care groups offering advice through books, Web sites, DVDs and even personal consultations to help patients navigate the modern doctor’s appointment.

Though medical information has never been more accessible to consumers, many patients still don’t have the skills to talk to their doctors and cram all the questions they have about their health into a brief visit. They often ignore what they don’t understand, or leave delicate but important issues to the end and then run out of time. So to help patients get answers, health-care officials are offering new discussion aids, providing sample questions patients can ask, and offering advice ranging from making a list of your drugs, to starting with the biggest questions first, to checking that a doctor has your lab results before going to an appointment.

Given the growing concern about patient safety and malpractice liability, doctors, too, are under pressure to help patients ask the right questions in the limited time they have. The Joint Commission, a nonprofit group that accredits health-care organizations, recently began requiring hospitals to show that they are encouraging patients to participate in care. For example, health-care providers should be encouraging patients to ask questions, and using educational materials to help them make decisions. A growing number of health-literacy programs urge physicians to speak more slowly, use plain language, and, when possible, show models or actual devices or even draw pictures.

A survey by the Boston-based nonprofit Foundation for Informed Medical Decision Making found that the majority of adults have big concerns about doctors not spending enough time to explain all treatment options. The foundation, whose work stems from research originally conducted at Dartmouth Medical School about unwarranted variations in health-care practice, is working with physician-practice groups around the country to test videos, books and pamphlets called Shared Decision-Making programs. Used at the Dartmouth-Hitchcock Medical Center in Lebanon, N.H., and provided through health plans with about 20 million members, the aim is to see how they work when provided directly to patients by primary-care offices.

“The doctors don’t have time to explain everything you ought to know, and they may not even be the best people to provide basic information and frame it for the patients,” says Floyd J. Fowler Jr., the foundation’s president.

The Shared Decision-Making materials, which are organized by illness, procedure and condition, present background information to help patients make medical decisions, including pros and cons of various treatment options, risks and long-term survival statistics. Patients can review the information in the doctor’s office before an appointment and take materials home to review with family members. Unlike a broad Internet search, Dr. Fowler notes, the decision aids synthesize the most important information for the specific decision a patient has to make, such as whether to get a colorectal cancer screening or go forward with back surgery, and how different treatment choices might affect their lifestyle or personal preferences.

Yvonne West, a 41-year-old nurse and mother of two teenage girls who was diagnosed with breast cancer, learned of the Shared Decision-Making aids because Pittsfield, Mass.-based Berkshire Health Systems, the hospital where she worked, is participating in a test of the programs. Shortly before her own diagnosis, her husband died of cancer after being treated with radiation, and she was concerned about undergoing such treatment herself. Using the decision aids, she reviewed the evidence for different options and the risks of recurrence before consulting with her doctor, ultimately choosing a unilateral mastectomy and reconstruction. The videos include real patients talking about their choices and why they made them.

“The videos got me thinking about the different options, and really helped me with the decision process,” says Ms. West.

Consumers without access to such decision aids can still find help in preparing for doctor visits on Web sites sponsored by disease advocacy groups, hospitals and the federal government. The American Heart Association (americanheart.org), for example, offers a list of questions that patients with high blood pressure and high cholesterol should ask, while the Boston-based Joslin Diabetes Center Web site (joslin.org) offers a list of questions that diabetics should ask doctors who are managing their disease, and explanations of why each question is important.

Researchers at the University of California, Los Angeles, say that as many as 40% of patients bring more than one concern to a doctor’s visit — and possibly as many as three or more. In a study published this month in the Journal of General Internal Medicine, they suggest that a slight change in bedside manner can make a difference in whether all of these issues get addressed: Patients who were asked at the end of a doctor’s visit whether there was “something else” that needed attention were much less likely to leave with unmet concerns than those who were asked whether there was “anything else” that needed attention.

According to the study, “any” tends to be used in a negative context, predisposing patients to respond negatively. With many doctor visits averaging 11 minutes, doctors clearly have to make every question count, lead study author John Heritage notes.

Delia Chiaramonte, a Baltimore-area physician, started a business called Insight Medical Consultants that helps patients find medical experts, make treatment decisions and communicate effectively with doctors. She notes that patients often save their most important or embarrassing question for last, then find the appointment is over with no time to address their most important concern. “There is often a tremendous miscommunication between doctors and patients on what the visit is really about,” says Dr. Chiaramonte. “If your No. 1 priority is talking about your erectile dysfunction, it’s best to start with that.”

It’s also critical when making doctor’s appointments to be clear on whether it is simply a check-up or you have a specific urgent complaint or problems with a chronic health issue. Doctors schedule their time differently for all three and should be prepared ahead of time. Dr. Chiaramonte suggests asking office staff what the best time is to schedule an appointment if you need more time to talk, such as whether later in the day or the first appointment is best.

Dr. Weiss — whose book is titled “Seven Minutes: How to Get the Most from Your Doctor Visit,” available for $10 through her nonprofit Web site, breastcancer.org — advises that patients prepare a full report of any symptoms or concerns prior to the doctor’s visit, as well as a complete list of current medications. If you are awaiting interpretation of test results from a lab, make sure before you arrive that the results have been sent and that the office staff have given them to the doctor.

She also advises bringing family members or a trusted friend, not only for moral support, but to act as another set of eyes and ears to listen to what the doctor is saying and to help organize questions. Since grasping the doctor’s words can be the hardest part of the visit, she also advises using a tape recorder, but first asking the doctor’s permission to do so.

Ms. Dugery, who started a Web site, Save2ndbase.com, to help raise money for a foundation in her sister’s name, says she now uses Dr. Weiss’s advice to advocate for herself and others in her extended family. “Even though your doctor may be the captain of the ship, you are the first mate,” says Ms. Dugery. “It’s really empowering to be able to find your own voice in your own care and in the care of your loved ones.”