By Lisa Brown
Sugarcane workers in northwestern Nicaragua experienced a decline in kidney function during the harvest, with field workers at greatest risk, suggesting that heat stress or other occupational factors may be playing a role in the high rates of chronic kidney disease in the region, a new study led by School of Public Health researchers shows.
The study, published online in the International Journal of Occupational and Environmental Health, is a step toward identifying factors contributing to an unexplained epidemic of chronic kidney disease (CKD) in Central America that disproportionately affects young, male agricultural workers.
BU researchers have been working since 2009 to uncover the causes of the epidemic, which has claimed the lives of at least 20,000 people in Central America in the last two decades. The illness is not related to diabetes or hypertension—the most common drivers of kidney disease in the United States.
The research team recruited 284 Nicaraguan sugarcane workers performing seven different tasks. They measured urine albumin and serum creatinine and estimated glomerular filtration rate—markers of kidney function—both before and towards the end of the harvest season. Workers were queried on the quantity of water and electrolyte solution packets they consumed during a typical workday. The mean age of the workers was 33.6; most were men.
The researchers found that kidney function declined during the six-month harvest season and varied by job category, and that workers with longer employment duration had worse kidney function. Over the harvest season, the decline in kidney function was greatest among seed cutters, irrigators, and cane cutters—jobs that require strenuous labor in a hot and humid environment. The results provide evidence that one or more risk factors for the disease are occupational, the authors said.
The research team said that inadequate hydration also might play a role. While there was no effect of water or electrolyte solution consumption on kidney function among all workers, the study did find a protective effect of electrolyte solution consumption among the cane cutters—workers who have the heaviest workload.
The results are “consistent with the hypothesis that heat stress and dehydration may play a role in (kidney disease),” the researchers said. They said further study is needed to directly measure workers’ exposures to heat and dehydration, rather than using job categories as a surrogate exposure measure.
The study did not find support for the hypothesis that agricultural chemicals are a causal agent for kidney disease. Instead, among field workers, agrichemical applicators, who have the most direct contact with chemicals, were found to experience the smallest decline in kidney function.
Still, the authors said, “Agrichemicals are used extensively in the region and widely believed among community members as the cause of the epidemic.” They noted that in September 2013, El Salvador’s National Assembly voted to ban 53 agrichemicals due to the perceived link to CKD.
“Agrichemicals, therefore, remain an important hypothesis and warrant further study,” the researchers wrote.
The research team is now planning a new study to quantify exposure to heat and agrichemicals among manual laborers, including sugarcane workers, in Central America, and to determine whether those exposures are associated with kidney injury.
Authors on the study from SPH included: Rebecca Laws, a doctoral student in environmental health; Madeleine Scammell and Michael McClean, associate professors of environmental health; and Daniel Brooks, associate professor of epidemiology. Researchers from Tufts Medical Center, VA New York Harbor Healthcare System and Department of Medicine, Universidad Autónoma de Madrid, and Yale University contributed.
Funding for the study was provided by the Compliance Advisor/Ombudsman (CAO) of the World Bank Group and the Comite Nacional de Productores de Azucar. The CAO managed all funds and maintained the contract to conduct the research.
Submitted by Lisa Chedekel
Research Associate Professor in the Department of General Dentistry Dr. Sok-Ja Janket and Group Practice Leader and Assistant Professor in the Departments of General Dentistry and Periodontology Dr. Eleni Kanasi contributed a chapter to a new book titled, Infection and Autoimmunity, 2nd Edition, which was published by Elsevier in January 2015.
Their chapter titled, “Oral Infections and Autoimmune Diseases,” discusses the potential causal role oral infections may play in triggering the pathogenesis of autoimmune diseases. Highly associated with genetics and oral infections, autoimmune diseases may be involved in the pathogenic mechanism in genetically susceptible individuals. Many autoimmune diseases manifest in the oral cavity, and while dentists are familiar with identifying and managing the symptoms, looking at the oral infection as the causative factor is a new concept. The chapter was co-authored by Dr. Alison Baird, a professor at the SUNY Downstate Medical Center. Dr. Baird is a neurologist and longtime collaborator with Dr. Janket.
The pathogenesis of autoimmune diseases involves the development of naïve T-cells into Th17 cells and leads to disease with the help of the multiple transcription factors and cytokines also expressed in oral infections. The chapter describes the molecular biology of oral infections in the framework of autoimmune pathogenesis and provides evidence of a causal relationship between oral infections and various autoimmune diseases including atherosclerosis, rheumatoid arthritis, systemic lupus erythematosus, multiple sclerosis, antiphospholipid syndrome, Sjögren’s syndrome, and Crohn’s disease.
Dr. Janket was invited to write this chapter by the president of the Congress, Dr. Yehuda Shoenfeld, at the 9th International Congress on Autoimmunity last spring, after giving a well-received presentation on how salivary immunoglobulin can predict autoimmune diseases such as type 1 Diabetes. Animal modeling is a major component of the research to elucidate the pathogenesis of complex disease like autoimmune diseases, and Dr. Janket’s expertise as an epidemiologist is essential in order to translate the results from animal and in vitro studies for human populations.
Drs. Janket and Kanasi are thrilled to have their work published in such a highly regarded textbook on the interactions between infectious agents and autoimmunity. “It is great honor to be included in this textbook with so many accomplished colleagues.” said Dr. Janket.
If you are interested in picking up a copy of the book, contact Dr. Sok-Ja Janket at firstname.lastname@example.org
Provided by GSDM Communications office.
Boston University School of Medicine has developed an affiliation with Northern California Kaiser Permanente to offer two new clinical clerkship sites for our third-year medical students.
Beginning in May 2015, 12 third-year students will begin their clerkships at Kaiser Permanente Medical Centers in San Jose and Santa Clara. After an orientation with their classmates in Boston, six will stay for a full year, while six will stay for six months. Students will rotate in family medicine, OB/GYN, internal medicine, psychiatry and neurology at the San Jose site and in pediatrics, surgery, radiology and psychiatry at the Santa Clara site. Although this program is new for BU, Kaiser has a strong and well-established medical education framework that includes students from Stanford, UC-San Francisco, UC-Davis and Drexel.
In addition to an excellent clinical experience, the Kaiser Campus Third-Year Curriculum Program will expose students to Kaiser’s healthcare technology, preventive medicine and progressive healthcare delivery model. Students will participate in quality improvement training programs, master their electronic health system, and develop their own quality improvement projects.
Kaiser has revolutionized health care and health-care technology, providing more immediate and responsive patient care. A leader in patient safety and quality improvement, the Kaiser system has been the model for the future of medicine. Their focus on preventive care and an outpatient-centered care model reduces hospital admissions and testing.
“We are delighted to offer our students the opportunity to work in another innovative and evidenced-based system that is committed to high-value, high-quality medical care,” said Karen Antman, MD, BUSM dean and provost of the BU Medical Campus.
Despite the distance from Boston campus, students will receive uniform didactic instruction. Program Manager Monica Parker-James is coordinating the online educational experiences. Recorded lectures can be reviewed at the student’s convenience. The students also will be able to participate in live small-group discussions and case vignettes with Microsoft Lync access.
Microsoft Lync is a platform for unified communications including online meetings, instant messaging, audio and video calls, availability info and sharing capabilities.
Dr. Harley Goldberg, who has a long history of service in the Kaiser system and is involved in quality evaluations at San Jose, will coordinate the training and supervision of our students in California. He will work with students via video conferencing prior to June and will orient and mentor the students during their time in the Kaiser facilities. He has worked closely with the BUSM Kaiser Committee and clerkship directors to provide a seamless transition for the students.
Assistant Dean Paige Curran in the Office of Student Affairs will monitor student mental and physical health and support academic and career development through online communication and quarterly visits to California.
The BUSM students will have faculty support while in California and many will also be close to family and friends. In addition, we are planning a California BUSM alumni network for additional student support, mentoring and career development. Several alumni have already expressed interest, including Veronica Santini, BUSM class of 2000, an assistant professor of neurology at Stanford.
“We are impressed by how vested our counterparts in California are in making this a successful partnership,” said Anna Hohler, MD, assistant dean of academic affairs at BUSM. “This collaboration is a win-win. Kaiser will work with students who are smart, dedicated and professional. Our students will train in a leading health care system that shares our commitment to high-quality medical education, devotion to diverse patient populations and a vision for excellence in health care. We are thrilled to be able to offer this opportunity to our students.”
Researchers from Boston University’s Slone Epidemiology Center have developed a breast cancer risk prediction model for African- American women that found greater accuracy in predicting risk for the disease. The use of this model could result in increased eligibility of African Americans in breast cancer prevention trials.
The effectiveness of breast cancer prevention and early detection strategies depends in part on the ability to accurately identify individuals at increased risk of the disease. Models for predicting absolute risk of breast cancer have been used for chemoprevention decision-making and for determining eligibility for recruitment into prevention trials. The well-respected Gail Model has been used widely for breast cancer risk prediction in white women but has been shown to underestimate risk in African-American women. Underestimation of risk for African-American women has contributed to their underrepresentation in breast cancer prevention trials.
Researchers used prospective data from 55,000 African-American women age 30-69 at baseline in the Boston University Black Women’s Health Study to develop a breast cancer risk prediction model specifically for African-American women. It included family history of breast cancer, history of benign breast disease, age at menarche, age at first birth, bilateral oophorectomy, oral contraceptive use, hormone use, body mass index at age 18 and adult height.
“The model was well calibrated in that it predicted 486 cases in comparison to an observed 506 cases during the additional five years of follow-up,” explained senior author Julie Palmer, senior epidemiologist at Boston University’s Slone Epidemiology Center and professor of epidemiology at Boston University School of Public Health. “Based on the Black Women’s Health Study model, 14.6 percent of women age 30-69 were predicted to have a five-year risk of at least 1.66 percent. This is considerably higher than the proportion predicted by previous models to be above that end point,” said Palmer.
According to the researchers previous breast cancer risk prediction models for African-American women have used information on only a few factors and may have underestimated risk. “The new model appears to improve prediction and, if used for determining eligibility for entry into prevention trials, would likely result in a greater number of African-American women invited to enroll in the trials,” she added.
Funding for this study was provided by the Susan G. Komen for the Cure Foundation and the National Cancer Institute.
Jan. 26 Exploring the Role of Social and Cultural Determinants Influencing Latino HIV and Substance Abuse Health Disparities
BU Medical Campus faculty, residents and PhD students are invited to a colloquium sponsored by the BU School of Social Work. Join Mario De La Rosa, PhD, Professor at Florida International University, Miami as he discusses “Exploring the Role of Social and Cultural Determinants Influencing Latino HIV and Substance Abuse Health Disparities” on Monday, Jan. 26 at 10:45 a.m. Dr. De La Rosa is a candidate for the inaugural Director of the Center for Innovation in Social Work and Health. A luncheon will immediately follow the colloquium, RSVP required by Jan. 22 to email@example.com
- “Exploring the Role of Social and Cultural Determinants Influencing Latino HIV and Substance Abuse Health Disparities”
- Mario De La Rosa, PhD, Professor at Florida International University, Miami
- Colloquium: Monday, Jan. 26, 10:45 a.m.
- Hiebert Lounge, BUSM Instructional Building
- Luncheon following colloquium, RSVP required by Jan. 22, firstname.lastname@example.org
Making the Case-The Added Values of Social Work in Health Care and Service Delivery, Jan 12 Colloquium
BUMC faculty and PhD students are invited to attend a colloquium presented by Darrel Wheeler, PhD, MSW, MPH, Dean and Professor at Loyola University, Chicago. Dr. Wheeler is a candidate for the inaugural Director of the Center for Innovation in Social Work and Health and he will speak on “Making the Case-The Added Values of Social Work in Health Care & Service Delivery.”
- Monday, Jan. 12
- Colloquium: 10:45 a.m.-noon
- Lunch: noon- 1 p.m
- Hiebert Lounge, BUSM Instructional Building
BUMC Faculty and PhD students, RSVP to Patty Frasso by Thursday, Jan. 8 email@example.com
Jan. 22 Celebrate the Legacy of Martin Luther King, Jr., ” The Enduring Legacy and Lessons of MLK: From Birmingham to Ferguson”
All members of the BU Medical Campus are invited to a special presentation commemorating the legacy of Rev. Martin Luther King, Jr.
Kermit A. Crawford, PhD is a forensic psychologist and associate professor of Psychiatry at BU School of Medicine. He is the Executive Director of the Massachusetts Marathon Bombing Victims/Survivors Resiliency Center and the Director of the Center for Multicultural Mental Health, providing leadership across the nation in the aftermath of disasters, ranging from Sept. 11, 2001, to the Boston Marathon bombings.
Crawford has been honored with a doctorate from Boston College, as well as a doctoral degree of humane letters from the Massachusetts School of Professional Psychology. He has a variety of peer-reviewed publications and book chapters, and is the recipient of the Commissioner’s Excellence Award, the 2012 Excellence in Diversity Training Award from APPIC, the 2012 American Psychological Association’s Minority Fellowship Program James Jones Lifetime Achievement Award and the 2014 Culturally and Linguistically Appropriate Services Individual Award. He also has made presentations on culturally competent practices in mental health at several acclaimed national organizations.
Following Dr. Crawford’s presentation, a musical performance sponsored by the Boston University Medical Campus Arts Program, will feature BMC patient Joseph Payne (vocals) and Moisès Fernández Via (piano).
Celebrate the Legacy of Martin Luther King, Jr.
- Speaker: Kermit A. Crawford, PhD
- Topic: The Enduring Legacy and Lessons of MLK: From Birmingham to Ferguson
- Date: Thursday, Jan. 22
- Time: 12:30-1:30 p.m.
- Location: Keefer Auditorium
This event is brought to you by BUSM Office of Diversity and Multicultural Affairs in collaboration with BU Goldman School of Dental Medicine Office of Diversity, BU School of Public Health, BMC Human Resources Department and the BMC Minority Recruitment Program.
A Forum on the US Senate’s Committee Study of the CIA Interrogation Program
The release of the Senate’s Report on CIA Post-9/11 Interrogation Methods and Results has created wide-ranging debate on the use of torture, the results of torture (both in terms of intelligence obtained and harm done to the prisoners), and the role of physicians, psychologists and health care providers in the CIA’s torture and interrogation programs. Panelists will address these issues, national and international law on torture, the relevance of the Nuremberg Principles, applicable medical ethics standards regarding the physician’s role in torture and prison medicine, and what health and medical-related obligations, if any, the US owes.
Panelists: Sondra Crosby, MD, Michael Grodin, MD, George Annas, JD
Moderator: Leonard Glantz, JD
When: Tuesday, Dec. 16, 4-5 p.m.
Where: Bakst Auditorium
Sponsored by the Department of Health Law, Bioethics & Human Rights, BU School of Public Health and Global Lawyers & Physicians.
Med schools would remain separate, safety-net hospital would stay in place
Boston Medical Center, Boston’s “safety-net hospital” and the primary teaching hospital for the BU School of Medicine, is discussing a strategic partnership, including a potential merger, with Tufts Medical Center, the primary teaching hospital for Tufts University Medical and Dental Schools.
Karen Antman, dean of the School of Medicine and provost of the Medical Campus, stressed that any partnership or merger would not include the medical schools, which are parts of their respective universities.
Robert A. Brown, president of Boston University, says it is imperative that any partnership or merger maintain Boston Medical Center (BMC) as a premier academic medical center and as a safety-net hospital, fulfilling the hospital’s mission to provide exceptional care to the city’s vulnerable populations, regardless of insurance status or ability to pay. “BMC is a superb academic medical center and the city’s most important safety-net hospital,” Brown says. “If a partnership or merger can ensure that BMC continues to play both these roles in a stronger, sustainable way in the future, it is worth pursuing.”
Kate Walsh, president and CEO of Boston Medical Center, echoed Brown’s commitment to continuing to provide first-rate medical care for all. Walsh says conversations to date suggest that a strategic partnership may strengthen the missions of both medical centers and that “an affiliation that secures a long, bright future of continuing to provide exceptional care without exception would be of great interest to us.”
She says a partnership with Tufts Medical Center could have great potential benefits, including new options to serve patients, greater financial resources, and a larger referral network to attract new patients and better payments from insurers.
“Tufts Medical Center is our neighbor,” says Walsh. “We know them, we respect them, we share a common geography and a commitment to providing high-quality care to all patients. We also share a mutual commitment to our academic missions of teaching and research.”
Over the last 20 years, changes in health care models have made hospital partnerships and mergers a virtual requirement for a sustainable health care business, particularly in the Boston area. In 1994, Massachusetts General and Brigham and Women’s teaching hospitals teamed up to form Partners Health Care, which has since brought in several community hospitals around Boston. In a rival venture, Steward Health Care has, in the past few years, taken over 10 community hospitals as well at St. Elizabeth’s and Carney hospitals. Earlier this year, Beth Israel Deaconess Medical Center took control of Jordan Hospital in Plymouth and formed a joint venture with New England Baptist Hospital. Antman says many observers of Boston’s crowded health care arena consider a merger involving Boston Medical Center to be long overdue.
Similarly, changes in health care payments combined with cuts in research funding have hit academic medical centers particularly hard. An alliance between Tufts and BMC could produce efficiencies of scale, Antman says.
Walsh cautioned that while the two medical centers have much in common, “there is more work we need to do before we will know whether a partnership is the best option for our employees, and most importantly, our patients.”
A combination of the two medical centers could result in significant change for clinical faculty at both schools of medicine. Boston Medical Center currently has 724 physicians, including the clinical faculty at the BU School of Medicine, and Tufts Medical Center employs 500. BMC officials say any partnership involving the two hospitals would take years to accomplish, and that the medical center would continue to offer a full range of services.
“We do not underestimate the anxiety that this will create among our clinical faculty,” Brown says. “We also understand that the hospitals, and not the universities, control the outcome of any discussion. We will do all we can to provide support and advocacy on behalf of our clinical faculty during what will be a period of uncertainty.”
If the two hospitals merge, the two medical schools would remain separate, each with its own faculty, curriculum, and rotations, called clerkships. The merger would have no impact on the number of students enrolled at the BU Medical School or on the size of the medical sciences faculty who teach at the school. However, the consolidation may result in fewer hospital beds, which might reduce the number of clerkships and residency slots available to BU and Tufts Medical students in the consolidated hospital. Currently, 45 percent of BU medical students do their clerkships at BMC while 35 percent of Tufts medical students do theirs at Tufts Medical Center.
Antman says she does not foresee a shortage of clerkship opportunities for BU medical students. “We are affiliated with 20 other hospitals in the area,” she says, “and we have a program in place to identify even more clerkship and residency opportunities in Boston, and around the country.”
With more than 870,000 patient visits last year and more than 4,500 full-time staff, Boston Medical Center is the largest safety-net hospital in New England. Approximately 70 percent of BMC patient visits come from come from people who rely on government payers such as Medicaid, the Health Safety Net, and Medicare for their coverage.
Boston Medical Center struggled with changes to the health care business for years and only recently, under the leadership of CEO Kate Walsh, has it approached financial stability. In 2012, the hospital reversed three years of losses and posted a small but meaningful financial gain. At the same time, Moody’s Investor Service and Standard & Poor’s bumped up their ratings of the hospital from negative to stable.
“Kate Walsh’s excellent track record as our hospital leader gives us added assurance that any change is likely to be in the best interests of the hospital, the underserved, and those medical students and clinical faculty associated with the facility in the future,” Brown says.
Antman says she sees hope in successful mergers such as the 1998 partnership of New York Hospital and the Presbyterian Hospital, which created the 2,500-bed New York Presbyterian Hospital. That hospital, which has two distinct medical centers, Columbia University Medical Center and Weill Cornell Medical Center, serves as the primary teaching hospital for Columbia University’s College of Physicians and Surgeons and the Weill Cornell Medical College.
“In these initial discussions we are all looking forward to finding a new way to educate medical students in Massachusetts,” says Antman. “There is no reason we can’t work with our partners to create a better educational experience for our students.”
This BU Today story was written by Art Jahnke.
The BU Advocacy Training Program presents December Advocacy Grand Rounds, Leadership in Healthcare: A Conversation with Former Governor Michael Dukakis.
Governor Dukakis, Massachusetts’ longest serving governor and former Democratic Presidential candidate, has lectured extensively on healthcare policy and reform. Come hear about the changing landscape of healthcare in the US.
Where: BUSM Instructional Building, L-303
When: Thursday, Dec. 4, 5-6 p.m.
Dinner will be served. Sponsored by the BUSM Alumni Association