Health Sciences Report (1996)

Health Sciences Report Winter 1996 FROM THE EDITOR One of the more pleasant experiences of moving- which seem few when you're overwhelmed by packing boxes, stacks of furniture and decisions- is discovering where the previous homeowners planted spring flowers. You may suspect bulbs are buried here or there, but until the crocus leaves vault over the last remaining crust of snow, you're never sure. Similarly, if we can't see a cause of discomfort in people who seem always to be in pain, we may be uncertain whether to believe them. It's often not any easier for physi-cians. Alleviating pain is, of course, at the root of medicine. Every patient experiences pain at some time; every physician treats pain. But when the source of an individual's pain isn't visible- a surgical scar, swollen red throat or bleeding cut- the diagnosis can be difficult. If the pain has persisted for months, even years, disabling the patient to the point where he or she suffers not only loss of movement, but also finances, work, even identity, it can be much more difficult. Understanding chronic nonmalignant pain is much like seeing the blossom from a bulb, according to behavioral theories of learned pain. We see " pain behaviors"- the grimace, the awkward gait- and the " suffering," the outward expression of the emotional component of pain, both of which cause a person's disability. But we don't see the interplay of what the patient perceives as pain and the individual's past experiences with it. All of these layers of pain are explored in pain management treatment. This issue's cover story details the range of programs offered by the University health sciences center to treat chronic nonmalignant pain. The Headache Clinic and the Women's Pelvic Pain Center, each unique in their medical specialty, draw patients from through-out the Intermountain West. As part of the Spine Rehab Center, the Chronic Pain Rehab Program specializes in managing neck and back pain. The Pain Management Center provides care for adults and children who suffer pain related to a wide range of medical conditions, including an intensive day treatment program for those with chronic nonmalignant pain. Pain control is integral to much of the care provided by professionals at the health sciences center. Pharmacists, nurses and therapists help patients and their families learn healthier ways to deal with pain. So when the crocus and daffodils herald spring, we not only can see the possibilities of new beginnings, but also feel like moving forward to welcome them, r Susan Sample 1 9 9 6 Headlines. People. Features HEALTH SCIENCES REPORT UNIVERSITY OF UTAH Vol. 20, No. 1 Published by the Office of Public Affairs, University of Utah Health Sciences Center, 50 North Medical Drive, Salt Lake City, Utah 84132. Telephone ( 801) 581- 7387. Health Sciences Report is mailed to faculty, staff, alumni and friends of the University of Utah School of Medicine; to the staffs of University Hospitals & Clinics, and Spencer S. Eccles Health Sciences Library; and to the faculties of the colleges of Pharmacy, Nursing and Health. Articles may be reprinted with permission. Editor: Susan Sample Editorial Consultant: Anne Brillinger Contributing Writer: M a r y Chachas Photographer: Brad Nelson, Medical Illustration Service This issue o/ Health Sciences Report is printed on recycled paper as part of a major recycling campaign at the University of Utah Health Sciences Center. & Super Bugs The overuse of some " miracle" antibiotics actually helps bacteria survive and become drug- resistant. Up the Down Staircase At the U pain management programs, patients learn how to avoid the downward spiral of chronic nonmalignant pain. Lending a Helping Hand Faculty, staff and students reach out to the community in a variety of service projects featured in this photo essay. From the Bookshelf Looking for a new book to read? Check " The No- guilt, Unlimited- time Reading List" compiled by six health sciences faculty and staff. Research in Brief. Gift of Health Contributions fund cancer research, endowed chairs, a student scholarship and genetic studies. Opinion Politicians debate whether to fund basic or clinical research, but it's an artificial dichotomy, according to one medical school faculty member. HEADLINES Walter Stevens, Ph. D. STEVENS TO RESIGN AS MEDICAL DEAN • M i alter Stevens, Ph. D., dean of the Utah School of Medicine, announced last January that he will return to full- time teaching and research in the Department of Neurobiology and Anatomy. His resignation is effective July 1, although Stevens will continue to administer medical school affairs until a national search for a new dean is completed. For more than 15 years, Stevens has held top leadership posts at the health sciences center. He was named dean in February 1993, but served twice as interim dean from 1988- 91 and from January- February 1993. He was associate dean for research in the medical school from 1981- 93 and acting vice president for health sciences from 1991- 92. A member of the Department of Neurobiology and Anatomy faculty since 1962, Stevens holds two degrees from the U of U: a doctorate in anatomy, with a minor in radiobiology, and a bachelor's degree in experimental biology. He also serves as research professor of pharmacology and as chair of the Dean's Research Advisory Committee. The Salt Lake City native has had a prolific research career, recently focused in neuroendocrinology. He is well known nationally as principal investigator on a 10- year, $ 7 million study sponsored by the National Cancer Institute to determine if fallout from nuclear testing in Nevada during the 1950s was a causal factor in the incidence of leukemia and thyroid cancer among residents of southwest Utah who lived downwind of the test site. Stevens served as a member and chair of the health sciences center's Institutional Review Board, deputy director of the Utah Regional Cancer Center and the Clinical Research Center Advisory Council. Among his numerous professional affiliations are the Endocrine Society, American Association of Anatomists, Society for Neuroscience, International Society of Psychoneuroendocrinology and Radiation Research Society. Stevens was honored by the U School of Medicine Alumni Association in 1993 for his distinguished service to the medical school, h Lucy M. Osborn, M. D., M. S. P. H. OSBORN TO RETURN TO FACULTY POST Lucy M. Osborn, M. D., M. S. P. H., will resign as associate vice president for health sciences for clinical programs in August to return full time to her medical school faculty responsibilities. As professor of pediatrics, Osborn will devote two- thirds of her time to health services research and training, and continued mentoring of young faculty in the Division of General Pediatrics; the remainder will be spent in pediatric clinical care. She also will continue as adjunct professor in the Department of Family and Preventive Medicine. Osborn became associate vice president for health sciences for clinical programs July 1,1993. She continued to serve as principal investigator on two grants: primary care residency training, the first program in the nation in which residents spend a significant part of all three years in a private practice setting; and faculty development in general pediatrics. In 1994, Osborn was selected to participate in the " Scholars in Academic Administration and Health Policy" program, funded by The Pew Charitable Trusts. Osborn received her undergraduate degree from Stanford, her medical degree from Northwestern University School of Medicine and an M. S. P. H. from the U of U. In 1974, she completed a pediatric residency at the U and, from 1978- 80, had a Robert Wood Johnson Faculty Development Fellowship in the U Health Sciences Report Winter 1996 Department of Family and Preventive Medicine. After serving three years on the pediatrics faculty at the University of California/ Los Angeles Center for the Health Sciences, she joined the Utah medical school faculty in 1983. She was acting co- chair of the Department of Pediatrics in 1991 and vice- chair from 1989- 93. b SANDE TO HEAD INTERNAL MEDICINE Merle A. Sande, M. D., will be the new chair of the Department of Internal Medicine at the School of Medicine, it was announced as Health Sciences Report went to press. He will join the faculty in late spring or early summer, pending approval by the University's Board of Trustees. An infectious diseases specialist, Sande has been professor and vice-chair of internal medicine at the University of California- San Francisco School of Medicine, and chief of med-ical services at San Francisco General Hospital since 1980. e HUNTSMAN INSTITUTE NAMES ONCOLOGIST TO CLINICAL CARE oseph Simone, M. D., physician- J in- chief and CEO of Memorial Sloan- Kettering Cancer Hospital in New York City, was appointed director of clinical care at the Huntsman Cancer Institute at the University of Utah. " Dr. Simone has a tremendous inter-national reputation," noted Raymond L. White, Ph. D., executive director of the Huntsman Cancer Institute. " He is especially well known for building teams of health professionals in clinical practice that can effectively take advantage of research programs, such as those underway at the Huntsman Cancer Institute." Simone, who also will serve as executive director of the Huntsman Cancer Care Program, plans to invite oncologists who practice in the com-munity as well as at the U to establish a collaborative network throughout the Intermountain West that would pro-vide new diagnostics and treatments to cancer patients and their physicians. Simone and his wife, Patricia, will move to Salt Lake City in late spring. The Huntsman Cancer Institute was launched in 1993 with an initial gift of $ 10 million to the University from the family of Jon M. Huntsman, chairman of the board and chief execu-tive officer of the Huntsman group of companies, which include Huntsman Chemical Corporation and Huntsman Corporation. The Huntsmans increased their pledge to $ 100 million last fall. ( See story on page 28.) E CLARK TO CHAIR PEDIATRICS DEPARTMENT Edward B. Clark, M. D., a pediatric cardiologist at the University of Rochester School of Medicine and Dentistry, will assume responsibilities as chair of the Department of Pediatrics at the Utah School of Medicine in July. Clark, professor and chief of the Rochester Division of Pediatric Cardiology since 1987, was named to the Utah position last November. He also will serve as medical director of Primary Children's Medical Center in Salt Lake City. Clark pioneered techniques used to measure the functional characteristics of the developing cardiovascular system. He has published extensively in this area for 15 years and partici-pated in international conferences and research collaborations with investiga-tors in Iowa, Japan, Switzerland, The Netherlands and Russia. He heads a research team of 32 investigators in a five- year, $ 6.7 million study on the biomechanics of the devel-oping cardiovascular system, funded by the National Heart, Lung and Blood Institute of the National Institutes of Health. He also is co- principal investi-gator on a family study of congenital cardiovascular malformations. Clark received his medical degree from Albany Medical College in New York. His postgraduate education included an internship in internal medicine at Dartmouth/ Hitchcock, a Edward B. Clark, M. D. pediatrics residency and fellowship in pediatric cardiology at Johns Hopkins Hospital, and a senior residency in pediatrics at the University of Nebraska Medical Center. Board certified in pediatrics and pediatric cardiology, Clark has been a faculty member at the universities of Nebraska, Iowa, Rochester and Johns Hopkins. He is the U. S. represen-tative to the International Federation of Cardiology, Pediatric Cardiology Section. He also has served on committees of the American Academy of Pediatrics and the American College of Cardiology. He is past chair of the Council on Cardiovascular Disease in the Young, American Heart Association ( AHA). He served a five- year term as program chair for that group and initiated the AHA Task Force on Children and Youth. Author of many articles, abstracts and editorials in professional journals, Clark also has written chapters on cardiovascular development in leading textbooks. With his wife, Carleen Clark, a pediatric public health nurse, and Catherine A. Neill, he is co- author of the family reference book, The Heart of a Child, e Health Sciences Report Winter 1996 Michael K. Magill, M. D. MAGILL HEADS FAMILY MEDICINE Michael K. Magill, M. D., was named chair of the Department of Family and Preventive Medicine at the School of Medicine last fall. Magill, professor of family and community medicine, joined the Utah faculty in 1994. He also is director of the Utah Area Health Education Centers Program ( Utah AHEC), designed to improve health- care access in rural areas and underserved urban areas by providing educational support to health- care providers working in these areas. Before coming to the U, Magill was senior vice president for medical edu-cation and outreach at the Tallahassee Memorial Regional Medical Center in Tallahassee, Florida, where he also directed the family practice residency program for seven years. He taught students from the University of Florida College of Medicine and Florida State University. A diplomate of the American Board of Family Practice since 1981, Magill received his undergraduate degree from Dartmouth College, graduating suvima cum laude in psychology. He received his medical degree from Duke University, E HUMAN GENOME CENTER CELEBRATES 5 YEARS Anew probe chamber- an instrument invented, constructed and operated by the Utah Center for Human Genome Research- was featured last January at a celebration marking the fifth anniver-sary of the Human Genome Project. Special guests at the event, who also were featured at a scientific symposium, included Francis Collins, M. D., Ph. D., director of the National Center for Human Genome Research, National Institutes of Health ( NIH), and Gerald Rubin, Ph. D., John D. MacArthur Professor of Genetics at the University of California at Berkeley. Collins also was the featured speaker at a luncheon where he discussed genome science and the future of medicine. The Utah Genome Center was established in 1990, bringing together 40 molecular biologists, engineers and computer scientists to build an auto-mated sequencing system. One of the goals of the National Human Genome Project has been to develop efficient, inexpensive instruments for large- scale sequencing. The probe chamber is the core technology of Utah's automated sequencing system. Nylon membranes are used to process complex patterns of mixed samples and perform serial rounds of probing, scanning and read-ing to produce individual sequences. The national project is an ambitious effort to map and sequence all 3 billion DNA nucleotides contained in the human genome by the year 2005. The completed sequence will provide an encyclopedia of information that will reveal the hereditary instructions to make humans and will point to the differences that make each individual unique. The completed code will pin-point the location of 100,000 human genes and uncover new information about the evolution and biological functions of organisms. To accomplish this task, the NIH and the U. S. Depart-ment of Energy support genome research at 22 centers nationwide, E MEDICAL SCHOOL NAMES TWO NEW ASSISTANT DEANS oversees issues espe-cially relevant to Idahoans admitted to the Utah med-ical school. Utah and Idaho have a long- standing agreement regarding admission to the U medical school; six Idaho resi-dents are admitted each year. Some 148 physicians in Idaho are U of U graduates. Hale grew up in Idaho, graduating from high school in Idaho Falls, where he later practiced medicine for six years. He received both his bachelor's and medical degrees from theUofU. An infectious diseases specialist, Hale also is associate professor of pathology. He is medical director of the internal medicine clinic at the University's Wasatch Clinics. Judd, associate professor of pediatrics, is assistant dean for admis-sions. She served on the medical school admissions committee last year and, in her new position, supervises the admissions office staff and oversees all aspects of the admissions process. The School of Medicine received more than 1,400 applications for the 1995- 96 academic year and admits 100 students every year. A native of Salt Lake City, Judd has been on the U faculty since 1987. Prior to that, she was an assistant pro-fessor of pediatrics at Baylor College of Medicine, where she fulfilled her residency. She completed a fellowship in pediatric cardiology at Texas Chil-dren's Hospital and was a fellow in DeVon C. Hale, M. D., and Victoria E. Judd, M. D., were appointed assis-tant deans in the School of Medicine last September. Hale, professor of internal medicine, is assistant dean for Idaho affairs, a new position in which he DeVon C. Hale, M. D. 4 Health Sciences Report Winter 1996 Victoria E. judd, M. D. electrophysiology in the U Division of Cardiology. She received both her bach-elor's and medical degrees from the U. Judd, who is medical director of pediatric electrocardiology at Primary Children's Medical Center, practices at LDS Hospital and Utah Valley Medical Center in addition to University Hospital, c DUNN HEADS HEALTH COLLEGE ; ohn M. Dunn, Ed. D., began work J as dean of the College of Health last October, replacing Geary A. McCandless, Ph. D., interim dean. Dunn is a nationally recognized expert in physical education and recre-ation for individuals with disabilities. He came to Utah from Oregon State University ( OSU), where he held numerous administrative posts, most recently serving as associate provost for academic affairs. He also was assistant dean of research and graduate studies in the Oregon College of Health and Human Performance, and director of the OSU Special Physical and Motor Fitness Clinic. Dunn joined the Oregon faculty in 1975, after earning his doctorate at Brigham Young University in 1972. He served three years on the physical education faculty at the University of Connecticut, Storrs. He received his bachelor's and master's degrees from Northern Illinois University, DeKalb. Dunn has served in leadership capacities in numerous state and national organizations, including the American Alliance for Health, Physical Education, Recreation and Dance U RESEARCHERS REPORT MAJOR GENETIC FINDINGS University researchers identified the third and most common gene in a group that causes the hereditary disorder long QT syndrome, reported in the January issue of Nature Genetics. That same month, University investigators reported in The Journal of Clinical Investigation that they had located a gene that causes an inherited form of dilated cardiomyopathy, a disease of the heart muscle. Last October, another group of U of U researchers located the gene that causes a rare disease, ulnar- mammary syndrome, in which babies are born with missing or stiff fingers and malformed arms. This finding was published in Human Molecular Genetics. Mark T. Keating, M. D., an investi-gator at the Howard Hughes Medical Institute at the Eccles Institute of Human Genetics at the U, led the research group that identified the third gene, KVLQTI, involved in long QT syndrome. Although relatively rare, the syndrome results in sudden death, often in young individuals, according to Keating, U associate professor of human genetics at the School of Medicine. The disorder causes episodes of arrhythmia, which kill about 300,000 Americans each year. For patients known to have the hereditary long QT syndrome, this dis-covery, coupled with previous findings, will provide an immediate definitive diagnostic test for their offspring. The finding also will lead to the develop-ment of routine diagnostic tests that can alert otherwise healthy individuals to an increased risk for arrhythmias and allow them to take preventive measures against the disorder. Timothy M. Olson, M. D., an instruc-tor in the pediatrics and cardiology departments, and Keating led the research that pinpointed the location of the hereditary heart disease gene to chromosome three. Dilated cardiomy-opathy accounts for more than 100,000 deaths annually in the United States and is the most common reason for heart transplantation. Michael J. Bamshad, M. D., instructor of pediatrics, and Lynn B. Jorde, Ph. D., associate professor of human genetics, both in the School of Medicine, localized the gene for ulnar- mammary syndrome to a small region on chromo-some 12 by studying a large Utah family with 33 affected individuals. In addition to causing birth defects, the gene affects breast development later in life and delays the onset of puberty. The researchers' findings also suggest that a disease that causes missing bones in the lower leg maps to the same region. " Although the disease itself is rare, once we have found a disease gene, we can learn more about the way human limbs normally develop," said Jorde. " This will increase our understanding of human development, and it could ultimately lead to more effective disease prevention and therapy." Research to identify genes causing limb malformation syndromes is an ongoing collaboration between Shriners Hospitals for Crippled Children and U of U investigators. E ( AAHPERD). In 1990, he received a special recognition award from the AAHPERD Adapted Physical Activity Council for sustained contributions to enhance the lives of persons with disabilities. He recently was elected a fellow of the American Academy of Kinesiology and Physical Education. For 13 years, Dunn jofe; M. Dunn, Ed. D. was a director of the Corvallis, Oregon, School Board and was recognized by the National Association for the Advancement of Colored People and the National Association for Retarded Citizens for his efforts in promoting educational equality. Dunn is the author or co- author of four books and more than 50 book chapters and professional papers. Since 1987, he has been associate editor of Adaptive Physical Activity Quarterly, E Health Sciences Report Winter 1996 ' i ^ CKU ^ cMf € fM Dflfid G. Bragg, M. D. RADIOLOGY FACULTY TAKE CENTER STAGE AT RSNA MEETING David G. Bragg, M. D., will begin work as the Roentgen Centennial Fellow of the Radiological Society of North America ( RSNA) in July when he steps down as chair of the medical school's Department of Radiology. Bragg was awarded the fellowship at the RSNA national meeting last November in Chicago. Also honored were Anne G. Osborn, M. D., professor of radiology, who received the Marie Curie Award from the Association of American Women in Radiology ( AAWR), and B. J. Manaster, M. D., professor and director of the Division of Diagnostic Radiology, who was elected president of AAWR. Ten other members of the Utah radiology faculty gave presentations, lectures and courses at the national meeting. The department also hosted an alumni reception, which brought together 26 years of former radiology faculty members, residents and fellows. Bragg will remain a U professor of radiology when he assumes nationwide responsibility for coordinating radi-ology research for the 60,000- member RSNA. He cited technology assessment as a research priority. He also will spend time in Washington, D. C., discussing the need for an institute for radiologic sciences at the National Institutes of Health. Bragg joined the Utah faculty in 1970, when the radiology department had four members. Under his leader-ship the past 25 years, the department has grown to as many as 43 faculty. A graduate of Stanford University, Bragg received his medical degree from the University of Oregon. He chaired the radiology department at Memorial Sloan- Kettering Institute in New York for three years before coming to Utah. Bragg recently completed a six- year term on the National Cancer Advisory Board to which he was appointed by former President Ronald Reagan, e NEW CLINICS OPEN, OTHERS RELOCATE To meet increased demand for outpatient services, University Hospitals & Clinics opened new clinics and relocated others in the past year. " University Hospital's clinics are seeing the predicted increase in outpatient care. More health care is being delivered less expensively out-side hospitals in clinics and through home care," said Christine St. Andre, executive director of University Hospitals & Clinics. The new University Red Butte Clinic opened last October in nearby Research Park. It houses The Edwin L. and Grace G. Madsen Preventive Cardiology Program, complete with a swimming pool, state- of- the- art exercise equipment, large treatment and examination rooms, and conve-nient parking. The Pain Management Center moved from University Hospi-tal to the clinic, providing acute and chronic pain service for children and adults, particularly those with cancer. The clinic's third tenant, the Sports Medicine Clinic, is relocating from Wasatch Clinics this spring. A new vascular clinic replaced the Pain Management Center at University Hospital, while the Sports Medicine's space at University Wasatch Clinics is being remodeled into a new Breast Care- Women's Primary Care Center. In Summit County, the Park City Family Health Center became part of the University system last fall. University Hospital will open a second clinic- Summit Health Center- as soon as the building near Wolf Moun-tain is completed. The Sports Medicine program is operating a clinic at the Solitude Ski Resort again this year. University nurse practitioners continue to provide primary care at the Wendover Clinic on the Utah/ Nevada border with weekly visits by University physicians, while nurse midwives and practitioners deliver babies and provide primary care to women at the University Birthcare/ Healthcare Center in Holladay. University Hospital also operates a Pediacenter in Salt Lake's central city area. A combined family practice and rehabilitation clinic is planned for the Sugar House area, and the St. George area continues to be studied for future operation, E UTAH CARDIAC SURVIVAL RATES EXCEED NATION'S The UTAH Cardiac Transplant Program last November performed its 600th heart transplant with survival rates exceeding the national average. The program- a joint effort of University and LDS hospitals, and Primary Children's and Veterans Affairs medical centers- began March 8,1985, with Tony Shepard, now a healthy 26- year- old man living and working in Idaho. " We are proud that the survival rates for persons receiving heart trans-plants in Utah far exceed the national average," said Dale G. Renlund, M. D., program medical director and profes-sor of cardiology at the School of Medicine. Some 87 percent of those receiving heart transplants in Utah survive one year, compared to the national average of 82 percent. The five- year survival rate in the Utah program is 75 percent, while the national figure is 60 percent. The 10- year survival rate for Utah patients is 62 percent with the national average dropping to 40 percent. Despite such encouraging statistics, UTAH Cardiac continues to experience a lack of donor organs. " We have many more patients than available organs. We must continue to urge individuals and families to think organ donation in the event of unexpected death," said Renlund. E 6 Health Sciences Report Winter 1996 Faye Lincoln, R. N., B. S. N., M. B. A RETIREMENTS, STAFF CHANGES AT HOSPITAL, HSC Faye Lincoln, R. N., B. S. N., M. B. A., was named acting associate admin-istrator for University Hospital last October, replacing Evelyn Hartigan, Ed. D., R. N., who retired. Also retiring from associate administrative positions last fall were Jan Bair, Ph. D., and Dave Larsen, while Dale R. Gunnell retired as associate health sciences vice president for business operations. Their respon-sibilities were divided among other administrators. In her new position, Lincoln oversees hospital programs, including critical care units; inpatient medical/ surgical services; inpatient maternal/ child and psychiatry; nutrition care; perioperative services; home care; rehabilitation services; and nursing practice, education and research. Lincoln has been director of Alternative Care Services at University Hospital since 1985. She developed the home- care program in 1986, later adding the long- term home- care pro-gram. She also developed the Univer-sity Home- care Network, a statewide home- care program responsible for contracting with managed- care companies. Hartigan joined University Hospital in 1985 as associate administrator for patient care services and associate dean for nursing practice at the U College of Nursing. Bair, who also serves on the College of Pharmacy faculty, began working at University Hospital in 1969 as director of pharmacy services. Tarsen started as a buyer in University Hospital's purchasing department in 1972 and was named director of purchasing the next year. In 1980, he was appointed director of material services and, in 1986, associate administrator. Gunnell retired after 26 years of service to the University. He joined the hospital in 1969 as budget director and moved up the managerial ladder to assistant administrator, chief financial officer and interim director. In 1993, he was appointed associate health sciences vice president for business operations, e NURSING FACULTY WIN FULBRIGHTS Two College of Nursing faculty members were awarded Fulbright Scholarships for the 1995- 96 academic year. Mary E. Duffy, Ph. D., R. N., profes-sor of nursing in the Division of Social and Behavioral Systems, has been a visiting lecturer/ research scholar at the University of Gothenburg in Sweden. Internationally known for her work with single- parent families, Duffy is working primarily with graduate students in Sweden and teaching community health nursing, including issues related to gender and single-parent families. In 1994, Duffy was a visiting professor at the University of Kuopio in Finland. Susan L. Beck, Ph. D., R. N., research associate professor in the Division of Parent- child and Adult Nursing, is a Fulbright Scholar at the University of Pretoria in South Africa, where she is studying government policy, drug availability and education, prevalence and management of cancer pain. An expert in symptom management and psychosocial issues in cancer patients, Beck and her Utah colleagues established a nurse- managed cancer symptom management clinic, Supportive Care for Cancer, at the U in 1993. She also was project director of University of Utah Hospital's Program to Improve Patient Care, funded by The Robert Wood Johnson Foundation, b NATURAL DRUGS FOCUS OF STUDY WITH NCI GRANT Chris M. Ireland, Ph. D., professor of medicinal chemistry in the College of Pharmacy, was awarded a $ 2.8 million grant from the National Cancer Institute to study anticancer drugs found in unique natural products. Internationally recognized for his work in discovering " natural" drugs found in the sea, Ireland is heading a team of researchers from Cornell University, University of British Columbia, University of the Philippines, Wyeth- Ayerst Research and the U. Natural products, the chemicals found in nature, have played key roles throughout history in treating human diseases, ranging from infections to congestive heart failure to cancer, according to Ireland, e STUDENT NURSES EXCHANGE SCHOOLS Six students from the College of Nursing spent last fall quarter at universities in Finland, gaining experi-ence in community health, while two Finnish nursing students spent time learning about American nursing at the Utah college. The student exchange program between the nursing college and the Finnish universities of Kuopio and Savonlinna was arranged by Mary E. Duffy, Ph. D., R. N., a Utah professor of nursing who was a visiting professor at Kuopio in 1994. Four more nursing students from Finland will arrive in Utah for spring quarter. Foreign study among College of Nursing students has been increasing. Sixteen students and two instructors spent four weeks in Guatemala study-ing health care in July 1992. In 1994, six students spent a summer at the Christian Medical College and Hospital College of Nursing in Vellore, India, r Health Sciences Report Winter 1996 U OF U HOSPITAL NAMED AMONG U. S. BEST University of Utah Hospitals & Clinics was named one of the nation's leading centers in the special-ties of cardiology, geriatrics, gynecology and rheumatology in the sixth annual hospital ratings report published last year in U. S. News & World Report. Rankings of the top 40 hospitals, based on ratings in 16 specialties, were listed. University Hospital's rankings are cardiology, 30; geriatrics, 32; gynecology, 35; and rheumatology, 30. U. S. News, in conjunction with the National Opinion Research Center, objectively assessed hospital care for AIDS, cancer, cardiology, endocri-nology, gastroenterology, geriatrics, gynecology, neurology, orthopedics, otolaryngology, rheumatology and urology. Some 150 board- certified physicians in each of the 16 specialties evaluated pediatrics, psychiatry, ophthalmology and rehabilitation. The model used to determine the rankings combines three years of U. S. News reputational surveys and two years of death- rate statistics published by the federal Health Care Financing Administration with up to nine categories of information related to quality. For the first time, data such as the ratio of physicians to beds, procedures to beds, and mortality rates were specialty- specific in seven of the 12 specialties. Mortality data specifi-cations also were changed, counting deaths from admission to discharge, rather than deaths that occur up to 30 days after discharge. Specialty- specific technologies ( cardiac catheterization lab, CT scanner and MRI for cardiology, for example) also were counted, e U RESEARCH RANKS HIGH IN INFLUENCE Clinical medical research produced at the University of Utah is among the nation's most influential, according to the Institute for Scientific Information. The Philadelphia- based institute measured how often research from 50 top federally funded U. S. universities was cited or quoted between 1990 and 1994. The U ranked 19th in overall impact of its research, according to the institute's Science Watch survey. Each university published more than 1,000 papers during that time with the U ranking 37th in the amount of research produced- 1,933 papers. The University was cited as one of four schools to " significantly better their standing" in the overall impact scale, since the institute last released an analysis in 1991. The U ranked 34th that year. E PROGRAMS TOUT HEALTH CAREERS FOR UTAH TEENS To encourage more girls to consider careers in medicine and more students from underrepresented populations to pursue health sciences professions, the University sponsored two workshops this winter. About 200 Utah school counselors and teachers participated in the second annual " A Day in the Health Sciences for School Counselors, Math/ Science Teachers" last January. Sponsored by the health sciences center and the State of Utah Office of Education, the program included four workshops that provided information and opportuni-ties about health sciences professions, as well as motivational techniques. More than 700 Utah junior and senior high school girls learned about career opportunities in medicine at the second annual " A Day for Women in Medicine" last November. The students interacted with female physicians, residents and medical students while participating in a vari-ety of workshops, including: reading X- rays; blood typing; delivering babies; and research opportunities. The keynote speaker was Lucy M. Osborn, M. D., associate vice president for health sciences for clinical programs and professor of pediatrics, who discussed the importance of balancing professional and personal life for women who enter medicine. Some 42 percent of applicants to American medical schools are women. In Utah, only 24 percent are women. The workshop is designed to teach young women the realities of becoming physicians and to help them better understand career options in medicine, according to Victoria E. Judd, M. D., assistant dean for admissions at the U medical school, e ECCLES LIBRARY OPENS MODEL MULTIMEDIA CENTER The Multimedia Support Center for health sciences faculty opened last winter at the Spencer S. Eccles Health Sciences Library. Funded with a grant from the National Library of Medicine, the new center serves as a national model for incorporating multimedia services into the health sciences, according to Sharon E. Dennis, M. S., head of Computer and Media Services at the Eccles Library. She and Paul Burrows, a producer/ director at KUED, are principal investigators for the grant. The center includes a multimedia library, which offers digitized pho-tographs, clip art, sounds, full- motion digitized video, videodisc images and case studies to all health sciences faculty members with access to the worldwide web. They may use the items for their individual files, computerized lectures and learning programs. The center also serves as a " concept-to- maturity" resource, according to Dennis. Staff members- graphic artists and a computer programmer- will assist faculty members in developing their own computer- based learning programs. Faculty from the U, as well as from universities in Philadelphia and New York, already are using this resource, b Health Sciences Report Winter 1996 Michael A. Ashburn, M. D., M. P. H., associate professor of anesthesiology in the School of Medicine and director of University Hospital's Pain Management Center, was named one of six fellows of The Robert Wood Johnson Foundation's Health Policy Program for 1995- 96. He is using his sabbatical to participate in the program in Washington, D. C. e Jan N. Bair, Ph. D., recently retired associate administrator at University Hospitals & Clinics, and professor of pharmacy practice in the College of Pharmacy, was named a fellow of the American Society of Health- system Pharmacists at the group's annual meeting in Philadelphia last October, E Sandy Beveridge, Ph. D., associate professor and chair of the Department of Exercise and Sport Science at the College of Health, was elected to a three- year term as president of the Southwest District of the American Alliance for Health, Physical Education, Recreation and Dance during the group's 61st annual meeting in Kahuhu, Hawaii, last July, e Robert S. Fujinami, Ph. D., professor of neurology in the School of Medicine, and Sung Wan Kim, Ph. D., professor of pharmaceutics and pharmaceutical chemistry, and director of the Center for Controlled Chemical Delivery at the College of Pharmacy, accepted appointments last September to serve four- year terms on study sections in the Division of Research Grants of the National Institutes of Health ( NIH). Fujinami will serve on the Virology Study Section, while Kim will serve his second term on the Surgery and Bioengineering Study Section, E Becky Hatfield, coordinator of the Parent to Parent program at University Hospital, received the Recognition Award for Individual Contribution to Maternal and Child Health from the National Perinatal Association last November, e PEOPLE Judy Kiernan, Ph. D., R. N., director of nursing for medical, surgical and rehabilitation services for University Hospital, received the 1995 Adminis-tration Award from the Utah Nursing Association at its annual meeting last October in St. George, E B. J. Monaster, M. D., Ph. D., professor of radiology and director of the Division of Diagnostic Radiology at the School of Medicine, was named a fellow of the American College of Radiology at the annual meeting in Boston last October, E John M. Matsen, M. D., vice president for health sciences and professor of pathology and pediatrics at the School of Medicine, was elected last November to the board of directors of the American Clinical Laboratory Association, which includes the leading providers of independent laboratory services in the United States. Matsen chairs the board of directors of Associated Regional and University Pathologists, Inc. ( ARUP). E Royce Moser, Jr., M. D., M. P. H., professor of family and preventive medicine at the School of Medicine, and director of the Rocky Mountain Center for Occupational and Environmental Health, was named vice president for medical affairs at the American College of Occupational and Environmental Medicine in Arlington Heights, Illinois. He assumed the part- time adminis-trative post last November, while continuing as director of the Rocky Mountain Center, E Donald M. Pedersen, Ph. D., PA- C, associate professor of family and preventive medicine, and director of the Utah Physician Assistant Program at the School of Medicine, was elected last November to serve a second term as chair of the Physician Assistant Licensing Board in the Division of Occupational and Professional Licensing at the Utah State Depart-ment of Commerce, E Marvin L. Rallison, M. D., professor and chief of the Division of Endocrinology and Metabolism in the pediatrics department at the School of Medicine, participated last fall in the Nagasaki Symposium ' 95, marking the 50th anniversary of the atomic bomb explosion in Nagasaki, Japan. Rallison, who directed the Utah- Arizona Thyroid Epidemiology Study ( Phase 1) of the U. S. Public Health Service, 1966- 72, joined the session on " Health Consequences from Radiological Events and Emergencies." e YYYYYYYYYYYYYYTY Jesse M. Soriano, director of ethnic minority affairs at the health sciences center, was presented the Cesar E. Chavez Peace and Justice Award for Education last November in Salt Lake City. He also was recognized by Utah Gov. Mike Leavitt for serving five years on the Governor's Hispanic Advisory Council, E James R. Swenson, M. D., professor and chair of the Division of Physical Medicine and Rehabilitation at the School of Medicine, was elected to serve as vice president of the American Academy of Physical Medicine and Rehabilitation in 1997 and as president in 1998. E James Tsai- Yuan Wu, Ph. D., professor of pathology at the School of Medicine, received the Sunderman Award and was named Clinical Scientist of the Year by the Association of Clinical Scientists at its annual meeting last November, e Ann M. Voda, Ph. D., professor of adult physiological nursing/ continuous care practitioner- specialist and director of the Tremin Trust Reproductive History Program at the College of Nursing, be-came president of the North American Menopause Society at its annual meet-ing in San Francisco last September, E Health Sciences Report Winter 1996 ^ / V ^ i n d e r , " as in wonder drugs, isn't what it used to be. Penicillin is a dramatic example. An article in Science points out that, in 1941,10,000 units of penicillin, given four times a day for four days, cured patients of pneumococcal pneumonia. Today, a patient could receive 24 million units of penicillin a day and still die of pneumococcal meningitis. Bacteria have become resistant to many of the previous decades' " miracle" drugs, and excessive and inappropriate use of antibiotics, " Bacteria are still smarter than we are. They are in this for survival, and they will mutate and change their genetics in order to survive- and the broader spectrum antibiotics used so widely help them do this." Miracle Drugs Can Do Wonders for including broad- spectrum antibiotics, contributes to the development of resistant strains. " Bacteria are still smarter than we are," said Larry G. Reimer, M. D., professor of pathology and internal medicine at the School of Medicine. " They are in this for survival, and they will mutate and change their genetics in order to survive- and the broader spectrum antibiotics used so widely help them do this." Viruses and bacteria have few genes compared to humans. One mutation can change an organism's ability to infect, spread or cause disease. Also, microbes transform rapidly, because they occur in large numbers and quickly reproduce. By MARY CHACHAS " There's no question that common bacteria that cause such things as ear infections, sinusitis, respiratory bronchi-tis and pneumonia are more resistant, so it's a real concern when patients ask for antibiotics," said Reimer, a specialist in infectious diseases who is director of clinical microbiology at the Veterans Affairs Medical Center and director of postgraduate training in microbiology. Patient education is the most impor-tant aspect of controlling the problem, Reimer believes. Patients need to be counseled by physicians to help them understand the need to be conservative in prescribing antibiotics. Philip R. Fischer, M. D., assistant professor of general pediatrics, agrees. " It's an education thing. My regular patients know I won't prescribe an antibiotic unless I'm sure it's appropriate." Children, the top users of antibi-otics, do get lots of infections, and he acknowledges that mingling of children, many of whom have had antibiotics, increases the likelihood that the germs they get at such facili-ties as day- care centers are resistant. Still, Fischer urges physicians to use discretion in prescribing drugs. In many cases, this means dealing with anxious parents. " You hear things like ' My doctor always prescribes this for Junior's ear-ache,' or ' I know my child well enough to know this is strep.' Then, there're 10 Health Sciences Report Winter 1996 " Fluids, decongestants, acetaminophen, and remedies your grandmother might recommend- including chicken soup- are generally what patients with cold symptoms need, hut doctors can talk themselves blue in the face without convincing emergency room patients that this is what they should do." of patients believe antibiotics are effective against colds and flu always the mothers telephoning and asking a doctor to call in a prescription. I tell them ' no/ that the child needs to be seen before an antibiotic is prescribed." Parents should understand when antibiotics for children are appropriate: to treat an ear infection ( as distin-guished from an earache, which may have other causes); a strep throat; and serious illnesses, such as pneumonia and meningitis. " Prescribing antibiotics incorrectly not only wastes money and is a hassle, because kids don't like taking medicine, but there may be some side effects in young children such as diaper rash or diarrhea. " If an antibiotic is absolutely necessary, parents must deal with a fussy child or side effects; if there's not much risk, the super drugs should be avoided," Fischer said. Reimer, who treats adults, sees two common problems in diagnosing either the elderly or children. " It is often difficult to get a good enough history to know whether an infection is viral or bacterial; and secondly, neither kids nor older people have extra reserves, so if a mistake is made by not prescribing an antibiotic, it is much more serious. When one doesn't know for sure, it's probably better to err on the side of treatment." The emergency department ( ED) at University Hospital provides care to people without regular physicians or those who may have problems after regular office hours. ED physicians see lots of earaches and common colds, and most of these patients want a prescription and major reassurance, said Kurt T. Bernhisel, M. D., director of emergency medicine at University Hospital, and associate professor and division chief of emergency medicine. " Fluids, decongestants, aceta-minophen and remedies your grand-mother might recommend- including chicken soup- are generally what patients with cold symptoms need, but doctors can talk themselves blue in the face without convincing emergency room patients that this is what they should do," said Bernhisel. One patient in 10 may accept the suggestion that antibiotics aren't needed, but, frequently, patients who have alternative treatments recom-mended will dispute their bill when it arrives. Emergency room services cost more than clinic visits, and patients are unhappy when they don't get even a prescription out of the visit, Bernhisel said. Consideration must be given, how-ever, to transients who go to the emer-gency department. These patients may be unable and/ or unwilling to return for follow- up care, so physicians take that into consideration when recom-mending treatment. According to Bernhisel, the majority of patients who go to emergency departments have " rip- roaring infections- bronchitis, pneumonia, urinary tract infections, strep throat and sexually transmitted diseases. They're sick enough that antibiotic prescriptions are appropriate." Overuse of antibiotics isn't just a physician problem- non- compliant patients bear responsibility, too, said Karen Carroll, M. D., assistant professor of clinical pathology, adjunct assistant ( continued on next page) Health Sciences Report Winter 1996 professor of infectious diseases and director of Associated Regional and University Pathologists ( ARUP) infectious diseases laboratory. Many people stop taking prescribed antibiotics as soon as they feel better and keep the rest for later use, or they may treat themselves with another person's antibiotics. An inadequate dose of antibiotics may be worse than none at all, Carroll said. A partially treated infection may interfere with the physician's ability to make an accurate diagnosis by preventing recovery of bacteria by culture. A Gallup poll, released by the American Lung Association, shows that 52 percent of 1,010 adults who had taken an antibiotic said they didn't finish the prescription. Twenty- four percent said they hadn't completed the last antibiotics prescribed for a respiratory infection and, in this subgroup, more than half said they stopped therapy because they felt better. Of the 100 physicians sur-veyed, 84 percent assume that patients who don't finish prescriptions hang on to them for later use. Other findings showed that 60 percent of patients believe antibiotics are effective against colds and flu, and 70 percent of patients with a cold or the flu request prescriptions for antibiotics. In fact, Carroll pointed out, antimicro-bial drugs do not shorten the course of acute viral upper respiratory infections and do not prevent secondary bacterial infections. The food industry contributes to drug- resistant bacteria, too, Carroll said. " Tetracycline is put in chicken feed to prevent salmonella, and now we are seeing tetracycline- resistant salmonella. Fish farms use antibiotics to prevent fish diseases, because if one fish gets a disease, it can wipe out the entire business. There is data, however, of 1,010 adults who had taken an antibiotic said they didn't finish the prescription A partially treated infection may interfere with the physician's ability to make an accurate diagnosis by preventing recovery of bacteria by culture. of the 100 doctors surveyed assume that patients who don't finish prescriptions hang on to them for later use that the dairy industry monitors the antibiotic levels in milk. Unfortunately, no one is studying infections specific to the food industry; it's just not lucrative. " Although it is unclear how significant the food industry's use of antibiotics is in making bacteria resis-tant, there is growing concern because of increasing problems during the past decade." Societal changes contribute to the spread of disease. The enormous increase in worldwide travel carries resistant bacteria to all parts of the globe, and some foreign countries lack controls over antibiotics, Carroll added. In Spain, for instance, some powerful antibiotics are sold over- the- counter, and many Americans go to Mexico to obtain drugs that are not available here without a prescription. Within University Hospital and the U medical school, education and monitoring are ongoing. According to Reimer, the infectious diseases division faculty and many of the faculty in general internal medicine provide continuing education to resident house officers. Sophomore medical students learn about the problem in their micro-biology and pharmacology courses, and third- and fourth- year students, during their hospital clerkships. Continuously updated informa-tion about antimicrobial resistance patterns is provided to all University Hospital medical staff, including nurse practitioners, in an annual brochure published by ARUP, which provides clinical pathology services for Univer-sity Hospital. This brochure, Antibiotic Susceptibility Report, lists bacteria, the effectiveness of various antibiotics against them and the price of these drugs. Pharmacy and infectious diseases experts help determine which antibiotics should be tested. Patients admitted to hospitals today are sicker than they used to be and require more complicated treat-ment. According to Reimer, when very ill patients are admitted, housestaff generally treat them aggressively. " It's important to realize that it's not such a bad idea to give powerful drugs right away, but it is a bad idea to continue using them if more specific drugs would be as effective when all the labo-ratory data are known," Reimer said. When a patient is hospitalized, microbiology laboratory tests are done to identify bacteria that may be involved in the illness and the drugs to which they are resistant. It should be standard practice for physicians to use these test results in formulating a definitive treatment plan, both Reimer and Carroll said. Specific steps are taken at University Hospital to control overuse of antibi-otics and to monitor drug- resistant infections. The effort begins with the Pharmacy and Therapeutics Committee, 12 Health Sciences Report Winter 1996 University of Utah Health Sciences Center- Modified Antibiogram 1995 Data indicate percent susceptible Antibiotic pricing represents UUHSC Pharmacy Acquisition Costs, effective 1/ 96 ~ o + C- D » £ L. 01 X! E GRAM POSITIVE COCCI Z TMP/ SMX $ 17.20/ 10 days 160 mg IVq 6h AMPICILLIN $ 29.60/ 10 days 2 gm IV q 6h CEFAZOLIN $ 33.90/ 10 days 1 gm q 8h ERYTHROMYCIN $ 44/ 10 days 1 gm IV q 6h CLINDAMYCIN $ 65.70/ 10 days 900 mg IV q 8h PENICILLIN $ 72/ 10 days 2MU IVq 4h NAFCILLIN $ 91.20/ 10 days 2 gm IV q 4h VANCOMYCIN $ 128/ 10 days 1 gm IVq 12h Staphylococcus aureus 376 96 NT 100 83 88 6 100 100 Methicillin resistant S. aureus 119 53 0 0 2 5 0 0 100 Coagulase negative Staphylococcus 437 56 NT 36 39 68 6 36 100 Enterococcus spp. * * 360 NT 95 NT NT NT NT NT 95 Streptococcus pneumoniae 29 NT NT NT NT NT 79 NT 100 ** Gentamicin and a beta- lactam antibiotic appeared to be synergistic with 86% of enterococcal isolates. Streptomycin and a beta- lactam antibiotic appeared to be synergistic with 71% of enterococcal isolates. NT= Not Tested Chart is part of the Antibiotic Susceptibility Report published by ARUP for UUHSC which issues guidelines for antibiotic usage, recommending certain types of medication for particular infections. " We have a policy to curtail the use of certain drugs, vancomycin, specifically- an important ' last line of defense' drug- to prevent emergence of organisms resistant to that drug," said Marion L. Woods II, M. D., assistant professor in the Division of Infectious Diseases and hospital epidemiologist. Vancomycin has been used since 1958 for bacterial infections not respon-sive to other therapies. Today, entero-cocci, bacteria that normally reside in the intestine, are becoming resistant to it. Vancomycin- resistant enterococci ( VRE) have been identified as causing bloodstream infection and can cause wound and urinary tract infections. Currently, there are no approved treat-ments for VRE. University Hospital has had no outbreak of VRE infections. Other ways of combatting the spread of infections in the hospital go back to basic things like hand washing, said Woods, chair of the University Hospital Infection Control Committee. " Hand washing is critical. The trans-mission of most bacterial infections in the hospital is related to hand wash-ing, or, more precisely, the lack of it. Constant vigilance is required to ensure that staff wash their hands appropri-ately. After investigating clusters of infections, we tell physicians our find-ings and revisit the areas to discuss other infection- prevention measures with staff. We can tell staff with certainty that, by washing their hands before and after seeing a patient, trans-mission of bacteria from one patient to another is curtailed dramatically." The Pharmacoepidemiology Pro-gram has been successful in improving the appropriate use of prophylactic antibiotics in surgery patients to pre-vent postoperative wound infections. If patients get this prophylactic antibi-otic at the correct time, there is a much lower incidence of wound infection. A plan was created for surgeons to assure that patients in University Hospital receive antibiotics at the appropriate time, Woods said. One of the reasons super drugs are being used inappropriately is that they are marketed so heavily, according to Woods. " Quinolones, for instance, a new class of antimicrobial drugs, are being used for skin infections, staphylococcus infections and are inap-propriately used to treat pneumonia. Pharmaceutical companies want physi-cians to use their drugs. Dealing with such selective marketing is something all physicians have to do." The overall impact of antimicrobial resistance is great. According to the National Institute of Allergy and Infec-tious Diseases ( NIAID) at the National Institutes of Health ( NIH), the evolu-tionary process in microbes often causes the reemergence of diseases previously controlled by antibiotics and other drugs. Examples include drug- resistant tuberculosis, malaria and diseases caused by new bacterial strains of Streptococcus pneumoniae and Enterococcus faecalis. Illness is pro-longed, hospitalization is more frequent and prolonged, therapies with greater toxicity are required, and mortality is doubled with resistant strains. The economic impact also is significant. The estimated annual cost associated with hospital- acquired infections caused by resistant bacteria and other organisms ranges from $ 100 million to $ 30 billion. For instance, the estimated cost of treating a patient with drug- susceptible tuberculosis is $ 12,000, compared to $ 180,000 to treat a patient with multidrug- resistant tuberculosis, n Reference Neu, Harold C. " The Crisis in Antibiotic Resistance," Science, Vol. 257, August 21, 1992, pp. 1064- 1073. Health Sciences Report Winter 19 Managing Chronic Nonmalignant Pain T attered copies of news magazines usually are strewn across tables in physicians' waiting rooms. But that's not to say Gothic mysteries wouldn't be more fitting for patients in pain. They might find the setting bolts of lightning slashing the darkness, thunder pounding- a vivid metaphor for their aching bodies. Physicians would be intrigued with the plot: why does one character, like certain patients, wait out the storm under the eaves of a forbidding mansion, while another opens the creaky door and By SUSAN SAMPLE descends the spiraling staircase of pain and depression? The analogy may seem overly dramatic. Everyone experiences pain, every physician treats pain, so it hardly warrants the horror suggested by Gothic fiction. Yet, many patients and physicians are trying to manage a condition that, if not a mystery, is often misun-derstood, misdiagnosed and mistreated: chronic nonmalignant pain. It's definitely not fiction. More than 4o million Americans suffer headaches severe enough to recjuire medical attention, according to the National Headache Foundation, which reports headache to be the most common pain complaint primary care physicians receive. 14 Health Sciences Report Winter 1996 Even 38 percent of children have experienced headaches. The medical care for chronic low back pain runs between $ 50 and 100 billion per year when the costs of absenteeism from work, surgery, litigation and medication are factored in, according to Perry G. Fine, M. D., associate director of the University of Utah Pain Management Center, where 60- 80 patients are evaluated for chronic pain each month. Pelvic pain is among the three most common reasons patients see gynecol-ogists, noted Howard T. Sharp, M. D., director of the University Women's Pelvic Pain Center. " It becomes somewhat of a Sherlock Holmes mis-sion to find what may not have been diagnosed. " During an ob- gyn residency, we learn about pelvic adhesions, endo-metriosis and pelvic inflammatory dis-ease," said Sharp, assistant professor of obstetrics and gynecology. " When we don't see these, it becomes a mystery." And, often, questionable to every-one- except the person in pain. " It's a silent epidemic," said Scot W. Russell, Ph. D., assistant profes-sor of psychiatry. " It's estimated that 50 percent of people over age 65 strug-gle with pain. " Chronic pain is silent, because many people cope with it," said Russell. " But it's also silent, because people are concerned that they'll be seen as fakes." When we watch a stranger hobble down a hallway, knee and calf enclosed in a cast, we might wince in sympathy. But when a friend is confined to bed for three days because of a headache, we're more likely to dismiss the severity of his or her condition and, instead of feeling empathy, attach blame for an inability to handle stress. " That in fact I spent one or two days a week almost unconscious with pain seemed a shameful secret, evidence not merely of some chemical inferiority but of all my bad attitudes, unpleasant tempers, wrongthink," writes Joan Didion in her essay " In Bed." " For I had no brain tumor, no eyestrain, no high blood pressure, nothing wrong with me at all: I simply had migraine headaches, and migraine headaches were, as everyone who did not have them knew, imaginary." Gynecologist Sharp recounts the diagnosis many of his patients received from others when they complained of persistent pelvic pain: " Their pain, they were told, is in their head." " Supratentorial pain"- literally, " pain above the ears"- frequently was written on patients' charts 20 years ago when physicians couldn't find an organic cause for the pain, according to Russell. " These patients weren't getting better, and their pain couldn't be ( continued on next page) Health Sciences Report Winter 1996 WITH ANY PAIN WHETHER A STUBBED TOE OR INJURED BACK, THERE ISA MENTAL COMPONENT. NO BRAIN, NO PAIN " IT'S A DANGEROUS THING TO SAY THE PAIN IS ALL IN YOUR HEAD. IT'S INAPPROPRIATE AND INCORRECT. OFTEN, THERE'S NOT A CORRELATION BETWEEN PAIN AND PHYSICAL INJURY IN CHRONIC NONMALIGNANT PAIN. WHAT MATTERS IS THAT THE PERSON IS HAVING PAIN...." explained medically, so, by default, it had to be in their head." As recently as the 1970s, pain was judged on the basis of a disease model. The amount of pain one experienced was related directly to the amount of injury, a theory dating back to the 17th century. The French philosopher Rene Descartes incorporated his notion of a mind- body split into his theory of pain, as well as his world view. Yet, experts now agree that " it doesn't work to dichotomize, to say it's in your head or your body. Pain is truly a mind- body phenomenon," explained Russell. " With any pain, whether a stubbed toe or injured back, there is a mental component. No brain, no pain." " It's a dangerous thing to say the pain is all in your head. It's inappropri-ate and incorrect," agreed John Speed, M. D., director of the Chronic Pain Rehab Program at the U of U Spine Rehab Center. " Often, there's little correlation between pain and physical injury in chronic nonmalignant pain. What matters is that the person is hav-ing pain and negatively functioning." The International Association of Pain has defined pain as " a stimulus that comes from tissue damage or perceived tissue damage." Chronic non-malignant pain- distinct from acute pain that is limited in time and directly related to a physical injury-" persists beyond the time expected for tissue healing: six months," said Speed. " There are some exceptions, some conditions that have persistent pain, such as rheumatoid arthritis. But there's not going to be healing of liga-ments, tendons or muscles in those cases," he added. Anesthesiologist Fine at the Pain Management Center would even short-en the time period. " Anyone who has a pain problem for three months" might qualify for treatment. As he reasons, it 16 would be beneficial to alleviate the pain before it becomes worse. " Prevention is by far the best approach," he noted. " It would be misleading, a cardinal sin, to say something is only physical or only psychological," said Fine. " On the other hand, trying to determine why some people adapt and cope, and why some people don't, is always difficult. " We try to sort out the problem and get the patient into life- enhancing therapy as soon as possible." N ot only is chronic nonmalig-nant pain misunderstood, it's also frequently misdiagnosed and, consequently, mistreated. " We see a significant number of organic causes" of chronic pelvic pain, said Sharp, who attributes much of the successful treatment of patients at the U Women's Pelvic Pain Center to " innovative therapies." The University is one of a handful of centers nationwide to offer pelvic venography, a unique imaging tech-nique in which contrast dye is injected into the muscle of the uterus. Using fluoroscopy, the gynecologist can measure the diameter of both uterine and ovarian veins to detect pelvic con-gestion, often referred to as " migraine of the pelvis." " Of 600 women examined at our center, 7 percent had pelvic congestion syndrome," said Sharp, whose father, Howard C. Sharp, M. D., U professor of obstetrics and gynecology, pioneered research on the condition. " More than 90 percent of these patients responded with surgical treatment. Of those, 70 percent retained ovarian function; 17 percent maintained fertility." Other causes of chronic pelvic pain, which occurs even in women who have had hysterectomies and had their ovaries removed, include residual Health Sciences Report Winter 1996 f- . J f i i endometriosis that recurs after surgery; irritable bowels, which often can be treated with fiber therapy or antispas-modic drugs; ovarian remnants, small pieces of an ovary that remain after surgery and can be removed surgically; and vaginal vault scars from a hysterectomy, which can be resected laparoscopically. Myofascical pain in the pelvic region usually can be treated, explained Sharp. The pain in the fascia, or muscle, of the abdomen may be due to hyper-sensitive receptors and neurons. To block or inhibit the neurons from firing, Sharp combines trigger- point injec-tions- a local anesthetic injected into the area on the abdominal wall that triggers pain- with either ice or stretching exercises. After four or five treatments, the pain usually is gone. " Patients hate to be told their pain is in their heads," noted Sharp. " But sometimes, there is a behavioral medi-cine component to the pain." When he suspects that, the gynecol-ogist works closely with physicians at the Pain Management Center. An anesthesiologist may perform a gradu-ated spinal block to numb the patient's entire abdomen. " If she still has pain, then surgery will not be effective," said Sharp. " Usually, after the procedure, the patient better accepts that her pain is a behavioral problem." A lthough upwards of 80 percent of adults suffer headaches, Americans are reluctant to accept headache as a cause of disability, according to The American Council for Headache Education. And some physi-cians " still don't realize that migraine is a problem. It's an underdiagnosed and underserved clinical area," said Kathleen B. Digre, M. D., director of the U Headache Clinic, one of only two in " EDUCATION IS THE MOST IMPORTANT TOOL FOR PATIENTS WITH HEADACHES. IF THEY UNDERSTAND WHAT IS GOING ON, THEY CAN TAKE CARE OF THEMSELVES. RATHER THAN FEEL VICTIM1ZED- " THE DEAD- DUCK APPROACH'- THEY CAN BE IN CONTROL." the Intermountain West. " People don't seek attention, or their pain is glossed over. Headaches aren't seen as impor-tant." Like other chronic nonmalignant pain, headaches are recurrent and can be debilitating, but, like pelvic pain, they often have organic causes. " There is some relationship to chronic nonmalignant pain, but some types of headache are a separate issue," explained Digre, associate professor of neurology. For instance, " migraine is a physiological change in blood flow, it's associated with a genetic predisposition and it's treatable." As with any type of chronic pain, Digre determines whether certain medical conditions may be causing recurrent headaches: structural prob-lems, such as brain tumors; metabolic causes like thyroid disease, lupus or other autoimmune diseases; medical problems, such as sleep disturbances; overuse of analgesics that can cause rebound headaches; or psychological conditions, including depression, internal conflicts, or a history of repressed sexual abuse. The neurologist then diagnoses the type of headache. Migraines are recurrent, pulsating headaches, usually unilateral, often accompanied by nausea and vomiting. They can be preceded by visual disturbances, and individuals often are light- sensitive and experience pain around their eyes during attacks. Women are more sus-ceptible, although 10- 20 percent of the population is genetically predisposed to migraines, according to Digre. Another type of headache is termed " chronic tension- type," which Digre admitted " may be a misnomer. It's not just muscle tension. It can have muscular- skeletal exacerbations. We don't understand it well." Some researchers believe chronic tension- types to be caused by abnor-malities in the pain regulatory systems of the brain. According to the National Headache Foundation, recent studies indicate they may be due to low levels of serotonin, which are found in migraine sufferers as well. This finding supports the theory that chronic ten-sion- type and migraine may be two extremes on the headache spectrum. ( continued on next page) Health Sciences Report Winter 1996 " EVERYONE HAS HIS OR HER OWN STYLE OF MANAGING PAIN THAT PROBABLY WAS LEARNED IN CHILDHOOD. HOW YOU REACT TO PAIN IS VERY MUCH A LEARNED PHENOMENON." Chronic daily headaches share symptoms with both migraines and chronic tension- type headaches, but can be more debilitating. Individuals suffer headaches " from the time they get up to when they go to bed," said Digre, prompting some patients simply to remain in bed all day. Cluster headaches are another type of disabling headache in which patients, predominantly male, suffer " the worst pain known," said Digre. " Some men become so distraught they will put their head in the freezer or drive with their head out the window of the car." These headaches, which last on an average one hour, occur in " clusters" of attacks, at least twice a week for two years or more. Patients may experience up to 15 attacks per day. They are accompanied by droopy eyes, tearing and a runny nose. Like other types of headache, cluster headaches can be treated and prevented. The key, according to Digre, is the right diagnosis: " Know your headache. What kind do I have? What are my options?" And she places heavy emphasis on the " I." " Patients must assume responsi-bility. I have them fill out a headache diary, so they can see what are trigger factors. They may be doing things that make their headaches worse," explained Digre. " Education is the most important tool for patients with headaches. If they understand what is going on, they can take care of them-selves. Rather than feel victimized- ' the dead- duck approach'- they can be in control." When Digre's patients leave the U Headache Clinic, they're armed with handouts, reading lists and treat-ment plans. For an acute headache, patients follow the " Principles of Treatment: prevent nausea, treat pain, sleep." Specific drugs, such as metoclo-pramide, may be recommended first to relieve nausea, followed by Midrin or, if nausea worsens or vomiting occurs, promethazine suppositories. Digre also may recommend changes in diet and exercise, and stress manage-ment techniques, as well as appoint-ments with physical therapists or anesthesiologists, if needed. " The art of the clinic is determining what works for each person. It's not an exact science; neurology is very indi-vidualized," she noted. " But if people understand their headache and have power over it, then they can be part of the solution." H elping people make the tran-sition from being dependent patients to capable adults is the goal of the day treatment program at the U of U Pain Management Center. " We have to change patients' views of themselves as sick and dysfunctional," said Fine. " The last promise we make is that people will be out of pain. We try to provide them with skills to limit their perception of pain, to manage the pain." A comprehensive, interdisciplinary program, the U Pain Management Center offers medical, psychiatric and psychological treatment for adults and children suffering pain related to a variety of conditions, from cancer to AIDS to arthritis to chronic nonma-lignant pain. Patients with the latter often enter the day treatment program, which incorporates behavioral and functional therapies, medical manage-ment and, if needed, substance abuse treatment. Since chronic nonmalignant pain cannot be traced to an organic cause and treated, it isn't curable. Like migraine, it also isn't terminal: " That 18 Health Sciences Report Winter 1996 no one dies of migraine seems, to some-one deep into an attack, an ambiguous blessing," writes Didion. But the pain can be extremely disabling, so treat-ment focuses on restoring patients' functioning- in spite of the pain. Shifting one's focus away from pain " sounds simplistic- but it isn't when you're caught in the pain cycle: a downward spiral of inactivity, pain and depression," said Speed, who directs the U Chronic Pain Rehab Program, specializing in the treatment of back and neck pain in adults. The cycle begins with an injury that triggers pain, causing a person to limit movement, explained Speed. Inactivity results in tighter, stiffer and weaker muscles, which leads to increased pain. The person becomes depressed, which increases pain and decreases movement- and the cycle repeats. To break out of this downward spiral, patients must " unlearn" ways in which they respond to pain. " Everyone has his or her own style of managing pain that probably was learned in childhood," said Speed. According to Russell, " it's well doc-umented that, during their childhood, 50 percent of people with chronic pain were around an adult experiencing reg-ular periods of chronic disabling pain. " Chronic pain isn't hereditary," said Russell, " but how we cope with pain, treat it and manage it in our daily lives is a learned behavior." At both the U Pain Management Center and the Chronic Pain Rehab Program, patients learn new ways to manage pain. Four to five days a week for up to five weeks, they work with physical therapists to increase their strength, endurance and flexibility; occupational therapists to improve their functional abilities, so they can return to work; and psychologists to learn new coping strategies for pain, CHRONIC NONMALIGNANT PAIN IS CONTAGIOUS: IT AFFECTS THE BEHAVIOR OF THOSE AROUND THE PATIENT AT HOME AND AT WORK. such as relaxation techniques and stress management, rather than relying on narcotics or other habit- forming drugs. Physicians coordinate the therapy and provide medical supervision. " It's not a quick fix," said Speed. " I tell patients that they're going to be putting a lot of sweat into it. If they don't, they won't gain." Patients sign contracts when they begin the Chronic Pain Rehab Program and strive to fulfill daily " goal cards" with very specific expectations, such as increasing their endurance by walking 3- 4 m. p. h. on the treadmill for 30 min-utes. They work individually and in small groups. Families also are involved in the treatment, since chronic nonmalignant pain is contagious: it affects the behav-ior of those around the patient at home and at work. " A solicitous spouse might say, ' Oh honey, don't try to do that. You'll hurt your back,'" said Speed, which reinforces inactivity and contrib-utes to the pain cycle. " It's important for family members to understand the patient is trying to increase his move-ment. They have to know how to reinforce healthy behaviors." Once patients begin to move around, they may find their pain decreasing. " Often, it's self- fulfilling," noted Fine. " When patients feel they are the locus of control, their perception of pain is limited. " Those things we don't under-stand and don't control cause anxiety," said the anesthesiologist. At the Pain Management Center, " we can help most of the people most of the time get reasonable control over their pain." With control comes acceptance. As Didion writes of her pain, " I have learned now to live with it, learned when to expect it, how to outwit it, even how to regard it, when it does come, as more friend than lodger." e Health Sciences Report Winter 1996 Lending a H e l p i n g Hand Working in the " helping professions" takes on additional meaning for many University health sciences faculty, staff and students who reach out to the community through volunteer service. A. Santa toting a bag full of golf clubs topped the Christmas tree decorated last win ter by members of Eta Sigma Gamma, a student honorary at the College of Health, for the " Festival of Trees." Over the past sixyears, the students have raised more than $ 6,000 from the sales of their theme trees, which they donate to Primary Children's Medical Center. More than 25 students work for six to nine months planning and decorating with funds fromASUU. Shown are: front row, from the left- Elizabeth Smith, Julia Kleinschmidt, Ph. D., assistant professor of health education and project coordinator, and Brandice Bringhurst; middle row- Onie R. Grosshans, H. S. D., M. P. H., associate professor and chair, Department of Health Education, and Darrin Sluga; and back row- Jennifer Jensen and Ivy Melton Sales. Festival of Trees Health Sciences Report Winter 1996 Calvary Computer Club Suspense awaits 11- year-old Ashley Hesleph, left, and Megan Tippets as they test survival skills on the Oregon Trail- via computer. Located in the basement of Calvary Baptist Church in downtown Salt Lake City, the lab provides youth with access to computers and, in the process, increased self- esteem. Megan, a junior working in Technical Services at the SpencerS. Eccles Health Sciences Library, volunteered weekly at the lab, a project of the University's Bennion Center Habitat for Humanity Health Sciences Report Winter 1996 Habitat for Humanity Summer is synonymous with building for Graham Lashley, a third- year student at the School of Medicine. Last year, he helped construct24 houses for needy California families in Watts. This summer, the North Carolina native will join former President Jimmy Carter and other Habitat for Humanity volunteers in Budapest Hungary, where they will build 30 homes. Families pay no interest for Habitat homes, but they do pay a purchase price and " sweat equity" as they work alongside volunteers. rus Is The New Home 0* Francisco & Graciela Gonzalez Htm** jfr i n ' FEDERAL BANK Senior Citizen High- rise in downtown Salt Lake City appreciated not only their new television and video-cassette recorder last Christmas, but also the holiday party they were given. Marianne Monson, left a junior at the College of Nursing, volunteers through theUBennion Center and directs the Mayor's Youth Volunteer Council She supervised 30 teens from seven local high schools who coordinated the event at the low- income senior center. Among those wereAlliette Frank, fourth from the left a senior at Rowland Hall- St. Mark's School. 22 Health Sciences Report Winter 1996 Special Olympics Strikes and spares filled scorecards last January as Special Olympic athletes practiced for the national bowling tournament held recently in Salt Lake City Susan Havlicak, center, administrative assistant for the Department of Pharmacy Practice at the College of Pharmacy, stopped by to cheer on her friends one Saturday: from left- Wayne Tucker, Melissa Howard, William Rigby and Tony Petersen. Susan has made arrange-ments for many Special Olympics'opening and closing ceremonies during the past four years she's volunteered with the organization. Share t h e Harvest 1 \ otonlydo Dennis and Myra Nicholl plant extra rows of vegetables in their garden to donate to Utahns Against Hunger, but the couple also has helped coordinate food drives and distribution centers throughout the Salt Lake Valley for nearly 10years. Dennis is a supervisor for Environmental Services at University Hospital. Health Sciences Report Winter 1996 READING LIST e i n g optimists, many of us have books stacked by our easy chairs, coffee tables a n d night stands, so t h a t as soon as we c a t c h up with t h e reading required for our professional roles, w e c a n indulge ourselves in: murder mysteries, Greek phi-losophy, bird- watching guides, f a i r y tales, even cookbooks. H e r e a r e some titles faculty and staff members f r om t h e health sciences center have set aside for those long winter evenings. ROBERTA H. ADAMS, M. D. Assistant Professor of Internal Medicine, School of Medicine The Tale of Genji, Shikibu Murasaki This is the first novel ever written, and it is, I'm told, full of action, imagination, love and the splendor of Meiji, Japan. The Odyssey, Homer This is one I missed in school. It's not the war story that The llliad is. It's an epic about life, filled with myth and allegory. From Beirut to Jerusalem, Thomas L. Friedman Having lived in Beirut as a child, I'm drawn to this area. Friedman straddles the fence between the two cultures: neigh-bors and enemies. He provides insight into the complexity of the ongoing hostility between the Arab and Jewish communities, which continues to intrigue me. Big Rock Candy Mountain, Wallace Stegner I've read and enjoyed almost everything that Wallace Stegner has written. He writes from the heart with a clear, personal and distinctly Western voice. White Man's Grave, Richard Dooling My husband was glued to this book for a week. He describes it as a marvelous paradox of American and African cultures. The story is full of irony and humor, showing a similarity between vastly different lifestyles. DON GLOVER, PH. D. Associate Director of Social Work, University Hospital Chaos, James Gleick I'd like to discover how science has been able to find meaning and order in seemingly random events. Hero With a 1,000 Faces, Joseph Campbell Campbell definitely has influenced my perception of experience. I'd like to read this book to learn how cultural myths and legends shape the human experience, particularly, how these myths shape the journey of those who transcend cultural limits. Grimm's Fairy Tales I'd like to reread these stories- the teaching stories of western culture- for their symbolic meanings. Open Secret: Version of Rumi, John Moyne and Coleman Barks The poetry of Jelaluddin Rumi, a 14th- century Sufi, is esoteric, yet grounded in the common experiences of every day. The Martian Chronicles, Ray Bradbury I enjoy science fiction, but have never read any of Bradbury's stories. CHRIS M. IRELAND, PH. D. Professor of Medicinal Chemistry, College of Pharmacy Hawaii, James A. Michener I did my postdoctoral training at the Kewalo Basin Marine BioMedical Research Lab at the University of Hawaii, where I fell in love with the islands and became fascinated with their history and the different ethnic groups that shaped Hawaii's culture. 24 Health Sciences Report Winter 1996 The Autobiography of Malcolm X, Malcolm X and Alex Haley I spent my formative years in the late 60s as an undergraduate in the University of California system, where black power and civil disobedience were hot topics. The Bourne Identity, Robert Ludlam I suppose being a " Cold War" child who grew up with James Bond, I enjoy a well- crafted, high- energy spy story with plenty of intrigue and a twisted plot. Men Are From Mars, Women Are From Venus, John Gray I figure it can't hurt to gain a little insight! Michael Jackson's Malt Whisky Companion: A Connoisseur's Guide to the Malt Whiskies of Scotland, Michael Jackson Being a natural products chemist by training, I enjoy chemistry in all of its natural forms. In addition to providing us with important medicinal products ranging from vitamins and antibi-otics to cholesterol- lowering agents, fermentation processes are the source of malt beverages. Jackson's guide would be a prerequisite for me for a trip to the Highlands of Scotland. KATHIH. MOONEY, PH. D., R. N. Professor and Director of the Division of Parent- child Nursing, College of Nursing Basin and Range, John McPhee I'm not much of a geology bug, but McPhee does a stunning job of using geology to teach the concept of " deep time." This philosophical understanding of time will not only alter your view of time, but many other perspectives as well. Stewardship, Peter Block A provocative book about designing organizations that integrate the management with those doing the work, rather than relying on hierarchies that control and direct. As incoming president of my professional specialty organization, I want to read a number of leadership books. This one is by far the most controversial, but likely offers the most innovative solutions that also could revolutionize higher education. Gift From the Sea, Anne Morrow Lindbergh Originally written in 1955, this is a simple but elegant guide to restoring perspective and meaning amid modern- day obligations. I try to re- read it every year or two. Lincoln, David Hebert Donald I enjoy comparing my impressions of historical people and events formed during my school days with the carefully researched views of historians and biographers. Lincoln is one of my favorite historical figures, so this new book is definitely on my list. L Is for Lawless, Sue Grafton A murder mystery is perhaps the most unlikely book for me to read; I avoid them. However, Grafton has me hooked! For an afternoon of light reading, I can think of nothing else so entertaining as going through her alphabet of murder mysteries. Journey to the Ants: A Story of Scientific Exploration, Bert Holldobler and Edward O. Wilson Ever since ninth grade when I typed a 20- page paper on ants, these tiny social insects have held my attention. Wilson is a noted authority on ants, a brilliant biologist and a sensitive writer; this book promises to be a remarkable account of both authors' personal adventures and scientific discoveries in the world of myrmecology. The Sagebrush Ocean: A Natural History of the Great Basin, Stephen Trimble Author, photographer and naturalist, Trimble presents the ecology and spirit of the Great Basin Desert in this detailed account of the " sagebrush ocean" landscape that lies between Salt Lake City and Reno. This book will be an education in the beauty, wonder and ecology of the desert. His photographs make the book worth the price. The Song of the Lark, Willa Cather While attending library school, I decided to make a study of Cather's writings. In reality, the demands of graduate school didn't allow for reading literature, so I put the idea on the back burner. I'd still like to read this story of a young artist and her struggle to come to terms with her talent and the constraints of her small- town upbringing. A Fish in the Water: A Memoir, Mario Vargas Llosa In preparation for a two- week bird- watching trip to Peru in February 1995, I read two fine novels by Peru's foremost writer, Vargas Llosa. His memoir, which presents his life story and experiences in running for Peru's presidency, should be very interesting, offering unique insights into this economically poor, but naturally rich, South American country. EDWARD RUDDELL, PH. D. Assistant Professor of Recreation and Leisure, College of Health The Complete Works of Aristotle, Jonathan Barnes, ed. I'm a big Aristotle fan. Philosophy is one of my strongest avocations, and I especially enjoy Aristotle's social philosophy and ethics. The Unfettered Mind, Takuan Soho When I moved to Utah, I began seriously studying the martial arts and reading about the mental and philosophical aspects of the art. This book is a martial arts classic, addressing the mental aspects of the martial arts and framed as a Zen master writing to a sword master. Sword and Brush, David Lowry The introduction includes a quote from an ancient Japanese scroll: " A flower scattering, falling without sound on moss, a flower scattering to be heard through the depths of mountains." What serious martial artist wouldn't be compelled to read further? Wandering on the Way, translation of Chuang Tzu by Victor Mair The Taoist classic, Chuang Tzu, is full of parables that are subtly humorous, zany, irreverent and mystical at the same time. Hua Hu Ching, translated by Brian Walker These are the fabled later teachings of Lao Tzu, the reputed author of another Taoist classic. Too Te Ching. The teachings are a set of aphorisms that cut deeply. JEANNE LE BER, M. S. Instruction and Information Librarian, Spencer S. Eccles Health Sciences Library North American Owls: Biology and Natural History, Paul A. Johnsgard An extraordinary ornithologist, Johnsgard has published more than two dozen books on the study of birds. Owls are fascinating creatures, and this book is sure to satisfy my curiosity for the biology as well as the folklore surrounding these mostly night fliers. Health Sciences Report Winter 1996 the University of Utah Health Sciences Center SCHOOL OF MEDICINE Venki Ramakrishnan, Ph. D., profes-sor of biochemistry, is studying The Structure of Chromatin. The DNA of higher organisms, almost a meter long if stretched out, is condensed into a cell nucleus microns in diameter with the help of DNA- binding proteins called histones. Increasing evidence suggests that, by modifying the properties of histones, the cell can make parts of the genome more or less accessible, so chromatin structure plays an important role in gene regulation. Ramakrishnan is using X- ray crystallography and biochemical methods to understand how histones interact with DNA and to learn how other proteins modify histones. e Ita Killeen, M. D., assistant professor of family and preventive medicine, and director, Family Practice Residency Program, and Christa Danielson, M. D., assistant professor of family and preventive medicine, are conducting a pilot study of Coding Practices of Faculty Physicians and First-, Second-and Third- year Residents. Educating residents on the importance of correct coding is of increasing importance in the managed care environment. Results of this study, conducted in conjunction with the Health Research Center at the Department of Family and Preventive Medicine, will assist the Family Practice Residency Program in determining which interventions are most useful when teaching residents how to code for time spent examining patients in clinic, e David A. Low, Ph. D., professor of pathology, is studying The Roles of DNA Methylation in Pili Gene Regu-lation. He is examining the expression of Pap fimbriae by uropathogenic Escherichia coli, which enable them to adhere to uroepithelial cells and are a critical factor in causing urinary tract infections. E. coli undergo a reversible switch between fimbrial expression ( ON) and non- expression ( OFF) states, which involve the methylation of specific regulatory DNA sequences. Using both biochemical and genetic techniques, he is determining the molecular basis of this phase variation mechanism, which should be useful in designing chemotherapeutic agents to block the attachment of these pathogens to host tissues, e Marina Myles- Worsley, Ph. D., assistant professor of psychiatry, is conducting A Genetic Study of Schizophrenia in an Ethnic Minority. Population isolates are useful in genetic studies of complex diseases, because disease susceptibility genes are more likely to reside on a single ancestral chromo-some, thereby increasing the probability of localizing disease gene regions using standard linkage techniques. She is searching for the genetic causes of schizophrenia in Palau, Micronesia, a geographically and ethnically isolated island population with large multi-generational clans showing high rates of the illness. If gene regions of linkage can be found, fine- scale mapping studies searching for linkage disequi-librium in affected Palauans should help to identify the specific mutations that lead to schizophrenia, e Frederic A. Gibbs, Jr., M. D., professor and acting chair of the Department of Radiation Oncology, is using Scanned Focused Ultrasound- induced Hyperthermia in Cancer Treatment. Hyperthermia is an effective adjunct to radiotherapy, although previous heating devices rarely achieved adequate tumor temperatures. Gibbs developed the system with Robert B. Roemer, Ph. D., professor, and Andrew W. Dutton, Ph. D., research assistant professor, both in the U mechanical engineering department. A joint clinical trial is being conducted with Duke University and the University of California at San Francisco, E Scott C. Miller, Ph. D., research profes-sor of pharmacology, and Fredrich Bruenger, M. S., associate research pro-fessor of pharmacology, are directing a collaboration and exchange program with the Institute of Medical Radiology, Kharkov, Ukraine, to improve methods for the Removal of Metals and Radiotoxins by Chelation Therapy. U of U investigators in the Division of Radiobiology developed orally admin-istered chelation compounds to remove metals from the body. Miller and Bruenger will explore whether some of the compounds might be useful in the Ukraine, where people have been exposed to heavy metals from polluting industries and radionuclides from the Chernobyl nuclear accident. The study, funded by the North Atlantic Treaty Alliance ( NATO), may provide new therapeutic approaches, E 26 Health Sciences Report Winter 1996 James L. Parkin, M. D., M. S., professor and chair of the Department of Surgery, and Roy Bloebaum, Ph. D., research professor of orthopedics, are studying the Osseointegration and Growth Effects of Temporal Bone Percutaneous Pedestals. They are evaluating osseoin-tegration of various pedestal materials for cochlear implant systems to help restore hearing to the profoundly deaf. Their findings will help ensure that implant systems will be well tolerated by the body, thus enhancing quality of life for deaf individuals, e COLLEGE OF PHARMACY Arthur D. Broom, Ph. D., professor of medicinal chemistry and director of the Molecular Pharmacology Program at the Huntsman Cancer Institute, is studying The Synthesis and Antiviral Activity of a Set of Novel Polynucleo-tides Containing Unusual Purines. The prototype compounds, PMTI and PMTG, have shown potent inhibition of human immunodeficiency virus ( HIV), which causes AIDS, and human cytomegalovirus ( CMV), a primary cause of blindness in AIDS patients. In the next few years, Broom, along with researchers at the Southern Research Institute in Frederick, Maryland, and Utah State University, will develop technology for large- scale production of these compounds for animal and clinical trials, E COLLEGE OF NURSING B. Lee Walker, Ph. D., R. N., assistant professor in the Division of Social and Behavioral Systems in Nursing, and Lillian M. Nail, Ph. D., R. N., associate dean for research and associate pro-fessor, are conducting " Facilitating Adjustment: Preparation vs. Expres-sion" to test an intervention aimed at providing specific information about what cancer patients can expect following the completion of radiation treatment. Most research on cancer patients' adjustment focuses on the treatment phase of illness or specific physical problems encountered years later. This study will test the effective-ness of an information intervention in improving psychosocial adjustment, n COLLEGE OF HEALTH Stephen C. Johnson, Ph. D., associate professor of exercise and sport science, is investigating The Physiology of Exercise Riding. Exercise riders are becoming one of the most popular home exercise devices, yet very little is known about the human physiology of exercise on them. Johnson will compare and quantify the magnitude of the metabolic and general systemic responses on the rider with those of other popular exercise devices, so he can characterize the rider's exercise mode. Professionals then may make appropriate recommendations on the quality of exercise on this new equipment. E Laurie J. Moyer- Mileur, Ph. D., R. D., C. D., assistant professor of foods and nutrition, is examining the effects of Physical Activity, Diet and Bone Mass in Premature Infants. Preliminary results from the study, in collaboration with a researcher at the University of Cincinnati, indicate that activity significantly increases bone density, which, in turn, should decrease a pre-mature infant's risk of non- traumatic fracture. The study will follow the infants through their first 12 months and should provide useful information for their clinical management, e Diane E. Nicholson, Ph. D., P. T., N. C. S., assistant professor of physical therapy, and Judith L. Gooch, M. D., associate professor of physical medicine and rehabilitation in the School of Medicine, are studying The Effects of Physical Restraint on Upper Limb Function of Children with Hemiparesis Secondary to Cortical Brain Injury. After a cortical injury, children learn to perform activi-ties using the ipsilateral arm, which they continue to use even after motor performance returns to the contralateral arm. By physically restraining the ipsilateral arm, researchers hypothesize that they can negate the effects of learned " non- use" of the contralateral arm in these children, e Linda S. Ralston, Ph. D., assistant professor of recreation and leisure, and Fen Ju Lin, a master's degree candidate, investigated The Influence of Attitudes, Subjective Norms and Perceived Behavioral Controls on Hotel Guests' Intention to Return: A Conceptual Model. They studied factors influencing guests' attitudes toward returning; subjective norms with respect to returning; perceived behavioral controls over returning; and guests' intentions of returning to a specific Salt Lake City hotel. Their study, which received the 1995 Excellence in Research Award from the Resort and Commercial Recreation Association, will be helpful to the lodging industry as it expands to accommodate the 2002 Winter Olympics, e Health Sciences Report Winter 1996 GIFT OF HEALTH HUNTSMAN FAMILY GIVES $ 100 MILLION TO CANCER RESEARCH Construction will begin this year on the Huntsman Cancer Institute building at the University thanks to a $ 100 million contribution from the Jon M. Huntsman family last October. The gift, to be made over a 10- year period, is the third largest cash gift ever made to a university in the United States, as well as the third largest ever to a public institution. " Our family's commitment is to help find a cure for cancer," said Mr. Huntsman. " We feel that, by combining internationally recognized scientists with a first- rate medical school, along with generations of genealogical records kept in Utah, the opportunity for a significant breakthrough never has been better. Cancer will be defeated." Funds to the Huntsman Cancer Institute will be used to build and equip a state- of- the- art research and treatment facility east of University Hospital, and to recruit top scientists, COMMITMENT TO CANCER- Standing before an architect's model of the Huntsman Cancer Institute building are, from left, Jon M. Huntsman, Jr., president and CEO, Huntsman Cancer Foundation; Raymond L. White, Ph. D., institute executive director; and Jon M. and Karen H. Huntsman. Barry C. Cole, Ph. D. clinicians and other cancer specialists. The center is directed by Raymond L. White, Ph. D., professor and chair of oncological sciences at the School of Medicine. " The Huntsman gift of $ 100 million represents one of the largest gifts ever made to an American university," said Arthur K. Smith, Ph. D., University of Utah president. " We are profoundly grateful to Jon and Karen Huntsman, and their family for their extraordinary act of philanthropy." The Huntsman Cancer Institute was launched in 1993 with an initial pledge of $ 10 million from the Huntsmans to the University's cancer research efforts. At that time, the family said their goal was to raise $ 100 million over 10 years to create one of the world's foremost cancer research and treatment facilities. Both of Mr. Huntsman's parents died of cancer. He was treated for prostate cancer at University Hospital in 1992. Mr. Huntsman is chairman of the board and CEO of the Huntsman group of companies, which include Huntsman Chemical Corporation and Huntsman Corporation ( formerly Texaco Chemical Company). Their 1995 sales revenues reached an estimated $ 4.3 billion, n CHILDS' GIFT COMPLETES CHAIR HONORING WOMEN A $ 550,000 gift from William and Patricia Child completed funding last fall for an endowed chair in the School of Medicine: The William H. and Patricia N. Child Presidential Endowed Chair in Radiology Honoring Pioneer-ing Utah Women in Medicine. The chair was initiated several years ago by Anne G. Osborn, M. D., professor of radiology, who wanted to highlight the history of Utah women in medicine as well as their role and opportunities at the School of Medicine today. Chairholders will be outstand-ing women faculty who exemplify the characteristics of pioneering Utah women in medicine. An anonymous donor also contributed to the chair. Originally, this gift provided an annual stipend for four years to release part of Dr. Osborn's time for educational outreach. The donor later redirected funds to the chair endowment, while the Department of Radiology continued to release Dr. Osborn's time for international education. A native of Syracuse, Utah, Mr. Child is the chief executive officer of R. C. Willey Home Furnishings. After attending Davis High School and Weber College, he married Darline Willey. Her father, Rufus C. Willey, had launched his home furnishing business in 1932 by selling appliances from the back of a pickup. He later opened his first store in Syracuse. Mr. Child, who earned a bachelor's degree from the University of Utah in 1954, took over the growing business after his father-in- law's death. He and his wife had four children. Following her death, Mr. Child married Patricia Wright, and they also had four children. In 1978, Mr. Child received a Distinguished Alumni Award from Weber State College and, in 1983, an Honorary Doctor of Humanities. He served on the college's Board of Trustees from 1987- 91. In 1989, he was named National Retailer of the Year. A member of the University's Health Sciences Council, Mr. Child also serves on Pioneer Theatre Company's Advisory Board and numerous other community boards, b BARRY COLE NAMED TO ENDOWED CHAIR IN RHEUMATOLOGY Barry C. Cole, Ph. D., professor of internal medicine at the School of Medicine, was named to The Nora Eccles Harrison Presidential Endowed Chair in Rheumatology last October. The chair was established in 1987 by the Nora Eccles Treadwell Foundation, one of the University's largest single private donors, contributing more than $ 28 million in the past 20 years. A native of Baker City, Oregon, the late Mrs. Harrison lived her forma-tive years in Logan, Utah. She was president of the Nora Eccles Treadwell Foundation until her death in 1978. The foundation operates under the direction of her husband, Richard Harrison, and Patricia A. Canepa, president and chair. Dr. Cole, a Utah faculty member since 1970, is internationally known for his work in the arthritogenic properties of microbial agents and their mecha-nisms of action. In the early 1980s, he pioneered the field of superantigens, now recognized as an important new group of agents believed to play a role in human autoimmune diseases, such as arthritis and diabetes, and possibly in infectious diseases, such as AIDS. ( continued on next page) Health Sciences Report Winter 1996 H. James Williams, M. D. Dr. Cole was born in Watford, England, and received his under-graduate and graduate training at the University of Birmingham, England. He immigrated to the United States in 1965. The author of more than 150 articles, he is active in a number of professional organizations, including the American College of Rheumatology, American Association of Immunologists, the American Society for Microbiology and the International Organization of Mycoplasmology. b WILLIAMS NAMED TO JEREMY CHAIR H. James Williams, M. D., professor and chief of the Division of Rheumatol-ogy in the School of Medicine, was named in January to The Thomas E. and Rebecca D. Jeremy Presidential Endowed Chair for Arthritis Research. The late Rebecca Jeremy established the chair after her husband's death in his honor and as a tribute to John R. Ward, M. D., who has retired from the medical school faculty after a long career as professor and chief of the rheumatology division. Ward diagnosed Jeremy's health problem as rheumatoid arthritis and cared for him for 20 years. Dr. Ward dedicated himself to help-ing her husband, Mrs. Jeremy said in an 1988 interview, and she credited the U physician with keeping her husband walking, instead of being confined to a wheelchair. Research leading to the cause of rheumatoid arthritis would be more worthwhile than naming a building for her husband, she said. Dr. Williams, a member of the U faculty since 1975, has been a professor of internal medicine in the rheumatol-ogy division since 1986 and chief of that division since 1990. He has been associate chair of the Department of Internal Medicine since 1980 and is director of Cooperative Systematic Studies of the Rheumatic Diseases, under contract with the National Institutes of Health. He serves on the editorial board of Arthritis and Rheumatism, and has contributed numerous chapters, articles and abstracts to professional publications. He chairs the Student's Committee, American College of Physicians, Utah Chapter, and has served the Utah Chapter, Arthritis Foundation, in several capacities. Dr. Williams is a diplomate of the American Board of Medical Examiners, the American Board of Internal Medicine and the American Board of Internal Medicine, Rheumatology; and a fellow, American Rheumatism Association, and the American College of Physicians. Dr. Williams, who served as a major in the U. S. Army Medical Corps from 1973- 75, received his bachelor's and medical degrees from the U. He completed an internship and residencies at Duke University Medical Center, and a rheumatology fellowship at the U. e KECK GRANT FUNDS RESEARCH ON FAMILIES A $ 1 million grant from The W. M. Keck Foundation will enable scientists at the University's Eccles Institute of Human Genetics to re- examine members of 47 Utah families whose DNA samples became the basis for a worldwide genetic bank for scientists. " The Keck Foundation grant makes it possible to revisit nearly 1,000 people from 47 of the original reference families," said Stephen M. Prescott, M. D., professor and director of the University's Program in Human Molecular Biology and Genetics ( HMBG), which will conduct the special project. " We have detailed information about their DNA; now, we plan to collect information on their health and compare this information with their DNA patterns. This should lead to important new insights into the role of inheritance in determining our health and to the discovery of genes respon-sible for common adult diseases." Families are the raw material for genetic studies. In order to identify genes that make people susceptible to specific diseases and traits, researchers look for differences in DNA through generations, matching genetic varia-tions with the presence of disease, such as hypertension and heart disease, or traits, such as eye color. Twelve years ago, University geneticists established an international archive to compile and coordinate map-ping information from a set of reference families- 47 from Utah and 13 from France- whose DNA was stored and made available to scientists worldwide 30 Health Sciences Report Winter 1996 Marvin G. Hess, M. S. working on detailed genetic maps of the human chromosome. They now have established more than 10,000 markers on human chromosomes and, at the same time, have determined the pattern of DNA for each of the individuals in the families. The W. M. Keck Foundation was established in 1954 by William M. Keck, founder of Superior Oil Company, one of the nation's largest independent pro-ducers of oil and gas. One of the four specific areas funded by the foundation is medical research, E HESS HONORED WITH SCHOLARSHIP An endowed scholarship honoring Marvin G. Hess, M. S., was established last spring on his retirement from the College of Health. The scholarship, funded by contri-butions from Mr. Hess, his colleagues and former students and wrestlers, is scheduled to be awarded this year. Mr. Hess has indicated he would like the recipient to be an undergraduate student athlete who plans to pursue teaching and coaching. Mr. Hess, assistant professor of exercise and sport science, served the University for 45 years as both faculty member and coach. He was head wrestling coach from 1955- 80, head track coach from 1958- 64 and an assis-tant football coach. He was inducted into the Utah Sports Hall of Fame in 1984 and the University's Crimson Club's Hall of Fame in 1993. His wrestling activities also brought him national recognition. In 1970, Mr. Hess was inducted into the Helms Amateur Wrestling Hall of Fame and, in 1991, was named " Man of the Year" by the Amateur Wrestling Association. The following year, he was inducted into the National Wrestling Hall of Fame. A Utah native, Mr. Hess received a bachelor's degree in physical education in 1951 and a master's degree in 1954, both from the University, e HHMI GRANT TO SUPPORT NEW HMBG FACULTY The Howard Hughes Medical Institute awarded a $ 2.4 million grant last January to the Program for Molecular Biology and Genetics ( HMBG) at the University's Eccles Institute for Human Genetics. The funds will enable HMBG to recruit 12 physician- scientists and support them while they obtain advanced research training and estab-lish independent laboratories. Together with sponsoring departments from the School of Medicine, the HMBG program also will provide mentors and financial support for the research projects. Directed by Stephen M. Prescott, M. D., professor of internal medicine, the HMBG program encourages the application of genetic research to human health by building a bridge between research and clinical medicine. The program consists of 19 faculty members with joint appointments in HMBG and medical school depart-ments, including internal medicine, pediatrics, human genetics, radiology, biochemistry, neurology, neurosurgery, ophthalmology and obstetrics and gynecology. The Howard Hughes Medical Institute, a nonprofit scientific and philanthropic organization, supports major research at the University, e DYNATECH GIFT HELPS DNA LAB The University's DNA Diagnostic Laboratory will be able to lower the cost of testing families with genetic disease thanks to a $ 10,000 contribution from Dynatech Video Group last July. The lab will use the gift, along with matching funds, to purchase new auto-mated equipment, enabling it to lower significantly the cost of testing, accord-ing to director Kenneth J. Ward, M. D., associate professor in the departments of obstetrics and gynecology, and human genetics. Only one in 13 fami-lies who contact the DNA Diagnostic Laboratory can afford to pay for the testing, which runs from $ 600- 1,000 per family. Dr. Ward estimates that there are more than 5,000 known genetic dis-eases; one in every 20 children is born with a genetic disease. A communications business, Dynatech Video Group provides equipment for the management, presentation, routing and distribution of video, audio and data communica-tions. Headquarters are in Salt Lake City with sales, research and develop-ment, and manufacturing facilities in Madison, Wisconsin; Ft. Lauderdale, Florida; England; and Hong Kong, e Health Sciences Report Winter 1996 OPINION W^ th fewer dollars available to fund medical research, what considerations should be weighed when deciding whether to fund basic research or clinical research projects? Andrew T. Pavia, M. D. By ANDREW T. PAVIA, M. D. Assistant Professor of Internal Medicine and Pediatrics, Divisions of Infectious Diseases, School of Medicine To ask whether we would get the most benefit from limited medical research dollars in basic science or in clinical research attempts to create two opposing camps of medicine. Such a conflict can arise out of academic prejudice and competition. However, in medicine, basic research and clinical research are closely intertwined and interdependent. As Louis Pasteur wrote, " No category of science exists to which one could give the name of applied sciences. There are science and the applications of science, linked together as fruit is to the tree that has borne it." AIDS research provides an example. Clinical trials of new antiviral drugs to control the human immunodeficiency virus ( HIV) or to treat complications are the final step in providing practical, direct benefits to patients. In the past year, clinical trials have demonstrated important advances, including the use of combination therapy with nucleoside analogues and an exciting new class of agents that attack a different target, the HIV protease enzyme. However, these advances would not have been possible without basic research. Understanding the kinetics of high-level viral production in HIV disease, describing the genetic makeup of the virus and understanding the genetic basis of its ability to mutate to become resistant to antiviral drugs are among the advances in basic research that made these clinical advances possible. Drugs that inhibit HIV protease could be developed only after the enzyme was isolated and its three- dimensional structure discovered. Methods to measure the amount of circulating virus originally were limited to basic scientists, but now allow clinical investigators to measure directly the effect of drugs on the virus. These techniques promise to speed the devel-opment of new and better treatments. However, several ideas that seemed promising in the laboratory have proven useless when carefully studied in patients, again showing that clinical trials and basic research cannot proceed without each other. Another problem with dividing research into two separate and distinct categories is that it ignores public health research, which has the greatest potential to prevent disease. For example, the most dangerous food-borne disease of our time is E. coli 0157: H7, best known for the large outbreak in Washington state, where undercooked contaminated hamburger caused more than 600 cases of bloody diarrhea and three deaths. Much of our understanding of this disease comes from neither basic nor clinical research, but from epidemiologic studies and outbreak investigations by public health scientists. Research on health economics, cost- benefit and efficacy are other areas ignored in the artificial dichotomy of basic versus clinical research. Unfortunately, research planning and priorities often are not set in a rational manner. Researchers feel 32 Health Sciences Report Winter 1996 / / / / / // pressured to conduct studies that can lead to funding, publication and promotion. Department chairpersons and grant reviewers also have their own strong prejudices as to which areas are important or relevant ( often, the area in which they work). Funding agencies and politicians wade into the debate at our peril, since they may have a limited understanding of important scientific questions. Valuable research asks important questions, is done carefully and expertly, and is woven into the fabric of understanding biology, medicine and health. The quality and thoughtfulness of the question, the quality of the research and some degree of luck determine if it will benefit human health, r Your opinions regarding this column or other facets of Health Sciences Report are welcome and may be printed in a " Letters" section of a future issue of the magazine. Address letters to Editor, Health Sciences Report, Office of Public Affairs, University of Utah Health Sciences Center, 50 North Medical Drive, Salt Lake City, UT 84132. FAX: ( 801) 585- 5188. E- mail: Susan. Sample@ hsc. utah. edu. Sherrod Beall and Dr. David Green offered helpful advice for nurtur-ing the health of the emerging generation on the " Opinion" page in the Winter 1995 Health Sciences Report. In particular, Beall's emphasis on encouraging personal and family situations that systemically will lead to physical and emotional balance was perceptive. However, one of the most significant factors was ignored, as it tends to be in most such discussions. That factor is the dominant shift in the American family in the past two generations and has accompanied the alarming rise in violence, alienation, dysfunction and suicide at younger and younger ages. It is the persistent and pernicious exclusion of fathers from the core family structure. In divorce and custody decisions made by courts, in the demands of the workplace, in the de facto treatment of fathers by custodial mothers, and in the bureaucratic handling of social services provided to troubled families, the role of fathers in the lives of their children has been institutionally minimized. The effect has been devastating. Beall stated, " resiliency or protective factors" include " families, regardless of their socioeconomic status, which were marked by warmth, cohesiveness and presence of some caring, responsible adult." In spite of often spiteful gender politics, fathers really can help their kids. If we want the next generation to grow up strong and balanced, fathers should not be excluded from families, as they are in the current legal system, m Matthew R. Sorenson Salt Lake City Health Sciences Report Winter 1996 33 Office of Public Affairs University of Utah Health Sciences Center 50 North Medical Drive Salt Lake City, Utah 84132 ( 801) 581- 7387 Nonprofit Organization U. S. Postage Paid Permit No. 1529 Salt Lake City, Utah