Decision Making, of the worst kind

A top-flight research hospital like Duke has the ability to pour tremendous resources and technology into saving the lives of newborn children who might otherwise have died within days, weeks, or months.

And it often does.

How does a family torn between hope, grief, guilt and despair sort out all the probabilities and technicalities? Do faith and hope make a difference? How do they live with the choices they've had to make?

Duke nursing professors Sharron Docherty (pictured here) and Debbie Brandon are trying to understand this complex, enormously stressful situation by doing a long-term study that they hope will help other parents and health care providers make these wrenching decisions in the future.

Funded by a 5-year, $2 million grant from the Institute of Nursing Research in the NIH, their study will enroll as many as 40 families with newborns who are extremely pre-term (before 26 weeks), have serious heart abnormalities, or genetic conditions requiring a stem cell transplant. Health care workers will be part of the data too, since they're part of the decision-making.

Probably 40 percent of these children won't make it to their first birthday, Docherty said. The survivors will likely face continued illness.

Doctoral candidate Kimberly Allen, RN describes one study case of a child who had cardiac arrest at 9 days of age, surgery on day 10, an abdominal surgery for another condition at 28 days, and again at 30 days, whereupon the baby died.

"How do you decide to go back in (for additional surgery)?" Allen asks. When -- and how -- do you make the excruciating decision to simply keep the baby comfortable and let it pass? "We tend, at a hospital like Duke, to do everything we can," Docherty said. Even though it may be a lost cause.

Families and caregivers are interviewed and given questionnaires at regular intervals for a year in an attempt to measure their thoughts, fears, hopes, and feelings throughout the roller coaster ride. The data are more qualitative and subjective than a statistician might like, but "this is the only way to do it," Docherty said at a recent research open house in the School of Nursing. "We've looked at decision-making for decades and haven't really got at this. We've been able to see a tree, but not the whole forest."

The team is working on ways to visualize their complicated findings with the Renaissance Computing Institute (RENCI). Read the abstract of their pilot study. (PDF file)

Engineering Futuristic Medicine

Massachusetts Institute of Technology professor Robert Langer gave a National Academy of Engineering summit focused on addressing worldwide needs a primer on how engineers can aid medicine.

One big challenge is figuring how to get "drugs of the future" into the human body in a way that can do some good, said the chemical engineer who won the 800,000 Euro 2008 Millenium Technology Prize for some of his innovations. Langer himself has "found over 200 different ways to get that not to work," he said in an address on Monday, March 9 at the Durham Performance Art Center.

The problem is that such large molecular weight drugs -- such as hormones, proteins, peptides and forms of DNA -- must reach targets such as a pancreatic cell in diabetes treatment or a tumor cell in cancer therapy without being chewed up by the body's own biochemistry. One successful stratagem his group has pioneered is placing the drug inside a protective polymer coat.
Another idea is designing polymers that be threaded though tiny bodily passages and then shift their shapes at internal body temperatures.

Langer's team has also created polymer scaffolds that experiments show may be usable to nurture cells needed to repair burned tissue, grow new noses or ears, even repair damaged spinal chords.

Aspirin: Small Dose, Big Benefits

In today's world of skyrocketing health care costs, it's nice to be reminded that cheaper sometimes is just as good -- or even better -- than expensive.

Duke medical center researchers have shown this to be true when it comes to using aspirin to prevent heart attacks, stroke or death among patients with cardiovascular disease. They found that using low doses of the 100-plus-year-old drug is just as effective as higher doses.

Moreover, low-dose aspirin -- commonly in the 81 milligram "baby aspirin" range -- worked just as well as several newer drugs.

"When you put aspirin up against newer medications like the cholesterol-lowering statins or blood pressure-reducing ACE-inhibitors -- which can be very expensive -- you see a similar pattern of benefit," says study investigator Dr. Jeffrey Berger, a cardiologist at the Duke Clinical Research Institute (photo above).

Results of the study, published in the January 2007 issue of the American Journal of Medicine, are described in a medical center news release.

The study also has had another result: it reminded me that many people at risk of developing heart problems -- including, in my case, men over 40 -- can benefit by taking a low dose of aspirin each day.

Of course, aspirin can cause side effects, such as serious bleeding, in some patients. So, as they say in the ads, consult your doctor -- but do keep in mind the potential health benefits of the lowly, often overlooked aspirin tablet.