Mr. Chairman, it is a pleasure to be here today to describe for you
NINR-supported research that demonstrates the relevance and rich variety of our research
endeavors. I also look forward to discussing our current and planned activities for
Fiscal Year 1998. The Nation's investment in health research has resulted in improved
health for our citizens. However, many more questions remain to be answered. This is
particularly true when we look at the implications of changing demographic trends on
the health of our Nation. The Nation's population is shifting to the upper decades of
life. With longer lives, we can expect an increase in chronic illnesses, which will
require longer and more costly health care. The demand for innovation through nursing
research discoveries has never been greater.
Nursing research is an emerging science that adds a vital and necessary
perspective to the conduct of research. Although the search for cures continues,
research on improved care is a parallel necessity. Nursing research focuses on the
patient in the pursuit of answers. This, in turn, can lead to basic laboratory studies or
clinical research, as well as to research on prevention of disease and promotion of
healthy life choices.
To demonstrate the contributions of nursing research, I would like to begin my
discussion of research funded by the Institute by highlighting a health concern that we
have all felt -- pain. Pain generates nearly 40 million visits to health care providers,
can prolong hospital stays, and may impede recovery. Pain research is complicated,
because while we all share a basic common physiology, we do not react to pain the
same way.
Recent findings from an NINR-supported study on pain have generated
national, scientific and media attention. In addressing the influence on pain of a variety
of factors, such as age and ethnicity, NINR-supported researchers focused on the role of
gender -- the first such study-- to determine if women and men respond differently to
painkillers. When completed, the study showed that women could obtain pain relief,
with fewer side effects, from commercially available but seldom used painkillers
known as kappa-opioids, such as nalbuphine or butorphanol. Men, however, were not
so fortunate. They received little benefit from the drugs. Kappa-opioids were tested on
young men and women who had their wisdom teeth removed which, as many of us
know, produces moderate to severe pain. Although kappa-opioids are in use to ease
women's labor pains, they are not generally in use for other pain reduction. Earlier
clinical testing, primarily on men, found these same painkillers ineffective.
Consequently, morphine-like opioids are typically used because they are effective in
both men and women. However, they can have the undesirable side effects of nausea
and disorientation. The recent findings present further questions about effective
management of pain. For example, we need to understand better the role of hormones
on the perception of pain. How do estrogen or testosterone mediate pain? Do women
have more kappa receptors on certain nerve cells than men, thus enabling kappa-opioids
to block pain better? Another question is are there gender differences in the way the
brain regulates pain relief?
Clearly, this continues to be an important area of research, with many yet unanswered
questions about better pain management for everyone.
With regard to another health problem, one that affects 10 to 15% of Americans
and two or three times more women than men, nursing researchers have made
important advances in understanding the mysteriously caused, unpleasant
gastrointestinal symptoms known as irritable bowel syndrome, or IBS. This disorder
accounts for more than two million medical prescriptions, 3.5 million physician visits,
and 34,000 hospitalizations each year. Existing research suggests IBS may result from
heightened arousal of the sympathetic nervous system, which governs the involuntary
activities of internal organs, including the intestines. With the goal of preventing and
treating IBS, NINR-supported investigators studied three neuroendocrine markers --
norepinephrine, epinephrine, and cortisol -- which indicate levels of sympathetic
nervous system activity. Three groups of women were studied, including a group of
patients diagnosed with IBS. Scientists found this group to have significantly higher
norepinephrine levels in the evening and morning, and higher epinephrine and cortisol
levels generally. Not unexpectedly, the patient group reported higher levels of stress,
the only consistent variable that accounted for higher arousal of the sympathetic
nervous system. As a next step, researchers will be designing screening programs to
distinguish between behavioral and physiological causes of IBS. The results of this
research will also have important implications for cost effective therapies. Currently,
IBS is diagnosed very indirectly -- through a process of eliminating other causes. How
many doctors visits could be avoided, with what savings to the health care system, if a
positive diagnosis were possible based on scientific methods?
Although cardiovascular disease is decreasing, it is still the number one killer of
more than 950,000 Americans each year, and accounts for at least $2 billion in
Medicare expenditures. Those who live with the disease may undergo invasive
therapeutic procedures, such as angioplasty or bypass operations. Extensive lifestyle
changes are usually required to preserve health. The roots of cardiovascular disease
often go back to childhood, and risks intensify as age increases. Interventions early in
life are key to achieving a healthy adulthood. Nursing investigators have designed and
tested an eight-week intervention to reduce cardiovascular risk factors in more than
2,200 third and fourth grade school youngsters in rural and urban areas, almost 20 % of
whom were African-American. By the study's end, students showed reductions in total
cholesterol levels, body mass index, and body fat. The children also showed increased
physical endurance. This intervention is being expanded to 1,600 middle school
students, 26% percent of whom are African-American. The focus of this study will be
on those living in rural areas.
Threaded throughout NINR's research portfolio is a responsiveness to ethnic
and cultural diversity. As we learned from important findings on the effect of gender in
pain, health care models need to address the requirements of diverse populations to be
effective and ensure improved health outcomes. From the research perspective,
questionnaires and health assessments written only in English exclude many
non-English-speaking subjects from health research. Consequently, ethnically and
culturally diverse groups miss the opportunity to participate in protocols, and research
findings will not adequately address their health needs. To deal with this issue,
NINR-supported researchers adapted an English language Arthritis Self-Management
Program for Hispanic patients with arthritis. Hispanics represent about 9% of the U.S.
population. About 20% are unable to speak English well, and about 11% are affected
with arthritis and other rheumatic conditions. Seven health assessment scales were
translated into Spanish and incorporated into questionnaires answered by Hispanic
subjects about various aspects of their health. Findings indicate that the reliability and
validity of the scales were not compromised in the translation process, and were
appropriate for a variety of Spanish speakers of different national origins and regions.
The research I have briefly described today is but a sample of NINR's research
portfolio. The vitality of research, however, stems from the many questions that still
remain to be answered. Therefore, I would like to discuss briefly several research
emphases for the fiscal year ahead: symptom management for chronic neurological
conditions; managing traumatic brain injury; improving quality of life for
transplantation patients; and attending to end-of-life care issues.
Two out of three Americans seek treatment in any given year for problems
involving the brain or nervous system at tremendous cost to the health care system.
The NINR will continue to support research dealing with symptoms typically
associated with such neurological disorders as stroke, epilepsy, Parkinson's disease,
and spinal cord injury. Symptoms include problems with mobility, pain, sleep and
depression. We also seek to identify factors related to successful family caregiving,
both from patient and caregiver perspectives. Collaborations addressing these issues
will be sought with other NIH institutes and the Veteran's Administration.
Another neurological issue, managing traumatic brain injury, also involves
nursing researchers. Traumatic brain injury alone accounts for the hospitalization of
500,000 people each year. Two-thirds survive with impaired brain function, and
another 5,000 develop epilepsy. Much of the damage that results from traumatic brain
injury is caused not by the initial injury but by the cascade of biochemical events
triggered by the injury. If untreated, brain tissue and cells are deprived of sufficient
oxygen, leading to the formation of metabolic toxins that contribute to the progressive
deterioration of the brain. NINR, in collaboration with a number of other NIH
Institutes and Centers, is supporting the development of promising antiacidosis
therapies to prevent this progression and its destructive sequelae. Last year, NINR
reported success in neutralizing metabolic toxins using an antioxidant, deferoxamine, in
an animal model. NINR will continue to investigate the role of antiacidosis therapies in
protecting viable brain tissue as a treatment for head trauma. In order to focus attention
on the prevention, treatment, and rehabilitative needs of children, NINR is
cosponsoring an NIH consensus development conference on managing traumatic brain
injury. A program announcement regarding research directions identified by this
conference will be issued in FY 1998.
Thanks to health research, twelve thousand Americans benefit from an organ
transplant each year. Many of these patients, the majority of whom have received
kidney transplants, have survived into their 50s and 60s, and are following long-term
drug regimens, including steroid and immunosuppressive therapies. These regimens
are not without side effects, such as osteoporosis, cancer, neurologic impairment,
cardiac dysfunction and atherosclerosis. In seeking answers about management or
prevention of these complications, the NINR is a partner with other institutes on an
interdisciplinary NIH workgroup that will explore research opportunities aimed at
improving the quality of life of long-term transplantation survivors.
Complex issues associated with the end of life have been receiving considerable
national attention. NINR funds studies of bioethical, biological and behavioral issues
directly related to the end of life. For example, its research portfolio includes
management of pain; family decisionmaking for patients who are incapacitated; and
surveys of end of life medical and supportive practices. This year a workshop will be
cosponsored by NINR and other NIH institutes to identify research needs in palliative
care. NINR will also collaborate in issuing a program announcement in 1998 on end-of-life
care, which will address four critical issues: 1) managing the transition to
palliative care, 2) understanding and managing pain and other symptoms, such as
nausea and depression, at the end of life, 3) measuring results, such as relief of
symptoms, and 4) documenting costs for patients and family caregiving during end-stage
illness.
As NINR begins its second decade at the NIH, current and emerging research
and societal issues intensify the need for the perspectives of nursing research.
Clinically-based, patient-oriented nursing research is well positioned to make important
contributions to improving health and quality of life for our citizens.
Mr. Chairman, the FY 1998 request for NINR is $55,692,000. I will be pleased
to answer any questions you might have.
