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Testimony on National Institute of Nursing Research's FY 1998 Budget by Dr. Patricia A. Grady
Director, National Institute of Nursing Research
National Institutes of Health
Accompanied by
Ms. Mary Cushing, Executive Officer, NINR
Ms. Ellen Moul, Budget Officer, NINR
Dr. Harold Varmus, Director, NIH
Mr. Dennis P. Williams, Deputy Assistant Secretary, Budget, DHHS

U.S. Department of Health and Human Services

Before the Health and Human Services, Education and Related Agencies
March 5, 1997

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.

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