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Pollution, sitting still and processed foods – things wreaking havoc on our immune systems

Environment triggers seem to throw the gut and its microbiome off balance first.

In 1932, New York gastroenterologist Burrill Crohn described an unusual disease in 14 adults. The patients had bouts of abdominal pain, bloody diarrhea, and lesions and scars on the bowel wall. Doctors in other parts of North America and Europe were seeing it in their patients, too. They called the rare condition Crohn’s disease. After World War II, the number of new people getting inflammatory bowel disease (Crohn’s disease and a related condition called ulcerative colitis) skyrocketed across the West in countries such as the U.S., Canada and the UK. In the last three decades, IBD has begun to crop up in newly industrialized parts of the world like Hong Kong and China’s big cities.

Other conditions, such as type 1 diabetes, rheumatoid arthritis and multiple sclerosis, are becoming more common, too. These diseases affect different parts of the body, but they all have one thing in common — they’re marked by a malfunctioning immune system. Doctors call these illnesses immune-mediated diseases. (Autoimmune diseases are a subset of these, though the terms often are used interchangeably in the popular press.) More than 100 conditions fall into this category. For the most part, these diseases are chronic and cause long-lasting disability. Most were rare or completely unknown until recently, but now constitute what some experts call an epidemic. In Hong Kong for instance, the incidence of IBD spiked 30-fold between 1985 and 2014.

“If you look at the past 100 years, you see a huge explosion of diseases that haven’t been seen at any other time in human history,” says Gil Kaplan, a gastroenterologist at the University of Calgary.

No one knows for sure what’s behind the increase in immune-mediated disease. However, Kaplan and others are now discovering that human-wrought environmental changes may play a major role.

The environment-immune connection

The immune system protects us from infection by attacking disease-causing organisms and substances that enter the body. But in people with immune-mediated diseases, the cells of the immune system go rogue and start to attack healthy tissues. “We don’t really know why the immune system goes wrong in most cases of disease,” says Michael Pollard, an immunologist at The Scripps Research Institute in La Jolla, California.

Genes likely play a major role, he says. But genes alone can’t account for the recent spikes in disease incidence, since genetic factors rarely cause big shifts in a single generation.

It’s likely, Kaplan says, that factors in the environment trigger immune disorders in genetically susceptible individuals. Understanding those environmental factors will help researchers devise more effective treatments for disease and guide prevention efforts.

“Environment” here encompasses all the things we eat, drink and breathe — from food to industrial chemicals and the drugs we put into our bodies. Scientists refer to this entire landscape as the exposome — all of the exposures that come from outside a person’s body. And combing the exposome for disease triggers is a huge job.

Some of the earliest evidence of environmental risk factors for immune-mediated disease comes from the “dusty trades” — mining, quarrying, tunneling and stonemasonry. Researchers have long suspected that occupational exposure to silica dust may account for the higher rates of autoimmune rheumatic diseases, including rheumatoid arthritis, lupus and scleroderma (a skin condition) found in individuals working in these jobs.

But exposure to silica dust is rare and isn’t a factor for most people with these diseases, says Sasha Bernatsky, an epidemiologist at McGill University in Montreal. She’s investigating a more ubiquitous airborne pollutant — fine particulate air pollution generated by activities such as fossil fuel combustion. Exposure to fine particulates “affects millions of North Americans and thus is potentially a much more important exposure than most other environmental factors evaluated to date,” she says.

Bernatsky and colleagues have found that air pollution exposure — a hallmark of modern life — may be associated with a number of autoimmune rheumatic diseases in regions of Alberta and Quebec, Canada. Tiny air pollution particles can trigger immune system cells that cause inflammation, a potential pathway for an aberrant immune response, say the researchers. Previous studies have suggested that air pollution may play a role in the development of IBD.

Haze due to particulate matter over North China in October 2014. (Image: NASA Goddard Space Flight Center/Flickr)
Haze due to particulate matter over North China in October 2014. (Image: NASA Goddard Space Flight Center/Flickr)

Researchers are also probing larger societal shifts wrought by industrialization. A sedentary lifestyle may increase risk of Crohn’s disease. And some studies have shown that use of antibiotics during childhood may be a risk factor for Crohn’s disease.

Across Asia’s rapidly urbanizing regions, a change in eating habits may be one of the most pronounced fingerprints of environmental change, says Siew Ng, a gastroenterologist at The Chinese University of Hong Kong. In one generation, Asian diets have shifted to look more like those in the West.

“A couple decades ago there was an emphasis on fresh food. Now people eat more processed convenience foods,” Ng says. She’s initiated a large study across nine Asian countries to look at environmental risk factors for IBD. She hopes to determine whether factors such as dietary change may be linked to the spikes in IBD in those countries.

The environment inside us

How exactly environmental factors such as air pollution or urbanization may increase disease risk in some people remains a puzzle. But scientists are beginning to put together the pieces. So far, many signs lead to the gut and its microbiome — the trillions of microscopic bacteria, viruses and fungi that reside there.

“In the last decades, we’ve started to think about the environment as two entities — the one around us and the one inside us,” says Kaplan.

“Everything that comes into our body has to go through the microbes first,” says Karen Madsen, a microbiologist at the University of Alberta. Some of the microbes in the gut are helpful. Others are harmful. A healthy gut depends on just the right balance. Some of the substances that enter our bodies have the ability to change the natural composition of those microbes, tipping the balance toward the harmful ones.

A bad balance of microbes can lead to an errant immune response, Madsen explains. People with IBD and other immune-mediated diseases tend to have fewer protective bacterial species and more potentially harmful ones. Madsen and others are studying what environmental factors are changing the microbiome, the repercussions of those changes and how to fix them.

Ng is asking similar questions in Asia. There’s a much higher incidence of IBD in China’s major cities than in the countryside. So Ng, along with her research on diets, is probing the rural-urban divide to see how the gut microbes of city and country dwellers differ.

Kaplan says that studies like Ng’s, which elucidate the links among IBD, the microbiome and the immune system, could help people with other immune-mediated diseases.

More than 200 genes are known to increase a person’s chances of getting IBD. Many of those same genes have been linked to an increased risk of other immune-mediated diseases such as multiple sclerosis or rheumatoid arthritis, explains Kaplan.

“Many of those genes relate to how the body’s immune system interacts with microorganisms in the gut,” he says. In other words, it’s possible there are some people with genetic susceptibility to a number of immune-mediated diseases given the right environmental exposures.

Understanding those microbiome-immune system interactions can give us clues about who those susceptible people are, Madsen says. That knowledge, along with knowledge of the most important environmental risk factors, could be used to both prevent disorders and devise treatments for afflicted individuals — helping to stem the rise of these devastating disorders and reduce the growing toll they take on human lives around the world.

This article was first published on Ensia.

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What hospitals can do to drive entrepreneurship and enhance patient experience

Hospitals can perform better by partnering with entrepreneurs and encouraging a culture of intrapreneurship focused on customer centricity.

At the Emory University Hospital in Atlanta, visitors don’t have to worry about navigating their way across the complex hospital premises. All they need to do is download wayfinding tools from the installed digital signage onto their smartphone and get step by step directions. Other hospitals have digital signage in surgical waiting rooms that share surgery updates with the anxious families waiting outside, or offer general information to visitors in waiting rooms. Many others use digital registration tools to reduce check-in time or have Smart TVs in patient rooms that serve educational and anxiety alleviating content.

Most of these tech enabled solutions have emerged as hospitals look for better ways to enhance patient experience – one of the top criteria in evaluating hospital performance. Patient experience accounts for 25% of a hospital’s Value-Based Purchasing (VBP) score as per the US government’s Centres for Medicare and Mediaid Services (CMS) programme. As a Mckinsey report says, hospitals need to break down a patient’s journey into various aspects, clinical and non-clinical, and seek ways of improving every touch point in the journey. As hospitals also need to focus on delivering quality healthcare, they are increasingly collaborating with entrepreneurs who offer such patient centric solutions or encouraging innovative intrapreneurship within the organization.

At the Hospital Leadership Summit hosted by Abbott, some of the speakers from diverse industry backgrounds brought up the role of entrepreneurship in order to deliver on patient experience.

Getting the best from collaborations

Speakers such as Dr Naresh Trehan, Chairman and Managing Director - Medanta Hospitals, and Meena Ganesh, CEO and MD - Portea Medical, who spoke at the panel discussion on “Are we fit for the world of new consumers?”, highlighted the importance of collaborating with entrepreneurs to fill the gaps in the patient experience eco system. As Dr Trehan says, “As healthcare service providers we are too steeped in our own work. So even though we may realize there are gaps in customer experience delivery, we don’t want to get distracted from our core job, which is healthcare delivery. We would rather leave the job of filling those gaps to an outsider who can do it well.”

Meena Ganesh shares a similar view when she says that entrepreneurs offer an outsider’s fresh perspective on the existing gaps in healthcare. They are therefore better equipped to offer disruptive technology solutions that put the customer right at the center. Her own venture, Portea Medical, was born out of a need in the hitherto unaddressed area of patient experience – quality home care.

There are enough examples of hospitals that have gained significantly by partnering with or investing in such ventures. For example, the Children’s Medical Centre in Dallas actively invests in tech startups to offer better care to its patients. One such startup produces sensors smaller than a grain of sand, that can be embedded in pills to alert caregivers if a medication has been taken or not. Another app delivers care givers at customers’ door step for check-ups. Providence St Joseph’s Health, that has medical centres across the U.S., has invested in a range of startups that address different patient needs – from patient feedback and wearable monitoring devices to remote video interpretation and surgical blood loss monitoring. UNC Hospital in North Carolina uses a change management platform developed by a startup in order to improve patient experience at its Emergency and Dermatology departments. The platform essentially comes with a friendly and non-intrusive way to gather patient feedback.

When intrapreneurship can lead to patient centric innovation

Hospitals can also encourage a culture of intrapreneurship within the organization. According to Meena Ganesh, this would mean building a ‘listening organization’ because as she says, listening and being open to new ideas leads to innovation. Santosh Desai, MD& CEO - Future Brands Ltd, who was also part of the panel discussion, feels that most innovations are a result of looking at “large cultural shifts, outside the frame of narrow business”. So hospitals will need to encourage enterprising professionals in the organization to observe behavior trends as part of the ideation process. Also, as Dr Ram Narain, Executive Director, Kokilaben Dhirubhai Ambani Hospital, points out, they will need to tell the employees who have the potential to drive innovative initiatives, “Do not fail, but if you fail, we still back you.” Innovative companies such as Google actively follow this practice, allowing employees to pick projects they are passionate about and work on them to deliver fresh solutions.

Realizing the need to encourage new ideas among employees to enhance patient experience, many healthcare enterprises are instituting innovative strategies. Henry Ford System, for example, began a system of rewarding great employee ideas. One internal contest was around clinical applications for wearable technology. The incentive was particularly attractive – a cash prize of $ 10,000 to the winners. Not surprisingly, the employees came up with some very innovative ideas that included: a system to record mobility of acute care patients through wearable trackers, health reminder system for elderly patients and mobile game interface with activity trackers to encourage children towards exercising. The employees admitted later that the exercise was so interesting that they would have participated in it even without a cash prize incentive.

Another example is Penn Medicine in Philadelphia which launched an ‘innovation tournament’ across the organization as part of its efforts to improve patient care. Participants worked with professors from Wharton Business School to prepare for the ideas challenge. More than 1,750 ideas were submitted by 1,400 participants, out of which 10 were selected. The focus was on getting ideas around the front end and some of the submitted ideas included:

  • Check-out management: Exclusive waiting rooms with TV, Internet and other facilities for patients waiting to be discharged so as to reduce space congestion and make their waiting time more comfortable.
  • Space for emotional privacy: An exclusive and friendly space for individuals and families to mourn the loss of dear ones in private.
  • Online patient organizer: A web based app that helps first time patients prepare better for their appointment by providing check lists for documents, medicines, etc to be carried and giving information regarding the hospital navigation, the consulting doctor etc.
  • Help for non-English speakers: Iconography cards to help non-English speaking patients express themselves and seek help in case of emergencies or other situations.

As Arlen Meyers, MD, President and CEO of the Society of Physician Entrepreneurs, says in a report, although many good ideas come from the front line, physicians must also be encouraged to think innovatively about patient experience. An academic study also builds a strong case to encourage intrapreneurship among nurses. Given they comprise a large part of the front-line staff for healthcare delivery, nurses should also be given the freedom to create and design innovative systems for improving patient experience.

According to a Harvard Business Review article quoted in a university study, employees who have the potential to be intrapreneurs, show some marked characteristics. These include a sense of ownership, perseverance, emotional intelligence and the ability to look at the big picture along with the desire, and ideas, to improve it. But trust and support of the management is essential to bringing out and taking the ideas forward.

Creating an environment conducive to innovation is the first step to bringing about innovation-driven outcomes. These were just some of the insights on healthcare management gleaned from the Hospital Leadership Summit hosted by Abbott. In over 150 countries, Abbott, which is among the top 100 global innovator companies, is working with hospitals and healthcare professionals to improve the quality of health services.

To read more content on best practices for hospital leaders, visit Abbott’s Bringing Health to Life portal here.

This article was produced on behalf of Abbott by the Scroll.in marketing team and not by the Scroll.in editorial staff.