Body

Exercising regularly, whether intensely or moderately, is a health recommendation accepted by all experts. Nevertheless, high-intensity physical training can trigger a series of physiological changes in the body, including the heart. The hearts of professional athletes adapt to training in a number of ways, including by increasing the number of structures called trabeculae in the inside of the heart. While this process, called hypertrabeculation, is harmless in athletes, it is also a pathological feature of the hereditary disease noncompaction cardiomyopathy, which can cause sudden cardiac death.

Now, scientists at the Centro Nacional de Investigaciones Cardiovasculares (CNIC) have used cardiac magnetic resonance technology to measure exercise-related hypertrabeculation in a general, non-athlete population. The results of the study have important practical implications because misdiagnosis of noncompaction cardiomyopathy in people who exercise regularly (whether professional athletes or amateurs) can trigger medical recommendations to stop physical exercise unnecessarily," explained CNIC General Director Valentín Fuster.

The study, published today in The Journal of American College of Cardiology (JACC), forms part of the PESA-CNIC-SANTANDER study, whose principal investigator is Dr Valentín Fuster. PESA, begun in 2010 and recently renewed until 2030, is one of the most important cardiovascular prevention studies on the international stage. The 700 PESA participants included in the new substudy published in JACC will followed up throughout this period, allowing detailed analysis of the development, reversibility, and clinical implications of this heart adaptation to physical exercise.

"It is crucial to distinguish this benign adaptation to exercise from noncompaction cardiomyopathy, a disease with a genetic component that can have severe consequences, including heart failure, thromboembolism, arrhythmias, and sudden cardiac death," said Dr Borja Ibáñez, Clinical Research Director at the CNIC, a cardiologist at Fundación Jiménez Díaz University Hospital, and leader of the JACC study.

In noncompaction cardiomyopathy, "the walls of the heart become thinner and the normally compact cardiac muscle is replaced by the spongy (trabecular) form, in direct contact with the interior of the ventricles," continued Dr Ibañez.

The problem is that this disease is often diagnosed in young asymptomatic people, resulting in a medical recommendation to immediately cease physical activity that might cause sudden cardiac death. However, the presence of trabeculae is not always a sign of noncompacted cardiomyopathy. "Certain physiological situations, such as those resulting from high-intensity physical training or pregnancy, are known to trigger changes in heart structure similar to those seen in noncompacted cardiomyopathy," explained Dr Ibañez.

Study first author and cardiologist José de la Chica explained that "it is essential to distinguish between the disease and the benign physiological adaptation, both to allow appropriate medical intervention to prevent disease progression and to avoid recommending healthy young people to unnecessarily avoid participation in sporting activities."

The association between hypertrabeculation and high-intensity physical activity in professional athletes was already known. The key innovation of the new study is its combination of cardiac magnetic resonance (the gold standard diagnostic method for analyzing heart structure and function) with objective measures of physical activity. "We previously lacked information about whether physiological hypertrabeculation occurs in the general population or is restricted to elite athletes," commented Dr Inés García-Lunar, an author on the study.

The study used cardiac magnetic resonance technology to assess accepted diagnostic criteria for noncompacted cardiomyopathy in more than 700 PESA-CNIC-SANTANDER study participants. These healthy Santander Bank workers have varying levels of physical activity, but none are professional athletes.

Physical activity was assessed objectively using accelerometers. These devices measure changes in movement speed in different body axes, and the participants wore them for week-long periods coinciding with each 3-yearly visit in the PESA protocol. Dr de la Chica explained that "this technology allowed us to classify individual physical activity as sedentary or as light, moderate, or vigorous exercise and to record the time spent in each type of activity during the week."

The study showed that participants who routinely did vigorous exercise during the study period had larger hearts with more muscle mass. "These changes are typical of 'athlete's heart' and are considered physiological," said García-Lunar.

A more surprising finding was that a third of participants with a high level of vigorous physical activity (both men and women) met the diagnostic criteria for noncompaction cardiomyopathy, even though they were obviously healthy.

Previous studies had suggested that hypertrabeculation could simply be a consequence of the dilatation of the heart during intense physical exercise. "Thanks to the data from the PESA-CNIC-SANTANDER study, we have now shown that hypertrabeculation and dilatation are independent phenomena," explained Dr de la Chica.

Key findings of the study are that none of the participants with trabeculated hearts showed signs of noncompaction cardiomyopathy and that all other test results were in the normal range.

The authors conclude that cardiac magnetic resonance criteria for diagnosing noncompaction cardiomyopathy should not be interpreted in isolation. Instead, imaging results should be placed in the context of other clinical parameters, genetic tests, and the level of physical activity. This is important even in a population of non-athletes in order to avoid misdiagnosis of the disease. Misdiagnosis can result in the unnecessary cessation of exercise, with all its associated negative physical and psychological consequences.

WASHINGTON -- Researchers report a new compact low-cost hyperspectral projector system that provides both depth information and hyperspectral images. The new system could be useful for autonomous driving systems, machine vision in industrial robotics, agricultural monitoring of crops, and monitoring material surfaces for wear and corrosion.

"Our work enables fast 3D hyperspectral imaging in an efficient and low-cost manner," said lead author Yibo Xu, who earned her Ph.D. from Rice University. "This could one day allow the sensors used for facial recognition on smartphones to be used as hyperspectral 3D scanners, which would improve color accuracy and increase the security of face classification."

Hyperspectral imagers detect dozens to hundreds of colors, or wavelengths, instead of the three detected by normal cameras. Combining this with 3D imaging is useful for perceiving and understanding real-world scenes and objects. Previous hyperspectral 3D imaging systems have required a complicated, high-cost hardware design and came with a long acquisition and reconstruction time.

In The Optical Society (OSA) journal Optics Express, the researchers detail their new simple design for a hyperspectral stripe projector and demonstrate that it allows the use of a monochrome camera to simultaneously capture depth information and also distinguish colors that appear visually similar.

"The combination of 3D spatial and spectrally specific material information is quite powerful," said research team member Kevin F. Kelly, Ph.D. "It can be used for analyzing cultural heritage objects and pieces of art, monitoring plants and agriculture for signs of nutrient deficiencies or disease, aiding industrial robot systems in sorting and assembly, and expanding current autonomous driving systems to better identify the roadway, other vehicles and potential hazards."

Optimizing for speed and simplicity

Most hyperspectral 3D imaging systems measure the spectral content of a scene using a hyperspectral camera. In the new work, the researchers redesigned the hardware and developed new software to allow the use of a monochrome camera to capture 4D information (3D spatial and spectral information) from a scene at once.

A traditional digital projector uses a color wheel with just a handful of colors and is not suitable for encoding the spectral information. The researchers used a different approach that creates hyperspectral stripe patterns that can each be programmed to have an arbitrary spectrum. This allows simultaneous 3D spatial and spectral encoding while only requiring a monochrome camera to capture the images.

The projector creates stripes by using a diffraction grating to split white light from a lamp into its different color components. Each color can then be subdivided into finer wavelengths and focused onto an array of tiny, programmable mirrors called digital micromirror devices (DMD). The unique optical layout that guides light through the system makes it simple, efficient and compact. The researchers also developed new algorithms to reconstruct the collected images into a hyperspectral, 3D visualization of the scene.

"Other systems typically require two or more gratings and multiple DMDs or light modulators," said Xu. "This not only makes them larger and more expensive but also means a brighter light source is needed. Our system achieves its compact form factor by requiring only a single DMD and a single diffraction grating."

Capturing 3D color detail

The researchers used their new system to analyze a scene that contained a small red and green ramp alongside red and green candies of different sizes. Although the green color on the ramp and the green coating of the candy look quite the same to the human eye and an RGB camera, the system was able to clearly distinguish the two materials from the reconstructed spectra as well as measure the correct heights for all the objects.

"By having an easy way to perform controlled hyperspectral depth imaging, researchers will be able to more easily identify the chemical compounds that make up objects of interest," said Kelly. "This could also be useful for a variety of applications from medical diagnostics to monitoring fresh produce for damage and contamination during sorting and delivery."

The researchers are already working on the next-generation design, which will have a more refined optical system and improved reconstruction algorithms. They are also building variations that will operate beyond the visible into infrared portions of the electromagnetic spectrum.

Berkeley -- The widely reported deaths of Michael Brown and Philando Castile reflect a grim truth in this country: According to data collected by The Washington Post, around 1,000 people are shot and killed by the police in the U.S. each year, and Black men are more than twice as likely to be victims as white men.

These inequities become even more stark for older and mentally ill, unarmed Black men, finds a new analysis which appeared online last month in the journal Annals of Epidemiology.

While young men still bear the brunt of police killings, the study found that police are five times more likely to shoot and kill unarmed Black men over age 54 than unarmed white men the same age. Police are also more likely to shoot and kill unarmed Black men who exhibit signs of mental illness, compared to white men with similar behaviors.

"The media have exposed the fact that there may be a disproportionate killing of unarmed men, Black men, in particular, and this is now considered not just a public health issue, but a public health crisis," said study lead author Marilyn Thomas, who completed the analysis as a doctoral student at UC Berkeley's School of Public Health. "Our analysis has found that, among those who happen to be killed by police, there are clear subpopulations that seem to be more vulnerable."

The study, which focused on how race and armed status affects the risk of being shot by police, also revealed geographic differences, with racial inequities in the killing of unarmed Black and white men being more pronounced in the South, the study found.

"Right now, there is a lot of national attention being given to excessive use of force by police, which, unfortunately, we have seen result in the killing primarily of unarmed Black and brown people in this country," said Amani Allen, executive associate dean of the UC Berkeley School of Public Health and senior author of the study. "Our results are particularly timely because they add actual scientific evidence to the deaths we are seeing in the media, which to some may seem like one-off events."

Lack of accurate data has long stymied efforts to understand who is most at risk of being killed by police action in the U.S. Statistics reported by the federal government, such as the FBI's annual list of "justifiable homicides by law enforcement," are notoriously inaccurate: A 2015 study found that the FBI's count missed more than half of the people killed by law enforcement each year.

After the high-profile deaths of Eric Garner, Michael Brown and Tamir Rice in 2014, the Guardian and the Post both launched projects to track the numbers and demographics of people who are shot and killed by police. These databases, combined with numbers from the Fatal Encounters project, which has been tracking fatalities at the hands of police since 2000, have finally given health and social scientists the data needed to understand how race and other factors contribute to police killings.

"Because of these databases, now we have reliable data where we can do more nuanced examinations of whether inequities exist," Thomas said. "And based on these more reliable data sets, we now know that, compared to white civilians, Black civilians are more likely to be stopped, they're more likely to be arrested and they're more likely to experience police use of force and deadly force."

The intersections of age and mental illness

To conduct the analysis, Thomas used data on nearly 3,000 law enforcement-related fatalities of Black and white men collected by the Post's Fatal Force project between 2015 and 2019. Of those, 212 men were reported as unarmed when they were shot.

Because Thomas only had data on men who were killed by police -- not on those armed or unarmed men who were patrolled by police, but not ultimately shot and killed -- she lacked what researchers call a "control group," a group used as a benchmark to validate the study findings. As a result, she used a form of statistical analysis called case-only design, which eliminates the need for controls.

Thomas found that, overall, there was no racial difference in the risk of being unarmed when killed by police, when other contributing factors were accounted for. However, she did find significant inequities when she broke the data down by age, signs of mental illness and region.

The finding that older Black men face such a dramatically higher risk of being killed while unarmed, compared to white men of the same age, was surprising to Thomas, given that much of the media attention surrounding the police killing of Black males focuses on younger Black men and even Black children, like Tamir Rice.

"In the older population, Black males are five times more likely to be unarmed when killed by police than white males. That's an incredible inequity," Thomas said. "Police use of force is sanctioned against those civilians who are perceived as a threat. There's a disproportionate sense of threat here, and so we have to think about what could be driving that."

Denise Herd, professor of community health sciences at UC Berkeley's School of Public Health, who was not involved in the study, points out that older Black males may be suffering from chronic physical or mental illnesses, including dementia, that may make them more vulnerable to police violence. They may also be experiencing homelessness or have lost some of the familial or social ties that protect younger men.

"The people who are most vulnerable to police violence are the people who are falling through the cracks in our public health system," Herd said. "This is an age group where people have had cumulative disadvantages."

Mental illness, unlike age, is its own risk factor for police violence. The Fatal Force project found that approximately one in four people shot and killed by police were experiencing a mental or emotional crisis at the time of the shooting.

However, the finding that Black men exhibiting signs of mental illness are also at higher risk of police killing than white men, particularly while unarmed, is indicative of a concerning pattern in policing: While white men with mental illness are more likely to be given treatment, Black men with similar behaviors are more likely to be criminalized for their actions.

"Black people are much more likely to have psychiatric disorders, whereas white people are more likely to get mental health treatment and intervention," Thomas said. "What that leads to, and what we see in our criminal system right now, is an overrepresentation of people with severe mental illness, because they are being taken to jail or being assaulted or injured and ending up in the hospital rather than getting the mental health intervention that they need."

The fact that police are killing certain groups of unarmed Black men at disproportionate rates, compared to unarmed white men, raises questions about police training programs and the unconscious biases that drive police behavior, the researchers said.

"We have to really look at what's happening within these policing organizations and interrogate the policies, the practices, the trainings and the culture in police departments that are leading to these results," Allen said.

The tip of the iceberg

The results, paired with the limitations of the case-only design approach, highlight the need for more research into the disproportionate impacts of police killing -- and, more importantly, more reliable data, Thomas said.

"The fact that we had to use data from publicly available media sources is problematic; it shouldn't be that way," Thomas said. "We should have a national registry where these data are available for analyses, so that we can intervene in this public health crisis, like it is a crisis."

The hundreds of Black people who are shot and killed by police each year only represent a sliver of the public health crisis that results from disproportionate police violence on this community, Herd added.

For example, the collective grief, stress and social fragmentation that result from this kind of violence can lead to long-term mental distress and even physical illness and death. In April, public health experts at UC Berkeley argued that the stress of police violence may be contributing to the disproportionate impact of COVID-19 on the Black population.

In addition, police violence also causes many more serious injuries than deaths, and research has found that, between 2001 to 2014, emergency departments in hospitals treated 683,000 people for injuries caused by police.

"I think police violence has a tremendous effect that is still not fully recognized," Herd said "Police killings are just the tip of the iceberg."

Boston--At the onset of the COVID-19 pandemic, just as public institutions and businesses closed, research programs performing human participant research (HPR) also largely ceased operations. Now, universities and healthcare organizations conducting HPR are considering reopening.

While guidelines from federal and state government and medical specialty societies currently exist to help restarting health services and resuming clinical trials, no clear guidance is available to aid resumption of HPR at community-based, observational cohort studies.

In a narrative review in the Journal of the American Heart Association, researchers from the
Boston VA Healthcare System and Boston University School of Medicine (BUSM), describe a potential path forward for safely reopening community-based observational studies, drawing on scientific knowledge and best practices from a variety of medical and lay sources.

"We outline a framework for how human subjects research can be potentially resumed during the pandemic while simultaneously ensuring the safety of human participants," explained corresponding author Raghava S. Velagaleti, MD, MPH, FSCAI, cardiologist at the VA and adjunct instructor of medicine at BUSM.

The researchers highlight current recommendations and useful metrics for guiding decisions regarding safe reopening/reclosing and for screening and surveillance of COVID-19 among employees and participants. They also suggest ways in which observational studies can potentially aid the efforts to characterize the pandemic.

According to the researchers, indefinite stoppage of observational research carries harms to society and the research enterprise in terms of new knowledge not generated and research programs that may fail, leading to wasted resources and unrealized gains. "Scientists and researchers are putting in considerable thought and effort into developing frameworks for ensuring the safety of research participants during the pandemic and mitigating the participants' likelihood of contracting COVID-19 because of their participation in research studies," said senior author Vasan Ramachandran, MD, FAHA, FACC, professor of medicine at BUSM and director of the renowned Framingham Heart Study.

The researchers believe that their redesigned research policies and procedures and a cautious approach to reopening, make it possible to resume research while simultaneously mitigating risk to participants and staff. "Our suggested approach can be a potential path forward not just for current resumption of observational studies, but also reengineer them to improve research participant experience and cope with possible future infectious disease pandemics," added Velagaleti.

Foliar diseases, such as gray leaf spot, northern corn leaf blight, and southern rust, were estimated to cause annual losses ranging from 19,029 to 244,149 metric tons from 2012 to 2015 in Kentucky. To mitigate these damages, farmers have turned to foliar fungicides. However, as plant pathologist Carl Bradley explains, "Kentucky corn farmers had questions about the best timing to apply a foliar fungicide to their corn crop."

To answer this question, Bradley and his colleagues at the University of Kentucky established corn fungicide research trials at nine locations throughout Kentucky. They evaluated a single fungicide application at the six-leaf collar stage (known as the V6 stage) or at the silking stage (known as the R1 stage) as well as a sequential application at both stages. They found that treatments at the silking stage provided the best foliar disease control. They also found that the single application at the silking stage did not differ from the sequential double application.

"Our findings suggest that Kentucky corn growers likely can rely on a more cost-effective single fungicide application at R1 for foliar disease management and improve return on fungicide investment rather than making multiple applications at different times," said Bradley.

As the data were collected from field trials conducted at nine locations across two years, Bradley and his colleagues were able to analyze a large dataset. "This helped us observe the effects of a foliar fungicide on corn across much of the corn-producing area of Kentucky, which gives much confidence in the results."

This research is also the first to show that severity of Curvularia leaf spot can be reduced with a foliar fungicide application in the U.S. This is a new disease of corn in the region and this finding is a first step toward learning best management practices.

Philadelphia, October 5, 2020--Through genetic sequencing and targeted treatment, researchers from Children's Hospital of Philadelphia (CHOP) have resolved a severe lymphatic disorder in a young woman with kaposiform lymphangiomatosis (KLA), a complex and rare disorder that causes lymphatic vessels around the heart and lung to leak fluid, causing breathing difficulties, infections, and often death. The treatment, which the research team has used successfully in other patients with lymphatic disorders, led to a complete resolution of the patient's symptoms and fully remodeled her lymphatic system within a matter of months.

The findings were recently published in EMBO Molecular Medicine.

"The resolution of lung disease with lymphatic remodeling is remarkable and potentially should change how we evaluate and treat lung disease in this patient population," said first author Jessica B. Foster, MD, an attending physician in CHOP's Division of Oncology. "These results offer hope to other patients with lymphatic-induced lung disease and warrant further investigation."

Brenna, the patient described in the paper, first developed symptoms related to KLA at age 6 and was diagnosed with the condition when she was 10. For nearly a decade, she was treated with a variety of therapies, including rapamycin, an immunosuppressant; prednisone, a steroid; and vincristine, a chemotherapy drug. Despite aggressive treatment, her debilitating symptoms persisted, and so her clinical team at CHOP decided to explore other therapies.

Many patients with KLA have a mutation in the NRAS gene, and the team had previously used a mitogen-activated protein kinase (MEK) inhibitor called trametinib in another patient with a severe lymphatic disorder and NRAS mutation. The drug resolved his symptoms and completely remodeled his lymphatic system. Although that patient did not have KLA, the researchers felt the success of trametinib in treating his severe lymphatic symptoms, combined with Brenna's rapidly deteriorating condition, warranted the request for expanded access to treat Brenna with the drug.

As Brenna began taking trametinib, a drug historically used to treat metastatic melanoma, the researchers sent samples of her lymph fluid for genetic sequencing. The researchers learned that Brenna did not harbor an NRAS mutation and instead had a mutation in a different gene: CBL, a gene that operates along the Ras pathway, the same genetic pathway implicated in other lymphatic disorders, including the one for which they had used trametinib with great success. Mutations along the Ras pathway result in an overproduction of MEK, which leads to the uncontrolled proliferation of lymphatic vessels. A MEK inhibitor like trametinib brings the production of MEK under control, putting the brakes on a system in overdrive.

Brenna was the first patient with KLA to take trametinib for a lymphatic issue, and within four weeks of starting a low dose, her symptoms improved. Her shortness of breath, coughing, and difficulty breathing while lying flat disappeared. She was able to exercise again, and during the second cycle of her therapy, she began training for a 5K race.

"The relatively low dose required for dramatic improvement in this case highlights that a small amount of trametinib may be sufficient to treat lymphatic disorders, which will likely limit the side effect profile compared to the higher doses used for oncologic cases," said senior author Yoav Dori, MD, PhD, Director of the Jill and Mark Fishman Center for Lymphatic Disorders at CHOP. "We are now preparing ongoing prospective studies to evaluate Ras pathway inhibition in clinical trials of large cohorts of patients."

Follow up tests have shown significant improvement in Brenna's restrictive lung disease, and the fluid in her lungs has disappeared. Her overabundant lymph vessels have remodeled themselves and are now behaving normally. Now 20 years old, she continues to take a daily dose of trametinib, which has kept her symptoms at bay.

"Genomic evaluation of vascular anomalies such as KLA have only just begun in recent years," said Denise Adams, MD, Director of the Comprehensive Vascular Anomalies Program (CVAP), a CHOP Frontier Program. "This case study demonstrates the power of collaborative, cutting-edge research that reaches across disciplines, from genetics to oncology to cardiology, to bring breakthrough treatments to patients."

Results of a first-of-its-kind clinical trial shed light on when antibiotics instead of surgery might be the better choice for treating appendicitis in some patients, according to researchers with The University of Texas Health Science Center at Houston (UTHealth), who led the Houston trial sites.

The results from the national Comparing Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial were published today in the New England Journal of Medicine.

"This was the first multicenter U.S. trial to study appendicitis treatment, and it assessed a diverse population in addition to a wider variety of appendicitis than previous trials," said Mike Liang, MD, associate professor of surgery with McGovern Medical School at UTHealth, who was the principal investigator at Harris Health's Lyndon B. Johnson Hospital, which was one of the largest enrolling sites of the 25 across the country that participated in the trial.

"We found that antibiotics were not worse than surgery when measuring overall health status, allowing most people to avoid an operation in the short term," said Lillian Kao, MD, division director of acute care surgery with McGovern Medical School and the principal investigator of the CODA trial site at Memorial Hermann-Texas Medical Center. "There were advantages and disadvantages to both treatments, and patients are likely to prioritize these in different ways based on their characteristics, concerns, and perspectives."

Across the U.S., 1,552 participants were randomized to receive either an appendectomy or treatment with antibiotics first for acute appendicitis. While nearly half of the antibiotics group avoided hospitalization for their initial treatment, overall, the time spent in the hospital was similar between groups.

"People treated with antibiotics more often returned to the emergency department but missed less time from work and school," said Bonnie Bizzell, chair of the CODA Patient Advisory Board. "Information like this can be important for individuals as they consider the best treatment option for their unique circumstance. The CODA trial is really the first of its kind to capture these measures for appendicitis shared decision-making."

Other initial findings of the CODA trial include:

Patients treated with either surgery or antibiotics experienced symptoms of appendicitis for about the same amount of time.

Approximately 3 out of 10 patients in the antibiotic group underwent appendectomy within 90 days, but 7 in 10 participants avoided an operation.

Patients with an appendicolith, a calcified deposit within the appendix, had twice the risk of complications than those without an appendicolith.

Participants with an appendicolith had an increased chance of appendectomy within 90 days (4 in 10 with appendicolith versus 3 in 10 without).

The CODA trial is the largest randomized clinical trial of appendicitis conducted to date and is funded by the Patient-Centered Outcomes Research Institute (PCORI).

"Many patients with appendicitis do well with and without surgery," Liang said. "Balancing these risks and benefits of each treatment should be personalized for each individual patient given their own situation and preferences. Using the data from this research, more information will be shared in the near future, including who might benefit most from surgery versus medical management as well as the long-term results of these two treatments."

"This is an important trial in many ways, primarily in that the question, the methods, and the outcomes were informed by patient stakeholders," Kao said. "Additionally, as a 'real-world' trial, CODA enrolled a broad spectrum of patients that truly represents the heterogeneous population that we serve. This is just the beginning of a national partnership that has the capacity to address unanswered questions regarding optimal patient-centered care in surgery."
The CODA Collaborative, composed of clinicians at each of the 25 CODA trial sites, patient advisors, and other stakeholders, will continue to share results from the trial as ongoing follow-up with participants is completed.

A UC Davis MIND Institute study of pregnant mice found that high amounts of folic acid during pregnancy harmed the brain development of embryos. Researchers say the findings indicate that more investigation is needed about the best recommended dosage for pregnant women.

"We believe there's a Goldilocks effect with folic acid. Too little is not good, too much is not good; you have to get it just right," said Ralph Green, UC Davis distinguished professor of pathology and medicine and a corresponding author of the study.

The research, published Sept. 30 in Cerebral Cortex, involved pregnant mice who were given either a normal amount of folic acid, 10 times the recommended amount, or none. The offspring of the mice that received the largest amount showed significant brain changes.

"It's not subtle. It's substantial," said Konstantinos Zarbalis, associate professor in the Department of Pathology and Laboratory Medicine and also a corresponding author of the research. "It makes a marked difference in brain structure if you take very high amounts of folic acid."

Paradoxically, changes in the brain due to too much folic acid mimicked those associated with a deficiency of folic acid. "This, to me, was an even more important insight," said Zarbalis, who is also on the UC Davis MIND Institute faculty. He noted that in humans, research shows that impaired folate uptake into the brain can cause cerebral folate deficiency, a syndrome that is often associated with the development of autism.

Folic acid and pregnancy

Folic acid (the synthetic form of vitamin B9, or folate) supplementation is widely recommended for women of child-bearing age. It has been shown to substantially reduce the risk of neural tube defects, such as spina bifida, in children. Research, including studies at the MIND Institute, has also shown that prenatal vitamins that include folic acid have a protective effect against the development of autism and other disorders.

Green was on the panel with the National Academy of Sciences and the Institute of Medicine (now called the National Academy of Medicine) that determined the recommended daily intake of folic acid (400 mcg) and the maximum daily safe upper limit (1000 mcg). He was also on the Food and Drug Administration (FDA) panel that recommended adding folic acid to foods, which led to the fortification of all cereals and grains with folic acid mandated by the Federal Government in 1998.

"Addition of folic acid to the diet was a good thing, and I've supported fortification, but there is a 'best amount' of folic acid, and some people may be getting more than is optimal," said Green.

Women who have given birth to a child with neural tube defects or who have certain conditions like epilepsy and take anticonvulsants, have generally been advised to take much higher doses of folic acid.

"In animal models, we have indications that very high amounts of folic acid can be harmful to brain development of the fetus, and the clinical community should take this indication seriously, to support research in this area to reevaluate the amount of folic acid that is optimal for pregnant women," said Zarbalis.

Zarbalis and Green suspect that the problem lies in the way folic acid is metabolized by the body and have plans to investigate the phenomenon further.

Antibiotics may be a good choice for some, but not all, patients with appendicitis, according to results from the Comparing Outcomes of antibiotic Drugs and Appendectomy (CODA) Trial reported today in the New England Journal of Medicine. The findings indicated that antibiotics were not worse than surgery when measuring overall health status, allowing most people to avoid an operation in the short term. Boston Medical Center, one of 25 hospitals nationwide where the CODA Trial was conducted, recruited the greatest number of patients among the three New England CODA sites and was in the top third for patient recruitment overall.

"There were advantages and disadvantages to both treatments, and patients are likely to prioritize these in different ways based on their own unique characteristics and interests," said F. Thurston Drake, MD, MPH, a general and endocrine surgeon at Boston Medical Center (BMC) who served as co-site lead for CODA at BMC. "As a surgeon, I can play an important role in helping patients choose the treatment options that are best for their individual situation and health needs."

While nearly half of the antibiotics group avoided hospitalization for their initial treatment, overall, the time spent in the hospital was similar between groups. "People treated with antibiotics more often returned to the emergency department but missed less time from work and school," said Bonnie Bizzell, chair of the CODA Patient Advisory Board. "Information like this can be important for individuals as they consider the best treatment option for their unique circumstance. The CODA Trial is really the first of its kind to capture these measures for appendicitis shared decision-making."

The CODA Trial, which was funded by the Patient-Centered Outcomes Research Institute (PCORI), is the largest randomized clinical trial of appendicitis conducted to date. Across the United States, 1,552 participants were randomized to receive appendectomy or antibiotics-first for uncomplicated appendicitis.

Other initial findings of the CODA Trial include:

Patients treated with either surgery or antibiotics experienced symptoms of appendicitis for about the same amount of time.

Approximately 3 out of 10 patients in the antibiotic group underwent appendectomy by 90 days.

Patients with an appendicolith, a calcified deposit within the appendix, had twice the risk of complications than those without an appendicolith.

Participants with an appendicolith had an increased chance of appendectomy by 90 days (4 in 10 with appendicolith vs 3 in 10 without).

"The results from this trial provide tremendous insight into how providers and patients can collaborate and develop treatment plans based on the options available and the needs of the patient," added Sabrina E. Sanchez, MD, MPH, a surgeon at BMC who co-led the BMC CODA trial site. "Patients are key players when determining their care plans, and their insight can lead to tailored treatment options based on their specific needs, which can improve health outcomes."

The CODA Collaborative, composed of clinicians at each of the 25 CODA Trial sites, patient advisors, and other stakeholders, will continue to share results from the trial as ongoing follow-up with participants is completed. The CODA Trial was led by Co-Principal Investigators David Flum, MD, MPH, professor and associate chair of the department of surgery at the University of Washington and David Talan, MD, professor of emergency medicine and medicine/infectious diseases at the David Geffen School of Medicine at UCLA.

CHICAGO - Universal COVID-19 testing of children who are having procedures requiring anesthesia promotes efficient use of personal protective equipment (PPE), according to research being presented at the ANESTHESIOLOGY® 2020 annual meeting.

Testing can rule out children who would otherwise be suspected of having COVID-19 based on symptoms or possible exposure to the virus. Ruling out COVID-19 prevents unnecessary use of the extensive PPE recommended by the Centers for Disease Control and Prevention (CDC). CDC-recommended PPE for treating COVID-19 positive patients includes a respirator mask, such as an N95 or PAPR, and a gown, in addition to the standard PPE of surgical mask, eye protection and gloves, which are always worn by health care workers during procedures requiring anesthesia.

Although early in the pandemic it appeared that children were rarely affected, their numbers have been growing and today children comprise more than 10% of COVID-19 cases.

"This study links the importance of universal testing for COVID-19, increased safety of staff and efficient use of PPE, especially items such as N95 face masks, which are in low supply," said Lenard Babus, M.D., lead author of the study and attending pediatric anesthesiologist, Children's Hospital of Philadelphia. "If universal testing were used outside the hospital, outpatient facilities and other treatment centers could experience similar PPE and safety benefits."

Hospitals frequently verbally screen patients for COVID-19 using three criteria: travel history, close contact or exposure to the disease, and symptoms such as fever, cough or shortness of breath. However, a positive screen doesn't guarantee the presence of COVID-19. Conversely, a patient may have no symptoms of the virus or apparent risk for COVID-19, but may still have the virus.

For the study, researchers analyzed results of COVID-19 testing in anesthesia procedures performed at the Children's Hospital of Philadelphia between March 26 and May 11, 2020. Patients required anesthesia for a wide range of procedures, from MRI testing to cancer surgery and appendix removal. All children were tested for COVID-19 using the polymerase chain reaction (PCR) test prior to receiving anesthesia. They then compared the test results to those who were suspected of being infected, based on the verbal screening method.

Overall, 1,033 children were included in the study and 146 children verbally screened positive for at least one of the three criteria. Without COVID-19 PCR testing, health care providers treating all 146 children would have been required to wear expanded PPE, including an N95 mask or respirator. However, because their COVID-19 PCR test was negative, 102 of the 146 patients received care with standard PPE, a reduction of 70%. They also found that 10 children who verbally screened negative for the disease actually tested positive for COVID-19, and may have otherwise been overlooked, increasing health care workers' risk of exposure.

CHICAGO: Limited English-language proficiency (LEP) is a risk factor for getting potentially lifesaving screening mammograms less often, according to new study results using national data. These findings, from women aged 40 and older living in the United States, are presented at the American College of Surgeons (ACS) Clinical Congress 2020.

"Spanish-only speakers appear to have a 27 percent less likelihood of having a screening mammogram than English speakers," said lead study investigator Jose L. Cataneo, MD, a general surgery resident at the University of Illinois at Chicago (UIC)/Metropolitan Group Hospitals.

"The impact of language barriers on screening mammography was previously unknown from a national database," Dr. Cataneo said. "It is important because approximately 67 million people in the United States speak a language other than English, and 41 million of those speak Spanish." He cited recent U.S. Census Bureau estimates.

Mammograms have well-known benefits, the study's senior investigator, Celeste Cruz, MD, a breast surgeon at Advocate Illinois Masonic Medical Center in Chicago, said.

"Mammography screening overall really reduces the rate of advanced and fatal breast cancers by finding cancers when they are at earlier stages and highly treatable," Dr. Cruz said.

Limited English proficiency common

The researchers defined LEP as speaking only or mostly a language besides English. For their study, they used a nationally representative database, the National Health Interview Survey, which is an annual survey of U.S. civilian, noninstitutionalized residents. Using the 2015 survey data, the research team included women between 40 and 75 years old--the age range usually recommended for screening mammography--who answered which language they primarily speak.

Among 9,653 women included in the study, 1,040 had LEP, according to the most recent study data reported at the Clinical Congress. Most of those women (756) spoke only Spanish, Dr. Cataneo said.

In 936 LEP group members who provided mammogram information, the overall rate of screening mammograms was reportedly 12 percent less than for proficient English speakers: 78 versus 90 percent.

Women with LEP who reported never having received a screening mammogram numbered 209. When Dr. Cataneo extrapolated that number, using statistical software, to the entire U.S. female population in the age range of 40 to 75, he estimated it would equal 450,000 women in the country who are eligible for a screening mammogram but may not have had one.

Because U.S. mammography screening guidelines vary by age, the researchers examined participants in different age groups: 40 to 50, 45 to 75, and 50 to 75.

"In all three groups, we found that those with limited English proficiency had less frequency of getting a screening mammogram," he said.

The American Cancer Society recommends that women at average risk of breast cancer begin getting yearly mammograms at age 45, with the option to get one beginning at age 40.2 The U.S. Preventive Services Task Force recommends that most women get screening mammograms every other year from ages 50 to 74, and women in their 40s may choose to get a mammogram every two years.3

To standardize the LEP and English-speaking groups, the researchers used a statistical method of matching them by age, race-ethnicity, insurance status, family income, and other factors. After this propensity score matching, speaking only Spanish predicted a significantly lower probability of getting a screening mammogram, with an odds ratio of 0.73, Dr. Cataneo stated. Thus, for every 100 English-speaking women who get a screening mammogram in the United States,73 Spanish-only speakers will get one.

Interventions needed

Many reasons probably exist why low English proficiency is linked to reduced mammography screening rates, Dr. Cruz said. In their study, women with LEP were more likely than others to be poor and lack health insurance.

These women also may have fears surrounding mammography, she suggested. Dr. Cruz said health care providers must dispel myths and focus on the importance of early detection of breast cancer.

Although breast cancer occurs in Hispanics at lower rates than non-Hispanic whites, it remains the leading cause of cancer-related death for Hispanic women, the American Cancer Society reports.4

Regardless of ethnicity or language proficiency, many women mistakenly believe they are not at risk of breast cancer because they have no family history of the disease, Dr. Cruz said. In fact, only 5 to 10 percent of breast cancers are hereditary.5

To address the language-based disparity in mammography screening rates, she said her hospital is increasing educational efforts about breast health, the importance of screening, and advances in breast cancer treatment. Now being done virtually because of the coronavirus pandemic, this education includes seminars in Spanish for community members. Dr. Cruz also lectures through community organizations for health care providers and employers that seek to promote breast health and screening.

Additionally, she said the hospital is working to make online mammography scheduling available in languages other than English.

CHICAGO: Young women with benign breast conditions may undergo surgery without jeopardizing their ability to breastfeed later on. One of the first studies to specifically evaluate the effects of surgery on breastfeeding outcomes and lactation capability reveals that more than 80 percent of young women successfully breast-fed or bottle-fed breast milk, including those with a history of a prior breast operation. Findings from the study were presented as a clinical poster at the virtual American College of Surgeons Clinical Congress 2020.

Benign breast conditions in women are common; nearly 1 million women each year are diagnosed with benign breast conditions in the U.S., and approximately 50 percent of women will have a benign breast lesion in their lifetime.1, 2 Many of these conditions are commonly managed with breast surgery. Other common breast procedures include reduction mammaplasty to treat macromastia (enlarged breast tissue) or augmentation for breast asymmetry or developmental breast conditions.

However, there is concern among breast surgeons about the potential for a surgical procedure that invades breast tissue to disturb the delicate subareolar complex and damage milk ducts or nerves 3,4 and interfere with a woman's future ability to breastfeed. (Such procedures include a minimally invasive procedure such as a diagnostic biopsy or a major surgery such as reduction mammaplasty.)

"Pediatricians and obstetrician-gynecologists who refer teenage patients for treatment of breast conditions, as well as parents, are concerned that surgery may impact breast development and eventual lactation," said Laura C. Nuzzi, BA, clinical research manager, Boston Children's Hospital, Boston, Mass.

Research about the relationship between breast surgery and later breastfeeding is limited. 3,5,6 "There have been some small cohort studies that examine breastfeeding after surgery for benign breast disease later on in life, but they don't ask these questions in adolescents and young women prior to having children," explained Shannon M. Malloy, BS, a clinical research associate in the Adolescent Breast Clinic at Boston Children's Hospital.

Researchers at Boston Children's Hospital studied the ability to breastfeed in eligible mothers between the ages of 18 and 45. The study compared breastfeeding capability among women who had been previously diagnosed and treated for a breast condition with those who had not.

Of the total 85 women in the study, 15 had a prior history of breast disease, including breast cysts, fibroadenoma (benign tumors), and macromastia (enlarged breasts). Sixteen women underwent breast surgery, including breast augmentation, reduction mammoplasty, and biopsy. Regardless of whether they had previous breast surgery or not, 80 percent of the women in the study were able to breastfeed or obtain breast milk for bottle feeding.

The researchers are continuing to study the relationship between prior benign breast surgery and future lactation and breastfeeding performance and hope to have more data in upcoming months. "We hope to augment the conclusions from this study that suggest plastic reconstructive surgeons, primary care practitioners, and any provider who comes in contact with women who have a benign breast condition can reassure them that an operation for a benign breast condition is safe and should not preclude them from enjoying the benefits of surgery for fear of impairing future breastfeeding satisfaction and lactation," Ms. Malloy said.

Young women in the study completed a survey that was developed by Boston Children's Hospital study team called the Mother and Infant Lactation Questionnaire (MILQ), which gathers information about the general health and well-being of mothers and their infants as well as the physical, socioeconomic, and emotional components of the breastfeeding experience. Some measures include maternal breastfeeding history, milk quality and quantity, challenges and barriers to breastfeeding, and breastfeeding initiation, duration, and satisfaction.

The survey is unique to the Adolescent Breast Center at Boston Children's Hospital. It was designed by the breast surgery research team, headed by Brian Labow, MD, FACS, director of the clinic and an associate professor of surgery, Harvard University School of Medicine.

The research team is disseminating the survey both within the hospital environment and in the greater community. They hope to validate the survey as an instrument for standardizing data capture related to lactation and barriers to having the best possible breastfeeding experience. With funding from the Plastic Surgery Foundation, the researchers plan to expand the use of the survey in the greater Boston area beginning fall 2020 to test its validity in racially and ethnically diverse populations.

"Our goal is to eventually validate the survey in a host of diverse populations. Once it's validated, we want to license the survey so providers can use it as a screening tool in their clinic and epidemiologists can use it for research purposes," Ms. Nuzzi said.

CHICAGO: Among accredited U.S. cancer centers, hospitals serving primarily minority patients are as likely as other hospitals to offer the standard of surgical care for early-stage breast cancer, according to results presented at the virtual American College of Surgeons (ACS) Clinical Congress 2020.

"There are a lot of health disparities in cancer: in access to care, treatment, and outcomes," said senior study investigator T. Salewa Oseni, MD, FACS, assistant professor of surgery, Harvard Medical School, Boston. "In our study, we were pleasantly surprised there was no difference between the care that Black, Hispanic, and white women receive."

The researchers examined hospitals' axillary management practices involving removal of the lymph nodes from under the arm called the axilla. At the breast cancer operation, the surgeon performs a sentinel lymph node biopsy to remove and test the sentinel lymph node or nodes. These are the lymph nodes where the cancer most likely will spread first. In the past, if the results show cancer in the sentinel lymph nodes, called node positive, the surgeon removed most lymph nodes under the arm, Dr. Oseni said. However, this procedure, known as a completion axillary lymph node dissection (ALND), often results in lymphedema, which is a condition marked by swelling and sometimes pain in the arm, hand, or breast.

"Five to 10 years ago, studies found that not every woman needs to have an axillary dissection after a positive sentinel lymph node biopsy," Dr. Oseni said. "The combination of radiation and chemotherapy in certain instances may be sufficient, with the same survival and fewer clinical complications."

Recommendations from these study results are rapidly becoming the standard of care in breast cancer with up to two positive lymph nodes, said lead study investigator Olga Kantor, MD, MS, an associate surgeon at Brigham and Women's Hospital in Boston. When more than two sentinel lymph nodes are positive, the standard of care remains an ALND.

Racial-ethnic disparities

Dr. Kantor and her fellow researchers assessed whether disparities exist in the application of these evidence-based guidelines depending on whether a hospital serves predominantly minorities. The researchers defined minority-serving hospitals (MSH) as those in the top 10 percent treating the largest proportion of Black and Hispanic patients.

Many patients at MSH lack health insurance and have decreased access to high-quality care, such as cancer specialists, she said. Additionally, some studies have found lower adherence to cancer treatment guidelines among MSH.1

Using data from the National Cancer Database, Dr. Kantor's group included more than 21,000 breast cancer patients treated in 2015 and 2016. Cosponsored by the ACS and the American Cancer Society, this database includes information on more than 70 percent of newly diagnosed cancer cases in the U.S. The information comes from more than 1,500 cancer programs, all accredited by the ACS Commission on Cancer, and is the largest database of its kind.

The researchers studied whether the cancer centers omitted ALND in appropriately selected patients, which they called uptake of results from three landmark clinical trials. These studies were the ACS Oncology Group (ACOSOG) Z0011 trial published in 2011,2 the ACOSOG

Z1071 trial in 2013,3 and the After Mapping of the Axilla: Radiotherapy or Surgery (AMAROS) trial by the European Organisation of Research and Treatment of Cancer in 2014.4

The studies included patients with early-stage breast cancer and small tumors on examination or imaging (clinical T1 or cT2) who underwent breast conservation (lumpectomy) or, in the AMAROS trial, mastectomy.

There was no survival difference in patients with one or two positive sentinel lymph nodes between those who had ALND and those who did not in the ACOSOG Z0011 trial. Similarly, the AMAROS investigators found no survival difference between patients who had ALND and those who received axillary radiation therapy but no ALND. The Z1071 trial results showed it was possible to do sentinel lymph node biopsy alone after a response to preoperative (neoadjuvant) chemotherapy.

Surprising results

Dr. Kantor and her team divided patients into three groups by matching the cancer characteristics to the inclusion criteria for these clinical trials.

Among the 7,167 patients who met the criteria for the ACOSOG Z0011 trial, there was a similar uptake of the recommendation to omit ALND between MSH and non-MSH (74.6 percent versus 72.9 percent, respectively), Dr. Kantor reported. Likewise, uptake of the ACOSOG Z1071 results was similar among the 4,546 patients meeting study criteria: 41.9 percent for MSH and 44.9 percent for non-MSH.

In the 9,433 patients who matched criteria for the AMAROS trial, uptake was slightly lower at MSH--11.7 percent--compared with 14 percent at non-MSH, according to the study abstract. However, after the researchers adjusted their statistical analyses for multiple factors, they found no difference in uptake by MSH status, Dr. Kantor said.

"Minority-serving hospitals offer a strong level of evidence-based breast cancer care if accredited by the Commission on Cancer," Dr. Oseni concluded. However, they cannot generalize their study findings to hospitals lacking this accreditation.

CHICAGO: To address the opioid epidemic, surgeons have embraced guidelines to reduce the number of opioid pills they prescribe to patients after surgery, and the efforts have helped to significantly reduce the number of opioids in circulation. But new research presented at the virtual American College of Surgeons Clinical Congress 2020 reports that these guidelines may be missing a small group of patients that need a greater level of pain control.

"The key findings of our study are that we were able to successfully reduce how many opioids we were prescribing for patients after operations using evidence-based guidelines, and that the reduction resulted in less unused opioids remaining in our community," said lead study author Cornelius A. Thiels, DO, MBA, a surgical oncology fellow at Memorial Sloan Kettering Cancer Center, New York, and a researcher at Mayo Clinic, Rochester, Minn., where the study was conducted. "But, importantly, that reduction also resulted in the majority of patients being overall still satisfied with their pain control after discharge and not needing more refills than if they were to get more opioids, as would have been the case in the past."

"However," he continued, "the other finding of our research is that there's still additional room to improve in terms of making sure all patients after surgery have their pain well controlled, because we believe there is a small subset of patients who have lower pain scores with the reduced opioid prescribing guidelines."

The researchers evaluated 138 patients who underwent one of 12 elective operations (May to November, 2019) after Mayo Clinic adopted the evidence-based opioid prescribing guidelines in early 2018. The researchers then compared those findings with 603 patients who had the same procedures before the guidelines (from March 2017 to January 2018). None of the patients in the study were taking opioids prior to surgery.

Overall patient-reported pain control, on a scale of zero to 10, was worse post-guideline vs. pre-guideline, 8 vs. 9 (p=0.002; a lower score represents worse pain control). The percentage of patients who were very or somewhat dissatisfied with their pain control more than doubled post-guideline, 9.4 percent vs. 4.2 percent (p=0.04), as did the percentage who said they were not prescribed enough pain medications after discharge, 12.5 percent vs. 4.9 percent (p=0.002). The study involved a 29-question telephone survey conducted an average of 26 days after discharge.

This is a follow-up study to research Dr. Thiels and Mayo colleagues previously published. A study in 2017 established that the majority of patients having elective surgery were overprescribed opioids.1 The second study a year later reported on the success of guidelines they developed for minimizing post-surgery opioid prescriptions.2

The goal of post-surgery pain management today, Dr. Thiels noted, is to employ what clinicians call "multimodal pain control," which is a combination of opioids with non-opioid pain relievers such as ibuprofen, naproxen sodium and acetaminophen.

"But we do know that some patients will still need opioid pain medications after major surgery, and our goal is to give them the exact right amount so that we limit the number of un-used opioids in our community while also making sure we don't reduce it down too far and then leave them in pain," Dr. Thiels said.

Adequate post-surgery pain management is all the more important as more operations move to outpatient surgery centers. "People are going home sooner and sooner, and that's great, but we need to make sure their pain is well controlled after they leave the hospital as well as balancing that issue with the risk of opioid dependence," Dr. Thiels said.

While this study enrolled patients who were not taking opioids at the time of their operation, the postoperative pain management guidelines Dr. Thiels and colleagues use also include recommendations for how to manage patients taking opioids before surgery and who may also be co-managed by a pain medicine specialist.

"There is a small subset of patients who we're not optimally managing yet, and this study confirmed that this is a small number," Dr. Thiels said. "However, I think that's a critically important subset of patients."

The next step for their research is to determine how to best identify patients in advance who may have lower pain scores after discharge with the reduced opioid prescribing guidelines, Dr. Thiels said. "The right answer may be more non-opioid based pain medications, better patient education and setting of expectations, or in some cases patients may actually require slightly more opioid medications, and that is OK," he said.

"But everybody should have their pain appropriately controlled after surgery," he added.

New research findings contradict statements linking wearing face masks to carbon dioxide poisoning by trapping CO2. During the COVID-19 pandemic the wearing of face masks has become a highly political issue with some individuals falsely claiming that wearing face masks may be putting people's health at risk. The study published in the Annals of the American Thoracic Society shows otherwise.

In "Effect of Face Masks on Gas Exchange in Healthy Persons and Patients with COPD," Michael Campos, MD and co-authors assessed problems with gas exchange, that is, changes in oxygen level or carbon dioxide levels in healthy individuals as well as veterans with chronic obstructive pulmonary disease or COPD before and while using surgical masks. People with COPD, according to the ATS Patient Education Fact Sheet on the disease, "must work harder to breathe, which can lead to shortness of breath and/or feeling tired."

"We show that the effects are minimal at most even in people with very severe lung impairment," said Dr. Campos of the Miami Veterans Administration Medical Center and the Division of Pulmonary, Allergy, Critical Care and Sleep Medicine at the University of Miami.

As for the feeling of breathlessness that some healthy people may experience, Dr. Campos explained: "Dyspnea, the feeling of shortness of breath, felt with masks by some is not synonymous of alterations in gas exchange. It likely occurs from restriction of air flow with the mask in particular when higher ventilation is needed (on exertion)."

If you're walking briskly up an incline, for example, you may experience feelings of breathlessness. An overly tight mask may also increase the feeling of breathlessness. The solution is simply to slow down or remove the mask if you are at a safe distance from other people.

Dr. Campos stressed the importance of wearing a face mask to prevent COVID-19 infection. If a surgical mask is not available, a cloth mask with at least two layers is recommended by the CDC. Patients with lung disease, in particular, should avoid getting infected and should wear a face mask, which, along with handwashing and social distancing, is proven to reduce the risk of COVID-19 infection.

The impetus for the study came after reports of a public hearing in Florida where individuals made inflammatory comments, namely that wearing masks were putting lives at risk and finding out that no data on the effects of surgical masks on gas exchange was available.

"We acknowledge that our observations may be limited by sample size, however our population offers a clear signal on the nil effect of surgical masks on relevant physiological changes in gas exchange under routine circumstances (prolonged rest, brief walking)," wrote the authors. "It is important to inform the public that the discomfort associated with mask use should not lead to unsubstantiated safety concerns as this may attenuate the application of a practice proven to improve public health."

"The public should not believe that masks kill," added Dr. Campos.