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ALEXANDRIA, VA - The American Academy of Otolaryngology-Head and Neck Surgery Foundation published the Clinical Practice Guideline: Nosebleed (Epistaxis) today in Otolaryngology-Head and Neck Surgery. A nosebleed is a common medical condition that occurs at some point in at least 60 percent of people in the United States.

"Although it is common, methods of diagnosis and treatment for nosebleed have not been uniformly used across clinicians and settings. To address that and to help reduce variations in care, this guideline provides evidence-based recommendations to improve quality of care," said David E. Tunkel, MD, Chair of the guideline development group (GDG).

A nosebleed is bleeding from the nostril, nasal cavity (inside of the nose), or nasopharynx (the part connecting the nose and throat). Nosebleed often happens without an obvious cause and occurs more often in children and the elderly, with three out of four children having a nosebleed at least once. A recent study based on data from the Nationwide Emergency Department Sample from 2009 to 2011 identified 1.2 million emergency department encounters for nosebleed.

Care for nosebleed ranges from self-treatment and home remedies to more intensive, procedural intervention in medical offices, emergency departments, hospitals, and operating rooms. This clinical practice guideline is designed for patients who cannot manage their nosebleeds through self-treatment and instead have bleeding that is severe enough to warrant medical advice or care. This includes bleeding that is severe, persistent, and/or recurrent, as well as bleeding that affects a person's quality of life.

"This is the first multidisciplinary, evidence-based guideline on nosebleed developed in the United States," said Dr. Tunkel. "It informs clinicians about the current level of evidence and includes areas of improvement of practice - such as providing patient instructions for nasal packing care - that were developed by the guideline panel after a review of all the literature."

The guideline delineates clear and actionable recommendations to implement quality improvement opportunities in clinical practice. The GDG used evidence-based research from five clinical practice guidelines, 17 systematic reviews, 16 randomized controlled trials, and 203 related studies to inform the Key Action Statements (KASs) for patient care.

The target patient for the guideline is any individual who is three years old or older with a nosebleed or history of nosebleed who needs medical treatment or who seeks medical care. The target audience for the guideline includes all clinicians who evaluate and treat patients with nosebleed.

January 7, 2020 - Careful monitoring of pressure within the skull (intracranial pressure, or ICP) is crucial for some neurocritical care patients. But current procedures for measuring ICP via an external ventricular drain (EVD) may not leave enough time for accurate ICP readings, reports a study in the Journal of Neuroscience Nursing (JNN), official journal of the American Association of Neuroscience Nurses. The journal is published in the Lippincott portfolio by Wolters Kluwer.

In patients with an EVD to drain excess fluid from around the brain, current practice in terms of temporarily clamping the drain does not provide sufficient time to reach the true ICP level in most cases, according to the new research by Xiuyun Liu, PhD, and colleagues of University of California, San Francisco.

Three-Fourths of EVD Closures Don't Leave Enough Time to Reach Stable ICP

The researchers evaluated procedures for ICP measurement via EVD in patients with subarachnoid hemorrhage (SAH). Subarachnoid hemorrhage is a severe type of stroke in which there is bleeding into the brain, most commonly caused by a ruptured aneurysm. Patients with SAH, traumatic brain injury, and certain other conditions are at risk of developing excessive pressure within the skull, which can cause secondary brain injury.

For these patients, surgical placement of an EVD within the ventricle is a lifesaving procedure, allowing drainage of cerebrospinal fluid (CSF) to control pressure within the skull. Regular and precise measurement of ICP is essential for clinicians to make decisions promptly to protect the brain. To perform these measurements, the EVD system must be temporarily clamped. This stops CSF drainage, allowing the true level of ICP within the brain to be reached.

A 2017 study in JNN suggested that a minimum 5-minute period without drainage is required to reach equilibrium, or a stable level of ICP. "This clinical practice still faces great challenges," the researchers write. "[R]ecent studies have revealed wide practice variations associated with monitoring, treating, and documenting ICP values using EVD."

Is the 5-minute waiting period long enough to reach a stable ICP level? To find out, Dr. Liu and colleagues analyzed high-resolution continuous ICP values recorded via EVD in 107 patients with SAH. The analysis included data from every clamping procedure performed throughout the patients' hospital stay: a total of nearly 33,000 episodes of EVD closure. The researchers developed an automated algorithm to determine whether EVD clamping times allowed enough time for ICP to reach a new equilibrium.

About 66 percent of EVD closures were less than one minute, while 16 percent were more than five minutes. Some closures were performed to test whether the patient was ready to be weaned off their EVD -whether their ICP remained under control without CSF drainage. In about 30 percent of tests, the patient was not yet ready for weaning.

Overall, just 23 percent of closures met study criteria for equilibrium, including a stable ICP level with an EVD closure time of longer than one minute. This suggested that more than three-fourths of EVD closures may not have left adequate time for accurate ICP measurement.

"The result is crucial, and it raises great concerns about the current practice of clamping EVD to measure ICP and obtain accurate readings," Dr. Liu and coauthors write. "A standard guideline and proper training to nurses are needed for ICP intermittent checking." The researchers also call for continued innovations in monitoring technology that can quickly and accurately show ICP trends at a "proper time scale," alongside other critical vital signs.

A single dose of an antibody-based treatment can prevent HIV transmission from mother to baby, new nonhuman primate research suggests for the first time. The findings are being published in the journal Nature Communications.

When that single dose is given is key, however. The study found rhesus macaque newborns did not develop the monkey form of HIV, called SHIV, when they received a combination of two antibodies 30 hours after being exposed to the virus.

Delaying treatment until 48 hours, on the other hand, resulted in half of the baby macaques developing SHIV when they were given four smaller doses of the same antibody cocktail. In comparison, the study found macaques that received the current standard HIV treatment - antiretroviral drugs - remained SHIV-free when they started a three-week regimen of that therapy 48 hours after exposure.

"These promising findings could mean babies born to HIV-positive mothers can still beat HIV with less treatment," said the study's corresponding's author, Nancy Haigwood, Ph.D., a professor of pathobiology and immunology in the Oregon Health & Science University School of Medicine, as well as the director at the Oregon National Primate Research Center at OHSU.

This is the first time a single dose of broadly neutralizing antibodies given after viral exposure has been found to prevent SHIV infection in nonhuman primate newborns. Previous research by Haigwood, Ann Hessell, Ph.D., and others showed four doses of antibodies started 24 hours after exposure prevented SHIV infection, with all 10 of the baby primates in that study not having any SHIV virus for six months. Both studies used a combination of two antibodies called PGT121 and VRC07-523.

The new study also suggests a much shorter course of antiretroviral therapy given after virus exposure could prevent HIV transmission to newborns. Human babies born from HIV-positive mothers typically take the drug cocktail - a personalized regimen of multiple drugs taken daily - for about six weeks before being re-tested. If the tests are then positive, they likely need to take HIV drugs for the rest of their lives. But this study showed nonhuman primate newborns didn't have SHIV after undergoing antiretroviral therapy for just three weeks starting 48 hours after exposure.

HIV-positive women typically take antiretroviral therapy drugs during pregnancy for their own health, as well as to prevent passing the virus onto their developing child. But mother-to-baby transmission sometimes still happens. Children born to HIV-positive mothers also are given antiretroviral therapy to further prevent infection. However, this drug cocktail can have many negative side effects, involves making special liquid formulations for newborns, and researchers worry about antiretroviral therapy's long-term consequences for development.

Antibodies, however, aren't toxic and can be modified to last a long time in the body, which reduces treatment frequency. This has led researchers to explore their potential to replace or supplement antiretroviral therapy for newborns with HIV-positive mothers as well as for HIV-positive adults.

Next, Haigwood and colleagues plan to see if different antibodies, or a combination of antibodies and antiretroviral therapy, could be even more effective. They also want to determine if the antibodies they evaluate actually eliminate HIV, or only prevent it from replicating.

The research team has regularly shared their primate research findings with the scientific community, including those involved in the International Maternal Pediatric Adolescent AIDS Clinical Trials Network, which is currently leading two trials evaluating a single antibody to treat HIV-exposed newborns.

The antibody-drug conjugate ado-trastuzumab emtansine (T-DM1) has promising activity in HER2 amplified salivary gland tumors, according to data published in the Annals of Oncology. The publication is for 'Arm Q,' which is one of nearly 40 single-arm phase two treatments in the NCI-Molecular Analysis for Therapy Choice (NCI-MATCH or EAY131) trial. NCI-MATCH is being co-led by the ECOG-ACRIN Cancer Research Group (ECOG-ACRIN) and the National Cancer Institute (NCI), part of the National Institutes of Health.

"We saw that two of the three NCI-MATCH patients with salivary gland tumors had significant tumor shrinkage by at least 30% with T-DM1 treatment, and this benefit lasted," said lead researcher Komal Jhaveri, MD, FACP, a medical oncologist and early-phase clinical trials specialist at Memorial Sloan Kettering Cancer Center in New York. "The benefit lasted two years in the patient with squamous cell cancer of the parotid gland, and nine months in the case of mucoepidermoid carcinoma of the parotid gland."

"This is a hint of activity that needs to become the focus of a larger trial," said Dr. Jhaveri.

Another recent T-DM1 trial (not part of the NCI-MATCH trial) reported interim results at the 2019 annual meeting of the American Society of Clinical Oncology. In that trial (NCT02675829), nine of the 10 patients with salivary gland cancers treated with T-DM1 responded either with tumor shrinkage by computed tomography (CT) scan or as assessed by positron emission tomography (PET). As a result, that trial has since been expanded to enroll additional patients.

T-DM1 is a targeted therapy that contains the monoclonal antibody trastuzumab, which binds to the HER2 protein found on some cancer cells. It also contains the cytotoxic drug DM1, which inhibits tumor cell division. Unlike chemotherapy, antibody-drug conjugates like T-DM1 are intended to target and kill tumor cells while sparing healthy cells. T-DM1 has improved overall survival and led to a new standard of care in HER2-positive metastatic breast cancer previously treated with trastuzumab and a taxane.

The primary objective of each arm in NCI-MATCH is to estimate the proportion of patients who had an objective response (OR). Under predefined criteria, an OR rate greater than 16% in a given NCI-MATCH arm would warrant further study of the agent(s).

Although the results from Arm Q did not meet these criteria, the signal in salivary gland tumors is important.

"We are excited about the prospect of this and other upcoming MATCH arms to shed new light on responsive tumor types, as there is far less data available in rare and uncommon disease types from previously conducted trials," said Keith T. Flaherty, MD, a medical oncologist at Massachusetts General Hospital Cancer Center in Boston and ECOG-ACRIN study chair for the overall NCI-MATCH trial. "Salivary cancer is a particularly understudied area and seeing evidence of benefit for a molecularly targeted approach strongly supports further focus on this cancer type."

Patients received T-DM1 at 3.6 mg/kg intravenously every three weeks until toxicity or disease progression.

Of the 38 patients enrolled in Arm Q, 36 were included in the efficacy analysis. Overall, this was a heavily pretreated group of patients with multiple unique histologies (excluding breast and gastric). Seventeen patients (47%) had stable disease with median duration of 4.6 months, including eight of 10 patients with ovarian and uterine carcinomas. The six-month progression-free survival rate was 23.6%. Common toxicities were fatigue, anemia, fever and thrombocytopenia. However, this arm did not find any new toxicities for T-DM1.

There was a trend for tumor shrinkage with higher levels of gene copy number as determined by the tumor sequencing assay. The median HER2 copy number was 17 (range: seven-139). Notably, the patient with squamous cell cancer of the parotid gland had a HER2 gene copy number of 129 and the patient with mucoepidermoid carcinoma of the parotid gland had a copy number of 21.

"NCI-MATCH seeks to determine whether matching certain drugs or drug combinations in adults whose tumors have specific gene abnormalities will effectively treat their cancer, regardless of their cancer type," said Lyndsay Harris, MD, Associate Director, Cancer Diagnosis Program, NCI, and co-PI of the NCI-MATCH trial. "In certain studies, such as this, we also saw benefit in rare tumor types. Such discoveries could be eligible to move on to larger, more definitive trials."

Using data from a large federal government telephone survey of adults, Johns Hopkins Medicine researchers report evidence that inhaling heated tobacco vapor through e-cigarettes was linked to increased odds of asthma and chronic obstructive pulmonary disease (COPD), conditions long demonstrated to be caused by smoking traditional, combustible cigarettes. The data, the researchers say, also suggest that odds of developing COPD may be as much as six times greater when people report they both vape and smoke tobacco regularly, compared with those who don't use any tobacco products at all.

Reports on the studies are published Jan. 2 in the American Journal of Preventive Medicine and on Oct. 16 in BMC Pulmonary Medicine.

For both studies, the researchers caution that they weren't designed to show that vaping directly causes lung disease, but only whether doing so was associated with an increased likelihood of having disease. The researchers also didn't distinguish between vaping tobacco compared with cannabis. They also cautioned that self-reports via telephone surveys may not be wholly reliable. However, they say their findings demonstrate the need for continued research with e-cigarette users over time to confirm and clarify the risks.

"Although e-cigarettes may turn out to be safer overall than traditional combustible cigarettes, our studies add to growing evidence that they carry health risks," says Michael Blaha, M.D., M.P.H., professor of medicine at the Johns Hopkins University School of Medicine. "These studies are the first in a series of larger and long-term studies that will more definitively provide evidence to inform tobacco users and regulators."

Asthma, marked by inflammation of the airways and shortness of breath, affects an estimated 25 million Americans, and life-threatening episodes can be triggered easily by pollution, allergies and smoking. COPD, which affects some 16 million Americans, describes a group of disorders including emphysema and chronic bronchitis that make it hard to breathe due to permanent damage to the lungs over time. Rates of asthma and COPD are rising worldwide, according to the World Health Organization. Most cases of COPD result from smoking traditional cigarettes.

A study published by Blaha earlier this year in the Annals of Internal Medicine estimated that 1.4% of people, or about 1.9 million people in the U.S., solely use e-cigarettes. Scattered reports have linked the practice to a spike in respiratory illnesses dubbed EVALI (e-cigarette, or vaping, product use-associated lung injury), affecting more than 2,500 people and associated with numerous deaths, according to the Centers for Disease Control and Prevention. Because vaping and the products inhaled with it are still relatively new to the market, its safety remains unclear.

To shed some light on the risk, the researchers took advantage of national survey data gathered by the Behavioral Risk Factor Surveillance System from 2016 and 2017. This annual survey, commissioned by the U.S. Centers for Disease Control and Prevention, consisted of telephone interviews of more than 400,000 adult participants and provides data on health-related risk behaviors and chronic medical conditions.

In the analysis published in BMC Pulmonary Medicine, the investigators analyzed data from 402,822 people who identified themselves as never smokers, meaning they said they had smoked less than 100 combustible cigarettes in their lifetimes. Of these, 3,103 reported using e-cigarettes or vaping, and separately 34,074 people reported having asthma. The average age of e-cigarette users was 18-24. About 67% of e-cigarette users were men. Approximately 57% of e-cigarette users reported that they were white, 19% were Hispanic and 12% were black.

Almost 11% of the e-cigarette users reported having asthma, compared with 8% of those who had never used e-cigarettes. Those people who reported being current e-cigarette users were 39% more likely to self-report having asthma compared with those people who said they never used e-cigarettes. Those who said they used e-cigarettes some days were 31% more likely, and daily users were 73% more likely to report asthma, compared with non-e-cigarette users.

For the study published in the American Journal of Preventive Medicine, the researchers analyzed the same data from all the questioned participants. From the more than 700,000 interviewees, about 61% reported being never smokers, about 9% were current smokers, 30% were former smokers, more than 3% said they currently used e-cigarettes, and 2% said they used both e-cigarettes and smoked. The e-cigarette users were more likely to fall in the age range of 30-34, almost 60% were men, 72% identified as white, 8% as black, 3.5% as Asian and 11% as Hispanic.

Of those who said they used e-cigarettes, about 11% said they had chronic bronchitis, emphysema or COPD, compared with 5.6% of people who said they had never used e-cigarettes. Among never smokers, current e-cigarette users were 75% more likely to report having COPD, compared with those who had never used them. Those who said they used both e-cigarettes and smoked cigarettes were almost six times more likely to report having COPD, compared with those who had never used either, whereas just using combustible cigarettes alone increased the odds by three times.

"As a physician, I am most worried about those who use both e-cigarettes and combustible cigarettes because they may end up taking in the most nicotine, which may do the most damage," says Albert Osei, M.D., M.P.H., a postdoctoral fellow at the Johns Hopkins University School of Medicine and lead author on the study. "Through public health campaigns, we finally had smoking levels down in some populations, but now with the current vaping epidemic, I foresee a whole new previously tobacco-naïve, young generation becoming dependent on nicotine if we do not intensify public health education efforts."

According to the CDC, of the 16 million people in the U.S. who have COPD, 38% of them still smoke.

Changing the microenvironment of tumors to increase the immune system's response to them has been the goal of countless research and clinical studies including the most recent use of checkpoint inhibitory antibodies. The majority of patients have tumors that are "cold" -- that is, the tumors don't contain many immune cells, or they have cells that suppress the ability of the immune system to fight them.

Increasing immune cells within a tumor can change it from "cold" to "hot" -- more recognizable to the immune system. Hot tumors show higher rates of response to treatment, and patients with such tumors have improved survival rates.

Physicians and scientists at Rush University Medical Center have found that injecting tumors with influenza vaccines, including some FDA-approved seasonal flu shots, turns cold tumors to hot, a discovery that could lead to an immunotherapy to treat cancer. The study results were published December 30th in the Proceedings of the National Academy of Sciences.

Inactivated flu vaccines can make tumors hot

Currently, some immunotherapies utilize live pathogens (disease-causing organisms) as cancer treatments, but these treatments only have shown lasting effects in a limited number of patients and cancer types. "We wanted to understand how our strong immune responses against pathogens like influenza and their components could improve our much weaker immune response against some tumors," said Andrew Zloza, MD, PhD, assistant professor in Rush Medical College's Department of Internal Medicine and senior author of the study.

Drawing on a National Cancer Institute database, researchers found that people who had lung cancer and hospitalization for a lung infection from influenza at the same time lived longer than those who had lung cancer with no influenza. They found a similar outcome in mice with tumors and influenza infection in the lung.

"However, there are many factors we do not understand about live infections, and this effect does not repeat in tumors where influenza infections do not naturally occur, like skin," said Zloza.

To find an alternative to the limitations of live infection, researchers inactivated the influenza virus, essentially creating a flu vaccine.

They found that direct injection of this vaccine into the skin melanoma of the mice resulted in the tumors either growing slower or shrinking. The injection made the tumor hot by increasing the proportion of a type of immune-stimulating cells (called dendritic cells) in the tumor, leading to an increase in a type of cells known as CD8+ T cells, which recognize and kill tumor cells.

Importantly, injecting a skin melanoma tumor on one side of the body not only resulted in the reduced growth of that tumor, but also in reduced growth of a second skin tumor on the other side of the same mouse that was not injected.

The study authors note that they observed similar systemic outcomes in a mouse model of metastatic triple-negative breast cancer, in which both primary tumor growth and the natural spread of the breast tumor to the lungs were reduced after injection only into the primary tumor. "Based on this result, we hope that in patients, injecting one tumor with an influenza vaccine with lead to immune responses in their other tumors as well," Zloza said.

FDA-approved flu shots also reduced tumor growth

"Our successes with a flu vaccine that we created made us wonder if seasonal flu vaccines that are already FDA-approved could be repurposed as treatments for cancer," Zloza said. "Since these have been used in millions of people and have already been shown to be safe, we thought using flu shots to treat cancer could be brought to patients quickly."

The researchers found that injection of such flu shots also resulted in reduction of tumor growth.

To determine if similar results could be obtained with tumors from patients, the researchers developed a mouse model, which they call AIR-PDX. To create this model, they implant a piece of tumor and immune cells from a patient with cancer into a mouse that does not have a functioning immune system of its own - which prevents the mouse from rejecting the implanted cells.

"Such transplant allows us to utilize patient-grade drugs in a living system. This is as close as we can get to testing something ahead of a clinical trial," Zloza said.

The researchers used a patient's lung tumor and a melanoma metastasis in AIR-PDX models. They found that putting the flu shot in these patient-derived tumors causes them to shrink, while untreated tumors continued to grow.

Influenza vaccines can be combined with immunotherapy

Since new treatments are often compared to or combined with current frontline therapies for cancer, the researchers used immune checkpoint inhibitors in their studies. Immune checkpoint inhibition "releases the brakes" on immune cells so that they can fight the tumor.

The researchers found that flu vaccines can reduce tumor growth when used alone, whether or not the tumor is responsive to checkpoint inhibitor therapy. When they combined the flu vaccine with a checkpoint inhibitor together, an even a greater reduction in tumor growth occurred.

"These results propose that eventually both patients who respond and who do not respond to other immunotherapies might benefit from the injection of influenza vaccines into the tumor, and it may increase the small proportion of patients that are now long-term responders to immunotherapies," Zloza said.

Not all effective flu vaccines work on cancer

Five different influenza shots for the 2017-2018 flu season were used in this research. Four were effective in achieving the same results in fighting tumors.

One flu shot with a synthetic adjuvant (an immune modifier) had no antitumor effect, and maintained other cells (called regulatory B cells or Bregs) that suppress an immune response. When the adjuvant was removed from the vaccine, it became effective. Similarly, when the B cells were removed, the vaccine also then became effective.

That all five vaccines provided protection from flu infection, but one was ineffective in reducing tumor growth "demonstrates a disconnect between the principals of immune responses needed to fight pathogens versus tumors," Zloza said. "It also highlights the need for additional consideration regarding what adjuvants are included in immunotherapies and which vaccines could be used to treat cancer."

Flu vaccine's FDA approval may speed clinical trials

"Since humans and mice are about 95% genetically identical, the hope is that this approach will work in patients. The next step planned is to conduct clinical trials to test various factors," Zloza said.

Clinical trials on average require four phases and can take between eight to 10 years to complete, but because the seasonal influenza vaccine is FDA-approved, the clinical trials for this study might be significantly shorter. "Although we are currently studying the use of other vaccines as well, the seasonal flu shot is safe and recommended for most people over 6 months of age, including most patients with cancer," Zloza said. "This is why we chose to start with it.

"The flu shot is inexpensive and it has a quick translatability since it is an FDA-approved drug that we are repurposing," Zloza continued.

Jochen Reiser, MD, PhD, professor in Rush Medical College, chairperson of the Department of Internal Medicine and a co-author of the study adds: Turning one own's immune system against cancer using something as available and simple as a flu shot may help certain patients with cancer in the near future, instead of within a decade."

Using a computer algorithm, scientists at Uppsala University have identified a promising new treatment for neuroblastoma. This form of cancer in children, which occurs in specialised nerve cells in the sympathetic nervous system, may be life-threatening. In the long term the discovery, described in the latest issue of the scientific journal Nature Communications, may result in a new form of treatment for children in whom the disease is severe or at an advanced stage.

The new treatment is based on activating a receptor protein, CNR2 (cannabinoid receptor 2), in the nervous system. A highly unusual method enabled this particular protein to be applied therapeutically. Instead of using traditional methods of drug development, this research group has developed a new computer algorithm capable of combining massive quantities of genetic and pharmacological data ('big data') from European and American hospitals and universities. The algorithm then suggested new treatments that could influence the basic mechanisms of the disease.

"We were astonished when the algorithm came up with completely new ideas for treatment, such as CNR2, that no one has ever discussed in this context. So we decided to investigate this further in the lab," says Sven Nelander, senior lecturer at Uppsala University's Department of Immunology, Genetics and Pathology, who is in charge of the study.

The new treatments were investigated using cell samples from patients and in animal models, where they proved efficacious. The cancer cells' survival rate declined, for example, and tumour growth in zebrafish (Danio rerio) decreased, following treatment with a substance that stimulates CNR2.

The researchers have also developed the computer algorithm to enable it to be applied to other forms of cancer.

"Smart algorithms will be increasingly important in cancer research in the years ahead, since they can help us scientists to find unexpected angles. We've already started a major project here in Uppsala, in which several types of cancer in children and adults will be investigated this way. Our hope is that this can result in more unexpected treatment options," Nelander says.

The number of girls receiving HPV vaccines in Denmark plummeted after vaccine misinformation spread through Danish media outlets from 2013 to 2016. Health officials launched a campaign in 2017 aiming to correct the misinformation and encourage girls to get vaccinated.

New research from the University of North Carolina at Chapel Hill shows that, despite substantial progress, about 26,000 Danish girls remain unvaccinated as a result of vaccine misinformation. About 33,000 girls are born annually in Denmark. Among the unvaccinated girls, researchers expect to see as many as 180 avoidable cases of cervical cancer and 45 deaths.

The researchers found that misinformation in Danish media outlets from 2013-2016 led to vaccinations dropping by 50.4%. An information campaign geared toward concerned parents helped increase vaccine uptake again, but uptake is still below the level before misinformation began, showing how difficult it is to undo the damages misinformation causes.

The study results were published Jan. 7 in Vaccine. The paper's lead author is UNC-Chapel Hill Latané Distinguished Professor of Economics Peter R. Hansen. Hansen worked with Noel Brewer, professor of health behavior at Carolina and Lineberger Comprehensive Cancer Center member, and Matthias Schmidblaicher, graduate student in the Department of Economics at the European University Institute, on the research.

"Denmark is a good case study to see how a country deals with vaccine misinformation. By using anecdotal stories, media can create a false equivalence between outrageous claims and scientific facts," Hansen said. "The media stories that include inaccurate information cut HPV vaccine uptake in half. Recovery has been slow and costly. Resources are being used to combat misinformation instead of being used for healthcare benefits."

The HPV vaccine is safe and can prevent six cancers, including up to 90% of cervical cancers. Receiving the vaccine at 11- or 12-years-old is important because the vaccine is most effective at that time and infections often begin at 13-years-old.

The Danish Health Agency, Danish Cancer Society and Danish Medical Association partnered on the information campaign, which was funded by the Danish Parliament's Health and Senior Citizen's Committee and the Danish Cancer Society. The campaign cost about $1 million USD in taxpayer funds, and aimed to provide information to people hesitant about the vaccine, as opposed to people unwilling to get the vaccine for their children, who likely wouldn't change their minds, the study said. The campaign focused on sharing personal stories from women with cervical cancer on social media and digital platforms.

"The main threat to the resilience of vaccination programs globally is vaccine misinformation," Brewer said. "When there's a large drop in vaccination coverage, it's almost always because there's an unproven vaccine safety scare. For example, Japan had their HPV vaccination rates drop from 70% to 7% in one year. This has happened in several other countries, and all were due to unsubstantiated safety concerns."

A virus that jumps from shrews to humans could have been causing encephalitis unnoticed for decades in regions where the host shrew lives in the wild.

Eight newly-identified fatal cases of Borna disease virus 1 (BoDV-1) suggest that where the virus occurs in the wild, it could be behind a high proportion of severe and deadly cases of encephalitis, according to results from 56 patients who had developed signs of encephalitis over the past 20 years, published in The Lancet Infectious Diseases journal.

Although there is no proven treatment, the researchers behind the new study suggest that clinicians should test for BoDV-1 more often, so that the true extent of infection in humans can be established. The authors suggest testing for its presence in all patients affected by rapidly evolving central or peripheral nervous system disorders where the cause is unknown and where the patient may have come into contact with the infected reservoir host, the bicoloured white-toothed shrew.

All patients in which the virus has been newly diagnosed died between 1999 and 2019, and they all lived in southern Germany. However, the authors cannot rule out that it could be behind milder cases of encephalitis, especially in regions of central Europe where the infected host animal species occur in the wild. It was thought it might play a role in psychiatric disorders, such as depression or schizophrenia, but until the virus was reported in four cases in 2018, its links to unexplained encephalitis were rarely investigated.

BoDV-1-infected bicoloured white-toothed shrews occur in Germany, Austria, Switzerland, and Liechtenstein, but how the disease virus jumps from shrews to humans is unclear. Symptoms in infected people start with a fever, headache and confusion, and continue with signs of brain disease such as an unsteady gait, memory loss, seizures, and a progressive loss of consciousness. In the new cases, symptoms deteriorated rapidly following patients' admission to hospital, leading to deep coma and death. All eight patients died within 16 to 57 days of admission.

"Our tests bring the total number of reported cases of human Borna disease virus in southern Germany to at least 14, so it is still relatively rare in absolute numbers, but it might be behind a larger proportion of unexplained severe to fatal encephalitis cases. Only more tests on patients with severe or even deadly encephalitis will find this out, and earlier detection might be possible using serum and cerebrospinal fluid samples from living patients," says Professor Martin Beer from Friedrich-Loeffler-Institut in Germany. [1]

For the current study, the researchers analysed brain tissue from dead patients with encephalitis thought to be caused by a virus that had not been identified. The samples were submitted for diagnosis between 1995 and 2018. The authors analysed for genetic signs of Borna disease virus. When sequences of BoDV-1 were detected, they compared them with gene sequences from shrews and from agricultural animals like horses and sheep accidentally infected by the virus.

In 28 patients, the cause of encephalitis was unknown, and nine of these patients died. Six of those who died have been newly diagnosed with BoDV-1 and an additional two cases were independently identified during diagnostics on brain autopsy samples. By contrast, no surviving patients were diagnosed with the virus. However, the scientists note that further research is needed to determine whether it could also be behind milder cases of brain inflammation.

"Our findings indicate that Borna disease virus infection has to be considered a severe and potentially lethal human disease transmitted from a wildlife reservoir. However, it's not a newly-emerging disease, but one that appears to have occurred unnoticed in humans for at least decades, and may have caused other unexplained cases of encephalitis in regions where the virus is endemic in the host shrew populations," says Professor Barbara Schmidt from Regensburg University Hospital, Germany. [1]

The authors note that a limitation of their study is that they were unable to establish an exact route of transmission from shrews to humans. However, they analysed available information on 14 patients and found that contact with animals, living in rural or suburban areas, agricultural work, and other outdoor activities were reported for most of the patients. In at least seven cases, close contact with cats was reported. When cats hunt, they might bring shrews into their homes, exposing humans to them.

The gene sequences of BoDV-1 in all eight of the new cases were different from each other and matched gene sequences from locally infected shrews or horses, suggesting that infection from the host wildlife reservoir occurred independently each time.

In 2016, three people developed severe or fatal encephalitis from Borna disease virus after receiving organs from the same transplant donor, so the researchers investigated the possibility of this route of transmission for two of the new cases. These two patients received organs from two different donors, followed by immunosuppressive therapy to avoid organ rejection. However, results from the current study argue strongly against the donor organs as a route of transmission. Other recipients of organs from the same donors did not experience any health problems of note, and sequences from the virus in one of the patients closely resembled sequences from infected horses and other infected humans from the same locality.

Writing in a linked Comment, Dr Tomoyuki Honda from Osaka University, Japan, says: "Niller and colleagues' study has several implications for the pathology and epidemiology of Borna virus infection." He continues: "For several decades, the field has been hindered by the controversy surrounding true and false human Borna virus cases. It is time to relaunch human Borna virus research based on a theoretical framework that integrates the knowledge from these confirmed human Borna virus cases."

DALLAS - Jan. 8, 2020 - Providing multidisciplinary team consults for HIV patients while they are hospitalized to help address social and medical barriers reduces future infection rates and boosts participation in follow-up care, results from a study on how to reengage patients show.

A multidisciplinary inpatient team of HIV medical specialists, HIV case managers, and transitional care nurses assigned to help patients overcome care gaps improved viral suppression rates by 30 percent and increased engagement in care after discharge by 30 percent compared with those without interventions (for whom viral suppression increased 7 percent and engagement 11 percent), researchers at UT Southwestern Medical Center report in the journal AIDS Care.

"As we focus on national initiatives to Ending the HIV Epidemic: A Plan for America, it is important to remember that many people living with HIV continue to struggle with staying engaged in care - particularly youth, minorities, and people who live in the South. Solutions to this problem require a collaborative and adaptable approach," says clinical researcher Ank Nijhawan, M.D., M.P.H., an associate professor of internal medicine, and of population and data sciences at UT Southwestern. "Our multidisciplinary approach of matching the type and intensity of intervention to the level of need resulted in significant improvement in the outcomes of patients with HIV."

Fewer than half of people living with HIV receive consistent, ongoing medical care, while vulnerable populations such as African Americans, Hispanics, and uninsured patients are at an even higher risk of disengagement and uncontrolled HIV infection, researchers say.

In this study, the UT Southwestern infectious disease researchers reviewed electronic health records for 1,056 people living with HIV in the Parkland Health and Hospital System between September 2013 and December 2015 - a year prior to and after the multidisciplinary intervention team launched its program. The intervention program initiated in October 2014. Hospitalized patients with HIV received one of the following: (a) an HIV medical consultation (as requested by primary treatment team), (b) an HIV medical consultation plus transitional care nursing (based on readmission risk), or (c) no specialized intervention beyond care coordination from the HIV case manager. Of the patients who were studied, 68 percent were male, 55 percent were African American, 23 percent were Hispanic, 77 percent were single, and 38 percent had AIDs.

In addition, 85 percent who were seen by the transitional care nurse reported at least one barrier to continuity of care - most commonly mental health and substance use disorders - and more than a third (39 percent) reported three or more such barriers. Many had poor engagement in outpatient HIV care and low virologic suppression rates.

The success of the team's multidisciplinary approach reinforced the importance not just of specialized medical care, but also the critical role of social determinants of health such as transportation, housing instability, and substance use disorders, the researchers say.

Patients and caregivers from diverse backgrounds across Ontario consistently prioritized insufficient publicly-funded home care services as the gap in the health system that most needed to be addressed to improve their experience going home from hospital, according to research led by St. Michael's Hospital of Unity Health Toronto.

The research, publishing on Jan. 6, 2020 in BMJ Quality and Safety, focused on understanding patient and caregiver priorities for improvement during the hospital-to-home transition and is based on input from over 700 participants over the course of 11 months in 2018.

The top three gaps in the system identified by patients and caregivers all related to home care services. Patients and caregivers reported not enough home care to meet the need, that home care support was not in place when patients arrived home from the hospital, and that they had to advocate for themselves to get enough home care. Other priorities related to being involved in discharge planning and once home, having a number to call if there was a problem.

"The transition from hospital to home is a tricky time for patients and caregivers, and if the appropriate supports are not in place, patients are at risk of experiencing poor outcomes," said Dr. Tara Kiran, principal investigator of the study, who is also a family physician and an associate scientist with St. Michael's MAP Centre for Urban Health Solutions.

The study was designed to inform the development of a quality standard for the province related to the transition from hospital to home. The work was done in consultation with a community advisory group that included patients and caregivers, as well as representatives from health service and community organizations.

The improvement priorities were consistent across multiple-subgroups in Ontario, including both patients and caregivers, males and females, rural and urban residents, pediatric and adult patients, as well as patients discharged to long-term care and elsewhere in the community.

"The engagement of patients and caregivers across the province over the course of this study was extensive," said Dr. Kiran. "The findings are entirely based on the lived experiences and priorities of Ontario patients and caregivers, including groups we sometimes don't hear from. It's telling that patients and caregivers from such diverse backgrounds all wanted to see more publicly-funded home care"

Dr. Kiran said she hopes this work and the related quality standard can help guide Ontario Health Teams as they choose where to focus their improvement efforts.

"Patients and caregivers need to be involved in discharge planning, they need to know who to call when they run into trouble when they get back home, and most importantly, they need sufficient and timely home care supports."

Families of children with autism face high physical, mental and emotional burdens, are sometimes ridiculed and even accused of child abuse, according to a Rutgers study.

The findings were published in the International Journal of Autism & Related Disabilities.

The study surveyed 25 caregivers of 16 children ages 2 to 20 with autism spectrum disorder to evaluate how their care affected their family dynamics, physical and mental health, and social functioning. The researchers also asked about the caregivers' worries, daily activities, family relationships and insurance.

"While the understanding of how autism spectrum disorders impact individuals has grown, the awareness of the burden on families who care for these individuals is less established," said Xue Ming, a professor of neurology at Rutgers New Jersey Medical School. "Caring for loved ones with autism spectrum disorder is emotionally and physically taxing."

The study found:

Emotional burnout was more likely in families with a child with low-functioning autism spectrum disorder and simultaneous conditions.

Social isolation was greater in families who reported significant emotional burnout.

Families with more than one caregiver experienced less emotional burnout and social isolation.

Families with a higher socioeconomic status tended to spend more money on medical treatments outside of their health insurance policy.

Families with an aggressive and irritable child tended to experience more social isolation and emotional burnout.

Simultaneous medical and behavioral disorders were common in these children.

Nine of the 16 families in the study reported being ridiculed or accused of child abuse, which they said limited them from attending social events, visiting public places such as churches, supermarkets and restaurants, and using mass transportation.

"This suggests that communities need to improve their inclusiveness for families with children with autism spectrum disorder," Ming said. "The study shows there is a need to raise public awareness of the burdens faced by these families and to alert medical providers to provide them with more support."

The findings also can be used to advocate for better resources for these children and families to improve their quality of life and reduce stress, she said.

ANN ARBOR, Mich. - One of the most expensive parts of having a baby may involve the birth itself, a new Michigan Medicine study suggests.

For some families, average out-of-pocket health care spending for maternity care - including the pregnancy, delivery and three months postpartum - jumped from $3,069 in 2008 to $4,569 in 2015, according to findings published in the January issue of Health Affairs.

And the Affordable Care Act (ACA), which required large, employer-based health plans (used by about 50% of women in the U.S.) to cover maternity care, hasn't protected families from shouldering a big brunt of costs.

The reason: while the ACA requires full coverage of preventive services, such as pap smears and mammograms, there are few restrictions on how plans impose co-pays, deductibles and cost-sharing for maternity care.

"We were surprised to learn that the vast majority of women paid for critical health services tied to having a baby," says lead author Michelle Moniz, M.D.,M.Sc., an obstetrician gynecologist at Michigan Medicine's Von Voigtlander Women's Hospital and researcher with the U-M Institute of Healthcare Policy and Innovation.

"These are not small co-pays. The costs are staggering."

The study included a national sample of 657,061 women enrolled in 84,178 employer-sponsored plans who had been hospitalized for childbirth from 2008 to 2015. Researchers analyzed costs for all health care services used before and after delivery that might influence pregnancy outcomes.

Ninety-eight percent of women were found to be paying some out-of-pocket costs.

Costs of childbirth

Childbirth is a leading reason for hospitalization among women of reproductive age. Not surprisingly, out-of-pocket costs for cesarean sections were higher, with mean total out-of-pocket spending rising from $3,364 in 2008 to $5,161 in 2015 for C-sections compared to an increase of $2,910 to $,4314 for vaginal births.

Women also seem to be bearing a higher proportion of total costs. Those with vaginal births covered 21% of expenses in 2015 compared to 13% in 2008. Women with C-sections could expect to pay about 15% of costs, up from 10% during the same years.

Maternity care services are vital to ensuring the best possible outcomes for moms and newborns, Moniz says. This is an especially important focus as data over recent years suggests that the U.S. continues to defy global trends as one of the only developed countries with a rising maternal mortality rate.

"The increasing maternal health costs burdening families over time is concerning. Research tells us that out-of-pocket costs for healthcare are often associated with skipped care," Moniz says.

"These financial burdens put women at risk of delaying or missing maternity care, which we know can lead to poor outcomes for women and babies. Restricting patient spending for maternity care may be an important opportunity to improve maternal and neonatal health for American families."

Higher deductible plans and co-pays, along with possible misconceptions about what the ACA requires for maternity health care coverage, may be areas advocates and lawmakers could target for improvement, Moniz says.

"There is strong rationale for policymakers to consider policies to protect the average consumer," Moniz says.

"Maternity and childbirth care are essential health services that promote the well-being of families across our country. Reducing patients' costs for these high-value services makes sense. We all want babies to have the best possible start in life."

The rising price of prescription drugs has led to a slew of proposals to lower costs and expand access to medications. However, a new study from researchers at Harvard Medical School and the City University of New York at Hunter College suggests that an effective reform model already exists: the pharmacy benefit of the Veterans Health Administration, commonly known as the VA. Researchers found that VA patients are significantly less likely than other insured Americans to go without needed medications, skip doses, or delay filling prescriptions because they are unable to afford them. The study found that VA coverage also reduced racial and economic disparities in prescription drug access.

The VA buys drugs at relatively low cost by using a combination of regulations, bargaining with drug companies to reduce wholesale prices, and utilizing a national formulary. The VA can then afford to provide drugs to veterans with low -- or no -- patient copays. The investigators assessed whether this benefit design lowered "cost-related medication non-adherence" by analyzing national health surveys conducted from 2014 to 2017. Although VA enrollees were older, sicker, and poorer than other insured Americans, fewer (6.1% of enrollees) reported that costs caused them to go without any medication in the course of a year -- compared to 10.9% of non-VA patients. The differences were even larger among patients with serious conditions like heart disease (6.1% vs. 14.4%) and chronic lung disease (6.4% vs. 19.9%).

"We face a crisis in drug affordability," noted senior author Dr. Danny McCormick, associate professor of medicine at Harvard Medical School and a primary care physician. "High copays and deductibles are forcing patients to skip their medications -- even for serious illnesses like heart disease or lung disease -- putting their health, and even their life at risk. The VA shows that there is a better way."

Previous studies suggest that drug costs would be lower for Medicare if it were allowed to negotiate prices directly with drug companies and use a national formulary, as does the VA. Currently, Medicare's drug benefits are only available through private plans, which often impose copays, deductibles, and co-insurance for drugs that can add up to thousands of dollars annually. VA enrollees instead pay at most $11 per prescription, and often less. The researchers found that while the VA prevented patients overall from skipping medications due to costs, it was especially beneficial for minority veterans and those with lower incomes.

"Our findings have important implications for the debate about the affordability of health reform," noted Dr. Steffie Woolhandler, distinguished professor at the City University of New York's Hunter College and lecturer (formerly professor) in Medicine at Harvard Medical School. "Both the House and Senate Medicare-for-All bills would borrow tools from the VA to cut drug costs, including price negotiations and a formulary. These steps could allow all Americans to afford their medications without burdensome copayments or deductibles," she added.

Dr. Adam Gaffney, a pulmonary and critical care physician at Harvard Medical School, noted that while a VA-like drug benefit model could save money, it could also improve patients' health. "Today, we have better drugs -- more ways to help our patients -- than ever before. But these drugs offer no help to patients who can't afford to take them. By reforming how we pay for prescription medications, we can improve health outcomes, while bringing our drug spending in line with that of other rich nations."

Scientists at the Columbia Center for Children's Environmental Health (CCCEH) have uncovered a link between prenatal exposure to phthalates--a ubiquitous group of plasticizers and odor-enhancing chemicals--and deficits in motor function in girls. Phthalates are widely used in consumer products from plastic toys to household building materials to shampoos and are thought to disrupt endocrine function, and possibly interfere with brain development in utero.

Results of a longitudinal study of 209 New York City women and their offspring are published in the journal Environment International.

The researchers measured seven phthalate metabolites in maternal spot urine obtained during the third trimester of pregnancy. Motor function was evaluated at age 11. After adjusting for potential confounders, they saw a decrease in fine-motor functions among girls, not boys, following exposure to high levels of specific metabolites. Accounting for mixtures of phthalates and motor functions, the analysis pointed to three phthalates most linked to the deficits: mono-butyl phthalate (MBP), mono-benzyl phthalate (MBzP), and mono-isobutyl phthalate (MiBP)--none of which are metabolites of Di-2-ethylhexyl phthalates (DEHP), the most common category of phthalates.

"There a growing awareness of the problem of plastics, which are destructive to animal life and ecosystems," says senior author Pam Factor-Litvak, PhD, professor of epidemiology. "In this study, we have found new evidence that phthalates--chemicals commonly used in cosmetics and plastics--are harmful to children's health. Girls with deficits in fine motor skills may have difficulty with their schoolwork, particularly related to problems writing and using electronic devices. They may also have problems with hand-eye coordination."

Phthalates are easily unbound from plastics and released into the environment; most exposure is from diet (where they are part of food packaging), air (as they are used in air fresheners, perfumes, etc.), and skin absorption (as they are used in personal care products). Phthalates cross the blood-placenta barrier and are associated with shortened gestational age, disrupted male reproductive development, and deficits in cognitive function and behavioral outcomes.

Phthalates were previously shown to alter the levels of thyroid hormones, which are critical for brain development, especially the development of the cerebellum, which is in part accountable for coordination and fine-motor movements. Phthalates were also shown to disrupt specialized neurons associated with the development of motor skills, including fine motor skills, which are known to develop earlier in girls than in boys.