Body

About 10-20 % of all known pregnancies unfortunately end in miscarriage or the loss of a fetus. Despite its common occurrence, there is still a lot of stigma surrounding miscarriage and many women find that their emotional and psychological needs are unmet as they go through a devastating grieving process. In 2014, Dr. Jessica Zucker, a clinical psychologist specializing in women's reproductive and maternal mental health, started a campaign on social media using the hashtag #ihadamiscarriage to address this cultural silence.

Amy Henderson Riley, DrPH, MCHES, assistant professor at the Jefferson College of Population Health, came across this campaign when she was seeking out support for her own experience. As a health communication researcher, she was struck by the breadth and honesty of people's stories on this public platform. In order to find out more about what women and men were sharing about their miscarriage experiences, she teamed up with Rebecca Mercier, MD MPH, assistant professor and OB-Gyn doctor at Thomas Jefferson University to conduct a qualitative research study on 200 posts of text and pictures shared by Instagram users. They published their findings in Obstetrics & Gynecology on December 5.

Their study found that the content posted by Instagram users included rich descriptions of the medical and physical experiences of miscarriage, and the emotional spectrum of having a miscarriage and coping with those emotions, the social aspect, and family identity.

"I find it endlessly fascinating that women are opening up to essentially strangers about things that they hadn't even told to their partners or families," says Dr. Riley. "But this is how powerful this community is."

"I think it's normal to be pissed at your body - especially when it feels like it failed you and even more so when it feels like it keeps failing you" - post #130.

"What surprised me the most was how many women and their partners identified as parents after their miscarriage and how the miscarriage lasted into their family identity after a successful pregnancy," says Dr. Mercier. "The extent to which this loss affects women and their families, and the longevity of their grief is a blind spot for clinicians."

"Every time I see a pregnant woman, I'm reminded of what should have been" - post #104.

These personal accounts also provided insight into patients' perspectives of typically defined experiences. For example, in the clinic, the typical definition of recurrent pregnancy loss is after three pregnancies. However, the researchers found that many patients who had had two or more miscarriages identified with having recurrent pregnancy loss.

"There is a push in the OB-Gyn field to redefine recurrent pregnancy loss. The findings from this study could help the field come to a new consensus," says Dr. Mercier. "This is a clear example of looking at a clinical problem through a public health lens and why this collaborative research is so important," adds Dr. Riley. "These testimonials can inform how providers care for patients with very specific needs, like recurrent pregnancy loss, and address it sooner rather than later.''

"As clinicians, we're trained to provide for women's medical needs as they go through a miscarriage. We don't always have to tools to address the emotional needs," says Dr. Mercier. "I'm hoping that this study will encourage clinicians to point patients to social media as a potential coping tool, as well as to approach this subject with bereaved and expecting parents with more respect and empathy."

Social media is becoming a common avenue for patient testimonials. For example, the social media platform TikTok has recently become a home for some users to make videos sharing their personal health struggles. The platform has also become an avenue for doctors to interface with their patients and rapidly disseminate information from vaping to reproductive health. Dr. Riley cautions that more quantitative and qualitative studies, like this one, are needed to properly evaluate the benefit to both patients and providers.

"As far as we know, this is the first study to look at the intersection of Instagram and miscarriage," says Dr. Riley. "But this is a drop in the bucket. Social media platforms are evolving rapidly and theoretically grounded research must follow."

WINSTON-SALEM, N.C. - Dec. 9, 2019 - Scientists at Wake Forest School of Medicine have identified a dead probiotic that reduces age-related leaky gut in older mice. The study is published in the journal GeroScience.

But what exactly is leaky gut and what does a probiotic - dead or alive - have to do with it?

Some research has indicated that leaky gut, in which microbes and bacteria in the gut leak into the blood stream through holes or cracks in the intestinal lining, causes an increase in low-grade inflammation, and these conditions are common in older people. This resulting inflammation is thought to play a role in the development of many age-related diseases, such as diabetes, obesity, cancer, cardiovascular disease and decline in physical and cognitive functions.

"We know that probiotics are instrumental in maintaining a healthy gut and preventing leakage, but there isn't much data available to pinpoint which ones work and which ones don't," said Hariom Yadav, Ph.D., assistant professor of molecular biology at Wake Forest School of Medicine and principal investigator of the study.

"Determining the strain that is most effective at reducing leaky gut and inflammation would help us target more effective strategies to address the problem, and help explain why probiotics work for some people but not others."

In the study, Yadav's team first screened eight strains of human-origin probiotics in roundworms, a commonly used model with a short lifespan of 11 to 20 days. They discovered that a strain of Lactobacillus paracasei (D3-5), even in the non-viable or heat-killed form, extended the roundworms' life span.

They then tested their initial findings in mice. The results showed that feeding heat-killed D3-5 to older mice prevented high fat diet-induced metabolic dysfunctions, decreased leaky gut and inflammation, and improved physical and cognitive functions.

"Not only did we determine which probiotic strain was the most effective in preventing leaky gut and inflammation, we also showed that the dead version of that probiotic had the same benefits," Yadav said. "This is the first-of-its kind study to show that a component (lipoteichoic acid) from the cell wall of a dead probiotic induced changes in the gut microbiome and mucin production, thereby reducing leaky gut and inflammation in elderly mice.

"We think our findings could be very useful to the food and supplement industries because dead probiotics have the potential to be more stable and have a longer shelf life than live probiotics."

First-of-its-kind study used machine learning and health data from the entire Danish population to create sex-specific suicide risk profiles, illuminating the complex mix of factors that may predict suicide.

A new study led by Boston University School of Public Health (BUSPH) researchers finds that physical illness and injury raises the risk of suicide in men but not women, along with a plethora of other insights into the complex factors that may increase a person's risk of suicide. The study, published in JAMA Psychiatry, is the first to use data from the population of an entire country (Denmark) and parse it with a machine-learning system to identify suicide risk factors.

"Suicide is incredibly challenging to predict, because every suicide death is the result of multiple interacting risk factors in one's life," says lead study author Dr. Jaimie Gradus, associate professor of epidemiology at BUSPH.

Denmark has a national healthcare system with the entire population's healthcare information compiled in government registries. This allowed Dr. Gradus and her colleagues to look at thousands of factors in the health histories of all 14,103 individuals who died from suicide in the country from 1995 through 2015, and the health histories of 265,183 other Danes in the same period, using a machine-learning system to look for patterns.

Many of the study's findings confirmed previously-identified risk factors, such as psychiatric disorders and related prescriptions. The researchers also found new potential risk patterns, including that diagnoses and prescriptions four years before a suicide were more important to prediction than diagnoses and prescriptions six months before, and that physical health diagnoses were particularly important to men's suicide prediction but not women's.

The findings of this study do not create a model for perfectly predicting suicide, Dr. Gradus says, in part because medical records rarely include the more immediate experiences--such as the loss of a job or relationship--that combine with these longer-term factors to precipitate suicide. Risk factors and patterns may also be different outside of Denmark. Still, after decades of research with little reduction in suicide rates, Dr. Gradus says the findings point to new factors to examine in working to prevent this persistent public health issue.

Podcast permanent link: https://soundcloud.com/cmajpodcasts/190747-res

Patients prescribed anticoagulants after a diagnosis of atrial fibrillation in the emergency department are more likely to continue long-term use of medications to treat the condition, according to research published in CMAJ (Canadian Medical Association Journal).

"In this multicentre study in Ontario, Canada, providing an oral anticoagulant prescription in the emergency department to patients with atrial fibrillation who were older than 65 years was associated with a marked increase in long-term use of this therapy," writes Dr. Clare Atzema, a senior scientist with ICES and the Division of Emergency Medicine, University of Toronto, with coauthors.

More than 33 million people around the world have atrial fibrillation, that is, an irregular heart beat that is associated with a fivefold increased risk of stroke as well as other cardiac issues. Use of oral anticoagulants can decrease stroke risk by 60%.

Usual practice is to refer patients seen in the emergency department for atrial fibrillation to primary care or a cardiologist for anticoagulant prescription and follow-up.

In this study performed at 15 centres in Ontario, researchers found that if an oral anticoagulant was prescribed in the emergency department to patients aged 65 years or older who were not at high risk of bleeding, there was a 31% absolute increase in the tendency to fill the prescription at 6 months, compared with referral to the patient's physician to consider starting the medication.

"Physicians working in the emergency department should consider initiating oral anticoagulants in similar patients [patients with atrial fibrillation] who are being discharged home, because this action is associated with improved use of stroke prevention long after the patient leaves the emergency department," the authors recommend.

"Prescribing of oral anticoagulants in the emergency department and subsequent long-term use by older adults with atrial fibrillation" is published December 9, 2019.

In a study conducted in Japan, even light to moderate alcohol consumption was associated with elevated cancer risks. In the study published early online in CANCER, a peer-reviewed journal of the American Cancer Society, the overall cancer risk appeared to be the lowest at zero alcohol consumption.

Although some studies have linked limited alcohol consumption to lower risks of certain types of cancer, even light to moderate consumption has been associated with a higher risk of cancer overall. To study the issue in Japan, Masayoshi Zaitsu, MD, PhD, of The University of Tokyo and the Harvard T.H. Chan School of Public Health, and his colleagues examined 2005-2016 information from 33 general hospitals throughout Japan. The team examined clinical data on 63,232 patients with cancer and 63,232 controls matched for sex, age, hospital admission date, and admitting hospital. All participants reported their average daily amount of standardized alcohol units and the duration of drinking. (One standardized drink containing 23 grams of ethanol was equivalent to one 180-milliliter cup (6 ounces) of Japanese sake, one 500-milliliter bottle (17 ounces) of beer, one 180-milliliter glass (6 ounces) of wine, or one 60-milliliter cup (2 ounces) of whiskey.

Overall cancer risk appeared to be the lowest at zero alcohol consumption, and there was an almost linear association between cancer risk and alcohol consumption. The association suggested that a light level of drinking at a 10-drink-year point (for example, one drink per day for 10 years or two drinks per day for five years) would increase overall cancer risk by five percent. Those who drank two or fewer drinks per day had an elevated cancer risk regardless of how long they had consumed alcohol. Also, analyses classified by sex, drinking/smoking behaviors, and occupational class mostly showed the same patterns.

The elevated risk appeared to be explained by alcohol-related cancer risk across relatively common sites, including the colorectum, stomach, breast, prostate, and esophagus.

"In Japan, the primary cause of death is cancer," said Dr. Zaitsu. "Given the current burden of overall cancer incidence, we should further encourage promoting public education about alcohol-related cancer risk."

Judith Tsui, a UW Medicine clinician specializing in addiction treatment, was seeing more and more patients she was treating for opioid-use disorder also using methamphetamines, a powerful, highly addictive stimulant that affects the central nervous system.

She would start the patients on buprenorphine, a medication to treat opioid use disorder, but they would often drop out.

So she and colleagues wanted to see if this was a common problem. They conducted a large study (799 people) at three sites - Harborview Adult Medicine Clinic in Seattle and Evergreen Treatment Services in Olympia and Grays Harbor.

The study published in the Journal of Substance Abuse Treatment reached the same conclusion. Methamphetamine use was associated with more than twice the risk for dropping out of treatment for opioid-use disorder.

"This study confirms anecdotally what we sensed," said Tsui. "The next step is to build into treatment models how we can help those patients who struggle both with opioids and methamphetamines to be successful."

One of the biggest issues is that currently there are not well-established and available effective treatments for methamphetamine addiction, and methamphetamine use is increasing, especially on the West Coast.

In a survey of sentinel community epidemiologists for the National Drug Early Warning System published in September 2018, more than 70 percent of local law enforcement agencies from the Pacific and West Central regions reported methamphetamine as the greatest threat in their area.

Exactly why it's harder for people with these co-addictions to get stay in treatment for opioid-use disorder is up for speculation, said Tsui. But she said many of these patients experience major challenges in their day-to-day lives.

"A substantial proportion of these patients are homeless and may use meth to stay awake at night just to stay safe and keep an eye on their belongings," Tsui said.

She said patients also tell her the streets are flooded with the drug and it's hard for them to say no. Some patients have requested treatment with prescribed stimulant medications like Adderall and Ritalin to help them stop using methamphetamines.

Tsui said she and colleagues are interested in conducting further studies the use of such medicines in treating methamphetamine addiction as there is currently a need for more evidence to support such an approach.

A computer betting game can help predict the likelihood that someone recovering from opioid addiction will reuse the pain-relieving drugs, a new study shows.

The game, now being developed as an app, tests each patient's comfort with risk-taking, producing mathematical scores called betas long used by economists to measure consumers' willingness to try new products. The team then used a statistical test to see whether changes in risk-taking comfort tracked with opioid reuse, and found that people who placed higher-risk bets had higher beta scores.

When combined with other test scores that quiz a patient about recent drug use and desire to use drugs, or cravings, the study found that patients who showed sharp increases in their total beta scores were as much as 85 percent likely to reuse within the next week. By contrast, those whose beta scores did not undergo a spike were much less likely to reuse during treatment, usually a combination of talk therapy and drugs to wean patients off their opioid addiction.

Researchers say the findings, published in the Journal of the American Medical Association (JAMA) Psychiatry online Dec. 8, could lead to the design of clinical tools for tracking and reducing the number of patients who reuse opiates during treatment. More than 2 million Americans are estimated to have some form of opioid-use disorder.

According to the NYU Grossman School of Medicine researchers who led the new study, which is also being presented at the annual meeting of the American College of Neuropsychopharmacology in Orlando, Fla., a majority of patients reuse at some point during treatment, and more than half relapse within a year of undergoing therapy.

And while drug treatments with methadone, buprenorphine, and naloxone are highly effective in weaning patients off opioids, researchers say their impact has been constrained by a lack of good tools for measuring how well patients are responding to any treatment and for determining when treatment should be tailored (e.g., by increasing or decreasing drug doses) to prevent reuse.

Researchers say current techniques are insufficient and rely too much on cravings and on urine testing, which only provides such information after a patient has already reused.

"Our study shows that computer-based diagnostic tests may offer a useful new option," says study senior investigator and neuroeconomist Paul Glimcher, PhD. "Ideally, clinicians would have several tools available for real-time monitoring of how well our patients are managing to free themselves from their addiction," says Glimcher, a professor in the Neuroscience Institute and in the Department of Psychiatry at NYU Langone Health.

Glimcher notes that while many patients experience reuse "slip-ups" during therapy, they are not considered to have relapsed unless they fail to return and complete a standard, six-month treatment plan.

For the study, researchers recruited 70 men and women undergoing opioid addiction therapy at NYC Health + Hospitals/Bellevue. Each played the betting game regularly for seven months when they came in for weekly or monthly clinic visits. Their results were compared to the results for 50 other Bellevue patients of similar race, gender, and age who also played the game weekly but were never addicted to opiate drugs.

As part of the game, patients had the option of accepting a known risk, such as an immediate chip reward worth $5, or gambling on a "riskier" bag of chips with the possibility of either greater reward, as high as $66, or nothing. Some bags contained only two chips, leaving players with a 50 percent of winning, while others contained more chips, with players not always knowing their chances of winning. Risk scores were then plotted on a graph for tracking each patient's willingness to take known or unknown risk. The game takes only a few minutes to complete.

Glimcher says patients typically demonstrate a pattern of "ups and downs" throughout treatment, with low beta scores when they feel in control of or even overconfident in their ability to resist any urge to reuse, but these scores then rise immediately before patients reuse, when they start "feeling lucky" and are willing to place higher-risk bets.

Once completed, Glimcher says his smartphone app based on the betting game could be used to provide daily monitoring of patients' progress. Test results could be "networked" to a patient's medical team and mental health support group, including close friends and family, to alert them when a patient is vulnerable and at greater risk of reuse.

Vienna, Austria - 7 December 2019: Women who can exercise vigorously are at significantly lower risk of dying from heart disease, cancer and other causes. The research is presented today at EuroEcho 2019, a scientific congress of the European Society of Cardiology (ESC).1

Study author Dr Jesús Peteiro, of University Hospital A Coruña, Spain advised women: "Exercise as much as you can. Fitness protects against death from any cause."

Exercise is good for health and longevity, but information on women is scarce. Women generally live longer than men, so dedicated studies are needed. This study examined exercise capacity and heart function during exercise in women and their links with survival. The study included 4,714 adult women referred for treadmill exercise echocardiography because of known or suspected coronary artery disease.

Participants walked or ran on a treadmill, gradually increasing the intensity, and continuing until exhaustion. Images of the heart were generated during the test. Fitness was defined as a maximal workload of 10 metabolic equivalents (METs),2 which is equal to walking fast up four flights of stairs or very fast up three flights, without stopping. Women who achieved 10 METs or more (good exercise capacity) were compared to those achieving less than 10 METs (poor exercise capacity).

During a median follow-up of 4.6 years there were 345 cardiovascular deaths, 164 cancer deaths, and 203 deaths from other causes. After adjusting for factors that could influence the relationship, METs were significantly associated with lower risk of death from cardiovascular disease, cancer, and other causes.

The annual rate of death from cardiovascular disease was nearly four times higher in women with poor, compared to good, exercise capacity (2.2% versus 0.6%). Annual cancer deaths were doubled in patients with poor, compared to good, exercise capacity (0.9% versus 0.4%). The annual rate of death from other causes was more than four times higher in those with poor, compared to good, exercise capacity (1.4% vs. 0.3%).

Dr Peteiro said: "Good exercise capacity predicted lower risk of death from cardiovascular disease, cancer, and other causes."

He noted that most study participants were middle aged or older women: the average age was 64 and 80% were between 50 and 75. "The results were the same for women over 60 and less than 60 although the group under 50 was small," said Dr Peteiro.

Regarding imaging of the heart, the researchers assessed function of the left ventricle (one of the heart's pumping chambers) during the exercise test. Patients with poor heart function during exercise had a higher probability of death from cardiovascular disease during follow-up. Heart function during exercise did not predict the likelihood of death from cancer or other causes.

Dr Peteiro said: "Looking at both examinations together, women whose heart works normally during exercise are unlikely to have a cardiovascular event. But if their exercise capacity is poor, they are still at risk of death from cancer or other causes. The best situation is to have normal heart performance during exercise and good exercise capacity."

ORLANDO - A new, experimental immunotherapy can put patients with B-cell non-Hodgkin lymphoma (NHL) that is resistant to or has come back after multiple other therapies, including CAR T therapy, into remission. A global, multi-center trial found almost half of patients with slow growing lymphomas had complete responses to the antibody called mosunetuzumab. Among patients on the study whose lymphoma progressed after CAR T therapy, 22 percent went into complete remission when treated with the drug. Stephen J. Schuster, MD, director of the Lymphoma Program at the Abramson Cancer Center of the University of Pennsylvania, will present the findings in a plenary session as well as during the press program at the 61st American Society of Hematology Annual Meeting and Exposition in Orlando (Abstract #6).

Non-Hodgkin lymphoma is a cancer that affects the lymphatic system, which is the body's way of clearing toxins and waste. About 85 percent of NHL cases are B-cell lymphomas, including diffuse large B-cell lymphoma (DLBCL) and follicular lymphoma. While many of these patients respond to frontline chemo-immunotherapy, those who do not frequently do not respond to second line therapies as well. About 40 percent of these non-responders with DLBCL can benefit from CAR T therapy, which is approved for use after two prior lines of treatment. CAR T is not approved for follicular lymphoma, though clinical trials have shown it holds promise.

"There is still a large need for new treatments in relapsed or refractory cases, since some patients fail CAR T and others are too sick to wait for cell manufacturing," Schuster said. "One of the benefits of this treatment is that it's 'off-the-shelf,' meaning it does not need to be manufactured for each patient."
Mosunetuzumab is an antibody designed to bind to two specific receptors on tumors cells. Just as CAR T therapies in lymphoma target a receptor called CD19, mosunetuzumab binds to CD20 as well as a natural receptor on T cells, one type of immune cell. Patients receive the therapy infusion over several months.

To date, more than 270 patients in seven countries in North America, Europe, Asia, and Australia have received the experimental therapy. All patients had B-cell lymphomas that had relapsed or had not responded to prior therapies. Of that group, 193 patients were evaluable. This included 124 (65 percent) with aggressive lymphomas and 67 (35 percent) whose cancers were slow-growing. The overall cohort included patients whose disease had progressed after stem cell transplant, as well as those whose disease did not respond to or relapsed after CAR T.

Among the group with aggressive lymphomas, 46 (37 percent) saw the amount of cancer in their body decrease, while 24 (19 percent) achieved complete remission. Among patients with slower growing lymphomas, 42 (63 percent) saw a decrease in cancer, and 29 (43 percent) achieved complete remission. The data also suggest that higher doses of the drug correlate with patient responses, but this still needs to be confirmed with additional analyses and longer follow up.

For the patients who saw their disease disappear entirely, the remissions appear to be long-lasting. At a median follow up of six months, 24 of the 29 (83 percent) slow-growing lymphoma patients and 17 of the 24 (71 percent) aggressive lymphoma patients were still disease free. In four patients whose disease came back after remission, three saw a response when they started treatment again.

This includes one patient who went back into a remission that has now been ongoing for 13 months.
Further, in some of the patients who had previously received CAR T therapy, molecular testing showed the CAR T cells in their bodies increased in number in their blood after treatment with mosunetuzumab.

"This could mean that not only does mosunetuzumab have the ability to kill cancer, but also that it may help re-engage CAR T cells and boost the effect of the prior CAR treatment," Schuster said. He notes further study is needed to confirm this and to determine when in the course of treatment mosunetuzumab may be most effective.
Cytokine-release syndrome (CRS), a toxicity known to be associated with cellular therapies, was reported in 29 percent of patients on this study. Only three percent required treatment with tocilizumab. Four percent of patients also reported moderately severe neurologic side effects.

Schuster said that while these findings are encouraging, they need to be confirmed by larger, randomized trials. He also notes that longer follow-up of patients on the current trial will ultimately provide more information on the durability of responses.

The ECOG-ACRIN Cancer Research Group (ECOG-ACRIN) today announced results from an extended follow-up analysis of patients in its randomized Phase 3 clinical trial, E1912. The results show that the combination of ibrutinib, a Bruton's tyrosine kinase inhibitor, and the antibody therapy rituximab, continue to provide superior progression-free survival and overall survival compared to standard chemoimmunotherapy for patients (aged 70 or younger) with previously untreated chronic lymphocytic leukemia (CLL). The analysis provides new safety and efficacy information on the patients in E1912 who completed ibrutinib plus rituximab therapy and continued to receive ibrutinib for as long as it remained effective.

The American Society of Hematology (ASH) featured the analysis today at its 61st Annual Meeting in Orlando. After a median follow-up time of four years, roughly 75% of patients in the ibrutinib plus rituximab arm of the trial remain on ibrutinib.

The researchers observed ibrutinib to be well tolerated by the majority of patients, only 14% of whom stopped ibrutinib due to side effects. Only seven percent of patients progressed while on ibrutinib therapy.

The trial was designed and is being conducted by ECOG-ACRIN with funding from the National Cancer Institute, part of the National Institutes of Health. Tait D. Shanafelt, MD, a professor of hematology at the Stanford University School of Medicine in Palo Alto, California, was the lead investigator on the study.

Today's analysis supports the earlier E1912 findings in the New England Journal of Medicine, which immediately advanced the standard of care for previously untreated CLL patients (aged 70 years and younger). The earlier E1912 results showed a two-thirds reduction in the risk of disease progression and less toxicity from therapy with ibrutinib plus rituximab compared to intravenous chemoimmunotherapy consisting of fludarabine and cyclophosphamide plus rituximab (FCR).

The current analysis, based on a median follow-up of 48 months, reports that 73 percent of patients in the ibrutinib plus rituximab treatment arm remained on ibrutinib. The median time on treatment was 43 months (range of 0.2 to 61 months). The median time to progression or death after discontinuing ibrutinib was 23 months. Superior progression-free survival benefits were sustained for the ibrutinib plus rituximab arm compared to the FCR treatment arm (hazard ratio [HR]=0.39; 95 percent CI, 0.26-0.57; p

The only pretreatment characteristic that predicted discontinuation of ibrutinib for a reason other than progression was the number and severity of health problems other than CLL. Among those patients, less than half progressed and the median time to progression was nearly two years.

Altruism and a lack of access and affordability are three reasons why people with chronic illnesses are turning to the "black market" for medicines and supplies, new research shows. Scientists at University of Utah Health and University of Colorado ran surveys to understand why individuals are looking beyond pharmacies and medical equipment companies to meet essential needs. The reasons listed were many but centered on a single theme: traditional healthcare is failing them.

Instead, people with chronic conditions, like diabetes, are turning to online resources that are more typically associated with gift shopping. They are scrolling through craigslist, browsing for second-hand goods on eBay and searching social media message boards. Rather than toys and sweaters, they are looking for leads to medications and supplies like glucose strips for measuring blood sugar, and insulin, a drug they must take regularly to keep their blood sugar in control.

"People have to make a decision. Do they want to maintain their health? And if so, what are the medications and tools that they need in order to stay healthy?" explains Michelle Litchman, Ph.D., FNP-BC, lead author of the study and a nurse practitioner and researcher at the College of Nursing at U of U Health. "In some cases, people have had to go to extreme measures and find a network that can supply their healthcare needs."

Results from the study were published online in the Journal of Diabetes Science and Technology.

An online survey of 159 people with diabetes and their caregivers showed the group had participated in different types of underground exchange activities, from donating (56%) to receiving donated goods (34%) to trading (24%), borrowing (22%) and purchasing (15%). Many had taken part in more than one kind of transaction.

When asked why they turned to underground exchange, lack of affordability and accessibility were frequently mentioned. These comments supported statistics showing that over half of participants in the study engaged in underground exchange activities out of financial necessity. People donated and traded with family, friends and strangers who could not get supplies themselves, despite most having health insurance.

In other instances, it was bureaucracy that got in the way. Delays in approval, filling a prescription or shipping prevented some individuals from getting supplies by the time they were medically needed. As a result, some resorted to making trades or accepting donations in order to meet their needs quickly and avoid hospitalization.

"I most likely would have ended up with ketoacidosis but I was lucky enough to get insulin from another person," wrote one survey participant.

Listen to an interview with Litchman about how people with diabetes are foregoing basic needs and taking part in underground trading just to stay healthy.

"People with diabetes resort to underground exchange of diabetes supplies and medications not because they want to, not to turn a quick profit, but because their needs aren't being met," says the study's senior author Sean Oser, M.D., University of Colorado, Denver. "Some turn to others to get what they need to feel safe."

Many weren't engaging in underground trading for themselves, but rather had excess items they knew others could use. "I... donate supplies to people who need them because it's not fair for me to have excess while they struggle to survive, or even die, because our healthcare system is broken," wrote another participant. In fact, altruism was a prevailing motivation behind underground exchange. Some reported feeling a strong desire to help others within the diabetes community but at the same time were aware that circumstances are volatile. Someone who is in a position to donate supplies on one day could become a person in need on the next.

A downside to acquiring medications and supplies outside the traditional health care system is lack of safety oversight, the study's authors say. However, fewer than 1% of study participants who made transactions through underground markets reported safety concerns. Those that occurred included receiving faulty equipment and unrefrigerated insulin, although recipients did not experience ill effects. Still, the authors indicate there is plenty of room for additional error. Poor shipping conditions could spoil medications without the recipient knowing. Another risk could be someone taking the wrong medication if it were inadvertently provided to them. Despite these risks, people continue to use underground exchanges because at this stage there are few alternatives, says Litchman.

Participants of the survey were mostly Caucasian women with a college education. Next steps will be to carry out larger studies that sample individuals across the country, including participants with varied income levels and of different ethnicities to provide a more comprehensive picture of underground exchange and its impacts on the public. In any case, Litchman says that the black market for medications doesn't appear to be going away soon.

"Underground trading of medications and supplies isn't ideal. But what other real solutions exist so that people can actually get what they need without increasing bureaucratic delays and burden?" Litchman says. "Our study points to an urgent need to improve access to medications that are essential for life."

Psychological support for those dealing with infertility and its treatment is received by only just half of those who want it in the UK - with many left to suffer with anxiety, depression, or suicidal thoughts, according to a new study published in Human Fertility.

Assessing how experiences of care and treatment of infertility - and more broadly involuntary childlessness due to reasons other than infertility - have changed over the past 20 years, Dr Nicola Payne and Prof Olga van den Akker, at Middlesex University, and Fertility Network UK, created an up-to-date, online version of a 1997 survey.

Nearly 800 respondents who had experienced problems with getting or staying pregnant (with 80% having one or more rounds of fertility treatment) completed the survey.

The new results show, despite some improvements since 1997 in the availability of funded fertility treatments (such as IVF) and psychological support, distress levels remain high. Respondents reported feeling, on average, sad, frustrated and worried almost 'all of the time', with 42% having experienced suicidal feelings at least 'occasionally'. These negative feelings were the same whether or not the respondents were receiving fertility treatment, with those for whom treatments had been unsuccessful experiencing the highest levels of distress.

The majority of respondents (75%) expressed an interest in receiving counselling to help deal with their negative emotions if it was free, but only 45% actually received any counselling and over half of these had to fund some of it themselves. This was still an improvement over the situation in 1997, when just 31% received counselling and almost 88% had to fund it themselves.

Financial burden

In addition, over half (55%) of respondents had to pay for at least part of their fertility treatment, such as IVF.

This is an improvement on the situation in 1997, when 75% had to pay. However, the study demonstrated costs of over £5,000 being paid out by the vast majority; and another example of the NHS 'postcode lottery' with the number of funded treatments that respondents could expect to receive varying from zero to three - dependent on where you live in the country.

Unfortunately, unsuccessful treatment outcomes were quite common too: the survey found that 68% of those who had received fertility treatment had failed to become pregnant at least once, while 31% achieved a pregnancy but no live birth at least once.

"Our findings suggest that involuntary childlessness and fertility treatment continue to have financial, emotional and relationship consequences for many people," Dr Payne states. "Despite some advances in the availability of funded treatment and psychological support, funding for treatment remains patchy across the UK and this inequity needs to be reduced. There also remains a lack of appropriate, funded psychological support."

Gwenda Burns, chief executive of leading patient charity Fertility Network UK, added: "Facing fertility problems is distressing enough, without being denied medical help because of where you live: 42% feel suicidal; 90% feel depressed; and 70% experience problems in the relationship with their partner. Denying access to NHS-funded IVF is also associated with health risks and economic consequences. Patients who are forced to self-fund treatment often travel overseas for treatment choosing multiple embryo transfer rather than single embryo transfer. Multiple embryo transfers are more likely to result in multiple births which pose greater health risks for both the mother and the twins/multiples with associated high healthcare costs.

"Patients are often very vulnerable after years of trying to become parents. Fertility struggles and going through fertility treatment can put an enormous strain on both a person's physical and mental health, but also their financial wellbeing when they are having to fund their own treatment. At Fertility Network UK, we offer a wide range of support. We have our Information Line and email service that you can use to ask us anything fertility related; and a nurse Support Line, run by a fertility nurse of 22 years. We also offer both face to face and online support groups throughout the country for those who are facing fertility problems. We believe that no question is too trivial, no worry is too small. You can find more details on our website, http://www.fertilitynetworkuk.org."

Because white women accounted for the vast majority (over 90%) of respondents to this online survey, the researchers recommend that further studies should focus on the impact of involuntary childlessness on men and people from differing cultural backgrounds.

Women who have C-sections are no more likely to have children who develop obesity than women who give birth naturally, according to a large study by researchers at Karolinska Institutet in Sweden published in the journal PLOS Medicine. The findings contradict several smaller studies that did find an association between C-section deliveries and offspring obesity but did not consider the numerous maternal and prenatal factors that the researchers did in this study.

Cesarean or C-section deliveries have soared in recent years, from 6.7 percent globally in 1990 to around 19.1 percent in 2014, according to earlier reports. The jump has sparked intense research into the long-term consequences of C-section on offspring health, and several studies have linked cesarean deliveries with increased risks for asthma, various allergies and obesity. The association with obesity has, however, mainly been confirmed in smaller studies that were unable to account for a wide array of possible confounders or differentiate between types of C-sections.

The researchers in this study set out to investigate if indeed increased C-section births could explain part of the rise in obesity also seen in the last decades, and whether this potential association held true once they accounted for maternal and prenatal factors known to impact offspring weight. They compared the body-mass index (BMI) of nearly 100,000 male 18-year-olds and divided them into categories depending on whether they were born through vaginal delivery, elective C-section or non-elective C-section.

According to the data, 5.5 and 5.6 percent of the men delivered through elective and non-elective C-section, respectively, were obese compared to 4.9 percent of the men delivered vaginally. But after accounting for other factors known to impact offspring weight - including pre-pregnancy BMI, maternal and gestational age and the presence of diabetes, hypertension, smoking and preeclampsia in the mother - the researchers concluded that the method of childbirth did not play a significant role in determining the risk of obesity in the offspring.

"We found no evidence to support a link between C-sections and the development of obesity," says Daniel Berglind, researcher at the Department of Global Public Health at Karolinska Institutet. "This tells us that how women give birth may not be an important factor in the origins of the global obesity epidemic."

The researchers also identified nearly 10,000 full brothers and concluded that sibling analysis, accounting for genetic and environmental factors, did not alter the overall findings.

The strongest confounder in the association between mode of delivery and obesity was how much the mother weighed before she became pregnant. This is consistent with previous reports on the heritability of obesity and the influence of maternal obesity on fetal health.

"Most of the association between C-section and obesity could be explained by maternal pre-pregnancy BMI," says Viktor H. Ahlqvist, researcher at the Department of Global Public Health. "This suggests that heritability and fetal exposure to obese-causing factors in the womb are more important when assessing the risk of obesity in the offspring than the mode of delivery."

LA JOLLA--(December 5, 2019) Metabolic syndrome affects nearly 30 percent of the U.S. population, and increases the risk for type 2 diabetes, heart disease and stroke. But lifestyle interventions such as adopting a healthy diet and increasing physical exercise are difficult to maintain and, even when combined with medication, are often insufficient to fully manage the disease.

Now, in a collaborative effort, researchers from the Salk Institute and the UC San Diego School of Medicine found that a 10-hour time-restricted eating intervention, when combined with traditional medications, resulted in weight loss, reduced abdominal fat, lower blood pressure and cholesterol, and more stable blood sugar and insulin levels for participants. The pilot study, published in Cell Metabolism on December 5, 2019, could lead to a new treatment option for metabolic syndrome patients who are at risk for developing life-altering and costly medical conditions such as diabetes.

"We have found that combining time-restricted eating with medications can give metabolic syndrome patients the ability to better manage their disease," says Satchidananda Panda, co-corresponding author and professor in Salk's Regulatory Biology Laboratory. "Unlike counting calories, time-restricted eating is a simple dietary intervention to incorporate, and we found that participants were able to keep the eating schedule."

Time-restricted eating (eating all calories within a consistent 10-hour window) supports an individual's circadian rhythms and can maximize health benefits, as evidenced by previous research published by the Salk team. Circadian rhythms are the 24-hour cycles of biological processes that affect nearly every cell in the body. Increasingly, scientists are finding that erratic eating patterns can disrupt this system and increase the risk for metabolic syndrome and other metabolic disorders with such symptoms as increased abdominal fat, abnormal cholesterol or triglycerides, and high blood pressure and blood sugar levels.

"Eating and drinking everything (except water) within a consistent 10-hour window allows your body to rest and restore for 14 hours at night. Your body can also anticipate when you will eat so it can prepare to optimize metabolism," says Emily Manoogian, the paper's co-first author and a postdoctoral fellow in the Panda lab. "We wanted to know if controlling the timing of food intake to support circadian rhythms would improve the health of individuals that were already being treated for cardiometabolic diseases."

"We suspected a 10-hour eating intervention might be beneficial because of Satchidananda Panda's pioneering work in animals, which showed that time-restricted eating led to dramatic health benefits, including a healthier metabolism," adds Michael Wilkinson, co-first author, assistant clinical professor of medicine at UC San Diego School of Medicine and a cardiologist at UC San Diego Health.

The pilot study included 19 participants (13 men and 6 women) diagnosed with metabolic syndrome who self-reported eating during a time window of more than 14 hours per day. Additionally, 84 percent of participants were taking at least one medication such as a statin or an antihypertensive therapy. Study participants used the Panda lab's myCircadianClock app to log when and what they ate during an initial 2-week baseline period followed by the three-month, 10-hour time-restricted eating intervention. Nearly 86 percent of participants correctly logged their food using the app, indicating high compliance throughout the study.

Participants did not report any adverse effects during the intervention. To reduce food intake to the 10-hour window, most participants delayed their first meal and advanced their last meal each day, so meals were not skipped. Although calories were not recommended to be reduced for the intervention, some participants did report eating less, likely due to the shorter eating window.

Overall, participants experienced improved sleep as well as a 3-4 percent reduction in body weight, body mass index, abdominal fat and waist circumference. Major risk factors for heart disease were diminished as participants showed reduced blood pressure and total cholesterol. Blood sugar levels and insulin levels also showed a trend toward improvement.

"Metabolism is closely linked with circadian rhythms, and knowing this, we were able to develop an intervention to help patients with metabolic syndrome without decreasing calories or increasing physical exercise," says Pam Taub, co-corresponding author and associate professor of medicine at the UC San Diego School of Medicine and a cardiologist at UC San Diego Health. "If we can optimize circadian rhythms then we might be able to optimize the metabolic system."

"Adapting this 10-hour time-restricted eating is an easy and cost-effective method for reducing symptoms of metabolic syndrome and improving health," adds Panda. "By delaying the onset of diabetes by even one year in a million people with prediabetes, the intervention could save roughly 9.6 billion dollars in healthcare costs."

The scientists are currently conducting a clinical trial funded by the National Institute of Diabetes and Digestive and Kidney Diseases to examine the benefits of time-restricted eating in a larger group of more than 100 participants with metabolic syndrome. The study includes additional measures that will help the researchers investigate changes in body composition and muscle function.

Mutation also causes increased anxiety and hyperactivity

Fewer synapses grow, so there is less communication between brain cells

'We have solved an important piece of the puzzle in understanding' the cause

CHICAGO --- Northwestern Medicine scientists have discovered why a specific genetic mutation causes intellectual disability and autism spectrum disorder in children.

"We have solved an important piece of the puzzle in understanding how this mutation causes intellectual disabilities and mental illness," said lead author Peter Penzes, director of the new Center for Autism and Neurodevelopment at Northwestern University Feinberg School of Medicine.

The paper will be published Dec. 5 in Neuron.

Northwestern scientists discovered genetic mutations in human patients in a gene called Usp9x result in the brain growing fewer synapses. That's because Usp9x protects another protein called ankyrin-G, whose role is to grow and stabilize synapses. The developing brain needs to build lots of synapses between neurons so cells can communicate while the brain grows, and to learn.

But when Usp9x is mutated, it can't stabilize the synapse-enhancing ankyrin-G. Thus, the would-be enhancer protein degrades and destabilizes, resulting in fewer synapses in the brain, scientists found. Individuals with this mutation have developmental delay, difficulty learning, increased anxiety and hyperactivity.

In addition to ankyrin-G, Usp9x also protects several other important synapse-enhancing proteins, which when mutated also cause intellectual disability and autism. Usp9x is a master-stabilizer of many key proteins essential for brain development and learning.

It is notable that severe mutations in ankyrin-G are also known to cause intellectual disability and autism. Or, if a person inherits a less severe form of the mutation in ankyrin-G, their synapses develop relatively normally in childhood. But during adolescence - when there is a big turnover of synapses as the brain matures - more of these vital neuron connectors are lost than normal. The result can be schizophrenia and bipolar disease.

A possible cancer drug connection

Interestingly, Usp9x and related proteins are also involved in cancer and have been of interest to the pharmaceutical industry. Hence, some candidates from the cancer drug development process could potentially be used to target Usp9x to treat some forms of intellectual disability, autism, schizophrenia and bipolar disorder.