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ORLANDO (November 26, 2018) - Ten percent of pediatric asthma cases could be avoided if childhood obesity were eliminated, according to research led by Nemours Children’s Health System. The research, published today in Pediatrics, the journal of the American Academy of Pediatrics, reported on the analysis of medical records of more than 500,000 children. The study is among the first to use the resources of PEDSnet, a multi-specialty network that conducts observational research and clinical trials across eight of the nation's largest children's health systems. PEDSnet is funded by the Patient-Centered Outcomes Research Institute (PCORI), a government-supported nonprofit.

"Pediatric asthma is among the most prevalent childhood conditions and comes at a high cost to patients, families and the greater health system. There are few preventable risk factors to reduce the incidence of asthma, but our data show that reducing the onset of childhood obesity could significantly lower the public health burden of asthma," said Terri Finkel, MD, PhD, Chief Scientific Officer at Nemours Children's Hospital in Orlando and one of three Nemours researchers participating in the study. "Addressing childhood obesity should be a priority to help improve the quality of life of children and help reduce pediatric asthma."

In this retrospective cohort study design, researchers reviewed de-identified data of patients ages two to 17 without a history of asthma, receiving care from six pediatric academic medical centers between 2009 and 2015. Overweight or obese patients were matched with normal weight patients of the same age, gender, race, ethnicity, insurance type, and location of care. The study included data from 507,496 children and 19,581,972 encounters.

In their analysis, the researchers found that the incidence of an asthma diagnosis among children with obesity was significantly higher than in children in a normal weight range and that 23 to 27 percent of new asthma cases in children with obesity are directly attributable to obesity. Additionally, obesity among children with asthma appears to increase disease severity. Being overweight was identified as a modest risk factor for asthma, and the association was diminished when the most stringent definition of asthma was used. Other significant risk factors of an asthma diagnosis included male sex, age of under 5 years old, African-American race, public insurance.

With 6 to 8 million cases of pediatric asthma previously reported in the United States, the study's data suggest that 1 million cases of asthma in children might be directly attributable to overweight and obesity and that at least 10 percent of all U.S. cases of pediatric asthma might be avoided in the absence of childhood overweight and obesity.

"This is the first study of its kind, looking at obesity and the risk of developing asthma entirely in a pediatric population, and is made possible through the PEDSnet data collaboration," said Finkel. "The PEDSnet collaboration brings the power of Big Data to pediatric research and medicine--as well as the expertise to structure the data and understand how to extract the most meaningful points."

Several limitations of the study are noted, including the retrospective design using electronic health data, which prevent the researchers from drawing absolute conclusions regarding the causal nature of the association between obesity and asthma. Additionally, while the study includes data from a large, geographically diverse population of children, rural children may be underrepresented in the study results.

The research team hopes in the future to use PEDSnet's capabilities to continue to gain new epidemiologic insights into the relationship between pediatric obesity and asthma, including measures of lung function, comorbidity, and medication data. Each PEDSnet member institution is able to map its own data onto the common data model, creating an enormous resource across the network with the power to produce findings relatively quickly.

The gap between the life expectancy of the richest and poorest sectors of society in England is increasing, according to new research from Imperial College London.

The research, published in the journal Lancet Public Health, also reveals that the life expectancy of England's poorest women has fallen since 2011, in what researchers say is a "deeply worrying" trend.

The study, funded by the Wellcome Trust, analysed Office for National Statistics data on all deaths recorded in England between 2001 and 2016 - 7.65 million deaths in total.

The results revealed the life expectancy gap between the most affluent and most deprived sectors of society increased from 6.1 years in 2001 to 7.9 years in 2016 for women, and from 9.0 to 9.7 years in men.

The life expectancy of women in the most deprived communities in 2016 was 78.8 years, compared to 86.7 years in the most affluent group. For men, the life expectancy was 74.0 years among the poorest, compared to 83.8 years among the richest.

The results also revealed that the life expectancy of women in the poorest sectors of society has dropped by 0.24 years since 2011.

Professor Majid Ezzati, senior author of the research from Imperial's School of Public Health, said: "Falling life expectancy in the poorest communities is a deeply worrying indicator of the state of our nation's health, and shows that we are leaving the most vulnerable out of the collective gain.

"We currently have a perfect storm of factors that can impact on health, and that are leading to poor people dying younger. Working income has stagnated and benefits have been cut, forcing many working families to use foodbanks. The price of healthy foods like fresh fruit and vegetables has increased relative to unhealthy, processed food, putting them out of the reach of the poorest."

He added: "The funding squeeze for health and cuts to local government services since 2010 have also had a significant impact on the most deprived communities, leading to treatable diseases such as cancer being diagnosed too late, or people dying sooner from conditions like dementia."

The research team also analysed the illnesses that contributed to the widening life expectancy gap. Although they found that people in the poorest sectors died at a higher rate from all illnesses, a number of diseases showed a particularly stark difference between rich and poor.

The diseases that led to particularly large loss of longevity in the poor compared to the rich were newborn deaths and children's diseases, respiratory diseases, heart disease, lung and digestive cancers, and dementias. In 2016, children under five years old from the poorest sectors of society were 2.5 times as likely to die as children from affluent families.

"This study suggests the poor in England are dying from diseases that can be prevented and treated," said Professor Ezzati. "Greater investment in health and social care in the most deprived areas will help reverse the worrying trends seen in our work. We also need government and industry action to eradicate food insecurity and make healthy food choices more affordable, so that the quality of a family's diet isn't dictated by their income."

The team conducted their analysis by using information on the where each death occurred, which was matched to small areas of England known as lower super output areas by the Office of National Statistics. These lower super output areas, which each have a population of around 1,500 people, are given a score of deprivation from the Office of National Statistics (called an Index of Multiple Deprivation). The research team point out this means the comparisons are based on a community's deprivation and affluence, and not that of individuals.

Gut-directed hypnotherapy delivered by psychologists appears as effective in group or individual sessions, potentially offering a new treatment option for irritable bowel syndrome in primary and secondary care.

Hypnotherapy might help relieve irritable bowel syndrome (IBS) complaints for some patients for as long as 9 months after the end of treatment, according to a randomised controlled trial of 354 adults with IBS in primary and secondary care published in The Lancet Gastroenterology & Hepatology journal.

After 3 months of treatment, adequate relief of IBS symptoms was reported by more patients who received individual (40%; 41/102 for whom data were available) and group hypnotherapy (33%; 31/91) than those given education and supportive care (17%; 6/35), and these benefits persisted at 9 months follow-up (42% [38/91], 50% [40/80], and 22% [7/31]).

Importantly, the findings suggest that group hypnotherapy is as effective as individual sessions, which could enable many more patients with IBS to be treated at reduced cost.

The study is the largest randomised trial of hypnotherapy for IBS to date, and one of the first conducted in primary care, where the vast majority of IBS patients are treated.

The study found that IBS patients undergoing hypnotherapy reported a greater overall improvement in their condition and were more able to cope with, and were less troubled by, their symptoms compared with those who received educational supportive therapy. However, hypnotherapy did not appear to reduce the severity of symptoms.

While the findings are promising, the authors conclude that more research will be needed to test the optimum number of hypnotherapy sessions, the effect that patient expectations may have on treatment outcome, and the extent to which hypnotherapy outcomes are influenced by the magnitude of the psychological complaints of the patient.

"Our study indicates that hypnotherapy could be considered as a treatment option for patients with IBS, irrespective of symptom severity and IBS subtype," says Dr Carla Flik from the University Medical Center Utrecht, Netherlands, who led the research. "It is also promising to see that group hypnotherapy is as effective as individual sessions, which may mean that more people could be treated with it at lower cost, should it be confirmed in further studies." [1]

"What's striking about these findings is the extent to which patient's perception of their illness has an effect on their suffering, and that their perception of symptoms appears to be as important as actual symptom severity." [1]

IBS affects around 1 in 5 people worldwide and is a persistent and difficult-to-treat condition, with symptoms that can seriously affect quality of life including abdominal pain, bloating, diarrhoea, and constipation. For many sufferers, drug and dietary treatments are not successful.

Psychological interventions have proven effective, but their use is limited by a shortage of trained therapists. Hypnotherapy has previously shown promising results for IBS, but the majority of studies have been done in highly specialised centres, and more research is needed into whether hypnotherapy is beneficial in primary and secondary care where most patients are treated.

The IMAGINE study recruited 354 adults (aged 18-65 years) with IBS who were referred by primary care physicians and hospital specialists to 11 hospitals across the Netherlands between May 2011 and April 2016. Participants were randomly assigned to receive either 45-minute individual sessions (150 patients) or group sessions (150) of hypnotherapy twice weekly for 6 weeks, or education and supportive care (54).

Hypnotherapy treatment was provided by psychologists who were trained as hypnotherapists and involved a technique of positive visualisation during which patients were given suggestions about how they could gain control over their digestive system to reduce feelings of pain and discomfort. Patients were also given a CD so they could practice self-hypnosis exercises at home for 15-20 minutes every day.

Participants completed assessments on their level of symptom severity, quality of life, psychological symptoms, health-care costs, and work absence at the start of the trial and immediately after treatment (3 months) and again 9 months later, as well as symptom relief immediately after treatment and 9 months later.

Results showed that immediately after treatment, participants in the two hypnotherapy groups reported satisfactory relief at substantially higher rates than those who received educational supportive care, and these benefits persisted for 9 months after the treatment ended (table 2).

Nevertheless, satisfactory relief of symptoms was not accompanied by a significant improvement in symptom severity.

As Dr Flik explains: "We do not know exactly how gut-directed hypnotherapy works, but it may change patients' mindset and internal coping mechanisms, enabling them to increase their control over autonomic body processes, such as how they process pain and modulate gut activity." [1]

Improvements in quality of life, psychological complaints, cognitions and reductions in medical costs and IBS-related work absence were similar between groups.

Overall, hypnotherapy was well tolerated. Eight serious unexpected adverse reactions (six in the individual hypnotherapy group and two in the group hypnotherapy group) were reported, mostly cancer and inflammatory bowel disease, but were not related to hypnotherapy.

The authors note some limitations--for instance, that 22 (15%) patients in the individual hypnotherapy group, 22 (15%) in the group hypnotherapy group, and 11 (20%) in the control group dropped out before or during therapy, and a substantial number of participants did not complete questionnaires at 3 months and 9 months after treatment, which might have biased the results (figure 1). They also point out that the inexperience of therapists in dealing with IBS, and the low number (six) of hypnotherapy sessions provided (half the usual number), might have led to underestimations of the effects of hypnotherapy.

Writing in a linked Comment, Professor Olafur Palsson, University of North Carolina at Chapel Hill, USA discusses factors that may have contributed to the "modest" therapeutic impact of hypnosis in the study.

He writes: "The hypnotherapy tested in this study might have been suboptimal in amount or implementation. However, as the authors note, the smaller therapeutic effect in this trial compared with most hypnotherapy trials in tertiary care might have been because IBS in primary and secondary care is different to that in tertiary care--perhaps simpler in nature and with less involvement of psychological factors. Therefore, despite this impressive investigative effort by Flik and colleagues, it remains unclear whether gut-directed hypnotherapy is well suited for the treatment of patients with IBS in primary and secondary care, and future trials are needed to provide definitive answers."

A woman lies in her hospital bed. Her heart rate is elevated, she has a slight fever and an elevated white blood cell count.

Could this be the beginnings of sepsis, a life-threatening reaction to an infection? Or could these simply be signs of a normal pregnancy?

Maternal sepsis, which occurs during pregnancy or postpartum, is a rare but possibly preventable complication that accounts for 12.7 percent of pregnancy-related deaths in the United States each year.

"A lot of the things you depend on to tell you there's an infection can be altered in pregnancy," says Melissa Bauer, D.O., of the department of anesthesiology. Those include a patient's vital signs such as heart rate, blood pressure and white blood cell count.

Which is why many clinicians face difficulty in diagnosing sepsis in laboring women fast enough to intervene and save lives.

"Currently, there are no good ways to identify these women early," Bauer says. "We're working on figuring out the best way to do that."

To address this challenge, she and a large team at Michigan Medicine and academic medical centers across the country and in Israel combed through medical records to see which of three screening tools would do the best job of catching sepsis cases.

The paper, published in Anesthesia & Analgesia, also identifies risk factors for developing sepsis, pointing to simple interventions that could reduce the number of maternal deaths.

"We need physicians to take a good, long look at the patient and make sure that vital signs are reassessed frequently, because things can change quickly." Melissa Bauer, D.O.

The right tool for the job

The team examined three screening tools commonly used over the past two decades to identify sepsis:

The Systemic Inflammatory Response Syndrome (SIRS) criteria, in use from 1992 to 2016

The quick Sequential Organ Failure Assessment (qSOFA), recommended by the Society of Critical Care Medicine and others to replace SIRS in 2016

The Maternal Early Warning (MEW) criteria, designed to identify women at risk for a wide array of maternal complications, including pre-eclampsia, hemorrhage and sepsis

Bauer's team collected information on vital signs, potential risk factors for sepsis, lab values and how the women were cared for in a set of patients with sepsis and a control set without the condition.

In doing so, they found that the screening tools had vastly different sensitivities and specificities.

A screening tool's sensitivity refers to its ability to correctly identify patients with a disease. Specificity refers to the ability of the test to correctly identify patients without the disease.

The SIRS tool had the highest sensitivity but the lowest specificity, while qSOFA had the lowest sensitivity and the highest specificity.

"In my opinion, it is better for a test to have a higher sensitivity so that anyone with sepsis is caught," Bauer says. Shockingly, the researchers found that qSOFA would miss about half of the sepsis patients they reviewed.

However, specificity is still important.

"If you have poor specificity, you'll probably run into alarm fatigue, with caregivers constantly on alert for patients who don't have anything wrong," Bauer notes. "There has to be a balance."

Vigilance is key

The study also points to areas for improvement in the care of laboring mothers.

Researchers note that the Surviving Sepsis Campaign international guidelines recommend administering broad-spectrum antibiotics within the first hour of diagnosis, something that was not achieved in almost 36 percent of sepsis cases they reviewed.

And delaying treatment can be deadly: 20 percent of mothers who did not receive antibiotics within the first hour died, compared with just over 8 percent of mothers who were treated more promptly.

Bauer hypothesizes that possible reasons for slow action were delays in getting the right drugs from the pharmacy, lack of adequate IV access and the failure to triage and verify the administration of antibiotics.

Their chart review also revealed a surprising lack of data on vital signs.

"Even some women who died hadn't had vital signs checked in quite a while," says Bauer, adding that care teams need to work together for the safety of every patient.

"We need physicians to take a good, long look at the patient and make sure that vital signs are reassessed frequently, because things can change quickly."

Nanyang Technological University, Singapore (NTU Singapore) scientists have developed a 'contact lens' patch with microneedles that could provide a painless and efficient alternative to current methods of treating eye diseases such as glaucoma and macular degeneration.

Current localised treatment methods such as eye drops and ointments are hindered by the eye's natural defences, blinking and tears. Eye injections can be painful and carry a risk of infection and eye damage. As a result, some patients are unable to keep up with the prescribed regime for their eye ailments, many of which require long-term management.

The proof-of-concept patch, successfully tested in mice, is covered with biodegradable microneedles that deliver drugs into the eye in a controlled release. After pressing it onto the eye surface briefly and gently - much like putting on contact lenses - the drug-containing microneedles detach by themselves and stay in the cornea, releasing the drug over time as they dissolve.

When tested on mice with corneal vascularisation, a single application of the patch was 90 per cent more effective in alleviating the condition than applying a single eye drop with 10 times more drug content.

This novel approach, developed by a team led by NTU Singapore Professor Chen Peng from the School of Chemical and Biomedical Engineering (SCBE), with clinical insights from Singapore National Eye Centre's Associate Professor Gemmy Cheung, was published in Nature Communications earlier this month.

The team includes Assistant Professor Wang Xiaomeng from NTU's Lee Kong Chian School of Medicine, and Assistant Professor Xu Chenjie and research fellow Dr Aung Than from SCBE.

Professor Chen, the biotechnology expert behind the fat-burning microneedle patch, said this approach could realise the unmet medical need for a localised, long-lasting and efficient eye drug delivery with good patient compliance.

He said, "The microneedles are made of a substance found naturally in the body, and we have shown in lab tests on mice that they are painless and minimally invasive. If we successfully replicate the same results in human trials, the patch could become a good option for eye diseases that require long-term management at home, such as glaucoma and diabetic retinopathy.

"Patients who find it hard to keep up with the regime of repeatedly applying eye drops and ointments would also find the patch useful as well, as it has the potential to achieve the same therapeutic effect with a smaller and less frequent dosage."

Prof Chen added that the patch could also help to tackle the rising disease burden of eye conditions. A local 2018 study projected that patients with eye diseases in Singapore will rise significantly by 2040, with glaucoma, diabetic retinopathy and age-related macular degeneration cases set to double.

Novel approach in treating eye diseases

Currently, localised treatment options are hampered by the eye's physiological and structural barriers, including blinking and tears that wash out any drugs applied directly to the eye's surface.

Topical drugs such as eye drops and ointments require repetitive applications with high dosage as less than 5 per cent of the drug is absorbed by the eye each time, and the drug is quickly cleared out by the eye.

Conventional eye injections can penetrate the surface barriers, but face the same problem or poor drug retention due to the backflow of injected solution and subsequent tear wash-out. Aside from carrying a risk of infection or permanent eye damage, patient compliance is poor due to pain and the need for frequent clinic visits.

Prof Chen added, "These two current methods only produce a burst release of drug with a short effective duration. This is not ideal, especially when treating chronic progressive eye diseases that require slow and sustained treatment, such as glaucoma."

To tackle these problems, the team developed a 2mm by 2mm patch with nine microneedles that can be loaded with drugs for lab tests on mice.

Each needle, thinner than a strand of hair, is shaped like a pyramid for optimal tissue penetration. The needle is made of hyaluronic acid, a substance found in the eye and is used often in eye drops. A modified version of the hyaluronic acid is added to form a second layer of the needle to slow down the rate at which the needle degrades, ensuring a slower release of the drug.

Dr Aung Than, NTU research fellow at SCBE, then planned and conducted experiments over a week on mice with corneal vascularisation, a sight-threatening condition where new blood vessels grow into the corneal tissue due to oxygen deprivation. In this study, the researchers loaded the microneedles with DC101, an antibody that targets the growth factor that promotes blood vessel formation.

In mice with the patches applied, there was a 90 per cent reduction in the area of blood vessels with a single treatment dose of 1 microgram. In contrast, when a single drop of the same drug with a much higher dose of 10 micrograms was applied, there was no significant reduction.

There was also no puncture found on the cornea after a week, suggesting that the microneedles are strong enough to penetrate the cornea, but not too stiff to spear through the whole cornea.

Prof Chen said the team has filed a patent, and is currently working on further improving the eye patch technology. They are also looking to partner clinician scientists to study the feasibility of conducting medical trials.

Singapore, 21 November 2018 - Misconceptions about the use of strong opioids showed to undermine optimal pain control among Asian cancer patients undergoing chemotherapy and radiotherapy according to a cross-sectional survey conducted at the Sarawak General Hospital in Malaysia. (1)

In a study to be presented at the ESMO Asia 2018 Congress, 133 patients with solid tumours across all stages treated with strong opioids were requested to rate their experience of pain during the week before the delivery of the survey questionnaire by using a visual analogue scale (VAS) from 0-10 and to self-assess the impact of pain on daily activities by completing the Brief Pain Inventory-short form (BPI-sf).

Researchers also investigated types of strong opioids used and patient-related barriers to effective cancer pain management; results were assessed by social determinants including ethnic group, religion and education level.

Overall, a good pain control was reported in 62% of survey participants (pain score Greater barriers for pain control were found in patients with higher education levels, which may reflect pervasive misconception of opioids use in social media. Fear of harmful effects from taking opioids was observed to be more common in the Malay community, followed by Chinese and Dayak groups. "These differences may reflect some inequities in access to optimal cancer care in the state, however multiple socio-economic factors may also play a critical role in the use of opioids, thus further investigations are needed", commented Dr Voon.

Although adequate pain relief is core to supportive care, it is still hindered by the lack of availability or accessibility to opioids in some countries, according to Prof Sumitra Thongprasert from Bangkok Hospital Chiang Mai, Thailand, co-chair of the ESMO Asia 2018 Public Policy programme. "Beliefs and other cultural issues may only partially explain a sub-optimal use of opioids analgesics, and several factors remain to be assessed including how information on benefits of these drugs is delivered by health care providers", she commented. "More importantly, access to prescription of opioids and government restrictions regarding the total amount that a patient could receive each time can significantly influence access and usage patterns among cancer patients."

Accessibility issues, costs and regulatory barriers that can limit prescribing and dispensing of opioid analgesics in low- and middle-income countries (LMICs) were firstly mapped in 2013 by the Global Opioid Policy Initiative (GOPI) (2) conducted by ESMO with other international partners and which expanded the results of a similar survey conducted in Europe in 2010. (3) Opioid availability was reported to be low in all 20 surveyed countries in Asia, except for South Korea and Japan, and evidence of over-regulation of opioid prescribing was found in the Asia-Pacific region that may restrict or impair access to pain relief treatments. Outcomes from this initiative also highlighted a concrete need to improve palliative care knowledge among clinicians in Asian countries.

"At present, although the availability of critical medications such as opioids, targeted medicines and immunotherapies may be potentially improved in Asia, accessibility issues will be hard to overcome in the next future due to the high costs of cancer treatments", continued Thongprasert. "Some countries across Asia/Asia-Pacific are simply not able to provide expensive medicines to local communities. Also, in countries where patients have to pay on their own for cancer treatments, high costs of medicines can be the primary reason of poor quality in cancer care."

Prof. Nathan Cherny from Shaare Zedek Medical Centre Oncology Institute, Israel, at the time co-coordinator of the Global Opioid Policy Initiative for ESMO, added: "According to the results reported in the paper published in 2013, there is agreement between the WHO, the International Narcotics Control Board, and ESMO, and the 20 international and national palliative care and oncology societies collaborating on the project, (4) about the fact that opioid analgesic therapy is the cornerstone of cancer pain management, and that there is no economic barrier to making opioids available for this indication, and that it must be made a public health priority."

Strategies to improve accessibility to and availability of cancer medicines in LMICs will be discussed in a thought-provoking debate to be held at the ESMO Asia 2018 Congress in Singapore. (5) "Since reducing cancer medicine costs could take some time, other potential strategies need to be assessed, such as the set-up of different pricing according to economic status; pharmaceutical companies providing Patient Access programme or Technology transfer to LMICs to manufacture their own medicines; availability of quality-assured generic and biosimilar medicines; and Compulsory Licensing of anti-cancer medicines. Beyond regulations, major barriers are likely to remain in these countries due to the rapid pace of development of new medicines, limitation of access to research projects and a lack of new technologies." added Thongprasert.

Global commitment on ensuring access to anti-cancer medicines has increased over recent years and according to ESMO President Josep Tabernero, cooperation among different stakeholders can contribute to better guiding the Asia-Pacific countries towards improving access to and availability of essential medicines, vaccines, diagnostics and medical devices.

"Overall, there is a need to adequately prioritise limited resources to clinical benefits, and collaborative efforts have resulted in new tools and approaches that can play a critical step in addressing policy issues in LMICs. One such platform is the ESMO Magnitude of Clinical Benefit Scale (ESMO-MCBS) (6,7) which can help governments to review and adjust their respective national medicine lists to ensure that they prioritise the most cost-effective ones that provide the greatest value to patients."

"Also, by facilitating education and updating of oncology professionals in the Asia-Pacific region, the annual ESMO Asia Congress, launched back in 2014, provides the arena for sharing knowledge as well as discussing and debating major challenges in oncology towards advancing the field and bringing about real and necessary change," the ESMO President concluded.

The amount of insulin needed to effectively treat type 2 diabetes will rise by more than 20% worldwide over the next 12 years, but without major improvements in access, insulin will be beyond the reach of around half of the 79 million adults with type 2 diabetes who will need it in 2030, according to a new modelling study published in The Lancet Diabetes & Endocrinology journal.

The findings are of particular concern for the African, Asian, and Oceania regions which the study predicts will have the largest unmet insulin need in 2030 if access remains at current levels.

The analysis underscores the importance of tackling barriers to the insulin market, particularly in Africa. The authors warn that strategies to make insulin more widely available and affordable will be critical to ensure that demand is met.

"These estimates suggest that current levels of insulin access are highly inadequate compared to projected need, particularly in Africa and Asia, and more efforts should be devoted to overcoming this looming health challenge," says Dr Sanjay Basu from Stanford University, USA who led the research. [1]

"Despite the UN's commitment to treat non-communicable diseases and ensure universal access to drugs for diabetes, across much of the world insulin is scarce and unnecessarily difficult for patients to access. The number of adults with type 2 diabetes is expected to rise over the next 12 years due to ageing, urbanization, and associated changes in diet and physical activity. Unless governments begin initiatives to make insulin available and affordable, then its use is always going to be far from optimal." [1]

Insulin is essential for all people with type 1 diabetes and some people with type 2 diabetes to reduce the risk of complications such as blindness, amputation, kidney failure, and stroke [2]. As global rates of type 2 diabetes soar and people with type 2 diabetes live longer (which will increase insulin requirements), a comprehensive picture of global insulin need is required because insulin treatment is costly, and the international insulin market is presently dominated by only three major manufacturers.

Using data from the International Diabetes Federation and 14 cohort studies (representing more than 60% of the world population with type 2 diabetes), researchers estimated the burden of type 2 diabetes in 221 countries and territories between 2018 and 2030. They estimated the potential number of insulin users, amount of insulin required, and the burden of diabetes complications under varying levels of insulin access and treatment targets (from 6.5% to 8% HbA1c, a measure of blood glucose), in adults aged 18 or older.

Results showed that worldwide, the number of adults with type 2 diabetes is expected rise by more than a fifth from 406 million in 2018 to 511 million in 2030, with over half living in just three countries--China (130 million), India (98 million), and the USA (32 million).

At the same time, global insulin use is projected to rise from 526 million 1000-unit vials in 2018 to 634 million in 2030, and will be highest in Asia (322 million vials in 2030) and lowest in Oceania (4 million) (table 2).

The authors calculated that compared to current levels of insulin access, if universal global access was achieved (with a treatment target of HbA1c 7% or lower), the number of people with type 2 diabetes worldwide using insulin in 2030 would double (from around 38 million [7.4% of all people with type 2 diabetes) to 79 million [15.5%]; table 2).

The estimates suggest that making insulin widely accessible would have the greatest impact in the African region--increasing insulin use 7-fold from around 700,000 people with type 2 diabetes at current levels of access to over 5 million--whilst universal access in Asia could more than double numbers of insulin users from 21 million to 48 million people (table 2).

The study also predicts that using a higher glucose target of 8% in the over 75s could halve insulin use and prevent more disability by cutting severe hypoglycaemic events (more common among older adults) by 44%, with only a 20% increase in diabetes-related harms from eye, kidney, and nerve complications (figure 2).

"Most guidelines recommend glucose targets of less than 6.5% or 7%. Targeting a more moderate threshold for control is likely to improve overall health by balancing the risks of hypoglycaemia with longer-term microvascular disease benefit," says Basu. [1]

The authors note several limitations, including that the projections of type 2 diabetes prevalence do not account for dietary and physical activity environments changing over time, which means that the disease could have a much larger or smaller impact in the future. They also note that the methods used assume that the relation between underlying demographics, treatment targets, and complications are similar across countries, which might not account for some ethnic variations.

Commenting on the implications of the study, Dr Hertzel Gerstein from McMaster University, Canada writes: "These comprehensive analyses explicitly accounted for a variety of circumstances. Nevertheless, they are based on mathematical models that are in turn based on other mathematical models. They are also based on a variety of assumptions...Such considerations suggest that predictions about the future need to be viewed cautiously. Regardless of these uncertainties, insulin is likely to maintain its place as a crucial therapy for type 2 diabetes, and as such a sufficient global supply needs to be estimated and ensured...Ongoing updates to models such as these that incorporate new data and trends as they accrue, may be the most reliable way of assuring their reliability and relevance to evidence-based care."

A team of scientists at Boston Children's Hospital has developed the first modeling system for testing age-specific human immune responses to vaccines -- outside the body. The practical, cost-effective new platform, using all human components, is expected to accelerate and de-risk the development, assessment and selection of vaccines.

In a study published today in Frontiers in Immunology, a team from Boston Children's Precision Vaccines Program, directed by Ofer Levy, MD, Ph.D., describes a three-dimensional human tissue culture construct that is able to reproduce immune responses of different populations and age groups in a laboratory setting. The platform is designed to enable researchers to test, evaluate and select human vaccine candidates for age-specific target populations, such as newborns and the elderly, before initiating costly human or animal trials.

"By allowing us to select specific formulations based on individual characteristics, we can save time and money in the development of new, more effective vaccines," says Levy, a physician-scientist in the Division of Infectious Diseases at Boston Children's. "We believe this system could disrupt and galvanize the entire field of vaccinology and ultimately save lives."

New approach to an old problem

Immunization is one of modern medicine's greatest success stories. Yet we still lack vaccines for common diseases, such as HIV and respiratory syncytial virus -- the number one cause of infant hospitalization in the United States -- while other vaccines, such as those against tuberculosis or pertussis, are only moderately effective. Moreover, the average vaccine can take a decade or more to develop, at a cost of hundreds of millions of dollars. The biggest stumbling block occurs late in development: Vaccines that worked flawlessly in mice regularly fail in clinical trials. Because of the high costs, many companies are reluctant to enter into vaccine development, despite the overwhelming need.

"It's simply not possible to conduct large-scale, phase 3, double-blind, placebo-controlled studies of every potential vaccine for every pathogen we want to protect against," says Levy. "We need a way to rapidly assess the candidates earlier in the process."

In 2010, Levy and his colleague Guzman Sanchez-Schmitz, MSc, Ph.D. received a grant from the Bill and Melinda Gates Foundation to create an in vitro model of the human immune system to test vaccines. It was a "man on the moon" effort, says Levy. The team set out to create a system that would not only faithfully replicate human biology but would also enable the study of targeted age groups.

"We were radically committed to being age-specific in our approach," said Levy. "Vaccines work differently in kids, and yet they are the group that needs the most protection."

Infants and the elderly are most at risk from infection, suggesting broad age-based differences in immunity. And while infants receive the most vaccinations, many vaccines don't provide sufficient protection initially, requiring multiple boosters to confer full immunity.

Personalized modeling of immune responses

The team designed the construct to replicate a human capillary vein and interstitium -- the fluid-filled spaces that line the circulatory system. It consists of a layer of endothelial cells, which typically line blood vessels, grown over a three-dimensional network of human proteins. To model the immune system of a newborn or an adult study participant, the researchers apply the participant's plasma and immune cells known as monocytes to the surface of the construct.

The monocytes naturally migrate down through the endothelium into the human proteins below. During this process, many differentiate to dendritic cells, immune cells that initiate specific immune responses from T cells. After two days, these dendritic cells rise back through the endothelial layer, just as in the body they would pass through the walls of lymphatic capillaries en route to the lymph nodes.

When effective vaccines are added to this system, the emerging dendritic cells pick up the vaccine antigens. These cells are then harvested and cultured with T cells to gauge immune response to the vaccine.

"We relied on only human components, ensuring that the only thing that is not human-derived is the vaccine," said Sanchez-Schmitz, first author on the paper. "That's what makes this platform powerful. You can detect small amounts of foreign material in a way that other systems cannot, because you lower the threshold of background noise. Just as nature intended it."

The team successfully validated the system using two common, licensed neonatal vaccines: Bacillus Calmette-Guérin (BCG), a live-attenuated bacterium widely used to immunize against child tuberculosis, and hepatitis B vaccine (HBV), containing inactivated fragments of the pathogen coupled with alum, added to boost immune response to the vaccine. "We started with vaccines that are recommended by the World Health Organization and given to newborns in resource-poor settings," says Levy. "If we were going to model responses by age, it made sense to choose vaccines that are given to newborns, such as BCG and HBV."

The system will also enable researchers to model the immune systems of other vulnerable populations, such as pregnant women, the elderly or the chronically ill, and open the door to testing individual responses.

"This construct is highly versatile. It can be newborn, if you use newborn cells and plasma. It can be your own cells and plasma. That's how personalized this system can be," says Sanchez-Schmitz.

The system marks a major advancement for Boston Children's Precision Vaccines Program, which was founded to bring precision medicine principles to vaccinology and catalyze collaboration between academia, government and industry, with the goal of accelerating vaccine development for vulnerable populations.

"Our in vitro systems are part of a larger precision vaccines paradigm that also includes special adjuvant systems to boost immune responses in distinct populations, targeted clinical trials, systems biology and animal modeling," says Levy. "This is an opportunity to bring molecular biology and innovative immunology to human settings, and to do science that not only is sophisticated, but has a real chance in the near term to enhance human health."

Both aspirin and a purified omega-3, called EPA, reduce the number of pre-cancerous polyps in patients found to be at high risk of developing bowel cancer, according to new research.

A clinical trial, led by the University of Leeds, found that both aspirin and EPA reduced the number of bowel polyps in patients one year on from a screening colonoscopy (large bowel camera test), although they did not reduce the chances of an individual having any polyps present in the bowel.

Patients who took aspirin developed fewer polyps overall, including on the right side of the large bowel, the part which is most difficult to monitor by colonoscopy being furthest from the back-passage.

Patients who took purified omega-3 EPA (eicosapentaenoic acid) also developed fewer polyps, but this effect was seen only on polyps on the left side of the bowel, which is nearest the back-passage.

The seAFOod Trial, the result of a multidisciplinary collaboration between the Universities of Leeds, Nottingham, Bradford and Newcastle, as well as others, is published today in The Lancet.

The trial was launched to determine whether aspirin or EPA could reduce the number of people who had any polyps at their one year follow up test, which they did not. However, both compounds had preventative effects by reducing the number of polyps of specific types in patients.

Lead author Mark Hull, Professor of Molecular Gastroenterology at the University of Leeds, said: "The seAFOod Trial demonstrates that both aspirin and EPA have preventative effects, which is particularly exciting given that they are both relatively cheap and safe compounds to give to patients.

"Given this new evidence, clinicians need to consider these agents for patients at elevated risk of bowel cancer, alongside regular colonoscopy surveillance."

Bowel cancer remains the second largest cause of cancer deaths in the UK. Despite a national screening programme, bowel cancer still resulted in over 16,000 deaths in England and Wales in 2014.

People at high risk of the disease are regularly monitored by specialists who use a flexible camera to examine the lining of the large bowel, also called the colon, by a technique called colonoscopy.

During a colonoscopy, a specialist looks for polyps, which are fleshy growths on the lining of the colon. The growths are usually benign but they can turn cancerous and so they are removed. However, colonoscopy is not fool-proof and a significant number of people still continue to develop bowel cancer.

The seAFOod Trial, funded by the EME Programme - a Medical Research Council (MRC) and National Institute for Health Research (NIHR) partnership - was conducted to see if aspirin and EPA could provide another layer of prevention, alongside colonoscopy.

Professor Hull is a practising Gastroenterologist at the Leeds Teaching Hospitals Trust and is a member of the NHS Bowel Cancer Screening Programme (BCSP) Research Committee. He said: "With the BCSP in England being extended to cover everyone from the age of 50 in England, there will be even more people found to have bowel polyps, who we know are at increased risk of bowel cancer. We should now evaluate how aspirin and EPA can best provide added benefits to patients given our limited colonoscopy resources."

Just over 700 people took part in the study from 53 hospitals in England, all of whom were identified as being at higher risk of developing bowel cancer after having a colonoscopy in the BCSP. This study is the first drug trial to have taken place in the English BCSP.

People who took part were randomly allocated to one of four treatment groups and, each day over the following year, they took either a 300 milligram aspirin tablet; 2 grams EPA in four capsules; a combination of both aspirin and EPA; or placebos only.

Patients who took aspirin had 22% fewer polyps at the end of the one year study compared to those who took the placebo.

Those who took EPA had 9% fewer polyps at the end of the study compared to those who took the placebo, although this difference was not statistically significant. However, patients who took EPA had 25% fewer polyps in the left side of the bowel compared to those who took the placebo.

The study suggests that a 'precision medicine' approach may be the most appropriate way to use aspirin and omega-3 to prevent bowel polyps, in which patients at risk of particular types of polyps are given treatment specific to that risk.

Professor David Crossman, Interim Director of the NIHR's Efficacy and Mechanism Evaluation (EME) Programme, said: "The seAFOod Trial results are very exciting and I'm particularly pleased that the MRC/NIHR collaboration funded this study.

"Prevention is key in this common disease and it's fascinating that the combination of widely available and relatively cheap drugs seemed to have such an impact."

EPA is naturally present in fish oil, but was given to patients at a higher dose than is present in most omega-3 supplements that are available to the public. Aspirin was provided by Bayer AG and EPA was partly provided by SLA Pharma AG.

Although aspirin and EPA had beneficial effects on polyp number on their own, the combination of aspirin and EPA together appeared to have an even greater effect.

However, the trial was not designed to provide a definitive answer about combination treatment and further research is needed to test aspirin and EPA treatment together for polyp prevention.

Treatment with aspirin and EPA was safe with no increased bleeding risk seen. Individuals who took EPA on its own had a slight increase in stomach-upset symptoms.

Myotubular myopathy is a severe genetic disease that leads to muscle paralysis from birth and results in death before two years of age. Although no treatment currently exists, researchers from the University of Geneva (UNIGE), Switzerland, - working in collaboration with the University of Strasbourg, France, - have identified a molecule that not only greatly reduces the progression of the disease but also boosts life expectancy in animal models by a factor of seven. Since the molecule - known as tamoxifen - is already used for breast cancer, the researchers hope to soon set up a clinical trial so that patients can be given the medication. You can read all about the results in the journal Nature Communications.

Myotubular myopathy is a severe genetic disease that weakens all the skeletal muscles from birth. Ninety percent of affected babies do not live to two years of age. "The disease affects the X chromosome in one in 50,000 male infants," begins Leonardo Scapozza, full professor at the School of Pharmaceutical Sciences at UNIGE's Faculty of Science. Only boys are struck by myotubular myopathy, since the second X chromosome in girls generally compensates for the possible mutation of the first.

Although there is no existing treatment for this genetic defect, valuable research in gene therapy is currently underway. "But it will take years before we can come to a conclusion about how effective the clinical trials are," points out Olivier Dorchies, a researcher in the School of Pharmaceutical Sciences. "That's why we turned to a molecule that is already authorised for other treatments in humans, in the hope of finding a quicker way to counter this life-threatening disease."

Tamoxifen: a multi-purpose molecule

The researchers focused on tamoxifen, which has been used for many years to treat breast cancer, because the molecule has several interesting properties for protecting muscle fibres: it is antioxidant, anti-fibrotic and protects the mitochondria. "In a previous study, we used tamoxifen against Duchenne muscular dystrophy, which is also an inherited muscular disease that affects one in 3,500 boys, where the life expectancy is 30 years," explains Elinam Gayi, a PhD student in UNIGE's School of Pharmaceutical Sciences . "The results have been excellent, and a clinical trial is also in progress." This is why the scientists have been looking at the molecule in an attempt to combat myotubular myopathy, which - although it also leads to muscular paralysis - does not have the same mechanisms of action as in its cousin Duchenne.

"Myotubular myopathy is caused by a lack of myotubularin, an enzyme that transforms the lipidic messengers. Without it, the protein known as dynamin 2 accumulates and brings on muscle atrophy," continues Elinam. In the search for a cure, one of the avenues explored by several groups - including UNIGE's colleagues in Strasbourg - is to target dynamin 2, which is modulated by tamoxifen.

Oral treatment that increases life expectancy sevenfold

The scientists administered tamoxifen orally on a daily basis to sick mice with the same symptoms as affected babies, mixing it with their food. Three doses were tested: 0.03 milligrams per kilogram, 0.3 milligrams per kilogram and 3 milligrams per kilogram. The highest dose matches that used for treating breast cancer in women if we consider the metabolic differences between mouse and human. The results obtained by the research team left no room for argument.

An untreated sick mouse lived for 45 days on average. With the lowest dose, the average life expectancy was 80 days, rising to 120 days with the intermediate dose. "But with the biggest dose, life expectancy went up to 290 days on average - seven times higher than for an untreated mouse. Some even survived for over 400 days!" says Professor Scapozza. In addition, the progress of the paralysis was slowed down enormously or even completely stopped. Muscular strength was tripled, and it was possible to recover 60% of the muscular deficit between a healthy mouse and a sick mouse.

The scientists began the treatment when the mice developed the first symptoms, namely paralysis of the hindlegs at about three weeks. However, they have not ruled out that administering the drug earlier might be more efficacious against muscle weakness. "In parallel to our study, a team from the Children's Hospital of Toronto tested the drug on even younger mice, and the disease did not develop," says Olivier. "The problem is that in humans, myotubular myopathy starts during foetal development, so it's hard to know whether the total absence of paralysis might be achieved if this molecule is given after birth."

Is a clinical trial on the horizon?

Elinam adds: "Since tamoxifen is already authorised for use in humans, and a clinical trial is underway for Duchenne muscular dystrophy, we're hopeful that a clinical trial will come on line within a couple of years." It is now up to clinicians to make the most of our research and put it into practice.

The UNIGE researchers will continue to explore the multiple uses of tamoxifen for treating genetic muscle diseases. They will try to combine it with other authorised molecules or in the final phase of clinical development. The goal will be to find treatments that can be put on the market quickly.

Patients who have persistently high levels of inflammation following percutaneous coronary intervention (PCI) for coronary artery disease are significantly more likely to die from any cause or to have a heart attack within a year, according to a study of 7,026 patients published in the European Heart Journal [1].

Residual inflammatory risk (RIR) refers to the risk of further heart and blood vessel problems caused by vascular inflammation in patients with known coronary artery disease. A biological marker - high sensitivity C-reactive protein (hsCRP) - is used as an indicator of the level of risk. Until now it has not been known what proportion of patients treated with PCI to widen blocked arteries [2] have persistent high RIR, and what effect it might have on patient outcomes.

In the first study to investigate the prevalence of persistent high RIR after PCI, researchers led by Professor Roxana Mehran, from the Mount Sinai Medical Center, New York, USA, looked at data from patients who had received PCI at Mount Sinai Hospital between 2009 and 2016. They included all patients who had two measurements of hsCRP taken at the time of the PCI and then again at least four weeks later.

Patients were stratified into four groups according to their RIR: high RIR was defined as having levels of hsCRP of more than 2mg per litre of blood. If both measurements were high, then they were considered to have persistent high RIR; patients with a high first measurement, but then a low second measurement were considered to have attenuated RIR; those with a low and then high measurement had an increased RIR; and those whose measurements were both low had a low persistent low RIR.

Of the 7,026 patients, 2,654 (38%) had persistent high RIR, 719 (10%) had increased RIR, 1,088 (15%) had attenuated RIR, and 2,565 (37%) had persistent low RIR. One year after PCI, death from any cause had occurred in 2.6% of persistent high RIR patients, 1% of increased RIR patients, 0.3% of attenuated RIR patients and 0.7% of persistent low RIR patients. Heart attacks (myocardial infarction) occurred in 7.5%, 6.4%, 4.6% and 4.3% of the patients, respectively.

After adjusting for various factors that could affect the results, such as age, gender, body mass index, diabetes, high blood pressure and other conditions, the researchers found that compared to patients with persistent low RIR, persistent high RIR patients were more than three times more likely to die within one year from any cause and were 1.6 times as likely to have a heart attack.

Professor Mehran said: "Our results show that in patients for whom serial hsCRP measurements were available, more than a third of PCI patients had persistent high residual inflammatory risk. Moreover, cardiologists are clearly not evaluating residual inflammatory status in all patients after PCI. This should be considered, as we find it is associated with a higher risk of dying from any cause or suffering a heart attack within one year of PCI. Additionally, it is of interest because there are treatment strategies emerging aimed at lowering residual inflammatory risk."

She pointed to the results of a recent trial, CANTOS (Canakinumab Anti-inflammatory Thrombosis Outcomes Study), that found that a monoclonal antibody, canakinumb, which reduces hsCRP, significantly reduced deaths from cardiovascular disease, stroke, myocardial infarction, and reduced the incidence of major adverse cardiac events in patients who had a history of heart attacks and elevated hsCRP.

"The results of the CANTOS study were astonishing. Not only a reduction in hsCRP was found, but more importantly a significant reduction in heart attack, stroke or cardiovascular death was found in patients who took canakinumab. It is clearly important to identify the patients at highest risk who can benefit from the therapy, and to evaluate this in a prospective study. I do believe that we need data from randomised controlled trials to confirm our observational findings in patients undergoing PCI and with persistent high residual inflammatory risk.

"Our study emphasises that treating patients with coronary artery disease is not 'one-size-fits-all'. Patients fall into different risk categories and it's the clinicians' task to evaluate all residual risks after PCI. I hope that in the future we will be able to treat all patients according to their own individual risk profile."

Professor Paul Ridker, Director of the Center for Cardiovascular Disease Prevention at the Brigham and Women's Hospital, Boston, USA, who is an expert on inflammation in heart disease, developing the clinical application of hsCRP testing to evaluate cardiovascular risk and leading the CANTOS trial, has written an accompanying Viewpoint article with European colleagues, which is published today (Monday) [3]. He writes that while European clinicians "enthusiastically measure cholesterol and blood pressure in virtually all of their patients, surprisingly few measure high sensitivity C-reactive protein (hsCRP), a validated measure of cardiovascular inflammation".

He writes that the current study provides yet more evidence of the importance of measuring hsCRP to prevent further cardiovascular problems, and concludes: "Physicians can only address the biologic processes they measure. Without assessment of LDL cholesterol, it is impossible to effectively identify and manage hyperlipidaemia. Without knowledge of systolic and diastolic blood pressure, it is impossible to effectively identify and manage hypertension. Without measuring hsCRP, it is unclear how we will effectively identify and manage residual inflammatory risk. while today the management of the residual inflammatory risk involves more aggressive and guideline-based treatment of the currently known risk factors, the introduction of effective anti-inflammatory drugs in the near future will provide even better control of this residual risk."

Limitations of Prof Mehran's study include that it is observational; however, the hsCRP measurements were collected at the time of PCI and during follow-up, but were evaluated retrospectively rather than in a standardised prospective way.

The tissues in our bodies largely are made of fluid. It moves around cells and is essential to normal body function.

But in some cases, this fluid may be doing more harm than good.

In people who have glioblastoma, the deadliest form of brain cancer, this fluid has a much higher pressure, causing it to move fast and forcing cancer cells to spread. And a common cancer therapy, which inserts a drug directly into the tumor with a catheter, can make this fluid move even faster.

A team of researchers at Virginia Tech, led by Jennifer Munson, an assistant professor in the Department of Biomedical Engineering and Mechanics in the College of Engineering, may have found a solution to stopping this inevitable cancer cell spread.

In an article published on Nov. 19 in Scientific Reports, Chase Cornelison, lead author and a postdoctoral researcher at Virginia Tech, details the use of a drug that Munson's team found can block the way cancer cells respond to fluid flow. This work is part of a Munson-led five-year research grant project across multiple universities, examining the role of interstitial fluid flow in the spread of glioma cells. Interstitial fluid is the fluid that surrounds cells in the body.

In labs, Cornelison and others on Munson's team used mice with glioblastoma to test how a particular approach to delivering cancer treatment, called convection enhanced delivery, caused glioma cells to invade the rest of the brain. To block the fluid's rapid movement and the spread of cancer cells, they tested a drug called AMD3100. The drug, which already has been used in clinics, appeared to be a game changer, Cornelison said.

The majority of this research happened at the University of Virginia, where Munson previously worked before she came to Virginia Tech in 2017.

This finding could lead to stopping glioblastoma from spreading, Cornelison said.

"I am hopeful that since the drug that we used to block flow stimulation is currently used in patients that maybe clinicians, when they do consider using convection enhanced delivery, will combine that with this drug," he said.

Munson has been studying glioblastoma for more than 10 years, with a more recent focus on the role of interstitial fluid flow on cancer cells and the brain.

"It [glioblastoma] is so deadly, and there hasn't been a shift in treatment response in decades. Something needs to change," she said. "With my expertise and looking at fluid flow, maybe there's an answer there that we haven't seen."

Raising awareness of interstitial fluid flow throughout the body is Munson's aim in her research.

"This is a force that isn't accounted for much in brain tissues," she said. "My goal is to have more people thinking about this force and that it can actually have effects on cells that we don't intend."

In 2017, the American College of Cardiology and the American Heart Association released new blood pressure guidelines, lowering hypertension threshold to 130/80 mm Hg from the previous 140/90 mm Hg. A new study predicts that achieving and maintaining the 2017 guideline blood pressure goals could prevent more than 3 million cardiovascular disease events over ten years. The results of the study will appear online in the November 19 issue of Circulation.

"Treating high blood pressure is a major public health opportunity to protect health and quality of life for tens of millions of Americans," said the study's lead author Adam Bress, Pharm.D., M.S., assistant professor in Population Health Sciences at University of Utah Health. "Achieving these lower goals will be challenging."

Bress and his team wanted to explore the impact of achieving and maintaining the lower guideline-recommendations on the public compared to earlier blood pressure and treatment levels, as well as patients' ability to achieve and maintain earlier guideline recommendations.

The team predicted the number of cardiovascular events averted in middle-age adults based on the blood pressure goals of the 2017 blood pressure guidelines (JNC7) guidelines (JNC8) guidelines (140/90 mg Hg for patients younger than 60 and 150/90 mm Hg for patients older than 60).

Their analysis projects 3.3 million fewer cardiovascular disease events after achieving and maintaining the 2017 blood pressure goals compared to current blood pressure levels. They also found that achieving and maintaining the JNC7 and JNC8 recommended blood pressure goals would prevent 2.6 and 1.6 million cardiovascular disease events, respectively.

This study made these predictions using several contemporary, population-based databases. The NHANES dataset is a national representative survey of the U.S. adult population and provides population sizes of hypertension treatment groups by blood pressure levels and chronic conditions. The REGARDS database provides a source for the risk of fatal and nonfatal cardiovascular events. A recent meta-analysis of 42 randomized blood pressure-lowering clinical trials, consisting of more than 140,000 participants, provides the risk reduction predictions for cardiovascular events based on achieving and maintaining different blood pressure treatment targets.

The majority of cardiovascular disease events prevented came from those with current blood pressure levels above 140/90 mm Hg. Models assumed that patients achieved and maintained blood pressure goals over the course of the simulation.

Previous studies suggest the initial upfront investment for treating more adults for hypertension leads to health gains and cost savings over the lifetime of treatment. But change does not always come easily.

"A change in longstanding clinical guidelines is disruptive to patients and providers who are accustomed to clinical practice patterns that integrate the earlier guidelines," said Andrew Moran, M.D., M.P.H., associate professor of Medicine at the Columbia University Irving Medical Center and senior author on the paper. "It is important to project and quantify the range of potential benefits and risks expected if we make these fundamental changes to the way health care providers practice."

Treating more patients to achieve lower blood pressure goals does have risks. Bress notes that medications often come with side effects, which need to be monitored and managed.

"The number of medication-related adverse events was roughly equivalent to the number of cardiovascular disease events prevented," Moran said. "But the adverse events tend to be minor and transient, while the avoided cardiovascular events can lead to serious life time health problems and are sometimes even fatal."

The results are based on a database that is not representative of the diversity in the country, including information for only white and black patients that are at least 45 years old. It also does not directly account for future changes in blood pressure or changes in antihypertensive medications through time.

"A conversation and shared decision making between provider and patient about benefits and risks of increasing the dose of a medication or adding a new medication to achieve a lower target are important," Bress said. "Benefits to reduce the risk of heart attacks, stroke and heart failure are clear and may often outweigh risk of minor, transient side-effects."

SEATTLE (November 18, 2018, 1:45 pm PDT) - The final research results for a new treatment for protection against accidental exposure to peanut was presented today at the American College of Allergy, Asthma and Immunology (ACAAI) Annual Scientific Meeting and published in the New England Journal of Medicine. The results show it is possible for some people with peanut allergy to protect themselves from accidental ingestion by building up their tolerance to peanut over time.

"We're excited about the potential to help children and adolescents with peanut allergy protect themselves against accidentally eating a food with peanut in it," says allergist Stephen Tilles, MD, ACAAI past president, study co-author, and consulting advisor for Aimmune Therapeutics. "Our hope when we started the study was that by treating patients with the equivalent of one peanut per day, many would tolerate as much as two peanuts. We were pleased to find that two thirds of the people in the study were able to tolerate the equivalent of two peanuts per day after nine to 12 months of treatment, and half the patients tolerated the equivalent of four peanuts."

Study participants ranged in age from 4 to 55 years, most were 4 to 17, and all had peanut allergy. One third of the participants were given a placebo, while the remaining two-thirds were given peanut protein powder in increasing amounts until reaching the "maintenance dose" - the dose they stayed on for the remainder of the study. The maintenance does was the equivalent of one peanut daily.

"This is not a quick fix, and it doesn't mean people with peanut allergy will be able to eat peanuts whenever they want," says allergist Jay Lieberman, MD, vice chair of the ACAAI Food Allergy Committee and study co-author. "But it is definitely a breakthrough. The hope would be to have a treatment available in the second half of 2019. If that happens, people who receive and are able to tolerate this treatment should be protected from accidental exposures."

All those in the study received peanut protein as part of an oral food challenge (OFC). A person in an OFC is given a very small dose of the food by mouth under the supervision of a board-certified allergist to test for a severe reaction. OFCs are considered the gold standard for testing food allergy.

"Reactions from the oral challenges at the end of the study were much milder than prior to treatment," says Dr. Tilles. "On average, the participants were able to tolerate a 100-fold higher dose of peanut at the end of the study than they did at the beginning. In addition, the symptoms caused by the 100-fold higher dose at the end of study were milder than the symptoms on the lower dose at the beginning of the study."

Facts about this pivotal study:

More participants and more detailed data than all prior oral immunotherapy studies combined

Fewer severe allergic reactions requiring epinephrine during oral food challenges

Fewer side effects than anticipated - e.g. only six percent dropped out of the study due to gastrointestinal side effects; Also, one-third of patients completed the study with no more than mild side effects along the way.

80 percent of participants successfully reached daily maintenance dose of the equivalent of one peanut.

There are currently no approved treatment options for peanut allergy. If this treatment is approved by the FDA, it will be available by prescription, and people with peanut allergy will need to remain on it to stay protected against accidental consumption. Once someone stops the treatment, there is no longer a protective effect.

SEATTLE (November 16, 2018) - If you've suffered with severe atopic dermatitis (eczema) for a long time and have tried what you think is every available option for relief, you may want to consider allergy shots. A medically-challenging case being presented at the American College of Allergy, Asthma and Immunology (ACAAI) Annual Scientific Meeting found that allergy shots provided significant benefits to the eczema symptoms suffered by a 48-year-old man.

"The man had suffered with severe eczema since childhood," says allergist Anil Nanda, MD, ACAAI member and lead author of the paper. "He had tried many previous therapies for years including mild and high strength topical corticosteroid cream, as well as other topical anti-inflammatory creams and topical moisturizer creams. Biologic therapy has been available to treat eczema for about a year and-a-half but was not yet a treatment option at the time we saw this man. We thought allergy shots might be beneficial because he also had multiple allergies."

Atopic dermatitis is an allergic disease, and patients who have it often also have other types of allergies. Symptoms of eczema include severe itching along with excessive dryness or scaling, red or inflamed skin, sleep disturbance and skin pain.

"We conducted skin testing and found the man was allergic to dust mites, weeds, trees, grasses, mold, cats and dogs," says allergist Anita Wasan, MD, ACAAI member and co-author of the paper. "Because his allergies could all be treated with allergy shots, we thought treating his allergies might also benefit his eczema. After one year, he reported significant benefit to his symptoms, which was great news. And once he reached a maintenance dose of allergy shots, he no longer needed high dose steroid therapy for his eczema."

New and existing treatments for eczema can reduce the severity of symptoms like itching and excessively dry skin. Eczema is a chronic condition, and symptoms can come and go. An allergist can help you find relief from this chronic disease. Allergists are specialists in allergic diseases like eczema and are trained to help you take control of your symptoms, so you can live the life you want.