Body

A United Kingdom study designed to examine the association between primary care practitioner empathy and incidence of cardiovascular disease and all-cause mortality among type 2 diabetes patients found that those patients experiencing greater empathy in the year following their diagnosis saw beneficial long-term clinical outcomes. Using the consultation and relational empathy (CARE) questionnaire, which measures patients' experience of care with a focus on empathy, a numerical score for 628 participants from 49 general practices in East Anglia, UK, was computed 12 months after diagnosis. Those patients reporting better experiences of empathy had a lower risk (40-50%) of all-cause mortality over the subsequent 10 years compared with those reporting low practitioner empathy. While medicine moves increasingly towards precision, target-driven health care and technology-based assessment models, these findings suggest that interpersonal, empathic care may be an important determinant in the risk of mortality.

Women of color and young women may face elevated risks of developing triple-negative breast cancers, a type of cancer that spreads more quickly than most other types and doesn't respond well to hormone or targeted therapies, a study published in CANCER, a peer-reviewed journal of the American Cancer Society, shows.

Previous U.S. studies have found racial disparities in triple-negative breast cancer diagnoses, but few have looked beyond the scope of one state. To conduct a larger study, researchers in the Georgia State University School of Public Health analyzed all breast cancer cases diagnosed during 2010-14 from the United States Cancer Statistics database, a surveillance system of cancer registries with data representing 99 percent of the U.S. population.

The team identified more than 1.15 million cases of breast cancer, with triple-negative cases accounting for about 8.4 percent of all cases. The researchers uncovered a significant incidence of triple-negative breast cancer for women of color, specifically non-Hispanic black women, and for younger women.

Compared with non-Hispanic white women, non-Hispanic black women and Hispanic women had higher odds of being diagnosed with triple-negative breast cancer, respectively. More than 21 percent of non-Hispanic black women were diagnosed with triple-negative breast cancer, compared with less than 11 percent for all other types of breast cancer. Women younger than 40 years of age had twice the odds of being diagnosed with triple-negative breast cancer than women aged 50-64 years. Also, among women who were diagnosed with breast cancer, those diagnosed at late stages were 69 percent more likely to have triple-negative cancer than other types.

"Our results demonstrate that African American women of younger age are more likely to be diagnosed with triple negative breast cancer than younger women of other ethnicities," said Dora Il'yasova, epidemiologist and associate professor in the School of Public Health at Georgia State.

Because of the aggressive nature of triple-negative breast cancer and the lack of therapeutic options, it is important to know which individuals face a higher risk and what factors may influence this risk, the researchers noted.

"Until we have evidence of what environmental and genetic components contribute to this risk, it is imperative that women know their familial history of breast cancer, discuss that with their physicians and follow screening recommendations," said Lia Scott, lead researcher, recent doctoral graduate of the Georgia State University School of Public Health (Ph.D. '18), and current Steven M. Teutsch Prevention Effectiveness Fellow with the Centers for Disease Control and Prevention Division of Cancer Prevention & Control. "We hope that this update on the epidemiology of triple-negative breast cancer can provide a basis to further explore contributing factors in future research."

According to the American Cancer Society, most breast cancers are mainly classified by three proteins that can affect the cancer's growth: the estrogen hormone receptor, the progesterone hormone receptor and the human epidermal growth factor receptor 2 (HER2). Triple-negative breast cancer does not have any of the receptors, making it difficult to identify what is fueling the cancer's growth. Doctors have fewer options for targeted treatment to destroy these cancer cells. Chemotherapy is still an effective option for treating this cancer and reducing the risk of its return.

New Haven, Conn. -- A tool developed by researchers at Yale, Stanford, and Bioethics International can promote greater sharing of clinical trial data by pharmaceutical companies. While nearly one-third of the companies that the researchers assessed met standards for sharing data, others could be more transparent to the benefit of science and the public, the researchers said.

Their study was published in The BMJ (British Medical Journal).

Since the late 1990s, new laws and regulations have increased requirements for pharmaceutical companies to register and report results from clinical trials. Yet, some companies don't fully comply, and industry guidelines vary. To assess the data-sharing practices of large companies, lead author Jennifer Miller and her collaborators developed a new tool consisting of a set of standards and a ranking system.

The researchers applied the tool to large pharmaceutical companies with drugs approved by the FDA in 2015. Initially, the investigators found that 25% of companies fully met their standards. Those standards included registering clinical trials, sharing data and study protocols publicly, and reporting requests for data on an annual basis.

When given the opportunity to improve their score, a few companies responded, and the proportion of those meeting the standard rose to 33%. They did so by updating their policies to report annually or by adding timelines for data sharing, the researchers said.

"The findings show that this scorecard and ranking system work," said Miller. "It's one tool we can use to set standards and catalyze change in the industry."

However, the study also found that some companies could go much further to share trial data in a timely and transparent way.

Data sharing has many benefits, the researchers noted, including generating knowledge, promoting evidence-based guidelines, and maximizing use of data.

"Data sharing is important for advancing development of new cures and therapies," Miller noted.

The next step for the team is to make annual assessments of companies' data-sharing and transparency performance, and to expand the scorecard to address drug pricing and clinical trial design practices, said Miller.

PHILADELPHIA -- Nearly a million Americans live with thyroid cancer and doctors will diagnose more than 50,000 new cases this year. Fortunately, the survival rate for this kind of cancer is one of the best. Five years after diagnosis, more than 98 percent of patients are survivors.

Now a team of researchers led by Alliric Willis, MD, a thyroid surgeon in the Department of Surgery in the Sidney Kimmel Medical College at Thomas Jefferson University and researcher with the Sidney Kimmel Cancer Center - Jefferson Health, finds nearly a quarter of low-risk thyroid cancer patients receive more treatment than necessary. The practice carries potential long-term risk to the patient and added financial costs. The discovery could help to shift how doctors treat thyroid cancer patients.

"Just as a patient can be at risk of under treatment, a patient can be at risk of over treatment," says Dr. Willis, who published the work in the journal Surgical Oncology. "Our research really shines light on the fact that we are not treating all patients the same."

The thyroid is a butterfly-shaped gland that sits over the airway in the neck. The gland makes hormones that help to control heart rate, blood pressure, body temperature and how the body uses energy. When cells grow out of control in the thyroid, cancer develops.

Typical treatment for thyroid cancers that have not spread to other parts of the body begins with surgical removal of the gland. After completing surgery, patients can then go on to receive a second therapy known as radioactive iodine ablation. Radioactive iodine ablation is therapy taken as a pill. Because iodine is preferentially taken up by the thyroid gland, which relies on iodine to produce hormones, the radiation dose becomes concentrated there. The high amount of radioactivity in the iodine kills off any lingering cancer cells. Historically, patients have had fantastic results with radioactive iodine ablation treatment, Dr. Willis says. But the therapy does not come without costs.

Experts estimate the financial cost of radioactive iodine ablation exceeds $9 million dollars per year across the country. Additionally, for several days to weeks after surgery, patients who receive the radioactive iodine treatment must stay away from small children and pets. "They're virtually in isolation because the radioactivity will be on their clothing and on their sheets," Dr. Willis says. The dose of radioactivity in the treatment is so high that airport security has picked up radioactivity from patients as well as their spouses.

The treatment also carries the risk of permanent long-term side effects such as altering patients' perception of taste and the development of other cancers, particularly leukemia. Yet patients who have low-risk thyroid cancer--cancers that are small and have not spread to other parts of the body--do not benefit from the additional treatment. "Low-risk thyroid cancer patients have a five-year survival rate that is greater than 97 percent, whether they receive radioactive iodine ablation after appropriate surgery or not," Dr. Willis says.

In 2015, the American Thyroid Association released guidelines for thyroid cancer treatment that indicated radioactive iodine ablation is not always necessary for patients with low-risk thyroid cancer. Based on the guidelines, Dr. Willis and team sought to identify groups of patients that are most at risk of being overly treated for thyroid cancer.

"This is really important when we're talking population health and managing the increasing cost of health care by more effectively and efficiently using our resources," says Dr. Willis.

The researchers analyzed more than 32,000 thyroid cancer cases identified through the National Cancer Institute's Surveillance, Epidemiology, and End Results Program (SEER) database. They found more than half of patients were low-risk. About 25 percent of the low-risk patients received radioactive iodine ablation treatment, the researchers report.

Patients younger than 65 years old were most at risk of overtreatment, according to the study. Men were also more at risk of over treatment as were Hispanic and Asian patients.

"Young healthy patients are certainly going to be willing to receive whatever treatment may benefit them, but again we're talking about something that's been demonstrated to be over treatment," Dr. Willis says.

Some low-risk patients had their lymph nodes removed in addition to the thyroid gland, even when the cancer had not spread to the lymph nodes. These patients were more likely to go on and have radioactive iodine ablation treatment.

"That's particularly interesting because that tells you they may be in a setting where people are more aggressive in their approach to surgery and subsequent treatments," Dr. Willis says. "This is where guidelines such as those outlined by the American Thyroid Association, can really help. The guidelines can say this more extensive treatment is unnecessary. You will not have better outcomes because of it."

Dr. Willis hopes that his team's research will make people more aware of the fact that some patients are at risk of over treatment. "I think it will make people more mindful of following recommended guidelines with all patients so that we can give each patient the most effective treatment and get the best outcomes possible," he says.

PITTSBURGH, July 10, 2019 - A new study from the University of Pittsburgh Graduate School of Public Health and UPMC Hillman Cancer Center found that children born to obese mothers were more likely to develop cancer in early childhood.

Using Pennsylvania birth records, the researchers found a correlation between pre-pregnancy body-mass index (BMI) in mothers and subsequent cancer diagnosis in their offspring, even after correcting for known risk factors, such as newborn size and maternal age. The final version of the paper published online today in the American Journal of Epidemiology.

"Right now, we don't know of many avoidable risk factors for childhood cancer," said lead author Shaina Stacy, Ph.D., postdoctoral scholar in the Pitt Public Health Department of Epidemiology and UPMC Hillman Cancer Center. "My hope is that this study can be, in a way, empowering and also motivating for weight loss."

Stacy and colleagues pored through nearly 2 million birth records and about 3,000 cancer registry records filed in the state of Pennsylvania between 2003 and 2016 and found that children born to severely obese mothers--BMI above 40--had a 57% higher risk of developing leukemia before age 5. Weight and height also were individually associated with increased leukemia risk.

Further analysis showed that it wasn't simply that larger women were giving birth to larger babies or that heavier women tended to be older--known risk factors for childhood cancer--but rather, a mother's size independently contributed to her child's risk.

The researchers think the root cause of the effect they're seeing has something to do with insulin levels in the mother's body during fetal development, or possibly changes to the mother's DNA expression that are passed to her offspring.

Importantly, not all levels of obesity carry the same risk. Among the obese women in the study, higher BMI came with higher cancer rates in their children. So, even small amounts of weight loss can translate to a real reduction in risk, Stacy said.

"We are dealing with an obesity epidemic in this country," said senior author Jian-Min Yuan, M.D., Ph.D., professor of epidemiology at Pitt Public Health and co-leader of the cancer epidemiology and prevention program at UPMC Hillman Cancer Center. "From a prevention point-of-view, maintaining a healthy weight is not only good for the mother, but also for the children, too."

In community health centers in Medicaid expansion states, among established patients who were uninsured prior to the Affordable Care Act, many remained uninsured after implementation of the Obama-era law. Using electronic health record data across 11 Medicaid expansion states, an Oregon Health & Science University study tracking uninsured patients before and after the implementation of the ACA found that 21% of those patients remained continuously uninsured, 15% gained Medicaid, 12% gained other insurance, and 51% did not visit their Community Health Center post ACA implementation. The 21% who remained uninsured were largely Hispanic and spoke Spanish as their primary language, indicating both a language and potential legal barrier to enrollment in the ACA. These uninsured patients continued to have frequent healthcare visits and the majority had at least one health condition that would require continuous care. The results of this study point to a need for additional funding to support the needs of Community Health Centers serving the uninsured.

Cleveland Clinic's fourth annual analysis of Alzheimer's disease drug development found that the pipeline has grown in the number and variety of agents being tested over the past year, while highlighting several advances in the field including new clinical trial designs, more detailed criteria for making a research diagnosis, and an increased use of biological tests reflecting of the disease.

Based on the federal website ClinicalTrials.gov, the paper, Alzheimer's disease drug development: pipeline 2019, is Cleveland Clinic's fourth review of Alzheimer's disease drug development and appears as a July featured article in Alzheimer's & Dementia: Translational Research & Clinical Trials Interventions (TRCI), an open access journal of the Alzheimer's Association.

"Improvements to clinical trial design and new guidelines for a research diagnosis of Alzheimer's disease have allowed for accuracy in studies and precision in the staging of Alzheimer's disease, which are increasingly important in drug development," said Jeffrey Cummings, M.D., ScD, director emeritus of Cleveland Clinic Lou Ruvo Center for Brain Health, director of the Center for Neurodegeneration and Translational Neuroscience and research professor at the University of Nevada, Las Vegas department of Brain Health. "This progress is a result of key collaborations amongst stakeholders and has elevated us to an unprecedented stage of drug development. We've never seen more funding, more agents or more diversity in the pipeline."

At a time when scientists are now reexamining the role of therapies targeting amyloid, this year's pipeline shows a trend toward a more diverse approach in attacking Alzheimer's disease. These agents include, anti-tau, neuroprotective, anti-inflammatory, regenerative (stem cells) and metabolic interventions. Additional trends include a variety of approaches to deep brain stimulation as well as ribonucleic acid (RNA)-based therapies.

"It's been really disappointing to see these last couple of clinical trials fail. We were worried that this would have a devastating impact on Alzheimer's drug development, but when we surveyed the landscape, we were encouraged to see more, not fewer agents being developed," said Aaron Ritter, M.D., director of clinical trials at Cleveland Clinic Lou Ruvo Center for Brain Health. "Every drug failure is an opportunity for learning, and it is our hope that through this paper, the public will see the importance of clinical trial participation. The bottom line is that as the pipeline grows, so does the number of people needed to test these medications."

Drs. Cummings and Ritter, along with fellow authors Garam Lee, Pharma.D., a clinical research pharmacist at Cleveland Clinic Lou Ruvo Center for Brain Health; Marwan Sabbagh, M.D., director of Cleveland Clinic Lou Ruvo Center for Brain Health; and Kate Zhong, M.D., CEO of CNS Innovations examined all clinical trials from 2018 to 2019 to uncover the diversity in the pipeline as well as innovations utilized in current trials such as designs, outcomes, populations and biomarkers.

The authors note that several new clinical trial designs - including futility analyses and adaptive trial designs, as seen in the development of cancer and diabetes medications - increase the speed and sophistication of conducting Alzheimer's disease clinical trials. Another important trend in the field is a move toward testing medications in people either minimally effected or even before the onset of symptoms.

Several Alzheimer's prevention studies enrolling people based on their genetic predisposition to Alzheimer's disease are now being conducted. Moving forward, the authors' specific areas of interest include repurposed agents, immunotherapies, and novel mechanisms of action (MOA).

(Boston)--For the first time researchers have deciphered the near-atomic structure of filaments, called 'pili', that extend from the surface of bacteria that cause traveler's diarrhea. Without pili, these bacteria do not cause disease. Knowing this structural information may lead to the development of new preventive therapies for the disease.

Traveler's diarrhea is an inconvenience to many in the U.S., but worldwide it can be deadly. It produces a watery diarrhea, which can cause life-threatening dehydration in infants or other vulnerable populations. With more than one billion cases each year, hundreds of thousands of deaths can be attributed to this bacterial disease which is caused by enterotoxigenic Escherichia coli (ETEC), invading the small intestine via pili.

Researchers from Boston University School of Medicine (BUSM), University of Virginia and Umeå University used heat to remove the pili from the bacteria and then used an electron microscope to look at the filaments in a near-native state, frozen in a glass-like solid and kept cold using liquid nitrogen. Because pili comprise hundreds of copies of a single protein, they were able to merge information from many pictures to determine a high-quality, three-dimensional view of the filament.

"We anticipate that our new, detailed knowledge of the structure of pili will help in developing vaccines and drugs to prevent and treat traveler's diarrhea. In particular we are excited about a peptide found in saliva that can disrupt unwinding and/or rewinding of pili as a means of inhibiting bacterial adhesion and disease," explained corresponding author Esther Bullitt, PhD, associate professor of physiology and biophysics at BUSM.

BOSTON - Each year, one out of three U.S. adults aged 65 years or older falls - and the number of deaths from falls is rising. Falls cost the U.S. health system more than $23 billion in emergency room visits each year. Worse, they frequently contribute to serious injury in older adults, often resulting in persistent disability and premature death.

A study published today in the Journal of the American Geriatrics Society identifies new factors that contribute to falls, which points towards interventions that may help prevent them. Researchers led by Stephen Juraschek, MD, PhD, a primary care physician at Beth Israel Deaconess Medical Center (BIDMC) found that subclinical myocardial damage and cardiac wall strain are associated with a higher risk of falling in older adults without known cardiovascular disease (CVD). These findings suggest that optimizing cardiovascular health even in older adults without a CVD diagnosis might represent a strategy for preventing falls among seniors.

"Given that falls can often be fatal for older adults, greater knowledge of the factors that contribute to falls represents a significant public health priority," said Juraschek. "For the first time, our study shows that subclinical CVD is itself a fall risk factor. This raises the important question of whether treatment of subclinical CVD could help prevent falls among older adults."

Juraschek and colleagues followed nearly 4,000 older adults (average age of 75 years) for four and a half years. During this time, participants were asked to report any hospitalization; and their medical records as well as claims data from the Centers of Medicare and Medicaid Services (CMS) were linked with their study information. Falls were identified from hospital discharge ICD-9 codes or CMS claims.

In this older-aged community dwelling population without known CVD, stroke or heart failure, the researchers found that markers of subclinical myocardial damage and cardiac wall strain were strongly and independently associated with new falls. These findings suggest that biomarkers of cardiac damage and wall strain could be important risk factors for falls and may shed light on novel, independent pathways linking CVD to falls among older adults free of a history of clinical CVD.

"Our findings are informative for clinical discussions pertaining to both the primary prevention of CVD and fall interventions in older adults," said Juraschek. "Whether treatment of subclinical CVD could help prevent falls among older adults is beyond the scope of the present study, but represents an important subject of subsequent fall prevention research. Such research has the potential to inform practitioners considering the risk and benefits of primary prevention treatments in older adults at risk for falls."

By one official estimate, American manufacturing, transportation, residential and commercial consumers use only about 40 percent of the energy they draw on, wasting 60 percent. Very often, this wasted energy escapes as heat, or thermal energy, from inefficient technology that fails to harvest that potential power.

Now a team at the University of Massachusetts Amherst led by chemist Dhandapani Venkataraman, "DV," and electrical engineer Zlatan Aksamija, report this month in Nature Communications on an advance they outline toward more efficient, cheaper, polymer-based harvest of heat energy.

"It will be a surprise to the field," DV predicts, "it gives us another key variable we can alter to improve the thermo-electric efficiency of polymers. This should make us, and others, look at polymer thermo-electrics in a new light."

Aksamija explains, "Using polymers to convert thermal energy to electricity by harvesting waste heat has seen an uptick in interest in recent years. Waste heat represents both a problem but also a resource; the more heat your process wastes, the less efficient it is." Harvesting waste heat is less difficult when there is a local, high-temperature gradient source to work with, he adds, such as a high-grade heat source like a power plant.

Thermo-electric polymers are less efficient at heat harvesting compared to rigid, expensive-to-produce inorganic methods that are nevertheless quite efficient, Aksamija adds, but polymers are worth pursuing because they are cheaper to produce and can be coated on flexible materials - to wrap around a power plant's exhaust stack, for example.

Recently, scientists have been addressing this obstacle with a process called "doping." With it, researchers mix chemical or other components into polymers to improve their ability to move electric charges and boost efficiency. DV says, "Imagine that we've added chocolate chips, a material that improves conductivity, to a cookie. That's doping."

But doping involves a tradeoff, Aksamija adds. It can either achieve more current and less thermally-induced voltage, or more voltage and less current, but not both. "If you improve one property, you make the other worse," he explains, "and it can take a lot of effort to decide the best balance," or optimal doping.

To address this, DV and his chemistry Ph.D. student Connor Boyle, with Aksamija and his electrical engineering Ph.D. student Meenakshi Upadhyaya worked in what DV calls "a true collaboration," where each insight from numerical simulations informed the next series of experiments, and vice versa.

The chemists conducted experiments, while the engineering team performed efficiency analyses along the curve from "zero doping" to "maximum doping" to identify the best balance for many different materials. For the massive number of simulations they ran to test hundreds of scenarios, they used the Massachusetts Green High Performance Computing Center in nearby Holyoke.

Aksamija says. "We can now tell you, for every given material, what is the optimal balance of the two properties, and for a while, people were satisfied with just knowing that." But along the way, he adds, they discovered an entirely new variable that had not yet been accounted for, one that turned out to be critical to the doped polymer's ability to harvest thermal energy efficiently.

He says, "The original analysis didn't get at the question of the position of the doping components, whether the materials clump or not and how much they clump, or cluster, as we call it. It turns out that clustering is a critical variable." The team turned to chemist Michael Barnes, a co-author on their recent paper, who used Kelvin Probe Force Microscopy to probe the dopants at the nano level and show that clustering is indeed present in polymers doped at room temperature, but not at higher temperatures.

With that confirmation, the researchers turned to modeling an expanded trade-off curve, says Upadhyaya. From their theoretical modeling, she and Aksamija found that clustering alters the shape of that curve. To improve efficiency beyond the current-voltage trade-off, one must move the entire trade-off curve, she says.

This unexpected finding should provide a new path for designing more efficient polymers for thermo-electric devices, the researchers say. DV notes that until now, chemists and materials scientists have been trying to organize polymers to be more like the inorganics, "nicely aligned and very regular, which is difficult to do," he adds. "It turns out that this may not be the way to go; you can take another road or another approach. We hope this paper provides a basis to move polymer-based thermo-electrics forward."

For patients with Type 1 diabetes who don't respond well to insulin or have other serious medical complications caused by their disease, pancreas transplantation offers hope for a cure. But obese candidates who need a pancreas transplant often are denied the procedure because of poor outcomes, including high rates of incision infections, which are linked to an increased risk for failure and loss of the implanted organ.

But now, surgeons at UI Health have demonstrated that obese patients with Type 1 diabetes can safely receive a pancreas transplant when the surgery is performed robotically. Their findings are published in the journal Transplant International.

"The incidence of obesity among diabetic patients has risen dramatically over the past decades," said Dr. Mario Spaggiari, assistant professor of surgery in the UIC College of Medicine, and lead author of the paper. "We have shown that by using robotic surgical techniques, this population can be safely transplanted, meaning that those who would have previously been denied can have access to this procedure that can vastly improve quality of life."

Patients with diabetes who receive a pancreas transplant often can stop taking insulin, but they must stay on an anti-rejection drug regimen. Pancreas transplantation to treat Type 1 diabetes is not a first-line treatment for the disease and is only performed in patients who don't respond to insulin injections, and who have other severe complications that arise from their diabetes.

The procedure currently is performed using open surgical techniques where a single, long incision is made. The longer the incision, the higher the risk for an infection in the healing incision, which can lead to failure of the implanted organ. Robotic pancreas transplantation can be performed using a small, 5-centimeter incision, where the new organ will be slipped into the body, and four, 1-centimeter incisions for the surgical robot's arms.

Dr. Enrico Benedetti, professor and head of surgery at the UIC College of Medicine, and his colleagues pioneered the use of robotic surgery for kidney transplantation in obese patients who were routinely denied the procedure because of poor outcomes. Benedetti is a co-author on the paper.

Spaggiari, Benedetti and their colleagues looked back at the records of pancreas transplant patients who had procedures that took place at UI Health over a four-year period ending in December 2018. Forty-nine patients received a pancreas transplant over that time. Seventy-seven percent of the patients had Type 1 diabetes, and 70% had end-stage renal disease requiring dialysis. The average age of the patients was 43 years old.

Patients with body mass indices at or above 30 (indicative of obesity) underwent procedures using robotically assisted surgical techniques. Ten of the procedures were performed robotically, and 39 were performed using traditional, open surgical techniques. Eight of the 10 patients who underwent robotically assisted pancreas transplantation also received a kidney during the procedure. Of the 39 patients who received a pancreas using traditional surgical techniques, 37 received a kidney at the same time.

Compared with patients who underwent traditional open transplantation, those who underwent the robotically assisted procedure had less blood loss, and surgical complication rates were similar in both groups. The length of post-operative hospitalization was shorter for patients who underwent the robotic procedure. None of the patients who underwent robotic pancreas transplant developed any wound complications.

"We think that robotic techniques can also be used to improve outcomes for normal weight patients who need pancreas transplants because of the reduced risk for incision infection, which is linked to a higher risk of losing the transplanted organ," said Dr. Enrico Benedetti, a co-author on the paper.

Arlys Martinez, 45, of Plainfield, Illinois, was a recipient of a combined pancreas and kidney transplant at UI Health in March 2018. Martinez suffered from Type 1 diabetes since she was a girl, and her diabetes eventually led to kidney failure, which required that she go on dialysis in January. Due to her restricted ability to exercise and water retention caused by the dialysis, she was considered too overweight to undergo pancreas transplantation at other hospitals.

"I was told at other hospitals that I would have to lose a significant amount of weight in order to get the pancreas," Martinez said. "I was cleared for the kidney, but with the pancreas transplant, they didn't want to do the surgery because of the large incisions that would be required because of my weight. But it was too hard for me to lose weight at that time because I was so tired and bloated."

Ultimately, Martinez came to UI Health and was able to receive both a kidney and a pancreas using minimally invasive robotic surgery.

"I am actually a really good eater -- I eat mostly organic, and I knew I could lose the weight after the transplant, but only UI Health gave me the chance to prove that," she said.

Martinez was able to go off insulin after her transplant, and has so far lost more than 20 pounds, and continues to lose weight. She is looking forward to feeling better and better every day.

DES PLAINES, IL -- Antibiotic stewardship interventions for acute respiratory infection (ARI) is feasible and effective and can significantly reduce overuse in the emergency department (ED) and urgent care center (UCC) settings. That is the conclusion of a study to be published in the July 2019 issue of Academic Emergency Medicine (AEM), a journal of the Society for Academic Emergency Medicine (SAEM).

The multicenter interventional study -- the first to evaluate the effectiveness of the Core Elements of Outpatient Antibiotic Stewardship when implemented as a bundle -- compared two approaches designed to help physicians make better antibiotic-prescribing decisions for viral acute respiratory infections (ARIs) without limiting the choices available.

The lead author of the study is Kabir Yadav, MD, MS, MSHS, Department of Emergency Medicine, Harbor?UCLA Medical Center, Torrance, CA and the Los Angeles Biomedical Research Institute, Torrance, CA.

Yadav, et al. found that while overall performance improvements are still needed in systems with both high and low performers, the study demonstrates that getting to zero inappropriate antibiotic use for ARIs is a potentially achievable goal, and for those institutions with average or high inappropriate prescribing rates, antibiotic overuse can be cut by one?third, with attention to the problem.

Commenting on the study is David A. Talan, MD, professor of medicine in residence (emeritus), David Geffen School of Medicine at UCLA and chair emeritus, Department of Emergency Medicine Faculty, Division of Infectious Diseases, Olive View-UCLA Medical Center:

"While this study did not demonstrate a significant reduction in inappropriate antibiotic use for upper respiratory tract infections with an enhanced educational campaign supplemented by peer comparison, the good news is that its rates are already remarkably low (~5%) in some emergency departments (EDs), and these campaigns appear feasible for EDs seeking more comprehensive models to improve stewardship and for application to other targets, such as urinary treat infections and shotgun empirical broad-spectrum IV treatments (e.g., vancomycin and piperaciilin/tazobactam)."

DES PLAINES, IL -- Pediatric emergency medicine (PEM) physicians are at risk for developing compassion fatigue (CF), burnout (BO), and low compassion satisfaction (CS), but proactive awareness of these phenomena and their predictors may allow providers to better manage the unique challenges and emotional stressors of the pediatric ED to enhance personal well-being and professional performance. That is the conclusion of a study to be published in the July 2019 issue of Academic Emergency Medicine (AEM), a journal of the Society for Academic Emergency Medicine (SAEM).

The lead author of the study is Jeanie L. Gribben, an MD candidate in the Division of Newborn Medicine and Department of Pediatrics, Kravis Children's Hospital, Mount Sinai Medical Center and Icahn School of Medicine at Mount Sinai, New York, NY

The findings of the study are discussed in a recent AEM podcast, "A Cross?sectional Analysis of Compassion Fatigue, Burnout, and Compassion Satisfaction in Pediatric Emergency Medicine Physicians in the United States."

Gribben et al. suggest that while CO, BO, and CS are distinct phenomena, there are degrees of overlap among their predictive factors that may be ripe for intervention. At the individual level, they suggest the key to provider well-being are positive interpersonal relationships, including therapeutic discussion with loved ones and compassionate connections with coworkers. At the institutional level, the authors recommend providing outlets for coping with difficult clinical situations. They also suggest that optimization of the physical work environment and administrative requirements may similarly improve health across all domains. Additionally, promoting self?care at both the personal and professional levels is essential to augment CS and protect against CF and BO in order to sustain emotional well?being throughout one's career.

Commenting on the study is Nathan Kuppermann, MD, MPH, a distinguished professor in the Departments of Emergency Medicine and Pediatrics and the Bo Tomas Brofeldt Endowed Chair in the Department of Emergency Medicine at the University of California, Davis School of Medicine:

"Burnout (BO) is highly prevalent among general emergency physicians; however, BO (and related compassion fatigue [CF] and compassion satisfaction [CS]) have not been studied comprehensively in groups of pediatric emergency physicians. In this study, although limited in sample size, and greatly focused on Caucasian women physicians in academic centers, BO, CF and CS were present in between 16-22 percent of respondents. The study analyses highlight the importance of interpersonal relationships, both with loved ones and coworkers, organization of the physical work environment, and mindfulness by employers of administrative burden on clinicians. For both their own well-being and for the benefit of their patients, we can no longer ignore the emotional health of clinicians."

Gay men in China ages 25-29 are eight times more likely to feel criticized and rejected compared with men in that country ages 20 or younger, new University of Hawaii at Manoa research shows.

The reason may be that 25- to 29-year-olds tend to be out of college and in the workforce, where they may face overwhelming social discrimination, according to a study co-authored by Assistant Professor Thomas Lee in the Office of Public Health Studies at the Myron B. Thompson School of Social Work.

"There is great pressure from society and family that may be imposed on Chinese gay men," said Lee. "We found that these men feel criticized and rejected, and that these feelings are linked with loneliness."

The study, published in the International Journal of Environmental Research and Public Health, is part of a recent effort among public health researchers to develop a better understanding of the mental health of the LGBTQ community.

Lee and colleagues administered questionnaires to 367 gay men in China. Some of the surveys were conducted face-to-face, but the majority were administered online. More specifically, the link to the survey was shared with live-chat applications specifically designed for gay men in China.

The men answered questions that allowed the researchers to measure feelings of loneliness and whether the study subjects were experiencing depression, anxiety or other psychological problems.

Several of the questions were aimed at measuring the men's degree of "interpersonal sensitivity," defined as a person's propensity to perceive and elicit criticism and rejection from others. People who are high in interpersonal sensitivity may have difficulty in communicating with others and are susceptible to depression and anxiety.

The findings showed that gay men who had no siblings or college degree and who earned less money than average were more likely have a high degree of interpersonal sensitivity and loneliness. Also, those who had experienced more sexual partners during their lifetimes showed lower measures of interpersonal sensitivity and loneliness.

There was no link between disclosing one's sexual identity to others and men's degree of interpersonal sensitivity, however, men who had disclosed their sexual identity to others felt less lonely.

"Traditional Chinese culture puts a strong emphasis on family inheritance and reproduction," said Lee. "Our results suggest that we need to be more aware of Chinese gay men's mental health and that everyone, especially family members, should offer more support to Chinese gay men and work to create a social environment that is more open and inclusive."

Historically, pregnancy in patients with systemic lupus erythematosus (SLE) was considered so risky that physicians counseled women to avoid becoming pregnant and recommended that women carrying a child terminate their pregnancy. Now, a new study published July 8 in the Annals of Internal Medicine demonstrates that pregnancy outcomes in the last two decades have drastically improved for patients with this disease.

"The biggest take-home message from this study is that more lupus patients are attempting pregnancy, most of the physicians are not recommending against it, and women are having successful deliveries," said lead study author Bella Mehta, MBBS, MD, MS, an assistant attending physician at Hospital for Special Surgery and an instructor in clinical medicine at Weill Cornell Medicine, in New York City.

SLE is a systemic autoimmune disease, which affects 241 per 100,000 people in North America; it is predominantly diagnosed in women of childbearing age. Years ago, women with SLE were advised to avoid having children due to high rates of complications, including pre-eclampsia and eclampsia. In more recent years, studies have shown that pregnancy in women with SLE carries a higher maternal and fetal risk than does pregnancy in healthy women, but this is improving. Between 1960 and 2003, rates of miscarriages and other pregnancy loss decreased from 40 percent to 17 percent in women with lupus. In the last two decades, a new understanding of the pathophysiology of SLE, new medications, and guidelines for risk assessment and management of patients with lupus have improved outcomes in patients, but just how this has impacted pregnancy in these women was unclear.

To shed light on this issue, researchers from HSS, the Icahn School of Medicine at Mount Sinai, Weill Cornell Medicine and New York-Presbyterian/Weill Cornell Medical Center, all in New York City, turned to the National Inpatient Sample (NIS) database. The NIS contains discharge data from approximately 20 percent of all community hospitals in the United States. It is the largest all-payer inpatient database in the United States focusing on adult pregnant hospitalized women with and without SLE. Using this database, the investigators examined data for all pregnant women from 1998 through 2015, focusing on in-hospital maternal mortality, fetal mortality, preeclampsia/eclampsia, c-section, non-delivery related admission, and length of stay.

Among the findings, the researchers identified a dramatic decline in in-hospital mortality in SLE patients, 442 per 100,000 admissions for the years between 1998 and 2000 compared with

"For lupus patients who are young and who are thinking of pregnancies, they should know that many other patients with lupus over the past two decades have successfully become pregnant and delivered, and mortality is minimal," said Dr. Mehta. "This is encouraging for young women with lupus. If they decide to have children, they can. In the 1980s, there were clinicians who advised young women with lupus not to get pregnant because they were so worried about mortality. What this study proves is this is no longer applicable."

Other findings from the study showed that preeclampsia/eclampsia rates decreased in patients with lupus during the two periods studied, from 9.5 percent to 9.1 percent, and increased in patients without lupus, from 3.3 percent to 4.1 percent. Hospital length of stay declined in lupus pregnancies, from a mean of 4.3 days to 3.8 days, but increased in non-lupus-pregnancies, from a mean of 2.5 to 2.7 days.

The percentage of lupus patients increased significantly from 0.9 percent to 0.16 percent in all pregnancy-related admissions and from 0.08 percent to 0.14 percent in delivery-related admissions. The researchers believe that as care for lupus has improved, more patients with the disease have attempted and succeeded in having healthy pregnancies.

Improved outcomes have likely been the product of better diagnosis and referral of patients with mild disease to rheumatologists, counseling of patients to attempt pregnancy when disease is quiescent, and improved therapies for lupus and lupus-associated pregnancy complications. Other factors improving outcomes include continuation of hydroxychloroquine throughout pregnancy and use of low dose aspirin and heparin for patients with antiphospholipid syndrome (APS), a condition that is common in lupus patients and associated with miscarriages and fetal loss.

"Lupus is a disease that largely affects women and most particularly women of color," said senior author Dr. Said Ibrahim, chief of the Division of Healthcare Delivery Service and Innovation, senior associate dean for diversity and inclusion and professor of healthcare policy and research at Weill Cornell Medicine. "While our study couldn't thoroughly examine race and income disparities in lupus pregnancy outcomes, the findings support the concept that improving quality of care for all patients is one way to address inequities in healthcare. It is a hopeful message."

"Besides mortality, complications that clinicians worry about in women with lupus, such as preeclampsia, have also decreased in the past two decades. The times are changing," said Dr. Mehta. "I think physicians should be aware of this, so they can advise patients and give them the right sort of guidance. It is okay for women with lupus to get pregnant, as long as they are under the care of a rheumatologist and high risk obstetrics."