Body

Kratom is a Southeast Asian tree with a long history of use in traditional medicine. In the region, the plant's leaves are widely consumed for pain relief, treatment of opioid addiction and other uses. Though its efficacy and safety are unproven, kratom use has spread to the U.S. and Europe. Now, researchers report in ACS Central Science that a metabolite of a kratom alkaloid could be responsible for the treatment's therapeutic effects.

Currently, kratom is legal and available in the U.S. as a gray-market product, but it has an uncertain regulatory future. In the meantime, scientists are investigating the substance's physiological effects. Some prior research attributed these effects to mitragynine, the major active alkaloid in kratom, and its binding to an opioid receptor. However, 7-hydroxymitragynine (7-OH), another alkaloid present in the leaf at far lower concentrations, also interacts with that receptor. To clear up the matter, Jonathan A. Javitch, Susruta Majumdar, Dalibor Sames and colleagues set out to probe the pharmacological and metabolic mechanisms behind kratom's analgesic effects.

Through studies in cells and mice, the researchers showed that most of the analgesic effect is from 7-OH rather than mitragynine. They also found that metabolism of mitragynine in mouse and human liver preparations actually produces much more 7-OH than is present naturally in kratom. The team says that the results shed light on some of the seemingly contradictory reports on kratom, but more studies are still needed to see whether their findings in mice extend to humans.

Ibrutinib and venetoclax, two FDA-approved drugs for treating chronic lymphocytic leukemia (CLL), have been shown to be effective when given together for high-risk and older patients with the disease, according to a study at The University of Texas MD Anderson Cancer Center.

Study findings were published in the May 29 online issue of the New England Journal of Medicine. Lead researchers included Nitin Jain, M.D., associate professor of Leukemia, William Wierda, M.D., Ph.D., professor of Leukemia; and Varsha Gandhi, Ph.D., department chair ad interim of Experimental Therapeutics.

Researchers followed 80 previously untreated patients in a Phase II study. Median age was 65 years with 30 percent over age 70. Ninety-two percent had high-risk genetic anomalies. Eighty-eight percent of patients had complete remission with normal or incomplete blood count recovery after 12 cycles of treatment. Sixty-one percent of patients had complete remission with undetectable minimal residual disease.

"These efficacy results are substantially better than what has been reported with ibrutinib or venetoclax monotherapy for CLL patients," said Jain "With monotherapy, the majority of responses have been partial, and remissions with undetectable minimal residual disease in bone marrow has been rare."

Jain added that more robust therapies are needed for patients with CLL given that the majority of patients are older than 65 and existing therapies are not always effective.

"This group of patients often has unacceptable side effects and has a lower rate of complete remission and undetectable minimal residual disease," said Jain. "Our data showed that non-chemotherapy, combination therapy with ibrutinib and venetoclax demonstrated no new toxic effects compared to what has been previously reported for the individual agents."

The study reported that 60 percent of patients developed low white blood cell counts, which was similar to what has been reported in other venetoclax combination trials. No new safety concerns were observed with the combination therapy.

While the current median follow-up of the trial is 14.8 months, Jain said that "a longer follow-up is needed to adequately assess the long-term safety of this combination."

WINSTON-SALEM, N.C. - May 30, 2019 - A minimally invasive procedure to repair abdominal aneurysms thought to be less effective than traditional open surgery has been shown to perform as well as the open repair and be as long-lasting.

Findings published in the May 30 issue of the New England Journal of Medicine showed that long-term overall survival was similar among patients who underwent endovascular repair and those who underwent open repair.

"This should be good news for patients because the endovascular procedure is less painful and has a much shorter recovery period than the open procedure, though it is more expensive," said the study's principal investigator, Julie Ann Freischlag, M.D., chief executive officer of Wake Forest Baptist Health, dean of Wake Forest School of Medicine and professor of vascular and endovascular surgery.

"Earlier studies conducted more than a decade ago in Europe had indicated long-term problems with the endograft used in the less invasive procedure. As a result, it isn't readily available for everyone in Europe and other parts of the world," Freischlag said. "Hopefully our study will dispel some of the concerns from the earlier studies and provide the scientific evidence to warrant a second look by the medical community."

An endograft is a tiny tube or stent that is surrounded by mesh-impregnated fabric to reinforce the weak spots in the abdominal aorta. It is inserted through small groin incisions using imaging to guide the graft into place. When permanently placed inside the aorta, it alleviates blood pressure by allowing blood to flow without pushing on the weakened, bulging artery.

In open surgery, the physician makes a large incision in the belly or side of the abdomen and uses a man-made, tube-like graft that is sewn into place to replace the weak and bulging section of the aorta in the belly.

In the study that began in 2002, 881 patients with asymptomatic abdominal aortic aneurysms were randomized to either endovascular repair or open repair groups. All of the participants were patients at 42 Veterans Health Administration hospitals in the United States and candidates for either procedure. Following the respective procedures, patients were followed for 14 years.

During the first four years of follow-up, overall survival appeared to be higher in the endovascular-repair group than in the open-repair group. But in years four through eight, overall survival was slightly higher in the open-repair group. After eight years, overall survival was once again higher in the endovascular group. According to the study authors, none of those trends were statistically significant.

The principal finding was that no significant difference was observed between the endovascular and the open-repair groups in the primary outcome of long-term all-cause mortality. Among younger patients, endovascular repair resulted in somewhat higher long-term survival than open repair, but among older patients, endovascular repair resulted in somewhat lower long-term overall survival than open repair. More deaths from chronic obstructive lung disease occurred in the open-repair group than in the endovascular group, but the research team could not determine a reason.

"So for younger patients or for those who had extensive heart disease, the endovascular procedure was somewhat better," Freischlag said. "Open surgery was a better option for older patients, which was just the opposite of what we expected."

(Toronto, May 28, 2019) - A first of its kind study is reporting that millions of women in low- and middle-income countries will need life-saving radiotherapy to treat their cervical cancer, despite the growth of essential human papilloma virus (HPV) vaccination prevention programs.

The availability of radiotherapy in these regions would generate millions of productive life years and billions of dollars in economic benefits for their families and communities.

The study modeled the long-term demand, benefit and cost of implementing a 20-year strategy for radiotherapy to treat cervical cancer in low- and middle-income countries between 2015 and 2035, alongside a simultaneous vaccination program.

Low-income and middle-income countries include those with a gross national income of less than $12,000 USD a year.

The research entitled "Scale-up of radiotherapy for cervical cancer in the era of human papillomavirus vaccination in low-income and middle-income countries: A model-based analysis of need and economic impact," by lead author Dr. Danielle Rodin and senior author Dr. Michael Milosevic, in the Radiation Medicine Program, Princess Margaret Cancer Centre is published in the May 24, 2019 online edition of The Lancet Oncology.

In the designated 20-year-time span, the study estimated that 9.4 million women in these countries will require radiotherapy - the gold standard for curing women with more advanced cervical cancer. This would result in a net benefit to the economies of these countries of $151.5 billion over the same time period as a direct result of women living longer, more productive lives.

HPV vaccination would result in a 3.9% reduction in cervical cancer incidence over the study period - assuming a best case scenario of vaccinating every 12-year-old girl in the world starting in 2014. By 2072, when the first vaccinated cohort reaches 70 years of age, there would be a 22.9% reduction in incidence, still leaving 41.6 million in need for radiotherapy over that time period.

Almost all cervical cancers are caused by human papillomavirus (HPV), a sexually transmitted infection. There are more than 100 types of HPV, of which more than 40 can cause cervical cancer. Persistent HPV infections can sometimes develop into cervical cancer if not treated.

"These are women in their prime who are working, caring for children, and contributing to their communities. We have made huge progress in tackling other infectious disease and in reducing maternal mortality, so that women are now living long enough to develop diseases such as cancer and heart disease," says Dr. Danielle Rodin, Clinician-Investigator and Radiation Oncologist, Princess Margaret Cancer Centre.

"Vaccination is hugely important, but we can't neglect the millions of women who are contracting cervical cancer and dying in pain without access to treatment. These are women who have curable cancers - even advanced cervical cancer can be cured with radiotherapy. The possibility exists to make this treatment universally available."

It's the third deadliest cardiovascular diagnosis, but doctors are still often stumped to explain why 40% of patients experience unprovoked venous thromboembolism (VTE). And after a patient has dealt with these dangerous blood clots once, a second and subsequent events become much more likely.

New research from a team of University of Michigan scientists may help solve the mystery of how to detect and deal with higher-than-usual clot risk in patients' veins. The study, done in mice and published in the Journal of Clinical Investigation, focuses on clots' relationship to the body's defense and repair system, which causes inflammation.

"We don't yet understand the molecular triggers which drive the development of life-threatening clots in deep veins," said Yogen Kanthi, M.D., the study's senior author and a vascular cardiologist at U-M's Frankel Cardiovascular Center. "Our work aimed to identify and block a previously unrecognized pathway linking inflammation and thrombosis."

Kanthi, also an assistant professor of internal medicine at Michigan Medicine, says VTE is triggered by some combination of coagulation and inflammation. But current treatments come up short, he says, because they only focus on one side of the equation: anticoagulation. After VTE, patients are often prescribed blood thinners for life.

Kanthi's lab is instead investigating inflammation's role in the development of deep vein thrombosis. His team's new study found an enzyme called CD39 diffused circulating "danger" signals and inflammatory cytokines in blood during thrombosis.

FDA-approved drugs already exist for other conditions that are affected by the same pathway, and in particular, the paradigmatic inflammatory cytokine molecule called interleukin-1 beta. In fact, when the researchers inhibited interleukin-1 signals in their study, they reduced the number and size of venous blood clots the animals formed, Kanthi said.

"Here, we focused on potential therapeutics at the intersection of inflammation and thrombosis," Kanthi said. "We showed that blocking interleukin 1 beta, a ubiquitous inflammatory molecule, was a powerful means to stop clot formation."

In a comprehensive study, researchers from Texas A&M University have determined that harmful particulate matter in the atmosphere can produce birth defects and even fatalities during pregnancy using the animal model.

The team of researchers from Texas A&M's Colleges of Agriculture and Life Sciences and Geosciences, the Texas A&M Health Science Center, and colleagues from the University of California-San Diego has had their findings published in the current issue of PNAS (Proceedings of the National Academy of Sciences).

Using female rats, the team examined the adverse health effects of exposure to fine particulate matter consisting of ammonium sulfate commonly found in many locations around the world. Large fractions of this substance were detected not only in Asia, but also in Houston (51 percent) and Los Angeles (31 percent).

During winter months in China and India, where severe haze events frequently occur, fine particulate matter levels were especially high at several hundred micrograms per cubic meter, the team concluded.

Air pollution is a century-old problem for much of the world. According to the World Health Organization, 9 out of 10 people worldwide breathe air containing high level of pollutants, and 1 of every 9 global deaths can be attributed to exposure to air pollution, totaling over 7 million premature deaths a year.

Even in the United States, about one third of the population still live under poor air quality conditions, according to a report released by the U. S. Environmental Protection Agency in 2018.

"People typically believe that ammonium sulfate may not be terribly toxic, but our results show large impacts on female pregnant rats," Renyi Zhang, Texas A&M Distinguished Professor of Atmospheric Sciences and the Harold J. Haynes Chair in Geosciences and one of the leading authors, said. "It is unclear yet what is causing these profound effects, but we speculate that the size of nanoparticles or even the acidity may be the culprit."

Zhang said sulfate is mainly produced from coal burning, which is a major energy source for much of the world in both developed and developing countries. Ammonium is derived from ammonia, which is produced from agricultural, automobile, and animal emissions, "so this certainly represents a major problem worldwide," Zhang said.

"However, our results show that prenatal exposure to air pollution may not dispose offspring to obesity in adulthood," said Guoyao Wu, Texas A&M University Distinguished Professor and another of the lead authors of the study. "Nutrition and lifestyle are likely major factors contributing to the current obesity epidemic worldwide."

Numerous previous studies have shown that air pollution is a serious public health threat throughout the world, with millions of people breathing air that is far less than standards set by the World Health Organization.

In addition, previous studies have shown such pollution to impair metabolic and immune systems in animal offspring, but the team's study shows definitive proof of decreased fetal survival rates, and also shortened gestation rates that can result in smaller body weight, in addition to damage to brains, hearts and other organs in the adult rat models.

The findings present obvious concerns and challenges on a multi-scale level, the team concludes.

"While epidemiological studies have been widely adopted to assess the health effects of air pollution, these tend to yield little insight into adverse outcomes and long-term effects," Zhang said.

"Furthermore, there is an absence of clinical recommendations for prevention and treatment of air pollution-related health issues. Our study has demonstrated that well-controlled exposure experiments using animal models offer major advantages for future air pollution control and are promising in the development of therapeutic intervention and treatment procedures."

A new study from researchers at the Johns Hopkins Bloomberg School of Public Health found that more than one in five older adults who were aging in place with a mobility or self-care disability reported experiencing negative consequences such as having to stay in bed or going without eating due to no one being available to help or the activity being too difficult to perform alone. The study also found that Medicare spending was higher for this group as compared with older adults with disabilities who did not experience negative consequences.

The findings, published online May 28 in the Annals of Internal Medicine, emphasize the importance of non-medical care and supports for older adults who continue to reside in the community.

"The data allow us to see on a granular level how many people are in situations where they don't receive the help they need to perform daily activities," says Jennifer Wolff, PhD, the study's lead author and director of the Roger C. Lipitz Center for Integrated Health in the Department of Health Policy and Management. "We are able to link that number to a public payer like Medicare and see how much extra the public is paying for services to older adults due to lack of adequate support with basic daily activities."

By the end of 2018, nearly 60 million people were enrolled in Medicare: expenditures are well over $700 billion dollars. An estimated 15 million Medicare beneficiaries are living in the community with disabilities, and Medicare spending is much higher in this group.

For their analysis, the researchers used data from the 2015 National Health and Aging Trends Study, a nationally representative, in-person survey of adults aged 65 and older. The study excludes older adults who were living in nursing homes or residential care facilities as well as those who did not survive 12 months following the interview. The analysis focused on 1,961 participants linked with fee-for-service Medicare claims who reported having difficulty in performing daily household, mobility and self-care activities.

The researchers examined study participants who reported difficulty or received help in performing daily tasks, categorized into three main groups: household activities (laundry, shopping, preparing meals, paying bills and banking), mobility (indoor and outdoor activities and transferring from the bed) and self-care (eating, dressing, bathing and going to the bathroom).

For each of these activities, participants who received help or reported difficulty with activities were asked whether they experienced a negative consequence because performing the activity was too difficult or they did not have enough help. Negative consequences were defined as going without clean clothes, going without groceries, not having a hot meal, trouble handling banking tasks, mistakes taking medications, the inability to move from the bed, not being able to go places or leave their home, going without eating or bathing or accidentally soiling their clothes.

The study found that overall spending was higher for those who had difficulty with mobility and self-care activities and subsequently experienced a negative outcome than those who did not. The researchers accounted for differences in characteristics of older adults that could affect Medicare spending.

Among older adults with disability in household activities, Medicare spending did not vary appreciably by whether they experienced negative consequences.

"To date, there has been little evidence of the potential magnitude of health care savings related to better meeting older adults' care needs," says Wolff. "This study suggests there may be value in terms of both quality of care and reduced costs associated with a broader orientation for paying for services."

Women have long been told fainting is a common but harmless symptom of pregnancy, but new research shows it may indicate issues for both the baby and mother's health, especially when it occurs during the first trimester.

The study--conducted by a team of cardiology researchers that included University of Alberta senior epidemiologist Padma Kaul and University of Calgary cardiology trainee Safia Chatur--was published in the Journal of the American Heart Association.

Cardiology researcher Padma Kaul said she wants to see fainting included with other pregnancy-induced conditions like pre-eclampsia and gestational diabetes as a warning sign for mothers' cardiovascular health. (Photo: Supplied)

Cardiology researcher Padma Kaul said she wants to see fainting included with other pregnancy-induced conditions like pre-eclampsia and gestational diabetes as a warning sign for mothers' cardiovascular health. (Photo: Supplied)

Researchers reviewed birth records of 481,930 babies born in Alberta between 2005 and 2014, as well as medical records of the mothers for one year after delivery, looking for frequency, timing and outcomes of fainting episodes.

The team found roughly one per cent of expectant mothers fainted--about a third of those during the first three months of pregnancy.

Among the pregnancies where fainting occurred during the first trimester, the research team observed higher rates of preterm births, and an increase in heart problems and further fainting episodes for the mothers. There was also an increase in congenital anomalies such as low birth weight among the babies when the mothers had passed out more than once.

Fainting, technically known as syncope, is a temporary loss of consciousness, usually caused by low blood pressure and a lack of oxygen in the brain. Pregnancy hormones can cause the heart rate and blood supply to increase, while blood vessels relax, all of which can lead to dizziness and fainting.

Women who faint during pregnancy should report it to their doctors, said Kaul, and their physicians should monitor the women and their babies more closely.

Kaul said fainting should be added to the list of pregnancy-induced conditions such as pre-eclampsia and gestational diabetes that can be considered warning signs for women's health.

"Pregnancy is a natural stress test for the woman's system," she said. "Fainting during pregnancy may identify women who are at higher risk of cardiovascular complications down the road."

Kaul said the researchers were surprised by the findings.

"Fainting is a relatively rare event and nobody has studied it systematically at a population level," she said. "Generally clinicians thought it was fairly benign. So that's what we were expecting to find."

Until now, research about fainting during pregnancy relied on anecdotal reporting and a small number of case studies. The pattern of issues for mothers and babies was only revealed when researchers were able to review a large number of birth records from a 10-year time period.

"Our study is significant because it's truly population-based. In Canada, thanks to universal health care, we're counting everyone," she explained.

Kaul is a professor of medicine and a member of the Women & Children's Health Research Institute.

Along with one of her co-authors, Roopinder Sandhu, a cardiac electrophysiologist at the U of A, Kaul is developing the Canadian Syncope Atlas for the Cardiac Arrhythmia Network of Canada, which also funded the research on fainting during pregnancy. The atlas will map out the prevalence of fainting across the country, cost to the health-care system, social determinants and outcomes.

While a large proportion of the population faints at some point in their lifetime, the underlying causes can be difficult to diagnose and can range from life-threatening to benign.

"I can imagine that it's a really scary event during pregnancy," said Kaul.

She hopes to see the research on fainting during pregnancy replicated in other countries where similar large sets of population data are available, to confirm the findings.

She warned that while the study shows a correlation between fainting and health issues for mothers and babies, it can't pinpoint causes or pre-existing conditions that might be responsible.

"It's a chicken-and-egg problem, so the associations need to be worked out through further study," Kaul said.

For many people with chronic obstructive pulmonary disease or COPD, a steroid inhaler is a daily necessity to keep their airways open and help them to breathe. Now, a new UBC analysis shows that these medicated devices may also reduce patients' risk of lung cancer by as much as 30 per cent.

The researchers evaluated 10 years' worth of medical and pharmacy data for 39,676 adults in British Columbia who were diagnosed with COPD, including 994 people who were later diagnosed with lung cancer. They compared outcomes for people who took inhaled steroids versus those who used beta agonists, another class of drugs used to treat COPD.

Beta agonists, which work by relaxing muscles in the lungs to widen the airways, are the first choice of treatment for COPD. But doctors will often prescribe steroids, which reduce the number of inflammatory cells called eosinophils in the lungs, for more severe cases.

"Results showed that if you had COPD and consistently used a steroid inhaler, your chances of getting lung cancer were between 25 per cent and 30 per cent lower compared to people who took other treatments," said study author Larry Lynd, a professor who leads the Collaboration for Outcomes Research and Evaluation project at UBC's faculty of pharmaceutical sciences and an associate member of the faculty of medicine.

COPD is a group of diseases, including emphysema and chronic bronchitis, that hamper airflow to the lungs and cause serious long-term disability and early death. Although there is no cure, treatments can help manage the disease.

"In Canada alone, more than 700,000 people have been *diagnosed* with COPD," said study co-author Don Sin, a professor of medicine at UBC and the Canada Research Chair in COPD. "These results highlight the importance of identifying which of those patients may be at the highest risk for lung cancer and may benefit from therapy with inhaled steroids."

The study, recently *published* in European Respiratory Journal, is limited by its reliance on administrative data, which limits the scope of data available for analysis, and the fact that COPD diagnosis was based solely on prescription records. For the next stage in this research, the researchers plan to do studies to understand how steroids reduce lung cancer risk in COPD patients.

"More work is clearly needed to understand the exact nature of the relationship between lung cancer risks and steroid use," said Lynd. "Over the next few months, we will find out which COPD patients would benefit the most from inhaled steroids."

DALLAS, May 28, 2019 -- Cardiomyopathies (heart muscle diseases) in children are the focus of a new scientific statement from the American Heart Association that provides insight into the diagnosis and treatment of the diseases as well as identifying future research priorities. It will be published in the American Heart Association's journal Circulation.

When a child has certain types of cardiomyopathy, their heart is not able to pump blood efficiently. Symptoms may include difficulty breathing, heart rhythm abnormalities, dizziness, swollen hands and feet or other indications.

Although rare, cardiomyopathies in children can be life threatening and often result in either a child needing a heart transplant or premature death. There are many causes of cardiomyopathies including genetic variations that affect basic heart functions, systemic diseases, such as infections, treatments for medical conditions that injure the heart and many others, some of which are not yet understood.

According to the statement:

Nearly 40% of children who are diagnosed with cardiomyopathies that produce symptoms receive a heart transplant or die within the first two years after diagnosis.

The percentage of children with cardiomyopathy who received a heart transplant has not declined over the past 10 years.

Cardiomyopathy remains the leading cause of transplantation for children over one year of age.

"This statement is designed to give medical professionals an overview of what we currently know about cardiomyopathies in children. Although we are able to provide effective treatments in many cases, research is urgently needed to better understand the causes of the diseases so we can help children with cardiomyopathies live their best lives," said Steven E. Lipshultz, M.D., the chair of the writing group and the A. Conger Goodyear Professor and chair of the Department of Pediatrics at the Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo.

Dr. Lipshultz is also the Chair of the Medical Advisory Board of the Children's Cardiomyopathy Foundation, which partners with the American Heart Association on funding pediatric cardiomyopathy research grants.

Despite potential for prolonging survival with treatment, one-third of patients with metastatic pancreatic cancer do not see a medical oncologist, and even more do not receive cancer-directed treatment, found new research published in CMAJ (Canadian Medical Association Journal).

Pancreatic cancer has a high death rate and is often diagnosed in advanced stages.

"The data suggest that there are many missed opportunities for important discussions between patients and cancer specialists," says Dr. Natalie Coburn, an author of the study and a surgical oncologist at Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, Ontario. "We have better chemotherapy drugs than in the past, but those standards of care aren't reaching patients. Spreading the reach of the standards of care, starting with a consultation with a medical oncologist, would have a big impact."

The study looked at data on 10 881 patients with a new diagnosis of advanced pancreatic cancer in Ontario from 2005 to 2016, and examined how many people saw a medical oncologist and how many received treatment after consultation. About 65% of patients had a consultation with a medical oncologist, and 38% of all patients received cancer-directed treatment. More than half of patients who did not receive cancer-directed treatment did not have a medical oncology consult.

By contrast, about 80% to 90% of patients with colorectal cancer see a medical oncologist and undergo treatment for the disease.

The study aims to raise awareness of this issue for pancreas and other high-fatality cancers.

"We want to debunk the idea that it's 'not worth treating' pancreas cancer. We want more people to access a medical oncologist so that they can have informed discussions about treatment options, symptom management and palliative care," says coauthor Dr. Julie Hallet, a surgical oncologist at Sunnybrook Health Sciences Centre and the University of Toronto. "We could achieve better results by getting more people to an oncologist and better access to best practice treatments right now than with new and often expensive experimental drugs in the future."

The authors suggest that changes to health policies are necessary to ensure all patients have equal opportunities for assessment and treatment.

"We also want to raise awareness amongst policy-makers about gaps in the health care system -- how can we ensure people are accessing the standard of care? How can we make it easier to reach a specialist in a timely manner?," she says.

"Low rates of specialized cancer consultation and cancer-directed therapy for incurable pancreatic adenocarcinoma: a population-based analysis" is published May 27, 2019.

Licorice tea, a popular herbal tea, is not without health risks, as a case study of a man admitted to hospital for a high-blood pressure emergency demonstrates in CMAJ (Canadian Medical Association Journal).

"Excessive amounts of some herbal products can have harmful side effects," says Dr. Jean-Pierre Falet, Department of Neurology, McGill University, Montréal, Quebec. "Products containing licorice root extract can raise blood pressure, cause water retention and decrease potassium levels if consumed in excess."

The 84-year-old man visited the emergency department for a high-blood pressure emergency, which was found to be induced by consuming homemade tea made from licorice root. His blood pressure was severely elevated, and he was suffering from a headache, light sensitivity, chest pain, fatigue and fluid retention in the calves. After admission to hospital and treatment, the patient, who had a history of high blood pressure, told physicians he had been drinking 1 to 2 glasses daily of homemade licorice root extract called "erk sous" for two weeks prior.

Licorice tea is popular in the Middle East and parts of Europe, and erk sous is especially popular in Egypt during Ramadan.

"Given Canada's multicultural population, physicians should consider screening for licorice root intake in patients with difficult-to-control hypertension," says Dr. Falet.

"Hypertensive emergency induced by licorice tea" is published May 27, 2019.

Canada should reinvent the Motherisk program to support pregnant women to have healthy babies, argues an editorial in CMAJ (Canadian Medical Association Journal).

"The loss of Motherisk has exposed a major public health and research void that is neither quickly nor easily reconciled," writes Dr. Nathan Stall, associate editor, CMAJ, with colleagues. "Although finding an immediate replacement for Motherisk is not feasible, reinventing a reputable and modernized clinical and research program in reproductive drug safety should be a national priority."

Motherisk, once a leader in evidence-based counselling on drug safety in pregnancy and breastfeeding in Canada, was shut down after losing credibility and funding amid allegations of research misconduct involving its former director.

To ensure trust in a reinvented program, there should be oversights to ensure responsible conduct, which could be achieved through affiliation with a respected research institute and federal support to guarantee independence from industry.

"We envision a national and interprofessional collaborative effort among clinical and research experts in reproductive drug safety; front-line providers in primary care and obstetrics; and health care organizations and specialty societies, including in family medicine, obstetrics and gynecology, nursing, midwifery, internal medicine, pediatrics and other relevant disciplines," writes Dr. Stall and colleagues.

Athens, Greece - 26 May 2019: Drug therapy for patients with stable heart failure can be simplified by stopping diuretics, according to late breaking results from the ReBIC-1 trial presented today1 at Heart Failure 2019, a scientific congress of the European Society of Cardiology (ESC).

"Heart failure patients have many pills to take for their heart failure and for comorbidities such as diabetes and hypertension," said principal investigator Dr Luis E. Rohde, of the Federal University of Rio Grande do Sul, Porto Alegre, Brazil. "Withdrawing one drug when it is no longer necessary should make it easier to take the ones that are needed."

"Patients don't like using diuretics because they feel they have to stay at home to use the bathroom and they get cramps," he added. "Patients would welcome being able to stop this medication."

Diuretics are commonly prescribed for symptom relief in patients with heart failure. The drugs get rid of the excess fluids (congestion) which cause shortness of breath, swollen legs, coughing, and weight gain. Once the symptoms have resolved, patients are maintained on a low dose due to concerns that symptoms may return. Observational research has shown that long-term diuretic use is associated with a worse prognosis.

The ReBIC-1 trial examined the safety and tolerability of withdrawing the diuretic furosemide in outpatients with stable chronic heart failure. The trial was conducted by the Brazilian Research Network in Heart Failure (ReBIC), which includes 11 tertiary care university hospitals in Brazil.

Eligible criteria were: no or mild symptoms (defined as New York Heart Association functional class I to II), reduced left ventricular ejection fraction (45% or below), no heart failure-related hospital admission within the last six months, and receiving low-dose furosemide (40 to 80 mg per day) for at least six months.

A total of 188 patients were randomly allocated to maintain or withdraw furosemide. Patients in the withdrawal group received a placebo pill. Both patients and investigators were blinded to the treatment allocation. The trial had two coprimary outcomes: 1) patient reported dyspnoea using a visual analogue scale at four time points across 90 days; and 2) the proportion of patients maintained without additional diuretics during the 90-day follow-up (on top of the randomly allocated diuretic or placebo).

There was no difference between groups in the self-perception of dyspnoea during the 90-day follow-up period. Also, 72 patients (75.3%) in the withdrawal group and 78 patients (83.9%) in the maintenance group were free of furosemide reuse during follow-up (p=0.16).

Senior author Dr Andréia Biolo, of the Federal University of Rio Grande do Sul, who presented the results in Athens, said: "The results show that patients with stable heart failure who stop diuretics do not have more dyspnoea than those who continue taking the drug. Withdrawal also does not lead to increased reuse of diuretics - around 20% of patients in both groups needed a top-up, presumably for symptom relief."

Dr Rohde said the findings indicate that diuretics can be safely discontinued in heart failure patients meeting the trial's eligibility criteria. "Most patients we see in the heart failure outpatient clinic fulfil the trial criteria and could benefit from this strategy," he said.

No extra follow-up is needed for patients who quit taking diuretics, noted Dr Biolo. "Patients can be followed-up in the usual way," she said. "And, as we do now, patients should be educated to seek medical help if they become breathless, get oedema, or have sudden weight gain which indicates fluid retention."

Athens, Greece - 25 May 2019: Women undergoing fertility treatment should urgently see their doctor if they have heart failure symptoms, according to a study presented today at Heart Failure 2019, a scientific congress of the European Society of Cardiology (ESC).1

Shortness of breath, swollen legs and waking up in the night to urinate could be warning signs of a pregnancy-associated heart failure called peripartum cardiomyopathy (PPCM). PPCM affects about one in 1,000 pregnant women worldwide and is life-threatening to the mother and baby. The heart becomes enlarged and weak in late pregnancy or after delivery.

"It is very difficult to distinguish normal pregnancy discomfort from heart failure symptoms," said Dr Tobias Pfeffer, study co-author and cardiologist at Hannover Medical School. "Our study shows that the risk of PPCM is five times higher in women who have fertility treatment so they should be aware that this discomfort may not be benign. PPCM is often diagnosed much too late, with direct consequences on prognosis."

"In all women who have conceived artificially, gynaecologists and fertility doctors should advise cardiac checks including echocardiography after delivery, or shortly before, to rule out PPCM," said Professor Denise Hilfiker-Kleiner, the study's senior author and Hannover's dean of research in molecular cardiology.

She noted that the pregnancy rate of artificial fertilisation varies between 10% and 50% per cycle according to age and method, meaning that women undergo multiple rounds of treatment if pregnancy doesn't start or is lost at an early stage. "Lost pregnancies can also induce PPCM," she said. "Women who have developed signs of cardiac stress or impaired function should know that another cycle may increase their risk of becoming severely ill."

Rising success rates and affordability have led to a steady increase in the proportion of babies born from assisted reproductive technology (ART) such as in vitro fertilisation (IVF) and intracytoplasmatic sperm injection (ICSI). In Germany for example it rose from 1.6% in 2006 to 2.6% in 2016, and in Denmark from 6.1% in 2012 to 10% in 2018.

The study found high rates of subfertility in patients with PPCM. One-third had difficulty getting pregnant despite regular sexual intercourse over at least six months, compared to around 20% in the general population in Germany. Births using ART were five times more common in women with PPCM: 13% of babies were conceived artificially compared to 2.6% in the general population.

The researchers said the high prevalence of subfertility and births using ART in patients with PPCM could be partly related to shared risk factors. "Women who undergo artificial fertilisation are normally older and delivery is more often by caesarean section, so they already have two risk factors for PPCM," said Professor Hilfiker-Kleiner. "Fertility treatments altogether induce multiple pregnancies, which also raises the chance of PPCM."

"We also think there may be genetic alterations that predispose women to both subfertility and PPCM but these analyses are ongoing," said Manuel List, co-author and medical student at Hannover. "So far there is no clear evidence that hormonal treatment, which is usually part of fertility therapy, increases the risk of PPCM."

Professor Hilfiker-Kleiner noted that clinical outcomes of PPCM patients in the study were not worse in women with fertility problems, including those who underwent fertility treatment, compared to those with normal fertility. "Having IVF or ICSI is not associated with a worse prognosis from PPCM," she said. "However, as subsequent pregnancies after PPCM have a high risk for relapse, fertility treatment in PPCM patients bears a high risk for mother and foetus."

The study was conducted in 111 patients with PPCM. Information on fertility and fertility treatment was obtained using a standardised questionnaire. Fertility centres provided treatment details.