Body

Jan. 22, 2019--Fish oil does not appear to improve asthma control in adolescents and young adults with uncontrolled asthma who are overweight or obese, according to new research published online in the Annals of the American Thoracic Society.

In "Fish Oil Supplementation in Overweight/Obese Patients with Uncontrolled Asthma: A Randomized Trial," Jason E. Lang, MD, MPH, and co-authors report that four grams of fish oil a day for six months did not improve asthma control, as measured by a standard asthma control questionnaire, breathing tests, urgent care visits and severe asthma exacerbations.

"We don't know why asthma control in obese patients is more difficult, but there is growing evidence that obesity causes systemic inflammation," said Dr. Lang, lead study author and associate professor of pediatrics at Duke University. "Because the omega-3 fatty acids in fish oil have anti-inflammatory properties, we wanted to test whether fish oil would have therapeutic benefits for these patients."

The 98 overweight/obese participants in the study ranged in age from 12 to 25 (average age: 14.6). All were diagnosed with asthma by a physician but had poor asthma control, despite using a daily inhaled corticosteroid to control their asthma. About half the participants were African American. For every three participants assigned to take fish oil for 25 weeks, one was assigned to take the soy oil placebo.

The researchers also looked at whether a variant in the gene ALOX5 affected study findings. It is known that mutations in the gene can reduce responses to anti-leukotriene drugs. Leukotrienes are inflammatory molecules that play a critical role in triggering asthma attacks. In this study, the ALOX5 variant did appear to be linked to leukotriene production but not to the effectiveness of fish oil in providing asthma control.

The authors wrote that the study's negative findings may not be the last word on fish oil and asthma. They acknowledged that larger doses of fish oil over a longer period of time may produce a different result.

Based on the current study, however, "there is insufficient evidence for clinicians to suggest to patients with uncontrolled asthma that they should take daily fish oil supplements to help their asthma," Dr. Lang said.

PHILADELPHIA - A novel "Enhanced Recovery After Surgery" (ERAS) protocol developed by Penn Medicine for patients undergoing spinal and peripheral nerve surgery significantly reduced opioid use. A new study published in the Journal of Neurosurgery: Spine showed that when an ERAS protocol was employed--which optimizes patients' surgical care before, during, and after surgery, including patient education, post-operative medications, and recovery plans--fewer patients needed pain medications one month after surgery.

Nearly 75 percent of patients at Penn Medicine who undergo spinal surgeries are opioid naïve--patients who are not chronically taking opioids on a daily basis--putting them at an increased risk for dependency following surgery. Previous studies have also shown that up to 7 percent of all patients who undergo spinal surgeries continue to take opioids one year after surgery. Part of the ERAS protocol at Penn includes a personalized, safe, and effective pain management plan to help prevent opioid dependency, which has rapidly become a public health crisis in the United States.

"ERAS protocols engage each aspect of the patient's surgical journey to improve clinical outcomes and optimize a safe recovery," said lead author and principal investigator Zarina S. Ali, MD, an assistant professor of Neurosurgery and neurosurgical ERAS physician lead at the Perelman School of Medicine at the University of Pennsylvania." This novel approach allows a framework for addressing pain management in a responsible and effective manner while dramatically reducing opioid use during and after surgery."

This prospective study included two groups who underwent elective spine or peripheral nerve surgery at Penn: 201 patients in the ERAS group treated between April and June 2017 and 74 patients who underwent traditional surgical care between September and December 2016. Preliminary findings were presented at the American Association of Neurological Surgeons 2018 Annual Meeting in May. This paper represents the full results.

Researchers found that use of intravenous opioid medications via patient-controlled analgesia (PCA)--known as a pain pump--was nearly eliminated in the ERAS group (0.5 percent) compared to over half of spinal surgical patients in the control group who relied on PCA. After one month, a smaller subset of patients in the ERAS group were using opioids (38 percent) compared to patients in the historical control group (53 percent). Despite that change, pain scores among each group were similar, suggesting PCA was not necessary in this population and that the ERAS pain management protocol, which relies on the use of both opioid and non-opioid medications, was effective in achieving appropriate pain control.

ERAS protocols involve coordination among the entire clinical team--including the surgeons, anesthesiologists, nurses, and outpatient staff--so patients can recover safely and with attention to all aspects of their care, not just the surgery. Protocols include standardized ways to educate patients on the procedure before the surgery along with consultations with specialists in primary care, pain management, nutrition, and sleep medicine, where applicable. Other efforts include smoking cessation and drinking liquid carbohydrates such as sports drinks prior to surgery.

ERAS also includes a robust multi-modal pain management protocol with judicious use of opioids only as needed. The protocol also calls for the patient to be up and moving regularly (three to five times per day) starting the day after surgery as this can improve blood flow and encourage healing.

"Easing opioid use after surgery is a daunting task, but the addition of non-opioid agents, like acetaminophen, helps mitigate the need for traditional, opioid-heavy pain management. This approach may have profound implications in limiting the risk of chronic opioid dependency in patients following spine surgery," Ali said.

While other ERAS protocols have been effective in the orthopaedic, urology, and colorectal surgery fields, this is the first to be successfully implemented for neurosurgery patients in a comprehensive program. Additionally, patient engagement with the ERAS protocol was facilitated through a Penn Center for Innovation pilot program, "Engaged Recovery at Penn," which utilized a text-messaging system to encourage ERAS behaviors for patients.

Future studies will aim to include cost-effectiveness of ERAS care as well as its effects on long-term health improvements. Additionally, a future focus on patient-reported outcome measures will be employed with well-validated questionnaires such as the Patient-Reported Outcomes Measurement Information System (PROMIS), which evaluates and monitors physical, mental, and social health.

CHICAGO --- Quitting smoking can significantly improve the effectiveness of cancer treatment, according to the U.S. Surgeon General, yet almost half of cancer patients continue to smoke after they've been diagnosed.

A new study from Northwestern Medicine and the Abramson Cancer Center at the University of Pennsylvania found cancer patients have better success quitting and are not as prone to relapsing one year later if they undergo counseling sessions for 24 weeks and take the smoking cessation medication varenicline (e.g. Chantix) for 24 weeks, compared to the routine 12 weeks.

"With the stress cancer patients are under, they tend to be at higher risk of relapsing for a longer period of time," said senior author Brian Hitsman, associate professor of preventive medicine at Northwestern University Feinberg School of Medicine. "So we thought providing treatment for longer would be more effective."  

The findings will be published Jan. 25 in the journal Psycho-Oncology. Patients in the study had a variety of cancers, ranging from breast to skin to lung cancer. Forty percent of patients actively had cancer while others had had cancer in the past five years. 

For Billie Green, 70, smoking while undergoing cancer treatments was the result of a combination of her 50-year smoking history and the stress of her life-altering lung cancer diagnosis that made it difficult to quit. 

"When someone tells you that you have cancer, you get scared," said Green, who lives in Chicago. "Smoking used to be my best friend when I was upset, after I ate. But I knew it didn't make any sense to keep smoking, if I'm going in for treatment all the time."

Green's daughter learned about the Northwestern Medicine smoking cessation study specifically aimed at cancer patients - one of the largest smoking cessation trials ever conducted with cancer patients - and asked her to enroll. Green did so a month later. 

Today, Green is in remission from her cancer. She still smokes but has dramatically cut back from one pack a day to one cigarette every other day. Green said the treatment - a combination of medication and behavioral counseling sessions - made her aware of what she was doing to her body.

The higher success of quitting, though was true only for the 43 percent of patients who took varenicline as directed for the full 24 weeks. For the other 57 percent of participants who did not take the medication as prescribed, there was no significant difference in quit rates or susceptibility of relapsing compared to the control group, who only received varenicline for the first 12 weeks.   

Both groups received the same behavioral therapy - counseling sessions to set quit dates, learn coping skills and manage withdrawal symptoms - over the course of 24 weeks. Many of the study participants in the control group and experimental group continued with the full counseling regimen, despite not always adhering to the medication regimen.

"While the behavioral therapy wasn't the focus of this study, we will need to study this part more closely because it can be a very powerful tool for cancer patients to quit smoking," Hitsman said. "You can imagine how someone going through a severe or significant disease and treatment process could benefit from the support we provided in this study."

This was only the second study to examine the use of varenicline for cancer patients. It was the first smoking cessation study -- for any population of smokers, not just cancer patients -- to double the length of the standard course of 12 weeks of varenicline and include behavioral therapy in the treatment.

Because varenicline treatment had never been given to a cancer population for longer than 12 weeks, the scientists wanted to assess its safety. The study found taking an additional 12 weeks of the medication did not increase the side effects for patients. 

"We hear from cancer patients and oncologists that varenicline may cause serious side effects or that managing the stress of the disease makes addressing tobacco use among patients inappropriate," said first author Dr. Robert Schnoll, associate professor in the department of psychiatry and associate director for population science at the Abramson Cancer Center. 

"But the results from this study show that this leading FDA-approved medication is effective for cancer patients, doesn't increase patient risk and yields increased benefits for those who take the medication as prescribed." 

"We need now to focus on how we can get more patients who smoke to use the medication and use it sufficiently if we are to see broader population-level gains," Schnoll said.

Researchers from North Carolina State University have developed an algorithm that could give pig farms advance notice of porcine epidemic diarrhea virus (PEDV) outbreaks. The proof-of-concept algorithm has potential for use in real-time prediction of other disease outbreaks in food animals.

PEDV is a virus that causes high mortality rates in preweaned piglets. The virus emerged in the U.S. in 2013 and by 2014 had infected approximately 50 percent of breeding herds. PEDV is transmitted by contact with contaminated fecal matter.

Gustavo Machado, assistant professor of population health and pathobiology at NC State and corresponding author of a paper describing the work, developed a pipeline utilizing machine-learning techniques to create an algorithm capable of predicting PEDV outbreaks in space and time.

Machado, with colleagues from the University of Minnesota and Brazil's Universidade Federal do Rio Grande do Sul, used weekly farm-level incidence data from sow farms to create the model. The data included all pig movement types, hog density, and environmental and weather factors such as vegetation, wind speed, temperature and precipitation.

The researchers looked at "neighborhoods" that were defined as a 10-kilometer radius around sow farms. They fed the model information about outbreaks, animal movements into each neighborhood and the environmental characteristics inside each neighborhood. Ultimately, their model was able to predict PEDV outbreaks with approximately 80 percent accuracy.

The most important risk factor for predicting PEDV spread was pig movement into and through the 10 km neighborhood, although neighborhood environment - including slope and vegetation - also influenced risk.

"This proof-of-concept model identified the PEDV spread bottleneck in North Carolina and allowed us to rank infection risk factors in order of importance," Machado says. "As we get more data from other farm sites across the U.S., we expect the model's accuracy to increase. Our end goal is to have near real-time risk predictions so that farmers and veterinarians can provide preventative care to high-risk areas and make decisions based on data."

Next steps for the researchers include improving the model to predict a wider range of diseases and expanding it to include other industries, such as poultry.

A study published today in the American Journal of Public Health estimates that 1,857 people injected drugs in the last six months in Cabell County, W.Va., a rural county with a population of 94,958. This estimate is based on an innovative survey technique that public health officials can now use in their own rural communities to address the opioid epidemic.

The study was led by researchers at the Johns Hopkins Bloomberg School of Public Health in collaboration with the Cabell-Huntington Health Department.

For their study, the researchers surveyed the population of people who inject drugs to understand their drug use and needs for essential public health services, including drug treatment and overdose prevention resources. Using these data, the study team was able to quantify the size and characteristics of the population of people who inject drugs. The study also found that most people who inject drugs in the county are white (83.4 percent), male (59.5 percent) and under age 40 (70.9 percent). Many reported injecting heroin (82.0 percent), crystal methamphetamine (71.0 percent) and fentanyl (56.3 percent) in the past six months.

"By understanding the size and characteristics of the populations in need, rural communities can tailor response strategies and begin turning the tide on the opioid crisis," says lead researcher Sean Allen, DrPH, assistant scientist in the Bloomberg School's Department of Health, Behavior and Society. "This research demonstrates that rural communities can leverage innovative population-estimation methods to better understand population-level needs for services among people who inject drugs," adds Allen.

Home to Huntington, W.Va., Cabell County has been particularly hard hit by the opioid epidemic; it saw 1,831 overdoses in 2017, and 152 were fatal.

This new data will allow public health officials, particularly those in rural areas, to appropriately scale their services, the researchers say. Michael Kilkenny, MD, physician director of the Cabell-Huntington Health Department, was the health department study lead. The Department has a comprehensive harm-reduction program that provides overdose prevention resources, drug treatment referrals and sterile injection equipment.

US doctors who receive direct payments from opioid manufacturers tend to prescribe more opioids than doctors who receive no such payments, according to new research published by Addiction. The report found that the association between payments and prescribing is strongest for hydrocodone and oxycodone, the most frequently prescribed opioids among Medicare patients (Americans of 65+ years and some younger people with disabilities). The Medicare population is estimated to have the highest and fastest growing prevalence of opioid use disorder in the US. (1)

Pharmaceutical companies can't pay doctors to prescribe their drugs; that sort of incentive is illegal. But they can pay doctors to talk about their drugs in speaking engagements, and pay for consulting work and conference attendance. They can also send 'detailers' (salespeople) to doctors' offices to promote their drugs, possibly paying for a meal or leaving drug samples behind. These types of incentives may make physicians consciously or unconsciously more inclined to prescribe a particular brand of drug, or prescribe it in greater quantities.

The data on direct payments to physicians came from the Open Payments website, which publishes data reported under the Physician Payments Sunshine Act (PPSA), the US healthcare law that requires medical product manufacturers to disclose payments and other transfers of value to physicians. The data on opioid prescriptions came from the Medicare Part D Prescriber Public Use File, which holds data on prescriptions provided to and filled by Medicare beneficiaries. Both datasets are available on data.cms.gov, a website maintained by the Centres for Medicare and Medicaid Services (CMS).

The study, led by Dr. Thuy Nguyen of Indiana University's School of Public and Environmental Affairs, looked at the prescribing practices of 63,062 US physicians who directly received opioid-related promotional payments, compared with over 802,000 physicians who received no such payments. From 2014 to 2016, the doctors who received payments prescribed, on average, over 13,070 daily doses of opioids per year more than their unpaid colleagues.

Lead researcher Dr. Nguyen states, "Our work supports earlier research on the pharma-physician relationship with respect to opioid prescriptions and offers more comprehensive evidence on the role of opioid-related promotional activities, including how prescribing may be affected by the extent and intensity of payments. Put simply, drug-related payments to physicians seem to increase drug prescriptions, and higher payments seem to increase them more."

As this is an observational study, the findings reveal associations between opioid manufacturer payments and the volume of opioid prescriptions by individual physicians that may not be causal. However, the associations remain after adjusting for a range of physician characteristics, local sociodemographic predictors, and state opioid control policies.

New research indicates that cancer survivors carry greater financial burdens related to medical debt payments and bills compared with individuals without a cancer history, with the greatest hardships in younger survivors. Published early online in CANCER, a peer-reviewed journal of the American Cancer Society, the study also found that among privately insured survivors, those who enrolled in high deductible health plans and did not have health savings accounts were particularly vulnerable to medical financial hardship.

Medical financial hardship can encompass three domains: material (such as problems paying medical bills); psychological (for example, worrying about paying medical bills); and behavioral (which might include forgoing or delaying care because of cost).

To examine these multiple domains of medical financial hardship in adults with and without a cancer history, Zhiyuan Zheng, PhD, of the American Cancer Society, and his colleagues analyzed information from the 2013 to 2016 National Health Interview Survey. The study included nationally representative samples of 10,354 cancer survivors and 124,436 individuals without a cancer history.

Compared with those without a cancer history, cancer survivors were more likely to report any material hardship (ages 18 to 49: 43.4 percent versus 30.1 percent; ages 50 to 64: 32.8 percent versus 27.8 percent; ages 65 and older: 17.3 percent versus 14.7 percent), psychological hardship (ages 18 to 49: 53.5 percent versus 47.1 percent, with similar rates for older groups), and behavioral hardship (ages 18 to 49: 30.6 percent versus 21.8 percent; ages 50 to 64: 27.2 percent versus 23.4 percent, with similar rates for ages 65 and older).

Among privately insured survivors, having a high deductible health plan without a health savings account was associated with greater hardship compared with low deductible insurance. This finding may have important policy implications.

"Identifying patients with medical financial hardship will be important for primary care and oncology care providers," said Dr. Zheng. "Developing and evaluating interventions to minimize medical financial hardship will be important for the research community. It may also require attention from health policy makers."

Dr. Zheng noted that younger cancer survivors--those aged 18 to 49 years--experienced greater financial hardship than their older counterparts. "It may be that they do not have the opportunity to accumulate financial assets to pay for medical expenses. In addition, a cancer diagnosis might interrupt employment, and consequently limit access to employer-sponsored health insurance coverage," he explained. "Although we could not identify the underlying reasons for greater hardship intensity in the younger group in this study, we believe it will be an important area for additional research."

Researchers have identified a cellular response to repeated concussions that may contribute to seizures in mice like those observed following traumatic brain injury in humans. The study, published in JNeurosci, establishes a new animal model that could help improve our understanding of post-traumatic epilepsy.

Stefanie Robel, Oleksii Shandra and colleagues induced mild traumatic brain injury in mice to mimic blows to the head that result in human concussions. A unique population of astrocytes responded to these injuries and the researchers observed spontaneous recurrent seizures in some mice within one month. These results highlight the role of astrocytes in the development of epilepsy following the most common type of traumatic brain injury in humans.

A new paper published in Pediatrics links successful implementation of Baby-Friendly™ practices in the southern U.S. with increases in breastfeeding rates and improved, evidence-based care. The changes were especially positive for African-American women.

Between 2014 and 2017, 33 hospitals enrolled into the CHAMPS (Communities and Hospitals Advancing Maternity Practices) program out of Boston Medical Center's Center for Health Equity, Education and Research, funded by the W. K. Kellogg Foundation. All birthing hospitals in Greater New Orleans, and 18 in Mississippi, signed up. Breastfeeding initiation at CHAMPS hospitals rose from 66 percent to 75 percent, and, among African Americans, from 43 percent to 63 percent, over the 3 years. The gap between White and Black breastfeeding rates decreased by 9.6 percent.

"U.S. breastfeeding rates differ by race," says Anne Merewood, PhD MPH, a Boston Medical Center researcher and the lead author on the study. "This is the first study that links better compliance with the WHO's Ten Steps to Successful Breastfeeding to lower racial inequities across a large number of hospitals."

Lakendrea Bush gave birth to her first daughter, Aubreigh, at Baptist Memorial Hospital, North Mississippi, on December 7th, 2018. The hospital is part of the CHAMPS program and working on improved maternal infant care.

"It was a wonderful blessing, a humbling and beautiful experience," says Lakendrea. "We had skin to skin for a whole hour after birth. Some hospitals take the baby away, but not this one," she said. "I cried. I gave her her first feed. It was my first child, and she was looking at me, and me at her. My husband was coaching me along. It was almost surreal."

Merewood, an associate professor of pediatrics at Boston University School of Medicine, says the fresh look at maternity care has led to the end of many outdated hospital policies and practices across the state. "We had hospitals routinely separating mothers and babies for 7 or more hours after birth; hospitals giving all babies glucose water, and some hospitals still breast-binding, even though the evidence against breast binding was pretty much settled in the 1960's. A lot of these practices were only being done because they'd 'always been done', and have now been discontinued."

Lakendrea also loved the hospital's 'rooming in' policy, which keeps mothers and babies together. "I really wanted my baby with me. I didn't want them to take her away. I'm breastfeeding as well, so it really helped to have her there." Lakendrea had some early challenges with breastfeeding but one month on says it's now going well. "It was difficult sometimes, but you know the baby's getting the best food, so everything else goes out of the window really," she said.

CHAMPS received new funds from the W. K. Kellogg Foundation and the Bower Foundation in 2017 to continue the work. Now, 38 of 42 Mississippi birthing hospitals are working with CHAMPS and 8 Mississippi hospitals are Baby-Friendly, up from zero in 2014. In December 2018, the Bower Foundation gave CHAMPS a new, 3-year grant to help continue the program in designated hospitals, with a focus on sustaining evidence based maternity practices in Mississippi, and making Baby-Friendly policies the norm.

As for Lakendrea, she says, "I really, really loved the experience. I'm already getting ready to have another baby!"

PROVIDENCE, R.I. [Brown University] -- Fentanyl is a synthetic opioid so potent that a miniscule amount equivalent to several grains of saltcan cause afataloverdose. Yet it's difficult for people who use drugs to detect, which presents a major public health hazard given how commonly fentanyl is used to lace heroin or cocaine.

In 2017, a team of researchers led by Brandon Marshall, an associate professor of epidemiology at Brown University's School of Public Health, provided rapid-acting fentanyl test strips to young adults in Rhode Island at risk of overdosing. In October 2018, the researchers reported that most of the young adults not only used the strips, but also reported changing their behavior to reduce overdose risk if they detected fentanyl.

The research team has now analyzed the results from in-depth interviews with the same study participants to learn more about their reasons for using or not using the fentanyl test strips. The new findings were published on Jan. 8 in Harm Reduction Journal.

"Qualitative interviews allow us to explore the thoughts and feelings of our research participants," said Jacqueline Goldman, an epidemiology master's student and first author on the study. "When researching the fentanyl test strips, we wanted to understand why participants did or did not use them. We used these interviews to examine the complex opinions and motivations that our participants experienced."

During the first stage of the study, each participant received 10 fentanyl test strips, which work like an over-the-counter pregnancy test. A single-use strip is dipped into water containing a bit of drug residue (before drug use) or urine (after drug use) and either one or two red lines quickly appear -- one line means the liquid contains fentanyl, and two lines means the test did not detect the drug. The strips cost about $1 each and are beginning to be distributed by harm reduction organizations in the United States.

All participants also received overdose prevention education and a naloxone kit -- which can rapidly reverse an opioid overdose -- to take home. Two to four weeks later, 81 of the original 93 participants returned and completed a brief survey and a 10- to 20-minute-long interview in which trained research assistants asked numerous open-ended questions.

The questions probed each participant's use of the test strips and any challenges they faced using them. Among other questions, the researchers asked: "Did you use any of the tests?" and "Is there anything that would make it easier to use the test?" The research team identified five key themes from the participant interviews:

(1) Participants used the fentanyl test strips as a tool to test suspicious drug supplies.

Generally, the participants found the test strips easy to use and said they were especially valuable for testing drugs from sources they did not trust.

A 23-year-old male participant said: "I contacted a local dealer of mine that I had gone to in the past... I was like questionable of his product, so I told him that I had these strips and that I was going to test, to test his stuff for fentanyl to see if it was good or not and showed him the positive result... With those tests, I was able to do that with a couple other dealers between now and then to root out my chances of getting a tainted product."

(2) Testing drug reside was more convenient than testing urine.

The first 40 participants were instructed to use the strips to test their urine after drug use. Then a study from the Johns Hopkins Bloomberg School of Public Health found that the test strips were effective at off-label testing of drug residue from bags, spoons or crushed pills dissolved in water. The participants enrolled in Brown's study after these findings were reported were trained to test their drug residue before using. Interviews found the participants from the first group expressed an interest in being able to test their drugs before using them.

"If there was a like test strip you know that you could mix a bit of your heroin, or what you think is heroin in water and dip the strip in it, and something like that... to be able to test it before you use it... Afterwards it could be too late, you know," said a 22-year-old male participant from the first group.

(3) Participants gave test strips to friends, family members and acquaintances they perceived as having a high overdose risk.

Nearly half of the participants reported giving fentanyl test strips to friends, family members and acquaintances in the previously published survey results. The researchers found the participants tended to give the strips to people they perceived as having a higher risk of using a drug contaminated with fentanyl.

"They were not just close friends, but a couple of people I met at the [methadone]clinic and stuff, and they actually were people who really want to know if the fentanyl is actually in the drugs they are using, and they actually use a little bit more than I do. On a daily basis they still use, so I felt like it was very important to have," a 28-year-old female participant said.

(4) Participants preferred testing their drugs in private, due to perceived stigma or legal concerns.

Though the participants found the test strips easy to use, they preferred to use them at home rather than go to a local health organization to get their drugs tested -- a common service offered at supervised injection facilities in Canada and parts of Europe. Their concerns were two-fold: being judged or facing legal ramifications.

"Just because it's more private, it's in my house, I wouldn't have to risk getting caught by the police bringing it somewhere. I would just, I don't know, I would never bring it somewhere to get it tested honestly, never," a 25-year-old female participant said.

(5) The presence of fentanyl led to self-reported behavior changes.

In the previously published survey results, 45 percent of participants who detected fentanyl using the test strips reported using smaller amounts, 42 percent proceeded more slowly when using, and 39 percent used with someone else present. The qualitative interviews found similar changes in behavior to reduce the risk of an overdose.

"A friend of mine was shooting up and before they did that I said let me test it, so I grabbed the cap after they used it and I tested it, and it was positive for fentanyl. And they asked me what exactly fentanyl does, and I said it's way stronger than your heroin and it has the potential to kill you with a drop. And they were like 'what am I supposed to do' I said, honestly, you shouldn't take that, but I know you're going to, so take it in portions... instead of putting the whole .4 to the face, they would do .1 at a time, and, you know, with a little bit of time in between... each one," a 21-year-old male participant said.

Another participant talked her cousin into disposing of a significant amount of fentanyl-contaminated heroin.

"I used one for myself, and then, the other nine I gave to my cousin who is a drug dealer... and I told him to give me nine samples of his dope, and I followed the video that I watched... And out of the nine that came back, seven were positive for fentanyl. So, I told him, you either have seven murder charges on your record, and you have the rest of your life in prison, you don't get to see your kids get married, graduate. Kinda give him a little guilt trip on it, but I convinced him to flush it. He had almost $2,000 worth of fentanyl-laced heroin and he got rid of it," the 26-year-old female participant said.

The researchers said that the interviews support other studies indicating that fentanyl test strips are a feasible and acceptable tool to reduce the harm of fentanyl overdoses.

"These results further underscore the benefits of fentanyl testing programs to reduce the risk of overdose from drugs contaminated with fentanyl," Marshall said. "We are grateful to our study participants for sharing their perspectives on fentanyl test strips, which were overwhelmingly positive."

Checking for minimal residual disease early in treatment can help some young high-risk leukemia patients avoid bone marrow transplantation without compromising their long-term survival A St. Jude Children's Research Hospital investigator led the international retrospective analysis that appears today in the Journal of Clinical Oncology.

The study involved children and adolescents with hypodiploid acute lymphoblastic leukemia (ALL). This high-risk subtype accounts for about 2 percent of pediatric ALL cases. It is characterized by a poor prognosis and leukemic cells with 25 to 44 chromosomes rather than the usual 46.

The historically poor prognosis has prompted many leukemia specialists to advocate for treating these patients with intensive chemotherapy followed by allogeneic bone marrow transplantation. Transplantation, however, carries its own short- and long-term health risks.

The largest study yet of children and adolescents with hypodiploid ALL found that transplantation did not significantly improve survival compared to chemotherapy alone. However, contemporary risk-directed therapy--with dose intensity based on early treatment response determined by measuring minimal residual disease levels in bone marrow following remission induction chemotherapy--was more closely associated with better patient outcomes.

Response and survival

"This study confirms our earlier observation that patients with hypodiploid ALL who have no evidence of minimal residual disease after remission induction therapy should not be transplanted," said first and corresponding author Ching-Hon Pui, M.D., chair of the St. Jude Department of Oncology. "We recommend continued treatment with intensive chemotherapy."

Remission induction therapy encompasses the first four to six weeks of chemotherapy. Minimal residual disease (MRD) negative patients are defined as having fewer than 1 leukemic cell in 10,000 white blood cells in bone marrow.

Overall, 58 percent of patients in the study became long-term survivors. Disease-free, long-term survival rates were 75 percent for the 87 patients who were MRD negative after remission-induction chemotherapy. Survival rates were similar, 74 percent, for hypodiploid patients with 44 rather than fewer chromosomes.

Transplantation and survival

The study included data from 306 hypodiploid ALL patients who were enrolled on 16 different protocols of national study groups or major institutions between 1997 and 2013.

Questions remain about how to improve outcomes for patients with fewer than 44 chromosomes with minimal residual disease following induction therapy.

This analysis found that compared to intensive chemotherapy alone, transplantation did not provide a significant survival advantage for patients with fewer than 44 chromosomes. Adjusted five-year overall survival was 57.7 percent for the 186 patients treated with chemotherapy alone versus 68.9 percent for the 42 patients treated with both chemotherapy and bone marrow transplantation. Pui said the difference was not significant, particularly considering the long-term health risks, including second cancers, associated with transplant-related radiation. He said additional studies are warranted for treating hypodiploid ALL with immuno- or cellular therapies, which do not involve radiation.

Precision medicine

Researchers said the growth of precision medicines holds promise for improved outcomes for patients with hypodiploid ALL and other high-risk subtypes. The list of promising possible treatments includes chimeric antigen receptor-modified T cells, genetically modified antibodies and inhibitors targeting cell signaling pathways that drive proliferation.

The study included 17 co-authors from 17 medical centers and research institutions in Europe, Asia and Israel.

The research was funded in part by grants (CA21765, CA36401, CA176063, GM92666) from the National Institutes of Health, and ALSAC, the fundraising and awareness organization of St. Jude.

ANN ARBOR, Mich.- Sleeping more than nine hours per night during pregnancy may be associated with late stillbirth, a new Michigan Medicine-led international study suggests.

Researchers analyzed online surveys involving 153 women who had experienced a late stillbirth (on or after 28 weeks of pregnancy) within the previous month and 480 women with an ongoing third-trimester pregnancy or who had recently delivered a live born baby during the same period.

The findings, which appear in journal Birth, suggest an association between lengthy periods of undisturbed maternal sleep and stillbirths that were independent of other risk factors. But researchers caution that further research is needed to better understand the relationship and what it means for pregnant women.

"Pregnant women often report waking up and getting up in the middle of the night," says lead author Louise O'Brien, Ph.D., M.S., a University of Michigan researcher in the Division of Sleep Medicine, Department of Neurology and the Department of Obstetrics and Gynecology at Michigan Medicine.

"While multiple awakenings during the night may concern some women, in the context of stillbirth it appears to be protective."

O'Brien says further studies need to delve deeper into what may drive the relationship between maternal sleep and stillbirths, with particular focus on how the autonomic nervous system - the control system that regulates bodily function - and the hormonal system are regulated during sleep in late pregnancy.

She notes that blood pressure reaches its lowest point during sleep but when someone is awakened, there is a surge in the nervous system activity that causes transient increases in blood pressure. It's possible that these brief increases in blood pressure are able to prevent long periods of relatively low pressure. This is important, O'Brien says, because low blood pressure has been linked with fetal growth problems, preterm birth, and stillbirth.

O'Brien also cautions that "pregnant women should not be waking themselves up at night." Very disruptive sleep has also been associated with poor pregnancy outcomes, including growth restriction and preterm growth.

She notes that while there is already evidence that very disrupted sleep and clinical sleep disorders are associated with poor pregnancy outcomes, few studies have looked at the opposite end of the spectrum, such as long periods of undisturbed sleep

"Our findings add to research indicating that maternal sleep plays a role in fetal wellbeing," she says. "Studies aiming to reduce stillbirths should consider maternal sleep as this is a potentially modifiable risk factor. Understanding the role of maternal sleep may help us identify interventions that would put us in a better position to advise women."

Stillbirth effects about 1 in 160 pregnancies in the U.S., with about 24,000 babies stillborn in the country every year - 10 times as many deaths that occur from Sudden Infant Death Syndrome (SIDS). About half of all stillbirths happen after 28 weeks of pregnancy and many remain unexplained.

Rates are even worse in low income countries but the stillbirth rate in the U.S. is still higher than in many other Western countries

Smoking, advanced maternal age, diabetes, obesity and drug abuse are among well-established risk factors for stillbirths. Maternal sleep practices, however, cover a relatively new area of investigation.

The new study follows other research looking at possible ties between maternal sleep and fetal wellbeing in recent years, including studies suggesting that women who report that they sleep on their backs have an increased risk of stillbirths. While the current study asked about maternal sleep position, not enough women reported sleeping on their backs for any meaningful analysis.

"Maternal sleep has been overlooked as a potential area for maternal and newborn health interventions even though it is related to many of the major, well-established risk factors for poor pregnancy outcomes. Until recently, it hasn't been on the radar for stillbirth research," O'Brien says.

"Many risk factors for stillbirths are not able to be modified once pregnancy has begun. But we should be looking at every possible intervention that may prevent poor outcomes. Progress in reducing stillbirth deaths has been slow but stillbirth is an urgent global health issue that should be at the center of more research programs."

Despite recommendations first issued more than a decade ago, antibiotics are still routinely prescribed in U.S. emergency rooms for infants with bronchiolitis, a common viral lung infection. Published in the Journal of the Pediatric Infectious Diseases Society, the findings highlight a concerning lag in translating evidence-based guidelines into clinical practice and underscore the need to continue educating health care providers and the public about appropriate antibiotic use.

Bronchiolitis develops when the lung's small airways, or bronchioles, become inflamed and congested, usually because of a viral infection, for which antibiotics offer no benefit. The illness is the leading cause of hospitalizations for U.S. children in their first year of life. In 2006, guidelines from the American Academy of Pediatrics recommended against antibiotic treatment for bronchiolitis in children without a documented bacterial infection.

In the new study, researchers analyzed data from a nationally representative survey of U.S. emergency room visits conducted annually by the Centers for Disease Control and Prevention. Between 2007 and 2015, approximately 25 percent of children under the age of 2 with bronchiolitis who were seen in an emergency room received antibiotics, the analysis found, suggesting minimal improvement in antibiotic prescribing compared to previous years. There were no significant changes over time in antibiotic prescription rates during the nine years after the guidelines were published. Among the patients who received antibiotics, 70 percent had no documented bacterial infection, for which an antibiotic may have been an appropriate treatment.

Antibiotics, like all medications, are not harmless and may cause side effects, including allergic reactions and adverse events. A previous study found that side effects from antibiotics result in approximately 70,000 emergency room visits among U.S. children each year. Overusing or misusing antibiotics also contributes to the development of antibiotic-resistant bacteria, which can cause drug-resistant, and harder-to-treat, infections, a growing threat to public health in the U.S. and around the world.

"Targeted interventions to reduce inappropriate prescribing among clinicians are essential," said Brett Burstein, MD, PhD, MPH, of the Montreal Children's Hospital and the Research Institute of the McGill University Health Centre in Montreal, Quebec, Canada, and senior author of the latest study. "But at the same time, informing the lay public about the potential downstream consequences and why it is important not to over-treat viral conditions are equally important."

The new analysis also found that increased antibiotic prescribing for children with bronchiolitis was associated with receiving treatment in hospitals that were not teaching hospitals or pediatric hospitals. The findings suggest that these types of facilities may benefit the most from efforts to more effectively translate guidelines for appropriate bronchiolitis treatment into changes in actual clinical practice, the study authors noted.

Fast Facts

Bronchiolitis is a common lung infection in young children, usually caused by a virus, in which the lung's small airways, or bronchioles, become inflamed and congested.

Antibiotics continue to be routinely prescribed in U.S. emergency rooms for infants with bronchiolitis, despite guidelines issued in 2006 that recommend against doing so.

From 2007 to 2015, one-fourth of children under age 2 with bronchiolitis who were seen in U.S. emergency rooms received antibiotics, among whom 70 percent had no documented bacterial infections, suggesting little improvement in antibiotic prescribing compared to previous years.

GRAND RAPIDS, Mich. (Jan. 17, 2019) -- A new approach to pancreatic cancer screening may help doctors detect the disease in people at high risk before it reaches more advanced and difficult-to treat stages.

A team led by Van Andel Research Institute (VARI) scientists has developed a new, simple blood test that, when combined with an existing test, detects nearly 70 percent of pancreatic cancers with a less than 5 percent false-positive rate. The results of the blinded study were published in Clinical Cancer Research, a journal of the American Association for Cancer Research.

Pancreatic cancer is difficult to diagnose because it often doesn't have obvious early symptoms. By the time the disease is found, it typically is quite advanced, complicating treatment and leading to poorer outcomes. Only 8.5 percent of people with pancreatic cancer survive past five years, a figure that has risen just slightly since the early 1990s.

"Pancreatic cancer is an aggressive disease made even more devastating by its tendency to spread before detection, which is a serious roadblock to successful medical treatment," said Brian Haab, Ph.D., a VARI professor and the study's senior author. "We hope that our new test, when used in conjunction with the currently available test, will help doctors catch and treat pancreatic cancer in high-risk individuals before the disease has spread."

Both tests detect and measure levels of sugars produced by pancreatic cancer cells that subsequently escape into the blood stream. The sugar measured by the new test -- sTRA -- is produced by a different subset of pancreatic cancers than CA-19-9, the sugar measured by the existing test. When used together, the tests cast a broader net and detect subtypes of pancreatic cancer that may have been missed by using one of the two tests on its own.

The CA-19-9 test was developed almost 40 years ago and detects only about 40 percent of pancreatic cancers. It currently is used to confirm diagnosis of pancreatic cancer or track disease progression rather than screen for the disease. The improved detection rate offered by the combined use of the sTRA and CA-19-9 tests makes this approach a viable option for screening and early intervention, particularly in people who have a higher risk for developing the disease. This includes people who have a family history of pancreatic cancer, who have had pancreatic cysts or chronic pancreatitis, or who were diagnosed with type 2 diabetes later in life. Emerging evidence has suggested that sudden onset of diabetes after age 50 could be an early symptom of some pancreatic cancers. Currently, life-long diabetes is not considered to be a risk factor for or indicator of pancreatic cancer.

"We believe using these tests in a complementary fashion will help physicians detect pancreatic cancers much sooner in the disease process, which significantly improves a patient's chance for survival," Haab said. "Right now, there are few options for people suspected to have pancreatic cancer. This combined blood test could be a simple, cost-effective way to detect disease early enough to improve patient outcomes."

Haab and his collaborators plan to partner with clinical laboratories to gain additional real-world validation for their method. If successful as expected, they envision the test becoming widely available as a screening tool for high-risk individuals.

NEW HYDE PARK, NY - Using ultraviolet (UV) disinfection technology to reduce the risk of hospital-acquired infections eliminated up to 97.7 percent of pathogens in operating rooms (ORs), according to a study published in the American Journal of Infection Control.

The study examined a UV light technology platform deployed by New York-based PurpleSun that can be used for a range of disinfection applications for ORs, patient rooms and other health care settings. Unlike other disinfecting tools, which includes chemicals that can take minutes to inactivate pathogens and at times can leave bacteria on surfaces due to human and product error, PurpleSun reaches multiple surfaces in seconds with UV light. The study found that it all but eliminates human and product error in the proliferation pathogens that can contribute to the spread of pathogens that contribute to infection.

PurpleSun's focused multivactor ultraviolet (FMUV) device can be deployed to surround equipment on all sides, with foldable partitions whose light hits five different surface points and uses higher levels of UV intensity in 90-second intervals. More than 3,000.microbiological samples following 100 different surgical cases were taken in and around the ORs at three different hospitals in the New York metropolitan area. The observational study is believed to be the first to use five-point multisided sampling in testing the effect of UV disinfection technology.

"Ultraviolet light technology will not replace manual cleaning and disinfection with chemicals, but it is has a place in health care settings. This technology can optimize environmental cleanliness, resulting in decreased pathogens that could potentially cause infection," said Donna Armellino, RN, DNP, vice president of infection prevention at Northwell Health and lead author of the study, called: "Assessment of focused multivector ultraviolet disinfection with shadowless delivery, using five-point multisided sampling of patient care equipment without manual-chemical disinfection."

Dr. Armellino says the intent of the study was to determine if UV technology reduces environmental pathogens for the purpose of making health care facilities safer and improving the patient experience.