Body

Philadelphia, December 6, 2018 - In a web-based study reported in the Canadian Journal of Cardiology, more than three quarters of French-speaking adults in Quebec, Canada, fall short of meeting current dietary guidelines regarding consumption of fruits and vegetables, whole grains, sodium, and saturated fats. The authors recommend stronger, more impactful actions to support everyone in adopting healthier dietary habits to reduce the risk of chronic diseases such as heart disease, diabetes, and cancer. While these observations relate specifically to the population analyzed, similar findings might apply to many other jurisdictions internationally if studied.

Unhealthy dietary habits have been identified as the second leading risk factor for mortality globally. "Despite years of efforts and campaigns aimed at having people consume more vegetables and fruits, low consumption of these healthy foods remains a major public health concern in the province of Quebec," explained lead investigator Benoît Lamarche, PhD, Chair of Nutrition from the School of Nutrition and Institute of Nutrition and Functional Foods, Université Laval, Quebec, Canada. "Regular monitoring of the population's food and nutrient intake is essential to develop effective nutrition-focused public health policies."

In this study, Dr. Lamarche and colleagues report results from data collected as part of the PRÉDicteurs Individuels, Sociaux et Environnementaux (PREDISE) survey, a web-based analysis designed to assess the association between individual, social, and environmental factors, and adherence to current dietary guidelines in Canada. PREDISE was a multicenter cross-sectional study involving five research centers in five administrative regions in the province of Quebec. The aim of this study was to provide dietary intake estimates using an age- and sex-representative sample of French-speaking adults with Internet access from these regions. Dietary intake was estimated from the average of three validated web-based 24-hour recalls collected from 1,147 participants, over half of whom were woman.

Less than 25 percent of participants met Canada's Food Guide recommendations for vegetable and fruit intake. Most participants reported consuming more than 2300 mg of sodium (prevalence 81 percent) and more than 10 percent of energy as saturated fats (74 percent). The mean Canadian Healthy Eating Index score on a scale of 0-100 was 54.5, reflecting poor diet quality according to current dietary recommendations.

"Comparison of these diet quality scores with scores measured in 2004 suggested no improvement, despite numerous efforts and campaigns to promote healthy eating over the years," observed Dr. Lamarche. "Subgroups with a lower socioeconomic status are particularly at risk of having a low quality diet.

"These data emphasize the need for more effective nutrition-focused public health policies to maximize cardiovascular disease prevention at the population level," he concluded. "This implies not only the need for nutrition education, but also a profound modification of the 'toxic' food environment to which the population is exposed."

In an accompanying editorial, James M. Brophy, MD, PhD, of the McGill University Health Center, Centre for Health Outcomes Research, Montreal, Quebec, Canada, observed, "The authors' conclusions about the need for more effective nutrition-focused public health policies to maximize cardiovascular disease prevention at the population level are very reasonable. The ultimate goal is not merely to enhance awareness/adherence of constantly evolving food guidelines, but to avoid further marginalization of the most deprived of our society by providing them with the educational and economic means to overcome existing nutritional barriers."

Providing supervised access to medical-grade heroin to people whose use continues after trying multiple traditional treatments has been successful in other countries, and should be piloted and studied in the United States, according to a new RAND Corporation study.

Evidence from other nations suggests that prescribing heroin to be injected under medical observation -- with optional take-home methadone -- can offer benefits over methadone alone for those who have repeatedly tried traditional treatments for heroin use disorder, including methadone, but still inject heroin, according to the analysis. This approach often is referred to as heroin-assisted treatment.

While the researchers say that the top priority is increasing access to traditional FDA-approved medications like methadone and buprenorphine, the severity of the opioid crisis provides urgency to evaluate other tools that might reduce its impact and save lives.

"Given the increasing number of deaths associated with fentanyl and successful use of heroin-assisted treatment abroad, the U.S. should pilot and study this approach in some cities," said Beau Kilmer, leader of the project and co-director of the RAND Drug Policy Research Center. "This is not a silver bullet or first-line treatment. But there is evidence that it helps stabilize the lives of some people who use heroin."

Researchers found studies from multiple countries suggesting that the approach can be more cost-beneficial than continuing to offer only methadone to those who have not responded well to methadone, notably because it is more effective at reducing criminal activity.

Opioid use disorders affect an estimated 9 out of every 1,000 Americans and opioid overdose-related deaths have quadrupled over the past 15 years. More than 49,000 people died from opioid-involved overdoses in the U.S. in 2017.

The RAND findings appear in five related RAND publications and are based upon one of the most-exhaustive analyses to date of the experiences in other parts of the world with two interventions that are implemented in some other countries, but not in the United States: heroin-assisted treatment and supervised consumption sites.

Supervised consumption sites, sometimes called drug consumption rooms or safe injection facilities, are places where individuals can consume already-purchased street drugs using sterile injection supplies in the presence of trained staff who monitor for overdose or risky injection practices, intervening when necessary. Some supervised consumption sites also provide additional services, such as referrals to treatment and access to drug content testing.

To assess the effectiveness of heroin-assisted treatment and supervised consumption sites, RAND researchers reviewed the high-quality scientific evidence and talked to more than two dozen stakeholders in Canada, the Netherlands, Switzerland and the United Kingdom to learn about their experiences with the approaches.

They also spoke to more than 150 people in New Hampshire and Ohio -- including policy professionals, frontline service providers and people who use heroin or other opioids -- to examine interest in the two approaches and perceived barriers. The two states have been hit hard by the U.S. opioid epidemic.

While the researchers found there were published clinical trials that support the benefits of heroin-assisted treatment, the full range of benefits of supervised consumption sites were not as well documented. The effects on consumption within a supervised consumption site are directly observed, but scientific evidence about the claimed and anticipated spill-over effects on behavior outside the facility's walls is limited both in quality and in the number of locations evaluated.

Although the RAND study found that supervised consumption sites can reduce the risk of a fatal overdose, disease transmission and other harms associated with unhygienic drug use practices, there is uncertainty about the magnitude of population-level effects of the strategy. Yet many such programs have been around for 15 to 30 years and have survived multiple changes in local and national governments.

"Persistence does not imply effectiveness, but it seems unlikely that supervised consumption sites -- which were initially controversial in many places -- would have such longevity if they had serious adverse consequences for their clients or communities," Kilmer said.

In the U.S., there are significant legal issues surrounding the implementation of supervised consumption sites. Interviews with international stakeholders also found that there often was vocal opposition to supervised consumption sites when initially discussed or opened. This opposition primarily revolved around concerns about enabling drug use and potential negative community effects. However, that resistance tended to dissipate over time.

The researchers suggest that it may be constructive to view heroin-assisted treatment and supervised consumption sites as exemplars of broader strategies, not as the only option within their class.

For example, supervised consumption sites currently supervise a very small proportion of all injection sessions even in cities where they are well established. Canadian cities recently have expanded the scale of supervised consumption by deploying smaller overdose prevention sites that typically offer fewer services than formal supervised consumption sites.

"It may even be worth asking whether the benefits of supervised consumption sites depend on there being a physical brick-and-mortar site, which may become a lightning rod for opposition, or if the key is just that consumption is supervised and whether there are other ways to get more opioid consumption supervised," said Jonathan P. Caulkins, a report co-author and a professor of public policy at Carnegie Mellon University.

Caulkins said it also is possible that supervised injection of hydromorphone -- a prescription opioid medication -- may achieve similar benefits as offering supervised injectable heroin for those with heroin use disorder, but with fewer regulatory barriers.

While heroin cannot now be prescribed in the United States because it is a Schedule I drug, it would be legal under federal law to conduct randomized controlled trials with the drug, according to the study. Hydromorphone is classified as a Schedule II drug and is currently prescribed for pain.

As Catholic health care systems expand nationwide, little is known about the reproductive outcomes of their patients compared to patients in other settings, according to researchers at the University of Colorado Anschutz Medical Campus.

"What we were essentially looking at is how religious guidelines that restrict reproductive care at Catholic facilities impact patient care," said the study's senior author Maryam Guiahi, MD, associate professor of Obstetrics and Gynecology at the University of Colorado School of Medicine.

The study was published today in the journal Obstetrics & Gynecology.

Researchers identified only 27 studies that described the provision of reproductive health services at Catholic health care facilities and found just one with reported patient outcomes. At the same time, they discovered a number of restrictions to care compared to non-Catholic settings.

In 2016, 14.5 percent of U.S. hospitals were Catholic-owned, accounting for one in six acute hospital beds. And 349 of the 654 Catholic hospitals had obstetric services, accounting for more than 529,000 deliveries.

Yet providers at these facilities are expected to adhere to the Ethical and Religious Directives for Catholic Health Care Services. These directives stress the sanctity of marriage between a man and a woman, allude to the moral imperative that intercourse involves both `love-giving' and `life-giving' intentions while stating that human life begins at conception, the study said.

"So according to these tenets, family planning methods cannot inhibit the `life-giving' aspect and infertility techniques cannot inhibit the `love-giving' aspect of the marriage or sex act," said Guiahi.

In analyzing the studies found in the review, Guiahi discovered differences in the way reproductive health services were provided in Catholic health care facilities. Often Catholic facilities limited common women's health services like contraception and sterilization.

"Patients may not know that tubal ligations or IUDs (intrauterine devices) are often restricted," she said. "When it comes to birth control, sometimes they are only offered pills, which have a 9 percent typical failure rate over a year and certain facilities may only offer natural family planning as a contraceptive method."

She noted that in many of these facilities, reproductive health care is acceptable solely to treat other medical conditions.

The review found that in most studies participants were primarily physicians and emergency department staff. Some of them reported that Catholic facilities either don't provide or are less likely to provide family-planning methods than non-Catholic facilities. One survey showed that 54.9 percent of Catholic hospitals do not dispense emergency contraception in any cases compared to 42.2 percent of non-Catholic hospitals.

"Some Catholic institution representatives reported there were policies in place that prohibited discussion of emergency contraception with rape victims," the study said. One national survey showed that less than 2 percent of Catholic-affiliated obstetrics and gynecology clinics offered abortion.

But some studies revealed that reproductive services were not completely prohibited in these settings. A 1975 study reported 60 percent of Catholic hospitals offered some form of contraception, most commonly instruction in the rhythm method. A study done between 2014-2016, found 95 percent of Catholic hospitals offered appointments for birth control and many were willing to provide IUDs or tubal ligation appointments.

"As many facilities do not always adhere to the directives, it is unclear to health care consumers how Catholic affiliation might impact the reproductive services they are offered," said Guiahi.

Overall, she said, most studies examined showed limited provision of reproductive health care services, reflecting adherence to the religious directives governing Catholic hospitals.

"We need to understand how institutional restrictions affect patient outcomes," Guiahi said. "We need to know that when women are denied tubal ligation, what percent of them get pregnant again. How are minorities and transgender patients affected when religion plays a role in their health care? These are all questions that require further exploration."

Medical software developed at UCL that overlays tumour information from MRI scans onto ultrasound images can help guide surgeons conducting biopsies and improve prostate cancer detection.

A team of engineers and medical researchers found that the technology enabled surgeons to pick up clinically relevant cancers that were missed when using current visual detection methods. The best approach would be to use both techniques in tandem, according to the findings published today in European Urology.

The software is deployed via a system called SmartTarget®.

The advent of MRI-targeted biopsies, where MRI scans are used to inform surgeons where a tumour lies before they conduct a biopsy (tissue sample), has improved detection rates to close to 90% from 50% in the last five years.

Now, the SmartTarget system has further enhanced this technique by allowing a 3D model of the prostate and cancer to be created for each patient from their MRI scans using advanced image processing and machine learning algorithms.

During a biopsy, this model is fused with ultrasound images to highlight the area of concern, which otherwise does not appear in the ultrasound images, helping to guide the surgeon while conducting the procedure.

Until last year when MRI targeting was introduced, the established way to test for prostate cancer involved taking a biopsy from the prostate without knowing where in the prostate a tumour was likely to be, resulting in close to half of life-threatening cancers being missed.

"Prostate cancer detection has been improving at a very fast rate in recent years, and this technology pushes the science forward even further, enabling clinicians to pick up prostate cancer quickly so that patients can access the right treatment early enough," said co-senior author Professor Hashim Ahmed, who began the research in UCL Medicine before moving to Imperial College London.

For the present study, 129 people with suspected prostate cancer underwent two biopsies - one using the SmartTarget system, and one where surgeons could only visually review the MRI scans. Funded by the UK Department of Health and Social Care and Wellcome Health Innovation Challenge Fund, the study was conducted at UCLH.
The two strategies combined detected 93 clinically significant prostate cancers, with each of them picking up 80 of these cancers; each missed 13 that the other method picked up.

The researchers say that surgeons' visual review of MRI scans should be used in tandem with SmartTarget as using this technique enables surgeons to learn to make subtle adjustments such as adapting to the movement of the patient and the prostate as the needle is inserted.

"We developed the SmartTarget system to equip surgeons with vital information about the size, shape and location of prostate tumours during a biopsy that is otherwise invisible on ultrasound images," explained co-senior author Dr Dean Barratt (UCL Medical Physics & Biomedical Engineering and UCL Centre for Medical Image Computing), who invented and led the development of the SmartTarget system.

"The software provides them with a clear target. As MRI-targeted biopsies require a very high degree of expertise and experience, we hope that the imagery displayed by SmartTarget will help to bring high accuracy prostate cancer diagnosis to a much wider range of patients and hospitals."

The researchers say the new methods could reduce the number of biopsies needed, and reduce the unnecessary surgeries caused by over diagnosis of less harmful cancers.

The SmartTarget software has been commercialised by SmartTarget Ltd, a company spun out by UCL's commercialisation company UCL Business PLC (UCLB), and the system is already in use by several hospitals in the UK and USA.

The inter-disciplinary study brought together engineers, urologists and radiologists, supported by the UCL Translational Research Office in project management and navigating the translational and regulatory pathway involved in taking the project from the lab bench to the operating room.

"There has been much discussion and speculation in the media recently on the degree to which computers and artificial intelligence will be integrated into clinical care. Studies such as this one are extremely important as they provide valuable evidence on the performance of a new technology in the clinical setting," said co-senior author Professor Mark Emberton (Dean, UCL Medical Sciences).

"With this study we now have hard data showing that SmartTarget is as good as a group of experts in targeting tumours in the prostate, and have a glimpse of how clinicians and computers will be working together in the future for the good of the patient."

Stroke patients prescribed a common antidepressant show no improvement compared with those given a dummy drug, a study has found.

Earlier research from France had suggested that taking the drug, called fluoxetine, might reduce disability after stroke.

The latest study found no difference between the improvement in physical ability of stroke patients who took fluoxetine for six months and those who took a placebo - an inactive substitute.

Experts stress that people already taking the drug should not stop without speaking to their doctor first.

Fluoxetine is a common type of antidepressant that includes the branded drugs Prozac and Prozep.

The University of Edinburgh-led study involved more than 3000 stroke patients at over 100 hospitals around the UK.

Half of the participants started taking fluoxetine daily within the first two weeks of their stroke, while the remainder took a placebo.

Those who took fluoxetine were less likely to develop depression, but, there was a small increase in bone fractures reported in this group.

Researchers say their findings do not support the use of fluoxetine to promote recovery after stroke in the UK.

The study, called FOCUS, is published in The Lancet and was funded by the Stroke Association and the National Institute for Health Research (NIHR). The findings are being announced at the UK Stroke Forum annual conference in Telford, UK.

Co-chief investigator Professor Gillian Mead, of the University of Edinburgh's Centre for Clinical Brain Sciences, said: "FOCUS has shown that there is no benefit in the routine prescription of fluoxetine to improve recovery after a stroke, contrary to the promising results of smaller trials.

"There are other reasons a patient may be prescribed fluoxetine and we do not recommend that people change their treatment regimen without first consulting with their doctor."

New Rochelle, NY, December 5, 2018--An examination of data from a multi-center case-control study of ovarian cancer in African American women found that women who reported higher levels of religiosity/spirituality had increased odds of stage III-IV ovarian cancer at diagnosis. Agreement with cultural/folk belief statements related to cancer was not associated with cancer stage at diagnosis. The full study findings are described in an article published in Journal of Women's Health, a peer-reviewed publication from Mary Ann Liebert, Inc., publishers. Click here to read the full-text article free on the Journal of Women's Health website until January 5, 2019.

In the article, entitled "Effect of Cultural, Folk, and Religious Beliefs and Practices on Delays in Diagnosis in Ovarian Cancer in African American Women," the researchers examined whether specific cultural/folk beliefs, religious practices, and perceived spirituality were associated with delays in diagnosis of ovarian cancer as indicated by later cancer stage at diagnosis or longer symptom duration before diagnosis. Cultural/folk beliefs and religiosity/spirituality were not associated consistently with symptom duration before diagnosis.

Patricia G. Moorman, PhD, Duke University (Durham, NC) coauthored the article with colleagues from the University of South Carolina (Columbia), Rutgers Cancer Institute of New Jersey (New Brunswick), Case Western Reserve University (Cleveland, OH), Baylor College of Medicine (Houston, TX), Wayne State University (Detroit, MI), University of Alabama-Birmingham, Medical University of South Carolina (Charleston), Moffitt Cancer Center (Tampa, FL), University of Virginia (Charlottesville), Louisiana State University (New Orleans), Hunter Holmes McGuire Veterans Affairs Medical Center (Richmond, VA), and the University of Tennessee (Knoxville).

"Although cultural/folk beliefs related to cancer were not associated with cancer stage in this study, Dr. Moorman and colleagues found that these beliefs were prevalent among the women and may have influenced their decisions to seek treatment for cancer," states Susan G. Kornstein, MD, Editor-in-Chief of Journal of Women's Health and Executive Director of the Virginia Commonwealth University Institute for Women's Health, Richmond, VA. "Increasing awareness among physicians about cultural and folk beliefs related to cancer, improving patient-provider communication about these beliefs, and involving churches in health education interventions may lead to better outcomes."

(Boston)-- While it is well known that gun deaths are a major public health problem, a new study quantifies the significance of substantially higher gun homicide rates in driving down life expectancy among black Americans.

"Understanding the life years lost by assault and suicide due to firearms among white and black
Americans can help us understand the race specific and intent-specific firearm mortality
burden and inform prevention programs," explained corresponding author Bindu Kalesan, PhD, MPH, assistant professor of medicine at Boston University School of Medicine (BUSM) and assistant professor of community health services at Boston University School of Public Health (BUSPH).

Researchers from BUSM and BUSPH used data from the Centers for Disease Control from 2000 to 2016 to calculate life expectancy loss due to firearm deaths. They found the overall life expectancy loss was twice as high among blacks compared with whites (black Americans lost 4.14 years while white Americans lost 2.23 years) and is driven by substantially higher homicide rates among blacks up to age 20. "Interestingly, we also found that suicides occur mainly among older whites contributing to a relatively lower life expectancy loss while assaults occur among young black Americans contributing to a very large life expectancy loss."

The authors believe this is the first contemporary study to quantifying the magnitude of life expectancy loss at different age groups due to assault and suicide firearm mortality among
black and white Americans.

"Our study shines a light on the magnitude of the problem in terms of how many years of life are lost due to guns, and there is an impervious gap between white and black Americans that has been left to grow. We hope that as much as gun carrying is a constitutional right, there should be an awareness regarding the burden of death due to guns and action to prevent these deaths."

A multi-disciplinary team of epidemiologists, trauma researchers, surgeons and biostatisticians from the Massachusetts Department of Public Health and the College of Health Sciences, University of Massachusetts Lowell, also contributed to this research project.

The findings appear online in BMJ Evidence-Base Medicine.

Currently, uterus donation is only available for women with family members who are willing to donate. With live donors in short supply, the new technique might help to increase availability and give more women the option of pregnancy. The first baby has been born following a uterus transplantation from a deceased donor, according to a case study from Brazil published in The Lancet. The study is also the first uterine transplantation in Latin America.

The new findings demonstrate that uterus transplants from deceased donors are feasible and may open access for all women with uterine infertility, without the need for live donors. However, the outcomes and effects of donations from live and deceased donors are yet to be compared, and the surgical and immunosuppression techniques will be optimised in the future.

The recipient of the transplant was a patient with uterine infertility. Previously, there have been 10 other uterus transplants from deceased donors attempted in the USA, Czech Republic and Turkey, but this is the first to result in a livebirth. The first childbirth following uterine transplantation from living donors occurred in Sweden in September 2013 and were also published in The Lancet [1]. In total, there have been 39 procedures of this kind, resulting in 11 livebirths so far (see Comment Appendix).

Infertility affects 10-15% of couples of reproductive age. Of this group, one in 500 women have uterine anomalies due to congenital anomalies, or through unexpected malformation, hysterectomy, or infection. Before the advent of uterus transplants, the only available options to have a child were adoption or surrogacy.

"The use of deceased donors could greatly broaden access to this treatment, and our results provide proof-of-concept for a new option for women with uterine infertility." says Dr Dani Ejzenberg, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, who led the research. "The first uterus transplants from live donors were a medical milestone, creating the possibility of childbirth for many infertile women with access to suitable donors and the needed medical facilities. However, the need for a live donor is a major limitation as donors are rare, typically being willing and eligible family members or close friends. The numbers of people willing and committed to donate organs upon their own deaths are far larger than those of live donors, offering a much wider potential donor population." [2]

The surgery took place in September 2016. The recipient of the uterus was a 32 year-old woman born without a uterus as a result of Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome [3]. She had one in-vitro fertilisation (IVF) cycle four months before transplant, resulting in eight fertilised eggs which were cryopreserved.

The donor was 45 years old and died of subarachnoid haemorrhage (a type of stroke involving bleeding on the surface of the brain).

The uterus was removed from the donor and then transplanted into the recipient in surgery lasting 10.5 hours. The surgery involved connecting the donor uterus' and recipient's veins and arteries, ligaments, and vaginal canals.

After surgery, the recipient stayed in intensive care for two days, then spent six days on a specialised transplant ward. She received five immunosuppression drugs, as well as antimicrobials, anti-blood clotting treatment and aspirin while in hospital. Immunosuppression was continued outside of hospital until the birth.

Five months after transplantation, the uterus showed no signs of rejection, ultrasound scans showed no anomalies, and the recipient was having regular menstruation.

The fertilised eggs were implanted after seven months. The authors note that they were able to implant the fertilised eggs into the transplant uterus much earlier than previous uterus transplants (where this typically occurred after one year). Implantation was planned to be at six months, but the endometrium was not thick enough at this stage, so it was postponed for one month.

Ten days after implantation, the recipient was confirmed to be pregnant. Non-invasive prenatal testing was done at 10 weeks, showing a normal fetus, and ultrasound scans at 12 and 20 weeks revealed no fetal anomalies.

There were no issues during the recipient's pregnancy, other than a kidney infection at 32 weeks which was treated with antibiotics in hospital.

The baby girl was born via caesarean section at 35 weeks and three days, and weighed 2550g (around 6lbs). The transplanted uterus was removed during the caesarean section and showed no anomalies.

Both the recipient and baby were discharged three days after birth, with an uneventful early follow-up. The immunosuppressive therapy was suspended at the end of the hysterectomy. At the age of seven months and 20 days (when the manuscript was written), the baby continued to breastfeed and weighed 7.2kg (15lbs and 14oz).

The authors note that transplants from deceased donors might have some benefits over donations from live donors, including removing surgical risks for a live donor, and that many countries already have well-established national systems to regulate and distribute organ donations from deceased donors. In addition, through implanting the fertilised eggs sooner they reduced the amount of time taking immunosuppression drugs, which could help to reduce side effects and costs.

The authors note that the transplant involved major surgery and recipients for uterus transplants would need to be healthy to avoid complications during or after this. They also note that the surgery used high doses of immunosuppression, which could be reduced in future. It also involved moderate levels of blood loss, although these were manageable.

The recipient and her partner received monthly psychological counselling from professionals specialised in transplants and fertility throughout before, during and after the transplant.

Writing in a linked Comment, Dr Antonio Pellicer, IVI-Roma, Italy, notes that while the procedure is a breakthrough, it is still in the early stages of refining and many questions are still unsolved. He says: "All in all, the research to be done in this field (whether from alive or deceased donors) should maximise the livebirth rate, minimise the risks for the patients involved in the procedures (donor, recipient, and unborn child), and increase the availability of organs. With the expansion of the field, the number of procedures will increase, and this will allow the community to set different types of study designs, such as comparison studies (ideally randomised) or long prospective series. In an expanding field such as uterus transplantation, the role of collaborative networks and societies such as the International Society of Uterus Transplantation or new interest groups in already existing scientific societies will be crucial. They should promote education and guidance so that the groups performing uterus transplantation for the first time can benefit from the experience of the pioneers. They should also encourage forthcoming procedures to be done and reported in a transparent way by endorsing prospective registration of the procedures and by developing accurate registries."

Berkeley -- Girls exposed to chemicals commonly found in toothpaste, makeup, soap and other personal care products before birth may hit puberty earlier, according to a new longitudinal study led by researchers at the University of California, Berkeley.

The results, which were published Dec. 4 in the journal Human Reproduction, came from data collected as part of the Center for the Health Assessment of Mothers and Children of Salinas (CHAMACOS) study, which followed 338 children from before birth to adolescence to document how early environmental exposures affect childhood development.

Over the past 20 years, studies have shown that girls and possibly boys have been experiencing puberty at progressively younger ages. This is troubling news, as earlier age at puberty has been linked with increased risk of mental illness, breast and ovarian cancer in girls and testicular cancer in boys.

Researchers in the School of Public Health found that daughters of mothers who had higher levels of diethyl phthalate and triclosan in their bodies during pregnancy experienced puberty at younger ages. The same trend was not observed in boys.

Diethyl phthalate is often used as a stabilizer in fragrances and cosmetics. The antimicrobial agent triclosan - which the FDA banned from use in hand soap in 2017 because it was shown to be ineffective - is still used in some toothpastes.

"We know that some of the things we put on our bodies are getting into our bodies, either because they pass through the skin or we breathe them in or we inadvertently ingest them," said Kim Harley, an associate adjunct professor in the School of Public Health. "We need to know how these chemicals are affecting our health."

Researchers suspect that many chemicals in personal care products can interfere with natural hormones in our bodies, and studies have shown that exposure to these chemicals can alter reproductive development in rats. Chemicals that have been implicated include phthalates, which are often found in scented products like perfumes, soaps and shampoos; parabens, which are used as preservatives in cosmetics; and phenols, which include triclosan.

However, few studies have looked at how these chemicals might affect the growth of human children. "We wanted to know what effect exposure to these chemicals has during certain critical windows of development, which include before birth and during puberty," Harley said.

The CHAMACOS study recruited pregnant women living in the farm-working, primarily Latino communities of Central California's Salinas Valley between 1999 and 2000. While the primary aim of the study was to examine the impact of pesticide exposure on childhood development, the researchers used the opportunity to examine the effects of other chemicals as well.

The team measured concentrations of phthalates, parabens and phenols in urine samples taken from mothers twice during pregnancy, and from children at the age of 9. They then followed the growth of the children -- 159 boys and 179 girls -- between the ages of 9 and 13 to track the timing of developmental milestones marking different stages of puberty.

The vast majority -- more than 90 percent -- of urine samples of both mothers and children showed detectable concentrations of all three classes of chemicals, with the exception of triclosan which was present in approximately 70 percent of samples.

The researchers found that every time the concentrations of diethyl phthalate and triclosan in the mother's urine doubled, the timing of developmental milestones in girls shifted approximately one month earlier. Girls who had higher concentrations of parabens in their urine at age 9 also experienced puberty at younger ages. However, it is unclear if the chemicals were causing the shift, or if girls who reached puberty earlier were more likely to start using personal care products at younger ages, Harley said.

"While more research is needed, people should be aware that there are chemicals in personal care products that may be disrupting the hormones in our bodies," Harley said.

Consumers who are concerned about chemicals in personal care products can take practical steps to limit their exposure, Harley said.

"There has been increasing awareness of chemicals in personal care products and consumer demand for products with lower levels of chemicals," Harley said. "Resources like the Environmental Working Group's Skin Deep database or the Think Dirty App can help savvy consumers reduce their exposure."

Dana-Farber Cancer Institute scientists will present research marking significant advances against the hematologic cancer multiple myeloma at the American Society of Hematology (ASH) Annual Meeting Dec. 1-4. Their findings provide new insights into the progression of the disease from precursor conditions and suggest approaches for novel treatments.

In related work, Dana-Farber investigators will also present a novel system for classifying patients with smoldering Waldenström macroglobulinemia by their likelihood of developing Waldenström's itself.

Here are some examples of this research:

Immune response may predict risk of progression to myeloma in patients with precursor conditions, study finds

Even before people with premalignant stages of multiple myeloma develop symptoms, immune system cells in their bone marrow undergo a variety of changes that affect the progression to myeloma, Dana-Farber scientists report in a new study. The findings, which offer the first detailed look at the interplay between malignant and immune cells in patients with myeloma precursor conditions, may lead to tests for predicting the advance of the disease and, potentially, to new strategies for treating it.

The study involved analyzing gene activity in individual plasma cells and immune system cells from the bone marrow of healthy people and patients with monoclonal gammopathy of undetermined significance (MGUS) and smoldering multiple myeloma, which are precursor conditions of myeloma. The analysis was performed by sequencing the RNA in each cell, providing an indication of which genes are active.

Researchers found that even at the earliest, premalignant stages of the disease, the immune microenvironment - the collection of immune cells in the bone marrow - undergoes a dramatic shift from that of healthy people. They found, for example, an influx of immune system cells called natural killer cells, macrophages, and T cells in patients with precursor conditions, as well as changes in surface molecules on plasma cells that made the cells harder for the immune system to detect.

"For the first time, we identify changes in immune cells that are present in the bone marrow microenvironment of patients at early stages of the disease, even at the MGUS stage," said Irene Ghobrial, MD, the principal investigator of the trial and co-director of the Center for Prevention of Progression of Blood Cancers at Dana-Farber. "We also define specific changes in these immune cells that can be targeted in the future with immunotherapy to prevent or intercept disease progression, making myeloma potentially a preventable disease."

Researchers will present their findings at Session 602, on Sunday, Dec. 2 at 6:00 p.m. PST in Hall GH of the San Diego Convention Center.

Three-drug combination produces broad response in patients with high-risk smoldering multiple myeloma

In the vast majority of patients with high-risk smoldering multiple myeloma (SMM), a combination of the drugs ixazomib, lenalidomide, and dexamethasone can substantially reduce the extent of their cancer with minimal side effects, initial results from a phase 2 clinical trial led by Dana-Farber researchers suggest.

The interim findings of the trial, which involved 29 patients with high-risk SMM, will be presented at Session 653, on Monday, Dec. 3, at 4:00 p.m. in Room 6F of the San Diego Convention Center. Among the participants who received at least three cycles of the three-drug regimen, 89 percent responded to the treatment, meaning they had at least a 30 percent reduction of their disease. Five of those patients had a complete response - a disappearance of all signs of cancer - and nine had a response characterized as very good. None of the participants, who began therapy between February 2017 and April 2018, have developed symptoms of myeloma.

The combination had minimal toxicities. The common side effects of the therapy were mild to moderate fatigue and rash. Severe (grade 3) hypophosphatemia (low phosphate levels in the blood) occurred in two patients, while grade 3 neutropenia (a reduction in the number of white blood cells) was found in only one patient.

Ixazomib is a proteasome inhibitor, which interferes with a structure in cells that breaks down unneeded proteins; lenalidomide kills cancer cells by a variety of mechanisms; and dexamethasone is a corticosteroid.

"Early intervention in patients with high-risk SMM has been shown to be a better approach to delaying or preventing progression of this cancer," said Dana-Farber's Mark Bustoros, MD, who is presenting the results of the trial at the ASH annual meeting. "We are expanding on that approach with this convenient drug combination. Patients with high-risk SMM have a higher chance of progression within a short period of time, yet they are asymptomatic and have their regular personal and professional lives. Providing this oral combination brings advantages of both efficacy and convenience."

"This is the first time we have seen a high response rate, including over 50 percent complete remission and very good response rates, in patients with high-risk smoldering myeloma using a well-tolerated combination of oral therapies," said Ghobrial. "We believe this could be a platform for therapy in the near future for patients with smoldering myeloma who are at high risk of disease progression and who benefit from early intervention."

Study identifies ID2-related pathways as potential drug targets in multiple myeloma

The search for potential drug targets in multiple myeloma has turned up a promising new candidate. In a study led by Dana-Farber scientists, researchers report that a protein called inhibitor of DNA binding 2 (ID2) helps suppress tumor cell growth and is significantly downregulated, or under-produced, in myeloma cells. By blocking proteins that keep ID2 production abnormally low, new targeted therapies could potentially restore the brakes on tumor cell proliferation.

By comparing the expression of ID2 (and the three other members of the ID protein family) in normal plasma cells and myeloma cells from 360 patients with the disease, researchers found that ID2 was sharply downregulated in the myeloma cells. When they overexpressed ID2 in myeloma cell lines, the cell proliferation rate dropped markedly.

Investigators next explored the mechanism that causes ID2 to be downregulated. In a series of experiments, they found that bone marrow stromal cells - which give rise to a variety of skeletal components such as bone and cartilage, supportive tissue, and fat cells - can interact with myeloma cells to reduce ID2 production.

"This study identifies a new mechanism in which genes act as decoy to increase function of other target genes," said the study's lead author, Nikhil Munshi, MD, director of Basic and Correlative Science at the Jerome Lipper Multiple Myeloma Center at Dana-Farber. "It provides clues to some of the less understood molecular mechanisms in myeloma and may lead to new therapeutic interventions." The lead author of the study is Tommaso Perini, MD, of the LeBow Institute for Myeloma Therapeutics and Jerome Lipper Multiple Myeloma Center at Dana-Farber, and University Vita-Salute San Raffaele, in Milano, Italy.

Researchers will give an oral presentation of their findings at Session 651, on Saturday, Dec. 1, at 8:45 a.m. in Grand Ballroom 7 of the Marriott Marquis Sand Diego Marina.

Researchers launch screening study of individuals at high risk of multiple myeloma

Researchers at Dana-Farber are seeking participants in a new study, funded as part of the Stand Up To Cancer Multiple Myeloma Dream Team, to identify people with conditions that are precursors of multiple myeloma and track their health over time. The study, dubbed PROMISE, will help scientists track the molecular changes that occur as precursor conditions - monoclonal gammopathy of undetermined significance (MGUS) or smoldering multiple myeloma - progress to myeloma. This information will be critical in the development of drugs that prevent the disease from advancing and improve patients' survival.

The study is open to two groups of individuals between the ages of 45 and 75 who have been identified to be at high risk of multiple myeloma and its precursor conditions:

African Americans, who are three times more likely than Caucasians to develop MGUS;

People with a first-degree relative (a parent, sibling, or child) with a plasma cell disorder such as multiple myeloma.

Participants will complete an online health questionnaire, provide blood samples periodically for analysis, and submit updated health information periodically. Participants whose blood samples test positive for a myeloma precursor condition will be assisted in scheduling an appointment with a hematologist/oncologist. They will also be asked to submit health information and blood samples every 3-6 months and may be eligible for clinical trials exploring treatments to prevent progression. These samples will be analyzed for molecular signs indicating the risk of disease progression.

"Our hope is that by screening and identifying the precursor conditions early, we can understand the molecular signs of progression to myeloma, and develop therapies that will replace 'watch and wait' and make myeloma a preventable disease," said Ghobrial, the study's principal investigator.

Initial participation in the trial is online or by mail. Local travel for blood draw is required. Testing will be performed at each participant's local Quest Diagnostics laboratory. To sign up for the study, please visit http://www.promisestudy.org.

Researchers devise risk-based classification system for patients with smoldering Waldenström macroglobulinemia

By analyzing data from hundreds of patients with smoldering Waldenström macroglobulinemia (SWM), researchers at Dana-Farber have devised a risk model for determining whether patients with SWM have a low, intermediate, or high risk of developing Waldenström's macroglobulinemia (WM).

Under this system, patients' risk is assessed using four measures: Bone marrow lymphoplasmacytic infiltration; serum immunoglobulin M levels; β2 microglobulin levels, and albumin levels. Stratifying patients into three risk groups based on these variables can improve patient monitoring and, importantly, identify high-risk patients who might benefit from early intervention, researchers say.

Waldenström macroglobulinemia is a low-grade form of non-Hodgkin lymphoplasmacytic lymphoma associated with overproduction of monoclonal IgM protein and is often preceded by SWM, an asymptomatic condition. "Patients with WM usually have symptoms of anemia, peripheral neuropathy, bleeding and other problems," said Bustoros, the study lead, who is presenting the final results at the ASH annual meeting. "Almost two-thirds of patients with SWM progress to the symptomatic stage. Higher values of the four biomarkers were associated with a significant risk of progression to symptomatic disease within few years. We will provide this model as an open access web application so it can help oncologists improve the care and guide the management of patients with this rare cancer."

"The model was generated based on 439 patients with SWM at Dana-Farber and was validated using two other cohorts, from the Mayo Clinic and University of Athens in Greece," said Dana-Farber's Romanos Sklavenitis Pistofidis, MD, first co-author of the study. "The model was a strong predictor in identifying high-risk patients, intermediate, and low-risk ones with high accuracy and precision."

"We hope this model will help in identifying patients at high risk of disease progression so they can be followed up closely or benefit from early treatment approaches through clinical trials," said Ghobrial, the senior author of this study.

Improving outcomes for patients with myeloid cancers who undergo stem cell transplantation is a focus of several studies to be presented by Dana-Farber Cancer Institute scientists at the American Society of Hematology (ASH) Annual Meeting Dec. 1-4. The research points to new opportunities for preventing relapse after transplantation and determining which patients should be considered for lower-intensity chemotherapy in preparation for transplant.

Here are two examples of this research:

Loss of HLA protein linked to relapse of acute myeloid leukemia after stem cell transplant from matched unrelated donors

Genetic changes that cause tumor cells to lose HLA proteins can spur relapses in patients with myeloid cancers who undergo stem cell transplants from matched, unrelated donors, Dana-Farber researchers report in a new study. The findings indicate that the loss of HLA proteins - which are used by the immune system cell to distinguish healthy cells from diseased ones - enable tumor cells to evade detection by the immune system and resume their proliferation.

The findings, to be reported in an oral presentation at Session 723 on Monday, Dec. 3, at 2:45 p.m. PST in Grand Hall D of the Manchester Grand Hyatt San Diego, suggest new avenues for immunological approaches to preventing relapse following transplant.

While stem cell transplants often produce remissions in patients with myeloid malignancies such as acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS), some patients relapse a year or more after transplant. Researchers sought to determine if these late relapses are the result of genetic alterations in tumor cells that prevent transplanted immune system cells from recognizing and attacking the cancer.

The investigators conducted a genomic analysis of tumor tissue from 25 patients with AML or MDS who had relapsed after undergoing a transplant with stem cells from a fully or partially matched donor. Samples were collected prior to transplant, 100 days after transplant, and at the time of relapse. Each sample was analyzed for abnormalities in any of 187 genes involved in myeloid malignancies or suspected of enabling cells to escape detection by the immune system.

Researchers identified three patients whose tumor cells lost HLA following transplant. Two of the patients had received stem cells from fully matched donors; the other had received them from a partially matched, unrelated donor. The findings suggest that HLA loss may enable tumor cells to foil the donor immune system's ability to detect important minor discrepancies in recipient leukemia cells.

"The donor's immune system is essential to cure after bone marrow transplantation," said R. Coleman Lindsley, MD, PhD, Dana-Farber physician and assistant professor of medicine at Harvard Medical School, who helped lead the study. "We show how some leukemias relapse by evading donor immune attack."

Telomere length linked to risk of death from toxicity of high-dose chemotherapy in stem cell transplantation for myelodysplastic syndrome

Patients with myelodysplastic syndrome (MDS) whose blood cells have short telomeres - structures that protect the tips of chromosomes - have a greater risk of dying from the high-dose chemotherapy used in preparation for a stem cell transplant than do patients with longer telomeres, Dana-Farber physicians report in a new study. Treating such patients with lower-intensity chemotherapy regimens may reduce that risk.

The study findings are based on a measurement of telomere lengths in whole blood DNA samples from 1,514 patients who received donor stem cell transplants for MDS. Investigators found that patients age 40 or older who had short or intermediate-length telomeres had poorer overall survival than those with long telomeres. The association between telomere length and transplant-related death held only for patients who received high-intensity chemotherapy in preparation for transplant, not for those who received reduced-intensity regimens.

To explore genetic connections to telomere length, the researchers sequenced seven genes known to be involved in telomere maintenance. They found that mutations in three of those genes - TERT, TERC, and DKC1 - are associated with patients with MDS who have short telomeres and poor transplant outcomes.

"This study identifies a group of MDS patients with shorter telomeres who are most vulnerable to the toxicities of bone marrow transplantation and points the way towards a more tailored approach to treatment," said Lindsley, the senior author of the study.

The findings will be discussed in an oral presentation at Session 637 on Monday, Dec. 3, at 3:30 p.m. in Grand Hall A of the Manchester Grand Hyatt Sand Diego.

Complete details on Dana-Farber's activities at ASH are available online here.

A new study from the University of Iowa finds rural hospitals that use tele-medicine to back up their emergency room health care providers not only save money, but find it easier to recruit new physicians.

Marcia Ward, study author and professor of health management and policy in the College of Public Health, says the results suggest that expanded use of tele-emergency services could play a key role in helping small, rural critical access hospitals maintain their emergency rooms.

"The study finds that expanding options for provider coverage to include tele-medicine in some rural emergency departments has noticeable benefits," says Ward, whose study was published Dec. 3 in the December issue of the journal Health Affairs. "This supports the viability of critical access hospitals at risk of closing and leaving their communities without local emergency care."

Many of the nearly 1,400 rural hospitals in the United States are struggling to provide health care services generally because of declining population and rising costs. One of those services is emergency medicine, as emergency rooms are expensive to operate and, until 2013, were required to be staffed with a physician on-site or on-call 24 hours a day. As a result, Ward says many rural hospitals are unable to staff their ERs with doctors trained in emergency medicine. Instead, they're covered by family physicians from the community who share ER coverage along with their regular clinic and hospital practice.

However, in 2013, a Medicare rule clarification allowed rural hospitals to fulfill their on-site staffing requirements using an advanced practice provider, such as a physician assistant or nurse practitioner, as long as they have remote access to a physician using a tele-medicine link. To measure the impact of that rule change, UI researchers analyzed 19 rural hospitals in the Sioux Falls, South Dakota-based Avera Health network. Seven of the hospitals took advantage of the Medicare rule clarification to back up their ER providers with tele-medicine doctors who work at the hub hospital in Sioux Falls.

The spoke hospitals were located in Iowa, Minnesota, North Dakota, South Dakota, and Nebraska.

Key findings from the study include:

The amount of time with on-site coverage by advanced practice providers backed up by a tele-ER increased from zero hours to an average of 17.1 hours a day within three years. Two hospitals adopted this model 24 hours a day.

Rural hospitals that switched to tele-ER back-up saved an average of $117,000 annually in health care provider costs because advanced practice providers receive less compensation than physicians. Rural hospitals in the same network that continued to staff their ER with on-site or on-call physicians saw an average increase of $138,000 in annual provider compensation costs.

Hospitals that switched to tele-ER services found it easier to recruit new physicians because they could offer a better work-life balance, as the doctor would not have to cover an ER shift. The model also gives physicians more downtime, Ward says, reducing burnout and increasing retention.

A new randomised trial of over 3000 people in The Lancet finds that sharing pictorial representations of personalised scans showing the extent of atherosclerosis (vascular age and plaque in the arteries) to patients and their doctors results in a decreased risk of cardiovascular disease one year later, compared to people receiving usual information about their risk.

Smoking cessation, physical activity, statins, and antihypertensive medication to prevent cardiovascular disease are among the most evidence-based and cost-effective interventions in health care. However, low adherence to medication and lifestyle changes mean that these types of prevention efforts often fail.

"Cardiovascular disease is the leading cause of death in many countries, and despite a wealth of evidence about effective prevention methods from medication to lifestyle changes, adherence is low," says Professor Ulf Näslund, Umea University (Sweden). "Information alone rarely leads to behaviour change and the recall of advice regarding exercise and diet is poorer than advice about medicines. Risk scores are widely used, but they might be too abstract, and therefore fail to stimulate appropriate behaviours. This trial shows the power of using personalised images of atherosclerosis as a tool to potentially prompt behaviour change and reduce the risk of cardiovascular disease." [1]

3532 individuals who were taking part in the Västerbotten County (Sweden) cardiovascular prevention programme were included in the study and underwent vascular ultrasound investigation of the carotid arteries. Half (1749) were randomly selected to receive the pictoral representation of carotid ultrasound, and half (1783) did not receive the pictorial information.

Participants aged 40 to 60 years with one or more cardiovascular risk factors were eligible to participate. All participants underwent blood sampling, a survey of clinical risk factors and ultrasound assessment for carotid intima media wall thickness and plaque formation. Each person in the intervention group received a pictoral representation of plaque formation in their arteries, and a gauge ranging from green to red to illustrate their biological age compared with their chronological age. They then received a follow up call from a nurse after 2-4 weeks to answer any questions. The same pictorial presentation of the ultrasound result was also sent to their primary care doctor. Thus, the study had dual targets.

Both groups received information about their cardiovascular risk factors and a motivational health dialogue to promote healthier life style and, if needed according to clinical guidelines, pharmacological treatment.

At one year follow up, the cardiovascular risk score for all participants (3175 completed the follow up) was calculated showing differences between the two groups (Framingham Risk Score decreased in the intervention group but increased in the control group [-0.58 vs +0.35]; SCORE increased by twice as much in control group compared to the intervention group [0.27 vs 0.13]).

Improvements were also seen for total and LDL cholesterol in both groups, but the reduction was greater in the intervention group than in the control group. A graded effect was also noted, with the strongest effect seen for those with the worst results.

"The differences at a population level were modest, but important, and the effect was largest among those at highest risk of cardiovascular disease, which is encouraging. Imaging technologies such as CT and MRI might allow for a more precise assessment of risk, but these technologies have a higher cost and are not available on an equitable basis for the entire population. Our approach integrated an ultrasound scan, and a follow up call with a nurse, into an already established screening programme, meaning our findings are highly relevant to clinical practice," says Prof Näslund [1].

Importantly, the effect of the intervention did not differ by education level, suggesting that this type of risk communications might contribute to a reduction of the social gap in health. The findings come from a middle-aged population with low to moderate cardiovascular disease risk.

Further research is needed to understand whether the results are sustainable beyond one year, and whether the intervention will lead to a reduction of cardiovascular disease in the long-term. Formal cost-effectiveness analyses will be done after 3-year follow-up.

Writing in a linked Comment, Dr Richard Kones, Umme Rumana and Alberto Morales Salinas, Cardiometabolic Research Institute (USA), says:

"Despite advances in cardiovascular therapies, coronary heart disease remains the leading cause of death in almost all countries. Two of the most remarkable recent treatments, percutaneous coronary intervention and the availability of proprotein convertase subtilisin/ kexin type 9 inhibitor drugs, have revolutionised cardiology practice. Although life-saving and now essential therapies, whether they will be able to reduce the incidence and associated morbidity and mortality of coronary heart disease remains unlikely since the increase in prevalence of obesity and diabetes is raising the background level of cardiovascular risk... Although there are proven methods of lowering cardiovascular risk and these are generally being better used generally in high-income countries, poor adherence and uneven availability and access in low income and middle-income countries still pose serious challenges... About less than half of all patients taking medications are adherent, which substantially increases morbidity and mortality. Non-adherence to medication accounts for 33-69% of all hospital admissions in the USA, and, among patients with coronary heart disease, the extent of low adherence is related to the number of adverse cardiovascular events. Poor adherence is multifactorial and can broadly be grouped into categories related to patients, physicians and therapies, communication, health-care systems, socioeconomic factors, and unpredictable negative effects of the internet. One of the most pertinent factors is patient-related perceived risk and motivation. Despite the many methods that have been proposed, effectiveness in improving adherence and outcomes has been relatively disappointing. It is in this context that the randomised controlled trial by Ulf Näslund and colleagues in The Lancet is relevant."

Only around a fifth of women at higher risk of developing breast cancer think they need to take a drug proven to help prevent the disease, according to new research funded by Cancer Research UK and published today (Monday) in Clinical Breast Cancer.*

Around 72% said they were worried about the long-term effects of tamoxifen and 57% believed that the drug would give them unpleasant side-effects.

The researchers, led by a team from the University of Leeds, asked more than 400 healthy women at a higher-risk of breast cancer, from 20 centres across England, whether they thought they needed to take tamoxifen and their concerns about medication.

They discovered that almost a third (29%) of the women thought doctors prescribed too many medicines, and more than a third (35%) thought doctors would prescribe fewer drugs if they had more time. Around a quarter (24%) of the women had experienced bad reactions to medicines in the past.

Almost a quarter (24%) of the women thought people on medication should take regular breaks from the drugs; 23% said they were very sensitive to medicines and 17% believed natural remedies were safer than medicines.

In a follow-up questionnaire, answered by 250 of the women, researchers found that fewer than 15 per cent were taking tamoxifen** despite having discussed preventive therapy with a healthcare professional. Women who believed the medication was less necessary and had more concerns about its use were less likely to be taking tamoxifen at follow-up.

Lead author Dr Samuel Smith, from the University of Leeds, said: "Women in our study were rightfully considering the potential harms and benefits of using preventive therapy. But some beliefs about the use of medicine were very negative. This appears to be putting some women off tamoxifen, despite its proven ability to help prevent breast cancer in the long term.

"We need to make sure health care professionals are adequately equipped to discuss the potential benefits and harms of preventive treatment with their patients so that women are well informed before deciding whether or not to take a drug."

Dr Julie Sharp, Cancer Research UK's head of health information, said: "It's understandable that women considering taking a new medicine might have some concerns and that, for some, it won't be the right option. There are some potential side effects with tamoxifen, and other medications that can help prevent cancer, but it's vital that they have all the information, so they can make the best choice for them. If women in this situation have any questions or want more information, they can visit our website or call our cancer nurses for a chat. ***

New research on the types of bacteria living in babies' noses could offer clues as to why some recover quickly from their first cough or cold, while others suffer for longer.

The study, published in ERJ Open Research [1], suggests that babies who have a wide variety of different bacteria living in their noses tend to recover more quickly from their first respiratory virus, compared to those who have less variety and more bacteria from either the Moraxellaceae or Streptococcaceae family.

The researchers say their findings do not offer an immediate solution to help babies recover more quickly from coughs and colds. However, the results could help scientists understand the importance of the bacteria living in the respiratory tract, and how they influence infections and longer term conditions such as asthma.

Dr Roland P Neumann from University Children's Hospital of Basel, University of Basel, Switzerland, was one of the researchers. He explained: "It's well known that different types of bacteria live in our gut. The respiratory tract is also home to a wide variety of bacteria and we are beginning to understand that the types and numbers of these bacteria, what we refer to as the microbiota, can influence our respiratory health.

"We know that babies often suffer with coughs, runny noses, sore throats and ear infections, and in some babies the symptoms seem to drag on for weeks. These are usually caused by a virus such as the common cold, but we wanted to investigate whether the microbiota of the nose might also have a role in how long symptoms last. This is important not only in terms of babies feeling unwell but also because respiratory infections in the early years are linked to the development of asthma in later life."

The research was part of a larger study that is following a group of babies from birth to investigate the complex interactions of genetic and environmental factors and their influence on lung health.

Parents taking part in this part of the study were asked to contact the researchers as soon as their babies developed symptoms of their first respiratory infection. This included more than two consecutive days when their babies were coughing, had a runny nose, signs of an ear infection or sore throat.

Researchers took swabs from the noses of babies at that point and then took swabs again three weeks later. They analysed the swabs by testing for the presence of respiratory viruses, such as the common cold, and for the types of numbers of different bacteria.

Working with sets of swabs from 183 babies, researchers were able to group the babies according to the makeup of their nasal microbiota.

On average, the babies' symptoms lasted around two weeks. Babies who were free of symptoms by the time the three-week swab was taken were more likely to have a wider mixture of bacteria in their noses and a microbiota that was not dominated by bacteria from the Moraxellaceae or Streptococcaceae family.

Among babies whose symptoms lasted three weeks or longer, researchers found less variety in the types of bacteria living in the babies' noses and the microbiota were more likely to be dominated by bacteria from the Moraxellaceae or Streptococcaceae family. These families include specific types that are known to be linked with respiratory disease.

They found no clear link between the type of respiratory virus and the persistence of symptoms.

Researchers took account of other factors that are known to have an impact on respiratory health, including the babies age, the season of the year, whether they had siblings or attended nursery, and whether they were exposed to cigarette smoke.

They say this study cannot explain why the link exists, but a possible explanation is that certain types of bacteria may be more likely to result in inflammation and a worsening in symptoms. Or, it could be that a more diverse set of bacteria offers some protective effect.

Professor Urs Frey, Chair of Paediatrics at the University Children's Hospital of Basel, University of Basel, Switzerland, was also a researcher on the study. He said: "This study helps us to understand how bacteria that naturally live in the upper airways are important for respiratory health.

"We know that antibiotics and environmental factors, such as season and childcare, can alter the numbers and types of bacteria in babies' noses. We do not yet know what combination of bacteria would be 'ideal' and this would need to be known before we understand how we might manipulate it."

Professor Tobias Welte, from Hannover University, Germany, is President of the European Respiratory Society and was not involved in the study. He said: "There is an association between respiratory symptoms in babies in the first year of life and the development of asthma by school-age. We do not yet fully understand this link but the bacteria living in the upper airways could play a role. We need to do more research to understand the relationship between these bacteria, respiratory infections and long-term lung health."