Body

BOSTON - (October 11, 2018) - People with type 1 diabetes are far more likely to develop cardiovascular disease than those without diabetes. Their risks climb even higher if they show signs of hypertension (high blood pressure) or dyslipidemia (unhealthy levels of cholesterol or triglycerides).

Interviewing both teens and parents, Joslin Diabetes Center researchers have identified strategies to help teens with these conditions manage them better, says Michelle Katz, MD, MPH, lead author on a paper about the work recently published in Pediatric Diabetes.

Among the key strategies, providers should offer realistic and specific guidance, and teens should be encouraged to recruit regular exercise partners, says Katz, who is associate director of Joslin's Pediatric, Adolescent and Young Adult Section.

Offering realistic and specific guidance begins with delivering basic knowledge about the conditions, says Katz, who is also assistant professor of pediatrics at Harvard Medical School. Asked about the risks of high blood pressure, for instance, teens might say that it could give you a headache, rather than realizing it might lead to a heart attack many years from now. Teens also often hoped that the condition might be "fixed" rather than needing to be continually managed.

"There's an immediacy in how teens view things," Katz says. "So we try to reach them where they're at, and think about what will motivate them. For example, a lot of heart-healthy behaviors may improve how they look and feel. Some teens may be motivated by the prospect of losing weight, or having more energy, or potentially having clearer skin."

"Teens also look for detailed personalized guidance," Katz says. "They want to know, 'What is my personal risk? What are my risk factors and what can I do about them? What are the foods that I can eat, what's a good menu for me, and what are good activities for me?'"

Exercise is just as crucial for heart health for teens as it is for adults. "What makes this easier is being on a sports team, having some sort of regularly scheduled exercise, or having a friend to go to the gym with," Katz says. "You always encourage teens to do the types of activity they like. Sometimes you have to get down into the details with them to coax them along: Do you enjoy playing basketball, do you have another friend who enjoys playing basketball, do you have a playground in your neighborhood or can you go to the local 'Y'?"

Based on semi-structured interviews with 22 teens who had type 1 diabetes (45% with dyslipidemia) and 25 parents (40% who had teens with dyslipidemia), the study highlighted issues that were viewed quite differently by teens and their parents.

Teen and parent perceptions varied, for example, about when to start heart protective medicines if and when they were recommended by a physician.

"Many parents were very hesitant to think about starting a teenager on medications; they really viewed that as very much a last resort," Katz says. "Some parents were worried about side effects. Some parents were worried that these medications are lifelong therapies and they are for conditions associated with older people." Teens, in contrast, were more likely to see the medicines as simply one more addition to their daily regimen of medications.

Teens also were more likely than parents to suggest that their own homes weren't the healthiest environments for food. As parents typically buy the groceries and do the cooking, making better choices calls for a team effort, Katz noted.

The Joslin team is now running a pilot study to encourage heart healthy behaviors in teens with type 1 diabetes and additional cardiovascular risk factors, using lessons learned from the study.

"We recognize that teens may not have a lot of knowledge, so we start our discussions at a pretty basic level, going over what blood pressure and cholesterol are," Katz says. "We encourage really specific goal-setting, drilling down on that with them. We're also putting teens on an exercise app with virtual exercise buddies, to help give them some motivation."

Scientists from Tartu have discovered a simple way how to improve infertility treatment in the future. The results of the study, published in Human Reproduction, a top journal in the field, can be used in precision medicine to account for the variability in each female patient's menstrual cycle. This personalised approach will first and foremost benefit those couples, who have experienced repeated IVF failure.

In 2017, more than 2800 in vitro fertilization (IVF) procedures were carried out in Estonia, resulting in the birth of 430 babies, which accounts for 3% of all births. The low 15% success rate of IVF can be caused by problems in several stages of the treatment. One of such stages is embryo implantation, which marks the beginning of the pregnancy. However, if the embryo is transferred into the uterus on the wrong day, even the best embryos cannot overcome this, resulting in a negative pregnancy test.

The task of the infertility treatment specialist is to recommend the best treatment for each patient. Female infertility can be caused by problems with endometrial (the inner uterine lining) receptivity. While in natural conception the developing embryo can "sit and wait" until the endometrium matures to peak receptivity, in IVF treatment it is of utmost importance to transfer the embryo on the correct day to increase the chances of pregnancy. Different methods are used to assess endometrial receptivity, the most accurate of which is a test measuring the expression patterns of different genes in an endometrial biopsy. For this, a minimally invasive endometrial biopsy is taken in the cycle preceding the IVF cycle on the day the endometrium is supposedly the most receptive. Analysis of the expression patterns of specific marker genes provides vital information to decide whether the "right genes are expressed at the right time". If needed, the time of the embryo transfer is adjusted, providing an example of precision medicine in infertility treatment.

The study, published in Human Reproduction, a leading journal in the field of reproductive medicine, is based on the well-known fact that the inner uterine lining consists of several different cell types. The novelty of the study lies in the fact that previous studies have not considered the effect of cell type proportions on endometrial gene expression profiles. This novel approach makes gene expression profile analysis more specific, thus also improving the performance of tests based on gene expression patterns. The paper has also been highlighted by the editor-in-chief of Human Reproduction, meaning that it is considered to be a remarkable improvement in this field.

The study was a collaboration between scientists from Estonia and Spain, and a natural progression to the earlier work of the research group in Tartu, which allows to improve IVF efficiency. Marina Suhorutšenko, the first author of the paper and a PhD student at the Institute of Clinical Medicine, University of Tartu, explains: "It is common knowledge that the inner uterine lining includes different cell types; however, all the previous studies have consistently ignored this fact. Our work shows how to account for this variability in cellular composition, and thus considerably improve the accuracy of biomarker discovery". In the clinical setting, only the whole tissue gene expression profile is usually analysed, as analysing cellular fractions separately is labour-intensive and expensive. "We have developed a pipeline that allows to skip this step, and instead uses a different data analysis approach to improve the accuracy without extra costs," added Suhorutšenko.

Dr. Triin Laisk, a Research Fellow at the Estonian Genome Center, who coordinated the data analysis of the study adds that the confounding effect of biopsy cellular composition has been largely ignored in the past, and not only in the field of reproductive medicine. "By taking it into account we can decrease the amount of random and false positive findings, and eventually improve our knowledge on the biology behind different conditions, as well as facilitate the discovery of novel biomarkers," said Dr. Laisk.

The results of the study have immediate practical value, and the research team is currently working on how to integrate these findings into a genetic test that is used in infertility treatment clinics to select the best day for embryo transfer. The Competence Centre on Health Technologies (CCHT), where the study in question was carried out, has developed an endometrial receptivity test called beREADY.

"We have done some important basic science, such as this study, that eventually will improve the efficiency of IVF treatment," explains Professor Andres Salumets, the coordinator of the study. "Tests and methods applied in the clinical setting are never the result of only one discovery. There are smaller and greater breakthroughs, but the elegant data analysis solution applied in this study is a good addition to the beREADY personalised treatment tool currently being tested by several clinics. From a technological point of view, we can use patented solutions in the beREADY test, but we also need to use smarter data analysis approaches to stand out among the competitors," said Prof. Salumets.

The age at which young women experience their first menstrual bleeding is linked to the age at which their sons start puberty, according to the largest study to investigate this association in both sons and daughters.

The research, which is published today (Friday) in Human Reproduction [1], one of the world's leading reproductive medicine journals, looked at 15,822 children and found that the earlier women had their first period, the earlier their sons started puberty, and the later they had their first period, the later their sons started puberty.

The same association was found for daughters but, whereas, it has been known for some time that mothers' age at puberty is associated with their daughters', much less was known about the link with their sons' age at puberty. The authors of the study say their results are consistent with other research that suggests that there is an overlap in the genes that influence the timing of puberty in both sons and daughters.

The researchers, based at Aarhus University, Denmark, studied a group of children who were part of the Danish National Birth Cohort and who were born between 2000 and 2003. They followed them up to October 2016 and during this time they interviewed the mothers twice during pregnancy and asked them to fill in a questionnaire when the children were seven. The mothers were asked about their age when they had their first menstrual bleed. From the age of 11 years, the children completed questionnaires every six months that included questions on puberty.

One of the study authors, Dr Nis Brix, said: "We found that mothers who reported having their first menstrual bleed earlier than their peers had sons with signs of puberty starting earlier than their peers. The largest difference was when hair started growing in the armpits, which started, on average, approximately two and a half months earlier; their voices broke nearly two months earlier, acne started to develop nearly two months earlier and their first ejaculation of semen was nearly one and a half months earlier. If their mothers started puberty later than their peers, then the sons experienced first ejaculation, growth of armpit hair and acne development later than their peers."

Similar results were seen in daughters. The largest difference was seen in breast development, which started up to six months earlier in girls whose mothers had experienced earlier periods than their peers, or up to four months later in girls whose mothers had started puberty later than their peers.

"The relationship between first menstrual bleeding in mothers and the first menstrual bleeding in their daughters has been reported in several studies. The novelty of our study was to include other markers of pubertal development in daughters, such as different stages of breast development and pubic hair development and to study sons; the relationship in sons has only been sparsely investigated," said Dr Brix.

The timing of puberty has become earlier over the past century, probably explained by better health and living standards. However, a younger age at puberty has been linked to increased risk of diseases in later adult life, such as breast and testicular cancer, diabetes and cardiovascular disease.

Dr Brix concluded: "Whenever a clinician meets a patient with delayed or early onset of puberty, the clinician obtains a family history on whether or not other family members also had either delayed or early puberty. Thus, the relationship between the mother's pubertal age and the son's pubertal age has been taken as common knowledge, but our data from a large national birth cohort confirm the relationship. Put differently: 'We already knew it, but now we have the results to confirm it'."

A limitation of the study is that it relied on mothers reporting information to the researchers. Another limitation is that it relied on children reporting their puberty information by themselves, but a recent validation study by the authors showed that the children were able to report their current pubertal status with moderate accuracy, which the authors believe is acceptable for a large-scale study like this.

**Country-level data and spokespeople available**

Globally, 21% births are delivered via C-section, higher than the level thought required for medical purposes (10-15%).

60% of countries overuse C-sections, and 25% underuse the procedure, suggesting wide disparities in adherence to clinical recommendations.

Within countries large differences in use of C-sections exist between the rich and the poor, between public and private sectors, and between regions.

Authors call on healthcare professionals, hospitals, funders, women and families to only intervene with a C-section when it is medically required, while also highlighting the need for quality childbirth care globally.

Globally, the number of babies born through caesarean section (C-section) almost doubled between 2000 and 2015 - from 12% to 21% of all births - according to a Series of three papers published in The Lancet and launched at the International Federation of Gynecology and Obstetrics (FIGO) World Congress in Brazil. While the life-saving surgery is still unavailable for many women and children in low-income countries and regions, the procedure is overused in many middle- and high-income settings.

C-section is a life-saving intervention for women and newborns when complications occur, such as bleeding, foetal distress, hypertensive disease, and babies in abnormal position. But, the surgery is not without risk for mother and child, and is associated with complications in future births.

It is estimated that 10-15% of births medically require a C-section due to complications, suggesting that average C-section use should lie between these levels. However, the Series authors estimate that more than one in four countries in 2015 had lower levels (28%, 47/169 countries), while most countries used C-section above the recommended level (63%, 106/169 countries). In at least 15 countries C-section use exceeds 40% [1].

"Pregnancy and labour are normal processes, which occur safely in most cases. The large increases in C-section use - mostly in richer settings for non-medical purposes - are concerning because of the associated risks for women and children. C-sections can create complications and side effects for mothers and babies, and we call on healthcare professionals, hospitals, funders, women and families to only intervene in this way when it is medically required," says Series lead Dr Marleen Temmerman, Aga Khan University, Kenya and Ghent University, Belgium. "In cases where complications do occur, C-sections save lives, and we must increase accessibility in poorer regions, making C-sections universally available, but we should not overuse them." [2]

Disparities in global C-section use

The Series tracks trends in C-section use globally and in nine regions based on data from 169 countries from WHO and UNICEF databases. Globally, C-section use has increased by 3.7% each year between 2000-2015 - rising from 12% of live births (16 million of 131.9 million) in 2000, to 21% of live births (29.7 million of 140.6 million) in 2015.

However, the pace of change varied substantially between regions. The South Asia region has seen the most rapid increase in use (6.1% per year), with C-section being underused in 2000 but being overused by 2015 (increasing from 7.2% of births via C-section to 18.1%). However, improvements have been slow across sub-Saharan Africa (around 2% per year), where C-section use has remained low (increasing from 3% to 4.1% of births in West and Central Africa, and from 4.6% to 6.2% in Eastern and Southern Africa).

C-section continues to be overused in North America, Western Europe and Latin America and the Caribbean, where rates increased by around 2% per year between 2000-2015. C-section use increased from 24.3% to 32% between 2000-2015 in North America, from 19.6% to 26.9% in Western Europe, and from 32.3% to 44.3% in Latin America and the Caribbean.

The authors found that the global increases in C-section use are attributed both to more births taking place in health institutions (about two-thirds of the increase) and to greater frequency of intervention through C-section in health facilities (one-third of the increase).

Looking at trends in Brazil and China where there is high use of C-section, the authors found that most C-sections were in low-risk pregnancies and in women who had previously had a C-section. In Brazil, particularly high levels of C-section use were seen in women who were highly educated, compared with less educated women (54.4% of births vs 19.4%). The Series is accompanied by a linked Comment from Gilberto Magalhães Occhi, the Minister of Health of Brazil which sets out the country's strategies to optimise C-section use (see link at end of press release).

In the 10 countries with the highest number of births in 2010-2015, there were large differences in C-section use between regions - for example, differences between provinces in China ranged from 4% to 62%, and inter-state differences in India ranged from 7% to 49%. The USA, Bangladesh, and Brazil reported C-section use in more than 25% of births nationally, but some regions within these countries used C-section around twice as much as others [3].

There were also significant disparities within low- and middle-income countries, where the wealthiest women were six times more likely to have a C-section compared with the poorest women, and where C-section was 1.6 times more common in private facilities than public facilities. The authors suggest that this could be explained by persistent issues with shortages in health facilities and staff in vulnerable and rural populations.

In addition, in the UK C-section use has increased from 19.7% of births in 2000 to 26.2% in 2015 (country-level data is available in links at the end of the press release).

Harms associated with C-section overuse and underuse

C-section improves maternal, newborn and child survival when complications arise, and can also lower the risk of incontinence and prolapse.

However, there are short and long-term risks associated with C-sections for mothers and children, and there are no benefits of C-section in cases without a medical indication. In these instances, women and children can be harmed or die from the procedure, especially when there are not sufficient facilities, skills, and health care available.

Maternal death and disability is higher after C-section than vaginal birth. In particular, C-sections have a more complicated recovery for the mother, and lead to scarring of the womb, which is associated with bleeding, abnormal development of the placenta, ectopic pregnancy, stillbirth and preterm birth in subsequent pregnancies. The authors say that it is important to note that these are small but serious risks, but each of these risks increases as a woman has more C-sections.

There is emerging evidence that babies born via C-section have different hormonal, physical, bacterial and medical exposures during birth, which can subtly alter their health. While the long-term risks of this are not well-researched, the short-term effects include changes in immune development which can increase the risk of allergies and asthma and alter the bacteria in the gut.

"Given the increasing use of C-section, particularly cases that are not medically required, there is a crucial need to understand the health effects on women and children. Greater understanding of this is important to help inform decision making by families, physicians, and policy makers. C-section is a type of major surgery, which carries risks that require careful consideration. The growing use of C-sections for non-medical purposes could be introducing avoidable complications, and we advocate that C-section should only be used when it is medically required." says Professor Jane Sandall, King's College London, UK. [2]

Tackling overuse of C-section

Common reasons why women request C-sections include past negative experiences of vaginal birth, or fear of labour pain or of the effects of labour such as pelvic floor damage, urinary incontinence, reduced quality of sexual functioning. To address this, the authors recommend further research to study relaxation training, childbirth training workshops, educational lectures and brochures, and meeting with health professionals to promote supportive relationships, collaboration and respect.

For healthcare professionals, improved education, guidelines and communication, and second-opinion policies may also be helpful to address influences such as women's requests, convenience, financial incentives, and fear of litigation. In particular, in some regions C-sections are seen as protective, and physicians are less likely to be sued if complications occur, than during vaginal delivery.

The authors warn that in many settings young physicians are becoming experts in C-section, while losing confidence in their abilities to assist in vaginal birth.

Clinical interventions are needed to reduce unnecessary C-sections, but there is a lack of research and investment in this area. Early evidence suggests that offering vaginal breech delivery to carefully selected women, and attempting vaginal birth for women who have previously had C-sections may be helpful in reducing C-section use. In addition, some evidence suggests that reducing the number of interventions involved in pregnancy may help reduce C-section use, and this could be achieved by midwifery-led care, planning labour in birth centres, or offering continuous labour support.

"Although there is almost universal consensus that C-section use has increased beyond the reasonable level of need in many countries, effective interventions to optimise use have proven elusive. Interventions should recognise previous birth experiences, consider the health effects of C-section, and provide emotional support. Interventions should provide a sense of empowerment for women, and will require meaningful conversations with health professionals, policymakers and advocacy groups to influence the discussion around maternity care." says Dr Ana Pilar Betran, World Health Organization, Switzerland. [2]

Also published in The Lancet, a new position paper of FIGO: How to stop the Caesarean section epidemic. This linked Comment proposes six recommendations to reduce unnecessary C-sections, including informing women of the benefits and risks of C-sections, matching costs for C-section and vaginal birth in private and public hospitals, and ensuring hospitals publish their annual C-section rates. Emeritus Professor Gerard Visser, University Medical Centre, the Netherlands, and Chair of FIGO's Committee Safe Motherhood and Newborn Health at FIGO writes: "Worldwide there is an alarming increase in caesarean section (CS) rates. The medical profession on its own cannot reverse this trend. Joint actions with governmental bodies, the health care insurance industry, and women's groups are urgently needed to stop unnecessary CSs and enable women and families to be confident of receiving the most appropriate obstetric care for their individual circumstances."

A Lancet editorial published alongside the Series says: "What is left unresolved are the tensions generated when women's agency in choosing a caesarean section go against medical directives to intervene against them. Although the Lancet Series says that women's demand is not a substantial driver of the current problem of overuse, efforts to reduce caesareans must, nevertheless, strongly respect women's rights to choose the circumstances of birth. NICE guidance in the UK, for example, states that a woman should be offered a planned caesarean section if she so wishes. But it also says that practitioners can decline to provide one, and the new WHO guidance urges avoidance when caesarean is not indicated. What then? With this new Series we hope to spark more debate and research about implementing recommendations to reduce caesarean section use."

Lugano-Munich, 12 October 2018 - Twitter is a place where many cancer patients go to share and discuss their experiences of the disease. This is the main finding of a recent exploratory study (1), to be presented at the ESMO 2018 Congress in Munich, which analysed the contents of over 6,000 tweets and retweets about breast cancer.

Social media today have become an echo chamber in which every societal issue is reverberated many times over - including cancer. Study author Dr. Rodrigo Sanchez-Bayona of Clinica Universidad de Navarra in Pamplona, Spain, said: "Many of the patients we see in daily practice use social media to search for information about their disease, so, as care providers, we wanted to know what kind of content they find there. At the same time, the sheer volume of posts on Twitter represents a rich pool of data we can use to assess attitudes and discourses surrounding cancer."

For this analysis, all tweets posted with the hashtag #BreastCancer over a seven-day period were collected and categorised according to their content, aim, user information and whether they displayed a stigmatising attitude towards breast cancer. The tweets were also grouped into four subthemes: diagnosis, treatment, prognosis and prevention. "This study was part of a larger, multidisciplinary project to observe the presence of different diseases on social media. In 2014, we found that cancer was the most mentioned pathology on Twitter globally. We decided to look more closely at breast cancer first, because it is one of the three most common tumours worldwide and the primary cause of cancer deaths in women."

The data collected included 3,703 original tweets and 2,638 retweets. "When examining the original tweets, we found that only one in three had medical content," said Sanchez-Bayona. "However, 90% of this medical information was appropriate, which is likely owed to the fact that 40% of tweets came from institutions and public accounts." The categorisation of tweets by aim showed that the most frequent motive was patients sharing their experiences, followed closely by patient advocacy. The most common subtheme by far was prevention (44.5% of tweets).

Out of the 2,559 non-medical tweets analysed, less than 15% contained stigmatising statements about the disease. "The numerous breast cancer awareness campaigns over the years have certainly contributed to reducing the stigma associated with this illness," said Sanchez-Bayona. "For many other tumours, there is still an unmet need. Going forward we would also like to explore and compare the social media presence of different tumours types."

"Although it would be interesting to do further research into the profiles of social media users who are the most active in the discussion about cancer, these initial findings may prove useful in themselves," he continued. "In particular, advocacy organisations can draw on them to create relevant medical content and counselling about cancer that will be more accessible to users. Social media can be used as a new way of providing information on cancer prevention and health education - not just to patients, but to a much broader audience."

Dr. Marina Garassino of Istituto Nazionale dei Tumori in Milan, Italy, commented for ESMO: "Twitter is a high-level platform that is much more credible than other social networks like Facebook, so I was not surprised to see that the majority of the news published there are accurate," she said. "This analysis also illustrates the presence of patients in large numbers on Twitter. We should take that as corroboration of a new reality: patients now use the web to find information, and social media must be an integral part of our communication with them. Academic institutions and key opinion leaders need to be even more active in spreading their findings through these channels to counteract the many 'fake news' circulating online."

Dr. Evandro de Azambuja, ESMO Executive Board member, further commented: "I agree that the volume of reliable medical content published on Twitter should increase. Healthcare professionals and organisations really need to use appropriate social media as a way of sharing relevant information - both between them and with patients - because that is where it has the potential to be picked up fastest and most broadly."

"Personally, I check Twitter daily for announcements of the latest publications of leading academic journals and fellow oncologists. I can then go and read the articles I'm interested in, knowing exactly where to find them. It's an efficient way of obtaining medical information as it is published," de Azambuja added. "When it comes to bringing the best evidence available in cancer research to the attention of as many people as possible, this platform is as powerful a tool as it gets."

The Philippines' highly politicised response to newly-reported risks of a dengue vaccine led to a dramatic drop in public trust in vaccines overall, according to new research published in Human Vaccines & Immunotherapeutics.

Led by the London School of Hygiene & Tropical Medicine (LSHTM), the study measured the impact of the Dengvaxia crisis on overall vaccine confidence before and after the manufacturer highlighted a risk associated with the vaccine and the associated political fallout.

The study of 1,500 participants revealed a dramatic drop in vaccine confidence, from the majority (93%) "strongly agreeing" that vaccines are important in 2015 to a third (32%) in 2018. The researchers say the findings highlight the importance of identifying gaps or breakdowns in public confidence in vaccines in order to rebuild trust before a pandemic strikes.

Dengue is a viral infection spread mainly by the bite of the Aedes aegypti mosquito, which is widespread around the Southern Hemisphere. Symptoms include fever, headache, and pain in joints and muscles. In some cases, symptoms can be more severe and lead to death.

With cases in the Philippines rising from 2012-2015, it was hoped an immunisation campaign with a new dengue vaccine (Dengvaxia), licenced in December 2015, would stem the spread. However, in November 2017, the manufacturer, Sanofi Pasteur, announced that Dengvaxia posed a risk to people who had not previously been exposed to dengue.

While other countries dealt with this assessment by updating guidelines and labelling accordingly, the news triggered outrage and political turmoil in the Philippines leading to broken public trust in the dengue vaccine and anxiety around vaccines in general.

Using the WIN/Gallup International's representative sampling approach with the Vaccine Confidence Index™, 1,500 participants were re-surveyed in 2018 to analyse the Philippines' confidence data against 2015 data for the country.

On the vaccine safety question, there was a four-fold drop in confidence from 82% strongly agreeing that vaccines are safe in 2015 to only 21% in 2018, while confidence in the effectiveness of vaccines dropped from 82% in 2015 to 22% in 2018.

Lead author Professor Heidi Larson, Director of the Vaccine Confidence Project at LSHTM, said: "The Sanofi announcement was a spark that fuelled the flames of underlying political ferment in the Philippines. Health authorities and immunisation programmes cannot solve political tensions, but trust issues and potential areas of anxiety and possible dissent must be considered in advance of a pandemic. This is especially important in an era of social media and the ability for mis-information to be spread far and wide at the touch of a button.

"We cannot wait until pandemics strike, but make trust-building an ongoing effort, preparing the ground for the next 'big one', when trust and cooperation will be key to containing the spread of disease and mitigating its health and societal impacts."

A new study has found that the Rehabilitation Enablement in CHronic Heart Failure (REACH-HF) programme, led by the University of Exeter and the Royal Cornwall Hospitals NHS trust, significantly improved quality of life and is deliverable within NHS cost guidelines.

The programme was co-designed by clinicians, academics, patients and caregivers to help increase participation in rehabilitation therapies for heart failure patients by bringing care into their own homes. The five year study received £2million in grant funding from the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research programme with contributions from a number of clinical and academic partners from across the UK including Exeter, Gwent, Birmingham, York, and Dundee.

Approximately 900,000 people are affected by heart failure in the UK, costing the NHS £1bn per year. Although NICE recommend that all people with heart failure should receive rehabilitation, less than one in 10 do.

With this in mind, the new 2018 heart failure guidelines from NICE recommend that patients are offered the option of a personalised home-based rehab programme that is easily accessible.

The rehabilitation programme includes: a chair-based exercise that can easily be done at home and a manual with advice on lifestyle and medication. Also included is an interactive booklet designed to facilitate learning from experience and record symptoms, physical activity and other actions related to self-care. There is another manual for use by caregivers aimed to increase their understanding of heart failure and aspects such as relaxation techniques, helping people come to terms with both the physical and psychological impact of heart failure.

In the study, researchers monitored patients participating in the programme for 12 months, and found that their quality of life was significantly improved compared to patients not undergoing rehabilitation. The cost of the intervention was £418 per patient (within the current price that the NHS pays for rehabilitation: £477).

This high-calibre multi-author study, jointly led by Professor Rod Taylor, and Dr Hasnain Dalal of the University of Exeter, has just been published in the European Journal of Preventive Cardiology.

Dr Hasnain Dalal, of the University of Exeter and the Royal Cornwall Hospitals NHS Trust, said: "Although previous hospital-based studies have shown an improvement in quality of life and reduction in hospital admissions for patients receiving cardiac rehabilitation, heart failure patients often find it difficult to attend rehabilitation centres in hospitals. This tends to be due to lack of access to transport, poor mobility, and other health problems and can lead to isolation and depression. Our research gives us hope that this more accessible rehabilitation intervention will increase participation and improve patients' quality of life."

The REACH-HF programme is a home-based programme of exercise and well-being for patients with heart failure and their caregivers which was designed to make rehabilitation more accessible. It builds on the existing Heart Manual (NHS Lothian), used with patients after a heart attack or surgery.

The study shows significant clinical benefit for participants when compared to patients not undergoing rehabilitation.

REACH-HF is aimed at patients with heart failure with reduced ejection fraction, where their heart muscles do not contract as effectively as they should, resulting in poorer circulation of blood around the body. This affects approximately half of heart failure patients.

The study involved 216 patients, with an average age of 70, Those undertaking the REACH-HF were assisted by specially trained cardiac nurses or physiotherapists for 12 weeks. In addition to education and psychological support the rehab programme included chair-based or walking exercises three or more times a week. The patients' quality of life was then monitored over the course of a year using a disease specific 'Health Related Quality of Life' questionnaire - the Minnesota Living with Heart Failure Questionnaire.

Professor Rod Taylor, of the University of Exeter Medical School said: "In this study we demonstrate the effectiveness of the REACH-HF programme on the quality of life, and ability of patients to better manage their condition.

"We now we hope to see REACH-HF rolled out across the UK as genuine menu option for all cardiac rehab programmes which will help improve uptake to rehabilitation and improve the quality of life of people with HF and their caregivers."

Professor Colin Greaves of the University of Birmingham who led the design team that developed the REACH-HF intervention while he was at the University of Exeter, said: "The results of this study provide compelling evidence that a home-based programme of exercise and self-care support for people with heart failure and their caregivers should now be rolled out as part of national NHS policy."

The study is entitled 'The effects and costs of home-based rehabilitation for heart failure with reduced ejection fraction: the REACH-HF multicentre randomized controlled trial'. The full list of authors is Hasnain M. Dalal, Rod S. Taylor, Kate Jolly, Russell C. Davis, Patrick Doherty, Jackie Miles, Robin van Lingen, Fiona C. Warren, Colin Green, Jennifer Wingham, Colin Greaves, Susannah Sadler, Melvyn Hillsdon, Charles Abraham, Nicky Britten, Julia Frost, Sally Singh, Christopher Hayward, Victoria Eyre, l Kevin Paul, Chim C. Lang, and Karen Smith.

Case study: "I would never have gone to the gym"

When Chris Edgeler's GP suggested he take part in a rehabilitation programme following a heart attack, he initially thought it wasn't for him. Despite his diagnosis of heart failure, he felt it would be hard to engage.

"I'm not the type of person to sit in groups talking about my feelings," said Chris, a retired council worker. "I would never have gone to the gym. The home-based rehabilitation programme was perfect for me. It even involved my wife. I hadn't realised that she was scared that I was going to drop dead, and previously everything we'd taken part in was all about me and my care. This helped us both understand how we were feeling."

Six years on, and Chris, now 58, has given up smoking and is eating more healthy foods. "The programme is really clear and easy to follow. The relaxation techniques are great too. One night they helped me to calm down and avoid ringing 999 when I was feeling unwell. It's a brilliant programme and it's worked so well for me."

Pneumonia-causing bacteria can be spread through picking and rubbing the nose, according to new research published in the European Respiratory Journal [1].

Pneumococcus, the bacteria that can cause pneumonia, is known to be spread through inhalation of airborne droplets containing the bacteria, for example in coughs and sneezes. This study is the first to show that transmission can also occur via contact between the nose and the hands after exposure to pneumococcus bacteria.

The study found that bacteria can spread at the same rate whether it is dry or wet, and at the same rate when a person picks or pokes their nose as when they rub their nose. The results suggest that ensuring good hand hygiene and keeping toys clean could help to protect young children from catching and spreading the bacteria on to other children and their elderly relatives, who may be more susceptible to infection.

Lead researcher Dr Victoria Connor, a clinical research fellow at the Liverpool School of Tropical Medicine and Royal Liverpool Hospital, explained: "Pneumococcal infection is a major cause of death around the world, and it is estimated that it is responsible for 1.3 million deaths in children under five years annually. The elderly and people with other causes of impaired immunity, such as chronic illness, are also at an increased risk of pneumococcal infections.

"Our current understanding of the transmission of pneumococcus is poor, so we wanted to look at how it may be spread in the community. Having a clearer understanding of how the bacteria is spread will allow for better advice on how transmission can be reduced, so that there is greater prevention of pneumococcal infections."

To assess the potential for hand-to-nose contact to cause pneumococcus bacteria to spread into the nose, 40 healthy adult volunteers were randomly allocated to four groups that were exposed to pneumococcus bacteria using different hand-to-nose methods.

One group had water containing pneumococcus bacteria applied to their hands and were then asked to sniff their hands ("wet sniff"). A second group were asked to sniff air-dried pneumococcus bacteria from the back of the hand ("dry sniff"). The third and fourth group were asked to pick or poke their nose with a finger that was either exposed to wet pneumococcus bacteria ("wet poke") or exposed to air-dried pneumococcus bacteria ("dry poke").

Two different detection methods were then used to test for pneumococcus, to confirm the presence of the bacteria in the participants' noses. These included a test to see if they could grow pneumococcus bacteria from wash samples of the participants' noses (culture), and whether they could detect the presence of bacterial DNA (qPCR).

The results showed that the highest rates of bacteria spread were among participants in the "wet poke" group, followed by the "wet sniff" group.

The researchers say that participants were just as likely to get pneumococcus bacteria in their noses whether they were exposed using wet or dry samples, but the total number of bacteria passed on was higher in the wet groups; the authors suggest this may be because the air-drying process leads to the death of some bacteria.

The tests also showed that the same amount of transmission occurred when the participants poked or picked their nose as when they rubbed their nose with the back of their hand.

Dr Connor said: "It might not be realistic to get children to stop picking, poking and rubbing their noses, and presence of the bacteria can sometimes boost the immune system of children and can reduce their chances of carrying it again later in life, so it is unclear if completely reducing the spread of pneumococcus in children is the best thing.

"But for parents, as this research shows that hands are likely to spread pneumococcus, this may be important when children are in contact with elderly relatives or relatives with reduced immune systems. In these situations, ensuring good hand hygiene and cleaning of toys or surfaces would likely reduce transmission, and reduce the risk of developing pneumococcal infection such as pneumonia."

The researchers highlight that using real people as part of the study design enabled them to test the survival of pneumococcus and the viability of transmission methods in a safe and controlled way.

Professor Tobias Welte, from Hannover University, Germany, is President of the European Respiratory Society and was not involved in the study. He said: "This pilot study is the first to confirm that pneumococcus bacteria can be spread through direct contact, rather than just through breathing in airborne bacteria.

"For clinicians, the findings reinforce the message that we must promote rigorous hand hygiene and basic infection control measures such as avoidance of sharing food, drink and mobile phones, in order to potentially reduce the transmission of respiratory bacterial pathogens such as pneumococcus. Pneumococcal vaccination is the best method for limiting the spread of S. pneumoniae in to the sinuses and lower airways, but vaccination rates are below 50% for those for whom it is recommended. To improve this is one of the major tasks for healthcare policy."

The researchers note that the bacteria samples used in the tests were given at a dose which may not represent a real-life scenario, so the results may be treated with caution. They plan to look at how pneumococcus is shed from the nose, and if hand washing reduces the spread from hand to nose.

Higher levels of biomarkers of dairy fat consumption are associated with a lower risk of developing type 2 diabetes, according to new research published today in PLOS Medicine. The study, in more than 60,000 adults, was undertaken by an international consortium led by scientists at the Medical Research Council Epidemiology Unit, University of Cambridge, and the Friedman School of Nutrition Science and Policy at Tufts University.

International nutritional guidelines commonly recommend regular consumption of dairy products as an important source of key nutrients, and in high-income countries, eating low-fat dairy products is encouraged as part of overall recommendations to limit saturated fat consumption. In some research, consumption of dairy products, in particular yoghurt and cheese, has been associated with a lower incidence of type 2 diabetes. But these findings are inconsistent and the evidence remains controversial.

The FORCE Consortium was established by researchers from Europe, North America, Australia, and Asia to examine the relationships of fatty acid biomarkers with diseases. Biomarkers are tell-tale molecules in the body that can be measured accurately and consistently, and act as indicators of dietary consumption.

Concentrations in body tissue of certain types of fat have been found to correlate with consumption of fat rich dairy foods, both in self-reported studies and in intervention studies where participants eat a controlled diet. These biomarkers of dairy fat offer a complementary approach, alongside self-reporting of food consumption, to investigate associations of dairy fat consumption with type 2 diabetes in large populations.

The researchers examined specific biomarkers of dairy fat consumption from a total of 63,682 adults from 16 multi-national studies that are part of the FORCE Consortium. These participants were all free from type 2 diabetes when the first samples were taken, and 15,158 of them went on to develop type 2 diabetes over the follow-up period of up to 20 years. In each of the studies, the researchers analysed the relationships of dairy fat biomarkers with the risk of developing type 2 diabetes.

When all the results of the 16 studies were pooled the researchers found that higher concentrations of dairy-fat biomarkers were associated with lower risk of developing type 2 diabetes. This lower risk was independent of other major risk factors for type 2 diabetes including age, sex, race/ethnicity, socioeconomic status, physical activity and obesity.

For example, if people among the top fifth of the concentrations of dairy-fat markers were compared with people among the bottom fifth of the concentrations, the top-fifth people had an approximately 30% lower risk of type 2 diabetes.

Lead author, Dr Fumiaki Imamura from the MRC Epidemiology Unit, University of Cambridge, said: "Our results provide the most comprehensive global evidence to date about dairy fat biomarkers and their relationship with lower risk of type 2 diabetes. We're aware that our biomarker work has limitations and requires further research on underlying mechanisms, but at the very least, the available evidence about dairy fat does not indicate any increased risk for the development of type 2 diabetes.

"We hope that our findings and existing evidence about dairy fat will help inform future dietary recommendations for the prevention of lifestyle-related diseases."

Senior author, Professor Dariush Mozaffarian, Dean of the Friedman School of Nutrition Science and Policy at Tufts University, said: "While dairy foods are recommended as part of a healthy diet, U.S. and international guidelines generally recommend low-fat or non-fat dairy due to concerns about adverse effects of higher calories or saturated fat. Our findings, measuring biomarkers of fatty acids consumed in dairy fat, suggest a need to re-examine the potential metabolic benefits of dairy fat or foods rich in dairy fat, such as cheese."

Despite the several advantages of evaluating fatty acid biomarkers, the researchers caution that the results cannot distinguish between different types of dairy foods (e.g., milk, cheese, yoghurt, others), which could have differential effects. While these biomarkers are known to reflect dairy fat consumption, levels of the biomarkers could also be influenced by other known or unknown factors or may not be exclusive to dairy intake. Data from non-white populations was also limited, and the authors recommend that further research should be undertaken in diverse populations where different types of dairy products may be consumed with different food preparation methods.

Ever wonder why things that normally feel gentle, like putting on soft shirts, are painful after a sunburn? In a study of four patients with a rare genetic disorder, NIH researchers found that PIEZO2, a gene previously shown to control our sense of our bodies in space and gentle touch, may also be responsible for tactile allodynia: the skin's reaction to injury that makes normally gentle touches feel painful. This and a second NIH-funded study, both published in Science Translational Medicine, used mice to show how the gene may play an essential role in the nervous system's reaction to injury and inflammation, making PIEZO2 a target for developing precise treatments for relieving the pain caused by cuts, burns, and other skin injuries.

"For years scientists have been trying to solve the mystery of how gentle touch becomes painful. These results suggest PIEZO2 is the gene for tactile allodynia. We hope that these results will help researchers develop better treatments for managing this form of pain," said Alexander T. Chesler, Ph.D., a Stadtman Investigator at the National Center for Complementary and Integrative Health (NCCIH) and a senior author of one of the studies.

The PIEZO2 gene encodes what scientists call a mechanosensitive protein which produces electrical nerve signals in response to changes in cell shape, such as when skin cells and neurons of the hand are pressed against a table. Since its discovery in mice by a team led by Ardem Patapoutian, Ph.D., Scripps Research, La Jolla, CA, the lead author of the second paper, scientists have proposed that PIEZO2 plays an important role in touch and pain in humans.

In 2016, Dr. Chesler's team worked with the group of Carsten G. Bönnemann, M.D., senior investigator at the NIH's National Institute of Neurological Disorders and Stroke (NINDS), to show that two patients who had mutations in PIEZO2 that eliminated its activity lacked proprioception, or a sixth sense of how our bodies are positioned in space. They were also unable to feel vibrations and were less sensitive to certain forms of gentle touch.

In this new study, Drs. Chesler and Bönnemann worked with pain expert Catherine Bushnell, Ph.D., at NCCIH, to examine four more patients at the NIH's Clinical Center and found that PIEZO2 controls tactile allodynia after a skin injury. To test for allodynia the researchers had participants sit at a table facing a barrier that blocked their view of their arms. The researchers then dabbed two creams onto a participant's arm. One was a placebo, which had no effect, and the other contained capsaicin, the ingredient that makes chili peppers hot and causes inflammation, as seen with sunburns.

The researchers found stark differences between how the capsaicin affected control participants and ones with mutations in PIEZO2. Swiping a cotton swab around the capsaicin patch consistently caused control participants to feel pain, which allowed each one to correctly identify where the inflammation was even though they could not see their arms. In contrast, the participants with the PIEZO2 mutation felt no difference between the areas where capsaicin and placebo had been applied.

"What's remarkable about the PIEZO2-deficient participants is the 'clarity' of their conditions. With their help we're getting fundamental new insights about how the loss of PIEZO2 affects them specifically and learning what PIEZO2 is normally used for, which could be of immense medical importance to all other people," said Dr. Bönnemann. "This type of PIEZO2-dependent pain makes it very hard to apply bandages to burns and wounds that are important for healing. Most pain treatments numb large areas of the body. Our results suggest that if we could shut down PIEZO2 in the area of a wound, we would hopefully relieve the pain and speed recovery."

Further experiments in mice by Dr. Chesler and Dr. Patapoutian confirmed the results observed in patients. Deleting PIEZO2 eliminated gentle touch sensations in mice as well as those felt during inflammation and injury.

Although neither study shows exactly how inflammation causes pain, their results suggest that inflammation does not alter the ability of PIEZO2 to detect gentle touches. For instance, Dr. Chesler's group showed in control mice that inflammation had no major effect on how the PIEZO2-containing neurons fired in response to gentle brushing. Instead, their results support the Gate Theory, which states that inflammation causes gentle touches to feel painful because neurons in the brain or spinal cord reinterpret signals from the rest of the body.

"It appears that inflammation doesn't change the ability of neurons in the skin to sense gentle touch but instead reroutes the information that's sent throughout the rest of the nervous system," said Dr. Patapoutian. "We hope these results help pain researchers better understand the mechanisms behind tactile allodynia."

Podcast permanent link: https://soundcloud.com/cmajpodcasts/180194-guide

The updated comprehensive C-CHANGE (Canadian Cardiovascular Harmonized National Guidelines Endeavour) guideline to manage cardiovascular disease will help primary care physicians across Canada provide better care for patients with, or who are at risk of, heart disease. The guideline, published in CMAJ (Canadian Medical Association Journal), updates the 2014 guideline, with 52 newly added or updated recommendations.

"Patients often have multiple comorbidities, complicated by conditions such as stroke or myocardial infarction," writes Dr. Sheldon Tobe, Division of Nephrology, Sunnybrook Health Sciences Centre, Toronto, Ontario, with coauthors. "A disease-silo approach to care leads to the risk of fragmentation, overlooking treatable risk factors. C-CHANGE helps to promote patient care by bringing guidelines from multiple groups together, formatted so that members of the interprofessional team can collaborate to formulate a comprehensive treatment plan directed to patient priorities."

The guideline, developed by nine Canadian guideline groups, is based on the best available evidence and provides a single nationally recognized set of best practices for physicians to use across the country.

New or updated recommendations include the following:

A new, lower threshold for treatment and blood pressure in high-risk patients with hypertension

Treatment of high-risk patients with dyslipidemia (high cholesterol) with statins to prevent cardiovascular disease (a risk-assessment should be performed in primary-care patients to avoid unnecessary pharmacologic treatment)

Diabetes testing with a two-hour plasma glucose after a 75 g oral glucose tolerance test

Use of direct oral anticoagulants instead of warfarin for nonvalvular atrial fibrillation

Lifestyle changes, such as lower sodium intake, in people with hypertension and screening and advice on smoking cessation

The guideline is aimed at primary-care providers treating adult patients who have, or are at risk of developing, cardiovascular diseases, such as hypertension, diabetes, high cholesterol, heart failure and stroke, as well as the risk factors for these conditions, including obesity, smoking and inactivity.

"The goal of the C-CHANGE process is for all Canadian health care practitioners to have easy access to a comprehensive and usable set of harmonized guidelines," write the authors.

"Canadian Cardiovascular Harmonized National Guidelines Endeavour (C-Change): guideline for the prevention and management of cardiovascular disease in primary care: 2018 update" is published October 9, 2018

Planned intermittent fasting may help to reverse type 2 diabetes, suggest doctors writing in the journal BMJ Case Reports after three patients in their care, who did this, were able to cut out the need for insulin treatment altogether.

Around one in 10 people in the US and Canada have type 2 diabetes, which is associated with other serious illness and early death. It is thought to cost the US economy alone US$245 billion a year.

Lifestyle changes are key to managing the disease, but by themselves can't always control blood glucose levels, and while bariatric surgery (a gastric band) is effective, it is not without risk, say the authors. Drugs can manage the symptoms, and help to stave off complications, but can't stop the disease in its tracks, they add.

Three men, aged between 40 and 67, tried out planned intermittent fasting to see if it might ease their symptoms. They were taking various drugs to control their disease as well as daily units of insulin. In addition to type 2 diabetes, they all had high blood pressure and high cholesterol.

Two of the men fasted on alternate days for a full 24 hours, while the third fasted for three days a week. On fast days they were allowed to drink very low calorie drinks, such as tea/coffee, water or broth, and to eat one very low calorie meal in the evening.

Before embarking on their fasting regime, they all attended a 6-hour long nutritional training seminar, which included information on how diabetes develops and its impact on the body; insulin resistance; healthy eating; and how to manage diabetes through diet, including therapeutic fasting.

They stuck to this pattern for around 10 months after which fasting blood glucose, average blood glucose (HbA1c), weight, and waist circumference were re-measured.

All three men were able to stop injecting themselves with insulin within a month of starting their fasting schedule. In one case this took only five days.

Two of the men were able to stop taking all their other diabetic drugs, while the third discontinued three out of the four drugs he was taking. They all lost weight (by 10-18%) as well as reducing their fasting and average blood glucose readings, which may help lower the risk of future complications, say the authors.

Feedback was positive, with all three men managing to stick to their dietary schedule without too much difficulty.

This is an observational study, and refers to just three cases-all in men. As such, it isn't possible to draw firm conclusions about the wider success or otherwise of this approach for treating type 2 diabetes.

"The use of a therapeutic fasting regimen for treatment of [type 2 diabetes] is virtually unheard of," write the authors. "This present case series showed that 24-hour fasting regimens can significantly reverse or eliminate the need for diabetic medication," they conclude.

Toddlers with asthma are more likely to become obese children, according to an international study led by USC scientists.

The finding is a turnabout for children's health as obesity has often been seen as a precursor to asthma in children, not the other way around. The study, conducted by a team of 40 scientists including researchers at the Keck School of Medicine of USC, was recently published in the European Respiratory Journal.

This is the largest study yet about early-onset asthma and obesity. It focused on more than 20,000 youths across Europe. It shows that, beyond wheezing and shortness of breath, asthma can lead to bodies that make young people more susceptible to other health problems later in life.

Lida Chatzi, the senior author and professor of preventive medicine at USC, says asthma and obesity pack a one-two punch against children's health, which raises concern about a public health crisis due to their prevalence.

"We care about this issue because asthma affects approximately 6.5 million children - about one in 10 - in the United States," Chatzi said. "It's a chronic childhood disorder and if it increases the risk of obesity, we can advise parents and physicians on how to treat it and intervene to help young children grow up to enjoy healthy, adult lives."

For two decades, scientists have documented the parallel epidemics of childhood asthma and obesity, with focus on how obesity is a risk factor for asthma. In adults, obesity is an important risk factor for new asthma, especially among women, but the relationships appear to differ in children. Few studies look at the problem the other way around to understand how asthma contributes to obesity in kids, which prompted scientists to undertake this research.

Drawing upon big data on children's health collected across Europe, the scientists investigated 21,130 children born between 1990 and 2008 across nine countries, including Denmark, France, Germany, Greece, Italy, the Netherlands, Spain, Sweden and the United Kingdom.

The children were diagnosed by physicians with asthma at 3 to 4 years old and the scientists followed toddlers into childhood up to 8 years of age. Their goal was to focus on health risks of early-onset asthma.

On average, the scientists found that children diagnosed with asthma had a 66 percent higher risk of becoming obese than those without an asthma diagnosis. For children with persistent wheezing symptoms, their risk of developing obesity was 50 percent greater compared to children without such symptoms. Children with active asthma were nearly twice as likely to develop obesity than those without asthma and wheezing, according to the study. The findings are consistent with previous, but smaller, longitudinal studies conducted in the United States that observed asthma increased the risk of obesity.

The causal direction between asthma and obesity is not well understood. Asthma is regarded as a barrier to children's physical activity that might lead to accumulation of fat in the body, while higher doses of inhaled corticosteroids had been hypothesized to increase risk of obesity in children with asthma. According to the study, children with asthma who used medication had the strongest risk of developing obesity.

Since both asthma and obesity have their origins early in life, it is possible that the asthma-obesity association is also established in this critical time window of child development. Previous studies have shown that in utero exposures, such as prenatal diet or maternal obesity, are associated with increased risk of both disorders.

"Asthma may contribute to the obesity epidemic. We urgently need to know if prevention and adequate treatment of asthma can reduce the trajectory toward obesity," said Frank Gilliland, professor of preventive medicine at the Keck School of Medicine, who participated in the study.

According to the U.S. Centers for Disease Control and Prevention, about 40 percent of Americans, or 93 million, are obese. The estimated annual medical cost of obesity nationwide was $147 billion in 2008, the CDC estimates. Obesity is linked to diseases such as diabetes, high blood pressure and stroke.

The CDC reports the number of people with asthma in the United States is growing every year. About one in 12 Americans is afflicted with the illness. In smoggy places, like California's San Joaquin Valley, about 1 in 6 children suffer from asthma, the highest rate in the country.

In Europe, 1 in 8 people die due to lung diseases - or about one person per minute. It includes well-known diseases like asthma and lung cancer and other less-known diseases like chronic obstructive pulmonary disease, which is now the third most common cause of death, according to the European Respiratory Society.

Refugee and immigrant youth in Ontario may face barriers to accessing mental health services through primary care, say the authors of a study of emergency department visits published in CMAJ (Canadian Medical Association Journal).

The study looked at emergency department visits for mental health issues or self-inflicted harm by youth between the ages of 10 and 24 years in Ontario. There were 118,851 youth who visited an emergency department with a mental health concern during the five-year study period (2010-2014), of whom 1.8% (2194) were refugees and 5.6% (6680) were non-refugee immigrants. For many of these youth, their emergency department visit was their first physician contact for mental health services. Rather than presenting first to primary care, 61.3% of refugee youth, 57.6% of non-refugee immigrants and 51.3% of non-immigrant youth presented to the emergency department with a mental health crisis.

Among immigrants, newcomers (fewer than five years in Canada) and refugees had the highest rates of first contact in the emergency department. Having a family doctor who practised as part of a team (versus a walk-in clinic model of care) was associated with better rates of receiving outpatient mental health care prior to presenting in crisis to the emergency department.

"Our study highlights that immigrants face barriers to using mental health services from a physician on an out-patient basis, but there is variability within immigrant groups by country and region of origin as well as by duration of residence in Canada," says Dr. Natasha Saunders, Department of Pediatrics, The Hospital for Sick Children (SickKids) and ICES.

"The results are consistent with those of other studies of adults that show immigrants and refugees may not have the same access to mental health services by physicians in the community compared with non-immigrants," she says.

"The findings suggest a need to understand the barriers and enabling factors that contribute to the use of mental health services and access to care, including focusing efforts to reduce stigma and identify mental health problems early, before crises. This is particularly important for refugee and newcomer youth and immigrants from Africa and Central America where we saw the highest rates of first contact in the emergency department," say the authors.

In a related commentary, Dr. David Cawthorpe, Alberta Children's Hospital Research Institute, University of Calgary, writes "What is clear from this study, however, is that first presentation with a mental health issue to the emergency department is common for all youth in Ontario, which signals general problems with access to appropriate mental health services in the province."

"There is no question that marginal groups may be overrepresented at the gateways to service, and it is necessary to understand and address the contributing factors. Nevertheless, failing to grasp the overarching issues, such as the lack of integration and organization of health and mental health services, will perpetuate current barriers to access and treatment. Youth mental health resources remain the orphan's orphan -- segregated and scarce -- and proven fledging innovations directed at shaping access to appropriate services require wider dissemination," he argues.

"Use of the emergency department as a first point of contact for mental health care by immigrant youth in Canada: a population-based study" is published October 9, 2018.

CAMBRIDGE, Mass. -- A class exercise at MIT, aided by industry researchers, has led to an innovative solution to one of the longstanding challenges facing the development of practical fusion power plants: how to get rid of excess heat that would cause structural damage to the plant.

The new solution was made possible by an innovative approach to compact fusion reactors, using high-temperature superconducting magnets. This method formed the basis for a massive new research program launched this year at MIT and the creation of an independent startup company to develop the concept. The new design, unlike that of typical fusion plants, would make it possible to open the device's internal chamber and replace critical components; this capability is essential for the newly proposed heat-draining mechanism.

The new approach is detailed in a paper in the journal Fusion Engineering and Design, authored by Adam Kuang, a graduate student from that class, along with 14 other MIT students, engineers from Mitsubishi Electric Research Laboratories and Commonwealth Fusion Systems, and Professor Dennis Whyte, director of MIT's Plasma Science and Fusion Center, who taught the class.

In essence, Whyte explains, the shedding of heat from inside a fusion plant can be compared to the exhaust system in a car. In the new design, the "exhaust pipe" is much longer and wider than is possible in any of today's fusion designs, making it much more effective at shedding the unwanted heat. But the engineering needed to make that possible required a great deal of complex analysis and the evaluation of many dozens of possible design alternatives.

Taming fusion plasma

Fusion harnesses the reaction that powers the sun itself, holding the promise of eventually producing clean, abundant electricity using a fuel derived from seawater -- deuterium, a heavy form of hydrogen, and lithium -- so the fuel supply is essentially limitless. But decades of research toward such power-producing plants have still not led to a device that produces as much power as it consumes, much less one that actually produces a net energy output.

Earlier this year, however, MIT's proposal for a new kind of fusion plant -- along with several other innovative designs being explored by others -- finally made the goal of practical fusion power seem within reach. But several design challenges remain to be solved, including an effective way of shedding the internal heat from the super-hot, electrically charged material, called plasma, confined inside the device.

Most of the energy produced inside a fusion reactor is emitted in the form of neutrons, which heat a material surrounding the fusing plasma, called a blanket. In a power-producing plant, that heated blanket would in turn be used to drive a generating turbine. But about 20 percent of the energy is produced in the form of heat in the plasma itself, which somehow must be dissipated to prevent it from melting the materials that form the chamber.

No material is strong enough to withstand the heat of the plasma inside a fusion device, which reaches temperatures of millions of degrees, so the plasma is held in place by powerful magnets that prevent it from ever coming into direct contact with the interior walls of the donut-shaped fusion chamber. In typical fusion designs, a separate set of magnets is used to create a sort of side chamber to drain off excess heat, but these so-called divertors are insufficient for the high heat in the new, compact plant.

One of the desirable features of the ARC design is that it would produce power in a much smaller device than would be required from a conventional reactor of the same output. But that means more power confined in a smaller space, and thus more heat to get rid of.

"If we didn't do anything about the heat exhaust, the mechanism would tear itself apart," says Kuang, who is the lead author of the paper, describing the challenge the team addressed -- and ultimately solved.

Inside job

In conventional fusion reactor designs, the secondary magnetic coils that create the divertor lie outside the primary ones, because there is simply no way to put these coils inside the solid primary coils. That means the secondary coils need to be large and powerful, to make their fields penetrate the chamber, and as a result they are not very precise in how they control the plasma shape.

But the new MIT-originated design, known as ARC (for advanced, robust, and compact) features magnets built in sections so they can be removed for service. This makes it possible to access the entire interior and place the secondary magnets inside the main coils instead of outside. With this new arrangement, "just by moving them closer [to the plasma] they can be significantly reduced in size," says Kuang.

In the one-semester graduate class 22.63 (Principles of Fusion Engineering), students were divided into teams to address different aspects of the heat rejection challenge. Each team began by doing a thorough literature search to see what concepts had already been tried, then they brainstormed to come up with multiple concepts and gradually eliminated those that didn't pan out. Those that had promise were subjected to detailed calculations and simulations, based, in part, on data from decades of research on research fusion devices such as MIT's Alcator C-Mod, which was retired two years ago. C-Mod scientist Brian LaBombard also shared insights on new kinds of divertors, and two engineers from Mitsubishi worked with the team as well. Several of the students continued working on the project after the class ended, ultimately leading to the solution described in this new paper. The simulations demonstrated the effectiveness of the new design they settled on.

"It was really exciting, what we discovered," Whyte says. The result is divertors that are longer and larger, and that keep the plasma more precisely controlled. As a result, they can handle the expected intense heat loads.

"You want to make the 'exhaust pipe' as large as possible," Whyte says, explaining that the placement of the secondary magnets inside the primary ones makes that possible. "It's really a revolution for a power plant design," he says. Not only do the high-temperature superconductors used in the ARC design's magnets enable a compact, high-powered power plant, he says, "but they also provide a lot of options" for optimizing the design in different ways -- including, it turns out, this new divertor design.

Going forward, now that the basic concept has been developed, there is plenty of room for further development and optimization, including the exact shape and placement of these secondary magnets, the team says. The researchers are working on further developing the details of the design.

"This is opening up new paths in thinking about divertors and heat management in a fusion device," Whyte says.