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Elective induction at 39 weeks reduces maternal and newborn complications

Newborns have fewer respiratory problems

Women report less labor pain, have lower rates of preeclampsia and gestational hypertension

Study involved more than 6,100 women

CHICAGO --- For many years, obstetricians counseled women that inducing labor increased the likelihood of a cesarean birth, although there was no solid evidence in clinical trials to support that.

Now, a large national study led by a Northwestern Medicine investigator shows electively inducing labor at 39 weeks actually reduces the rate of cesarean deliveries and decreases maternal and fetal complications.

In the study, women who were assigned to the elective induction group also reported experiencing less pain in labor and a greater sense of control over the labor process than women who were not in the induction group.

The paper will be published Aug. 9 in the New England Journal of Medicine.

"There's a lot of controversy around the consequences of inducing labor. People were convinced that it increased the risk of cesarean delivery, but the reality was actually unknown," said Dr. William Grobman, the Arthur Hale Curtis Professor of Obstetrics and Gynecology at Northwestern University Feinberg School of Medicine and a Northwestern Medicine physician. "This study provides evidence that inducing labor at 39 weeks actually reduces cesarean delivery."

In the U.S., approximately one-third of women give birth via cesarean delivery, which is associated with an increased risk of infection, hysterectomy, placenta implantation abnormalities in future pregnancies and respiratory illness in infants.

In the study, more than 6,100 women from 41 sites around the country were divided into two groups: one that waited for labor to begin on its own and one that would undergo an elective induction at 39 weeks of gestation.

The investigators chose 39 weeks because that is when babies have reached full term and have a low frequency of neonatal complications.

Among the key results:

Lower rates of cesarean delivery among the elective induction group (19 percent) compared to non-induction group (22 percent)

Lower rates of preeclampsia and gestational hypertension group (9 percent) compared to the non-induction group (14 percent)

Lower rates of respiratory support among newborns in the induction group (3 percent) compared to the non-induction group (4 percent)

The study's data suggest that one cesarean delivery may be avoided for every 28 deliveries among low-risk women giving birth for the first time who plan to undergo elective induction of labor at 39 weeks.

In addition to this large trial, a recent smaller study in Britain found that induction of labor also did not result in an increase of cesarean delivery.

"This new knowledge gives women the autonomy and ability to make more informed choices regarding their pregnancy that better fit with their wishes and beliefs," Grobman said. "Induction at 39 weeks should not be routine for every woman, but it's important to talk with their provider and decide if they want to be induced and when."

The rarity of appendix cancer, accounting for less than 1 percent of tumors that originate in the gastrointestinal tract, and the lack of scientific data for this disease means that current treatment guidelines recommend applying therapies to people with appendix cancer that are intended for those with colon cancer.

To understand why some patients with appendix cancer respond to standard treatment while others do not, University of California San Diego School of Medicine and Moores Cancer Center researchers, in collaboration with Foundation Medicine, performed genetic profiling on 703 appendiceal tumors -- the largest such study of this disease to date -- to compare mutations present in both cancer types.

The findings, published online August 8 in JCO Precision Oncology, confirm that genetic mutations in appendix cancer are distinct from those found in colon cancer and that mutations in the genes TP53 and GNAS are good predictors of survival among people with appendix cancer.

"For tumors that are rare like appendix cancer, obtaining molecular profiles will help identify potential treatment options since we don't have the clinical trial data to help guide treatments as we do in common tumors," said lead author John Paul Shen, MD, a postdoctoral fellow in the lab of co-author Trey Ideker, PhD, UC San Diego School of Medicine professor of medicine. "Equally important, the mutation profile can be used as a biomarker to separate high-risk patients, who need intensive treatment, from low-risk patients who may not need such an intensive treatment."

The retrospective study found that appendix cancer is comprised of five distinct subtypes: mucinous adenocarcinomas (46 percent), adenocarcinomas (30 percent), goblet cell carcinoids (12 percent), pseudomyxoma peritonei (7.7 percent) and signet ring cell carcinomas (5.2 percent).

A mutation in the gene GNAS, rare in colon cancer, was found to be quite frequent in appendix cancer, especially in mucinous adenocarcinomas (52 percent) and pseudomyxoma peritonei (72 percent). Patients with tumors harboring a GNAS mutation had a median survival of almost 10 years, while those whose tumors had a TP53 mutation had median survival of only three years. Patients who had neither gene mutation had a six-year median survival rate.

"This striking finding raises the question of whether patients with early stage, GNAS-mutant tumors need to be treated with chemotherapy, as it is possible they could be cured with surgery alone; a question we will focus on in our next study," said Shen.

"Understanding the molecular differences between the subtypes of appendiceal tumors is an important stepping stone for future clinical trials to develop and test different therapeutic approaches that are specific to this disease," said senior author Olivier Harismendy, PhD, assistant professor of medicine at UC San Diego Moores Cancer Center.

DALLAS, Aug. 8, 2018 -- Adults in their early 60s, who spend less time sitting and more time engaged in light to vigorous physical activity, benefit with healthier levels of heart and vessel disease markers, according to new research in Journal of the American Heart Association, the Open Access Journal of the American Heart Association/American Stroke Association.

The results from increased physical activity were found to be particularly good among women.

Physical inactivity is a well-known risk factor for cardiovascular disease and premature death from cardiovascular disease. Physical activity's protective effect is likely due in part to its impact on biomarkers in the blood that help predict atherosclerosis risk.

"The 60 to 64 age range represents an important transition between work and retirement, when lifestyle behaviors tend to change," said Ahmed Elhakeem, Ph.D., study author and senior research associate in epidemiology at Bristol Medical School, University of Bristol in the United Kingdom. "It may, therefore, be an opportunity to promote increased physical activity.

"In addition, cardiovascular disease risk is higher in older adults. It's important to understand how activity might influence risk in this age group," Elhakeem said. "We found it's important to replace time spent sedentary with any intensity level of activity."

Researchers studied more than 1,600 British volunteers, age 60 to 64, who wore heart rate and movement sensors for five days. The sensors revealed not only how much physical activity, in general, they were doing, but also how much light physical activity, such as slow walking, stretching, golfing or gardening, versus moderate-to-vigorous activity, such as brisk walking, bicycling, dancing, tennis, squash, lawn mowing or vacuuming.

Researchers analyzed participants' blood levels for markers of cardiovascular disease, including inflammatory markers C-reactive protein and interleukin 6 (IL-6); endothelial markers, tissue-plasminogen activator (t-PA), the molecule E-Selectin (a cell adhesion molecule that plays an important part in inflammation); and cholesterol markers leptin and adiponectin.

"We focused on these atherosclerosis biomarkers as they are less studied and have been shown to predict risk of cardiovascular events and death," Elhakeem said.

Researchers found:

Each additional 10-minutes spent in moderate-to-vigorous intensity activity was associated with leptin levels that were 3.7 percent lower in men and 6.6 percent lower in women.

Each additional 10-minutes spent sedentary was associated with 0.6 percent higher IL-6 levels in men and 1.4 percent higher IL-6 levels in women.

Each additional 10-minutes spent in light intensity activity was associated with around 0.8% lower t-PA levels in both men and women.

Less sedentary time and greater time in low-intensity activity were beneficially related to IL-6 and t-PA, regardless of time spent at higher intensity activity.

Those with better cardiorespiratory fitness (based on an oxygen uptake step test) also had a healthier biomarker profile, though this effect largely disappeared after controlling for related differences in body fat.

Total activity volume appeared related to these biomarkers independently of underlying cardiorespiratory fitness.

E-selectin was the only biomarker which showed no notable associations with physical activity and sedentary time (but was related to fitness levels).

Based on the study's findings, physical activity might lower cardiovascular disease risk by improving blood vessel function. Increased sedentary time may be adversely related to endothelial function, researchers said.

The study measured activity and biomarkers at the same time and didn't establish whether activity influenced the biomarkers, or the biomarkers influenced activity, Elhakeem said.

To improve overall cardiovascular health, the American Heart Association suggests at least 150 minutes a week of moderate intensity or 75 minutes a week of vigorous-intensity aerobic physical activity (or a combination of the two) and muscle-strengthening exercises two or more days a week.

GALVESTON, Texas -- A new national study has found that inducing labor in first-time mothers at 39 weeks can help prevent cesarean births and high blood pressure.

The University of Texas Medical Branch participated in the study and Dr. George Saade, chief of obstetrics and the principal investigator at UTMB, said that babies born to women induced at 39 weeks did not have worse outcomes compared to those who were not induced at 39 weeks.

"Actually, they had lower respiratory problems," Saade said. "This is the first large trial ever done on this topic and its result will have a significant impact on the management of pregnancy because it goes against the belief that induction would increase cesarean and lead to worse outcomes."

The study, published in the New England Journal of Medicine, was conducted through the Maternal-Fetal Medicine Units Network, which is supported by the National Institutes of Health Eunice Kennedy Shriver National Institute of Child Health and Human Development.

"First time mothers now should discuss this with their health care provider and decide whether they prefer to be induced at 39 weeks or wait for labor to start on its own," Saade said. "At UTMB, we have already made changes to our practice in order to address this new approach and the likely need for more induction of labor."

The study involved more than 6,100 healthy, first-time expectant mothers at UTMB and 11 other clinical centers across the U.S. About half of the women were randomly assigned to be induced at 39 weeks, while the other half waited for labor to begin naturally. Some women in the latter group were induced after 39 weeks for medical reasons.

While delivering by cesarean section is generally safe for mother and baby, it is a surgical procedure with potential risks and a longer recovery time.

"Nationally, the rates of cesarean births remain high," Saade said. "Most pregnancies after the first cesarean are delivered by cesarean again. So preventing the first cesarean is one of the most effective ways to decrease overall cesarean rates. We hope that this new study will lead to some significant decreases in cesarean rates nationally. We also hope that rates of hypertension in pregnancy, a condition that can lead to severe complications and even death, will decrease too."

BUFFALO, N.Y. -- Exercise can help prevent relapses into cocaine addiction, according to new research led by the University at Buffalo's Panayotis (Peter) Thanos, PhD.

"Cocaine addiction is often characterized by cycles of recovery and relapse, with stress and negative emotions, often caused by withdrawal itself, among the major causes of relapse," says Thanos, senior research scientist in the UB Research Institute on Addictions and Department of Pharmacology and Toxicology.

Using animal models, Thanos found that regular aerobic exercise (one hour on a treadmill, five times a week) decreased stress-induced cocaine-seeking behavior. Exercise also altered behavioral and physiological responses to stress.

Individuals who are addicted to cocaine have altered neural, behavioral and physiological responses to stress. Recent research by Thanos demonstrated how exercise can alter the brain's mesolimbic dopamine pathway, which is linked to the rewarding and reinforcing properties of drugs such as cocaine.

In addition, exercise has been shown to reduce stress hormones and elevate mood, which could assist in alleviating anxiety and negative emotions associated with withdrawal.

Studies already have shown that aerobic exercise (also known as "cardio") is an effective strategy against many physical health problems, including heart disease, diabetes and arthritis, along with certain mental health issues, such as stress, anxiety and depression.

"Our results suggest that regular aerobic exercise could be a useful strategy for relapse prevention, as part of a comprehensive treatment program for recovering cocaine abusers," Thanos says. "Further research is necessary to see if these results also hold true for other addictive drugs."

Even when sexual assault evidence kits, known as a 'rape kit' are available in hospitals, less than a third of those assaulted go through with the full procedure and release the forensic evidence to the police, reveals research published online in Emergency Medicine Journal.

Hospitals need to step up their efforts to help survivors of sexual assault secure justice in an often complex and stigmatising legal system, which contributes to a high attrition rate along the way and relatively few convictions, say the researchers.

In Canada alone, only 33 out of every 1000 cases of sexual assault are reported to the police. Only six lead to prosecution, of which three end up with a conviction.

Hospital emergency departments are often the first point of contact after a sexual assault. And the forensic evidence collected there from bodily fluids, fingernail scrapings, and DNA clothing samples (the rape kit) is essential for pursuing a prosecution in rape cases.

Yet many obstacles prevent survivors from accessing care and completing the rape kit process, say the researchers.

To find out more about the volume of cases and patterns of forensic evidence collection in hospital, the researchers drew on case registry data from the Sexual Assault and Partner Abuse Care Programme throughout 2015.

This programme is run by the emergency care department at Ottawa Hospital, Ontario, which is the only regional facility to offer rape kits.

In 2015, 406 patients from the Ottawa area were seen by the programme, nearly two thirds of whom (64.5%, 262) had been sexually assaulted.

Most (91.5%) of these cases were among women with an average age of 24, but ranging from 16 up to 80.

Drugs or alcohol had been involved in over half of the cases (53.5%). This can affect accurate recall of events, and is often used to undermine the survivor's credibility in court, the researchers point out.

A similar proportion (54.5%, 110) involved a known assailant or intimate partner. In 16 cases, several assailants had been involved. Most assaults had taken place in the victim’s or assailant’s home, although 1 in 20 incidents happened in student dorms.

Most sexual assault survivors (77%, 202) were eligible for a rape kit. Eligibility hinges on sampling being done within 24 hours to 12 days of the incident, depending on the type of assault.

But only 129 (64%) of those eligible completed the process and less than a third (30%, 60) subsequently handed over the forensic evidence to the police.

Young people aged between 16 and 24 were more than twice as likely to go through with the process, while those seeking care within 24 hours were also more likely to do so.

Those who didn't know their assailant, or who were unsure of their identity were more than three times as likely to release the rape kit evidence to the police, as were those who had been assaulted outdoors.

Going through with a rape kit can be invasive and potentially traumatic, and many survivors don't complete it because they are afraid of the process itself and/or going to court, say the researchers.

Sexual assault survivors need to be properly supported in emergency care departments, preferably by a dedicated sexual assault and domestic violence team, to help quell any fears they have and improve uptake of forensic evidence collection, they suggest.

"[Our] findings highlight a high case volume of sexual assault patients and describe hospital-based attrition points before entering the justice system," write the researchers. Ensuring that [emergency departments] are adequately equipped to provide comprehensive care to sexual assault survivors is a clinical imperative."

They add: "Achieving just outcomes is of critical importance."

PHILADELPHIA -- Twenty patients at Penn Medicine have been cured of the Hepatitis C virus (HCV) following lifesaving kidney transplants from deceased donors who were infected with the disease, according to a study published today in Annals of Internal Medicine. The researchers also report that the kidney transplants for these 20 patients are functioning just as well as kidneys that are transplanted from similar donors without HCV.

In 2016, Penn Medicine launched an innovative clinical trial to test the effect of transplanting kidneys from donors with HCV into patients currently on the kidney transplant waitlist who do not have the virus, and who would opt in to receive these otherwise unused organs. Recipients were then treated with an antiviral therapy in an effort to cure the virus after transplantation.

A research team co-led by Peter Reese, MD, MSCE, an associate professor of Medicine and Epidemiology, and David S. Goldberg, MD, MSCE, an assistant professor of Medicine and Epidemiology, report full data from the trial which includes 12-month HCV treatment outcomes in 10 patients and six month outcomes in another 10 patients--all of whom have received a lifesaving kidney transplant, who have been cured of their contracted HCV, and who have reported good quality of life following their transplants. More, the finding that these 20 kidney transplant recipients have kidney function that is similar to recipients of kidney transplants from donors without HCV suggests that the HCV infection did not harm the quality of the transplant.

"This study, and the results, are good news for those in need of a transplant, particularly those patients who were facing tremendous wait times - often five, seven, even 10 years - and who were spending so much of their daily lives on dialysis," said Reese. "While larger, longer term studies are important to confirm these results, we can confidently say that hospitals nation-wide could perform hundreds or thousands more transplants if we increased our acceptance of organs from donors with hepatitis C."

In addition to studying the safety and efficacy of this method in kidney transplantation, the team replicated this same approach for those awaiting a heart transplant in a study which launched in 2017. "We hope to see this same kind of success with our heart transplant recipients, many of whom are already showing no signs of HCV in their blood after transplantation and treatment," said Goldberg.

Among individuals with head and neck cancer (HNC), those who experienced childhood trauma were more likely to have advanced cancer, to have higher alcohol consumption, and to experience symptoms of anxiety and depression. Published early online in CANCER, a peer-reviewed journal of the American Cancer Society, the findings indicate that childhood trauma history should be considered during treatment for HNC.

Individuals may experience high levels of stress, anxiety, and depression during and after cancer diagnosis and treatment. Patients with HNC display emotional responses that may affect their adherence to treatment, and the maintenance of smoking and alcoholism.

Traumatic events in childhood have also been linked with the occurrence of anxiety and depression in adulthood. To evaluate the occurrence of childhood trauma in HNC patients and its association with anxiety and depression, a team led by Daniel Bernabé, PhD, of São Paulo State University, in Brazil, analyzed information on 110 patients with head and neck squamous cell carcinoma after they were diagnosed but before they started treatment.

Among the 110 patients, 105 (95.5 percent) had experienced at least one type of childhood trauma. The most common childhood trauma reported was emotional neglect (43.8 percent), followed by physical child abuse (30.5 percent), emotional child abuse (15.2 percent), and physical child neglect (8.6 percent). Only two patients (1.9 percent) reported sexual abuse.

Emotional neglect (absence of emotional support, as well as negligence related to child's complaints) was linked with advanced cancer stage and higher alcohol consumption. Experiencing child physical neglect (not receiving necessary care so that physical health is endangered) was a predictive factor for increased anxiety levels. Also, patients who had a higher occurrence of traumatic events in childhood had an almost 12-times higher likelihood of having increased depression levels before starting cancer treatment.

"Assessing traumatic events experienced in childhood may be of great value in understanding neuropsychological mechanisms related to alcohol abuse and anxiety and depression symptoms in patients with cancer. Therefore, the life history of the cancer patient, including their traumatic memories and derived feelings should be considered by the health team during the treatment of cancer patients." said Dr. Bernabé.

A medical program developed by clinicians at one of Australia's largest hospitals, the Royal Brisbane and Women's Hospital (RBWH), is successfully keeping elderly aged care residents out of hospital and reducing demand on emergency departments.

Dual Emergency and Palliative Care Staff Specialist at the RBWH, Dr Bill Lukin, evaluated the 'Hospital in the Nursing Home program and found the number of emergency department visits reduced significantly.

"The program led to an average 17 per cent decrease in aged care patients presenting to the RBWH Emergency Department, a 36 per cent drop in hospital admissions per emergency presentation and an overall 47 per cent decrease in hospital admissions," he said.

"That's about one ward of elderly people each month who are no longer being admitted to hospital.

"We also found the program is cost effective, delivering Royal Brisbane about AU$8 million a year in economic benefits after costs or a return of $17 for every $1 invested.

"Most importantly, getting treatment at home is almost always better for an elderly patient."

Backed by a $290,000 grant from the Emergency Medicine Foundation of Australasia (EMF), funded by Queensland Health, Dr Lukin led a research team to evaluate the impacts of the program, which was rolled out across aged care facilities caring for more than 2000 elderly residents.

Queensland Minister for Health and Ambulance Services Steven Miles said many elderly patients were sent to the emergency department by aged care homes for relatively routine procedures such as changing catheters, wound care or providing blood transfusions.

"The beauty of the Hospital in the Nursing Home program is it enables these more common procedures to be performed in the aged care facilities.

"Through the program, GPs and nursing staff at aged care facilities are provided with education and support to further manage the acute care of their residents, including having access to a contact person in the ED for advice.

"This is an excellent example of state-run and privately-run facilities working together to improve the health and well being of elderly Queenslanders."

In Brisbane, the program was rolled out across aged care facilities caring for more than 2000 elderly residents.

EMF Director Dr Anthony Bell said Dr Lukin's research would enable vital emergency medical resources to be allocated more effectively.

"Dr Lukin's research clearly shows that extra training and support can enable elderly Australians to access high-quality healthcare services without needing to leave their homes," he said.

"When emergency departments, hospitals and community health providers work together providing the best possible care for older Australians in their home, everyone benefits.

"Emergency and hospital beds are freed up and older patients are not unnecessarily coming into an unfamiliar and often stressful environment."

An economic evaluation of the program was recently published in the journal, PLoS ONE.

For the first time, researchers at University of California San Diego School of Medicine and Imperial College London, with international collaborators, have determined that Kawasaki Disease (KD) can be accurately diagnosed on the basis of the pattern of host gene expression in whole blood. The finding could lead to a diagnostic blood test to distinguish KD from other infectious and inflammatory conditions.

Results of the international study published on August 6 in JAMA Pediatrics.

Kawasaki disease is the most common acquired heart disease in children. Untreated, roughly one-quarter of children with KD develop coronary artery aneurysms -- balloon-like bulges of heart vessels -- that may ultimately result in heart attacks, congestive heart failure or sudden death.

"As there is no diagnostic test for Kawasaki disease, late diagnosis often results in delayed or missed treatment and an increased risk of coronary artery aneurysms," said Jane C. Burns, MD, pediatrician at Rady Children's Hospital-San Diego and director of the Kawasaki Disease Research Center at UC San Diego School of Medicine. "We sought to identify a whole blood gene expression signature that distinguishes children with KD in the first week of illness."

Researchers used a case-control approach, including children recruited in hospitals in the United Kingdom, Spain, Netherlands and U.S., with KD or similar illnesses. The majority of study participants with KD came from Rady Children's Hospital-San Diego. The overall study group comprised 404 children with infectious and inflammatory conditions (78 KD, 84 other inflammatory diseases, 242 bacterial or viral infections) and 55 healthy controls.

The researchers looked for tell-tale transcription in blood samples. Transcription is the first step in gene expression, in which information from a gene is used to construct a functional product, such as a protein.

"A 13-transcript blood gene expression signature distinguished KD from the range of infectious and inflammatory conditions with which it is often clinically confused," said Burns. "A test incorporating the 13-transcripts might enable earlier diagnosis and treatment of KD, preventing cardiac complications and reducing inappropriate treatment in those with other diseases. Our findings represent a step toward better diagnosis based on molecular signatures rather than clinical criteria."

Burns said there is currently no point-of-service test for KD. Engineers will have to devise a blood testing method that can be adapted to the emergency department or hospital lab setting to help bring these research findings into practice.

"We are already in discussions with a number of biotechnology companies that might help us turn our gene signature into a test," said Michael Levin, Professor of Paediatrics & International Child Health at Imperial College. "An accurate test for KD could prevent many children worldwide from being diagnosed too late to prevent coronary artery damage. If we can develop a test based on our gene signature, this could transform diagnosis and enable early treatment of children affected by the disease."

Prevalence rates of KD are increasing among children in Asia. Japan has the highest incidence rate, with more than 16,000 new cases per year. One in every 60 boys and one in every 75 girls in Japan will develop KD during childhood.

Incidence rates in the U.S. are lower --19 to 25 cases per 100,000 children under age 5 -- but it is rising, at least in San Diego County. Predictive models estimate that by 2030, 1 in every 1,600 American adults will have been affected by the disease.

(Vienna, August 7, 2018) Eleven percent of irritable bowel syndrome with diarrhoea (IBS-D) patients reveal that they suffer from suicidal thinking when their condition is bad, a new study has found(1).

The research, published in the UEG Journal, assessed the burden associated with irritable bowel syndrome with diarrhoea by surveying 513 patients and 679 healthcare professionals. A quarter of patients reported that IBS stops them from enjoying life and 11% agreed with the statement; 'when my IBS is bad, I wish I was dead'.

IBS is a functional bowel disorder, characterised by abdominal pain and altered bowel habits(2). The disease affects 11% of adults globally(3), of whom one third experience diarrhoea as the predominant symptom. IBS-D is considered to be a brain-gut interaction disorder and a range of treatment approaches have been proposed, including diet and lifestyle modifications, probiotics and fibre supplements and various prescription and over-the-counter medications.

Over a third of patients reported that they 'constantly' worry about whether and when their IBS symptoms will return and one in five stated that IBS had negatively affected their working life. Patients also revealed that, on average, they spend 18 days per month experiencing fatigue or a lack of energy. Half of patients reported that they would use a daily treatment for the rest of their life if it prevented their IBS symptoms (49%) and a 'willingness to try anything' to improve their condition (46%).

Despite these alarming statistics, the survey outlined that one third of IBS patients do not think that healthcare professionals take the disease seriously and should provide more support in disease management. When reviewing the attitudes of healthcare professionals towards IBS, results showed that two-thirds agreed that patients should feel listened to and supported, with the vast majority stating that the main aim of their care when managing IBS is significantly improving their patients' quality of life.

Professor Hans Törnblom, lead author of the study, comments on the findings, "IBS can be an extremely tough, emotional and difficult condition to live with and, in addition to dedicating resources to improve the physical burden of IBS, it is essential that care and investment is committed to providing psychological and emotional support for patients. This should come from multi-disciplined healthcare professionals, as well as family members, friends and colleagues."

"The majority of IBS sufferers do not seek medical advice for their condition" added Professor Törnblom. "Of those that do speak to a healthcare professional, it is clear that there are high levels of dissatisfaction with the level of care that they currently receive. Healthcare professionals experience a degree of uncertainty and complexity in managing IBS patients and the research indicates the need for higher levels of communication between care providers and patients to facilitate improved patient outcomes."

Boston, MA - Pregnant women who had low plasma levels of long chain n-3 fatty acids in their first and second trimesters were at a significantly higher risk of early preterm birth when compared with women who had higher levels of these fatty acids, according to new research from Harvard T.H. Chan School of Public Health in collaboration with Statens Serum Institut in Copenhagen. The study suggests that low concentrations of certain long chain fatty acids--eicosapentaenoic acid and docosahexaenoic acid (EPA+DHA)--may be a strong risk factor for preterm birth.

"At a time when many pregnant women are hearing messages encouraging them to avoid intake of fish altogether due to mercury content, our results support the importance of ensuring adequate intake of long chain omega-3 fatty acids in pregnancy. Consumers should consult the guidance issued last year by the U.S. Food and Drug Administration and Environmental Protection Agency to make informed choices about the best types of fish to consume and avoid in pregnancy," said lead author Sjurdur F. Olsen, adjunct professor of nutrition at Harvard Chan School and head of the Centre for Fetal Programming at Statens Serum Institut in Copenhagen, Denmark.

The study will be published online August 3, 2018, in EBioMedicine.

Preterm birth is a leading cause of neonatal death and is associated with cognitive deficiencies and cardiometabolic problems later in life among survivors. For decades, it has been hypothesized that high intake of EPA+DHA, which is found in cold-water fish such as Atlantic mackerel, anchovies, salmon, and tuna and also in leaner species such as cod and haddock, can reduce the risk of preterm birth. While some studies have supported this hypothesis, research findings have been inconsistent.

For this new study, researchers examined data from the Danish National Birth Cohort, a nationwide study that follows 96,000 children in Denmark through questionnaires and registry linkages. They analyzed blood samples from 376 women who gave birth very prematurely (prior to 34 weeks of gestation) between 1996 and 2003 and 348 women who had a full-term birth. All of the women gave blood samples during their first and second trimesters of pregnancy.

Analysis of the blood samples showed that women who were in the lowest quintile of EPA+DHA serum levels--with EPA+DHA levels of 1.6% or less of total plasma fatty acids--had a 10 times higher risk of early preterm birth when compared with women in the three highest quintiles, whose EPA+DHA levels were 1.8% or higher. Women in the second lowest quintile had a 2.7 times higher risk compared with women in the three highest quintiles.

The findings suggest that, among pregnant women with low levels of EPA+DHA, eating more fish or taking a fish oil supplement could potentially lower the risk of preterm birth. The authors cautioned, however, that broad generalizations about the study's findings may be limited due to the fact that it was conducted in Demark, where preterm birth rates are low, and said the results should be replicated in other populations. They also cautioned that the findings may not solely reflect a variation in diet; variation in underlying genetic factors may also play a role.

"An effect of this magnitude is rare, but the precision of the estimate is tight, which supports the reliability these findings. It will be important to replicate these findings in other populations, but the results of this study certainly suggest that assessment of plasma EPA+DHA status in women has the potential to be used in the future to help predict women's risk," said co-author Jeremy Furtado, senior research scientist at Harvard Chan School.

"Early preterm birth has immense health, economic, and emotional costs. Our findings are consistent with the results of most randomized trials of long chain omega-3 fatty acid supplements in pregnancy and support the importance of ensuring adequate intake of these nutrients during pregnancy, either through fish intake or supplements, to help prevent early preterm birth," said co-author Andrew Thorne-Lyman, an associate research scientist at Johns Hopkins Bloomberg School of Public Health who worked on this study while a faculty member at Harvard Chan School.

WASHINGTON (Aug. 3, 2018) -- Transgender individuals may be at higher risk for myocardial infarction and death due to cardiovascular disease, according to several studies. This increased risk may be due to the hormone therapy that transgender patients take for masculinization or feminization.

A review authored by Michael S. Irwig, MD, associate professor of medicine at the George Washington University (GW) School of Medicine and Health Sciences and director of the Andrology Center at the GW Medical Faculty Associates, examined several studies that followed transgender individuals on hormone therapy.

"Many transgender patients take either testosterone or estrogen for masculinization or feminization," explained Irwig. "Some studies have suggested that transgender people have an increased risk for heart attack and death due to cardiovascular disease."

The review focuses on cardiovascular events (myocardial infarction, stroke and venous thromboembolism) and surrogate markers -- including blood pressure and lipid concentrations -- in transgender patients on hormone therapy who may or may not have undergone gender affirmation procedures. The studies that the review covers show that transgender women appear to have increased risk for cardiovascular events due to hormone therapy whereas the data is unclear for transgender men. It is well known that estrogen therapy for trans women increases their risk of blood clots (deep venous thromboses).

"In clinical studies that followed transgender patients, rates for myocardial infarction were consistently higher in transgender women on estrogen therapy than in transgender men on testosterone," Irwig said. "The relationship between endogenous sex hormones and heart disease is complex. In cisgender women, estrogen may have a protective effect."

Given that hormone therapy is often essential in the management of transgender patients, Irwig suggests that more research is needed on the effects and risk of hormone therapy in older transgender populations and on the safest forms of estrogen therapy.

With expertise rooted in personal experience, people who have had mental health problems could offer support, encouragement and a model for recovery, helping reduce readmission rates.

Care from peer support workers with lived experience of mental health conditions may help reduce the likelihood of readmission for people who have recently left acute mental health care, according to a randomised controlled trial of more than 400 people in England published in The Lancet.

The study found that fewer people who received this type of support were readmitted to acute care a year after the study began, compared to people who only received a workbook.

In the UK, more than half of people admitted to acute care are readmitted within a year, and there is no robust evidence on how these readmissions can be reduced.

Support from people with lived experience of mental health problems is used in the UK and USA in programmes such as the NHS' Implementing Recovery through Organisational Change and the USA's Wellness Recovery Action Plan. This study is the first randomised trial to evaluate the effectiveness and shows positive results. However, more research, including to understand what causes the effect found, is now needed before the strategy is implemented nationally in the UK.

Self-management interventions may help people manage their mental health better, and in this study, the authors combined a self-management workbook with help from a support worker who had also experienced a mental health problem.

"People discharged from community crisis services are often readmitted to acute care. Not only does this impede recovery, but also consumes resources that might otherwise be dedicated to longer term improvements in functioning and quality of life," says lead author Professor Sonia Johnson, UCL, UK. "Peer support workers could provide support and encouragement that is particularly warm and empathetic because it is rooted in personal experience, as well as providing service users with a role model for their recovery." [1]

The new study took place across six crisis resolution teams in England, and people were recruited after they had been discharged by a crisis resolution team. Participants had a variety of diagnoses including schizophrenia, bipolar affective disorder, psychosis, depression anxiety disorder, post-traumatic stress disorder, and personality disorder. All people within the study continued treatment and usual care throughout the study.

Participants either received a personal recovery workbook (220 people) or peer support and the workbook (221 people). The workbook included sections on setting personal recovery goals, re-establishing their place in the community and support networks, identifying early warning signs and creating an action plan to avoid or delay relapse, and planning strategies to maintain wellbeing. Participants were asked to record observations and plans in each of these areas.

Participants who received support from a person who had also experienced mental health problems were offered ten one-hour sessions, which took place each week. The support worker listened to their problems and aimed to instil hope by sharing the skills and coping strategies they learnt during their own recovery. Support workers received training beforehand in listening skills, cultural awareness, self-disclosure, and confidentiality, and how to use the workbook.

The authors monitored participants' health records to determine whether they were readmitted to acute care (such as acute inpatient wards, crisis resolution teams, crisis houses, and acute day care services) within one year, and conducted interviews with participants at four and 18 months to obtain their views on the intervention.

After one year, readmission to acute care was lower in the intervention group than in the control group - with 29% (64/218) of participants readmitted in intervention group versus 38% (83/216) of participants in the control group.

Uptake of the intervention was good - 72% (160/221) of people offered the support and workbook attended at least three meetings with their peer support worker, and a third (65/198) attended all ten meetings.

Similar numbers of participants in the intervention and control groups read the booklet (84% [133/158] of people in the control group vs 88% [142/162] of people in the intervention group), but more people in the intervention group used it to make written plans (58-64% of people in the intervention group vs 28-44% of people in the control group).

During the study there were 71 serious adverse events (29 in the intervention group and 42 in the control group), but none were deemed related to the study. These included 55 readmissions to acute care, 11 attempted suicides, one attempted murder, two suicides and two deaths with unclear circumstances.

"Our study provides the most robust evidence for the effectiveness of any peer-provided support in a UK secondary mental health setting," continues Professor Johnson. "Our novel findings are potentially important as the intervention is acceptable to patients and feasible for service managers and users who would like to avoid relapse and readmission to acute care." [1]

The authors note some limitations, including that the secondary outcomes of the study gave unclear results, so it is not possible to identify which part of the intervention caused the improvement in patient outcomes. In addition, a high proportion of people in the control group used the booklet, and readmission rates in this group were below the national average, which may suggest that the booklet is effective on its own too. This could mean the effectiveness of peer support was under estimated in the study.

Writing in a linked Comment, Drs Marcia Valenstein and Paul Pfeiffer, University of Michigan, USA, says: "There is much to celebrate but also much left to do following the publication of these findings. The completion of a substantial, adequately powered randomised controlled trial with high ascertainment of the primary outcome and blinded raters is welcome. The finding of reduced readmissions is also welcome, given that implementation of peer support has proceeded apace despite the scarcity of substantial evidence regarding its efficacy. With the publication of this trial, peer-delivered self-management programmes might be considered one of the configurations of peer support with the strongest evidence. That said, the lack of a significant effect on almost all secondary outcomes and potential mediators leaves the mechanism of reduced readmissions unclear. We are left with a complex intervention that appears to reduce readmissions but with few insights into what the active or necessary parts of the intervention might be--eg, support and sharing of life experiences with the peer, engaging actively with the recovery workbook, changes in self-management behaviours that were not apparent through the self-reported measure."

Rockville, Md. (Aug. 2, 2018)--A high-fat diet may promote the growth of pancreatic cancer independent of obesity because of the interaction between dietary fat and cholecystokinin (CCK), a digestive hormone. In addition, blocking CCK may help prevent the spread of pancreatic tumors to other areas of the body (metastases). The new findings are published ahead of print in the American Journal of Physiology--Gastrointestinal and Liver Physiology. The research was chosen as an APSselect article for August.

CCK is released by the small intestine and is associated with obesity. Dietary fat triggers the secretion of CCK; those who follow a diet high in saturated fats often have high levels of CCK. Previous research has shown that obesity and high-fat diets both together and independently increase the risk of pancreatic cancer. CCK also regulates regeneration that takes place after partial surgical removal of the pancreas. Pancreatic growth and regeneration occurs through interaction of CCK with CCK receptors, proteins that bind to CCK to produce a physiological reaction.

Researchers from Georgetown University conducted separate mouse studies involving the interactions between dietary fat, CCK and pancreatic cancer cell growth. In all studies, half the mice were fed a high-fat diet and the other half followed a normal diet.

In the first study, half of the animals were treated with proglumide, a medication that blocks CCK.

In the second study, the mice had tumors lacking CCK.

In the third study, the mice were deficient in CCK and had pancreatic tumors.

The researchers found that mice treated with proglumide had less tumor growth than the untreated mice, even when fed a high-fat diet. The mice lacking CCK also did not respond to a high-fat diet. These results suggest that CCK is needed to stimulate the growth of pancreatic cancer. The high-fat diet-fed mice lacking CCK receptors did not show any tumor growth, suggesting that without receptors to bind to, increased CCK from dietary fat is unable to promote cancer.

Proglumide treatment also protected the mice from the development of excessive fibrous tissue (fibrosis) that can be associated with cancer metastases and resistance to chemotherapy.

"Most patients with advanced pancreatic cancer succumb to the disease due to metastases; therefore a compound that blocks metastases, even when the primary tumor size is large, may have clinical significance," the researchers wrote. "CCK [receptor] blockade may play a role in the treatment and prevention of pancreatic cancer."