Body

Continuous skin-to-skin contact starting immediately after delivery even before the baby has been stabilised can reduce mortality by 25 per cent in infants with a very low birth weight. This according to a study in low- and middle-income countries coordinated by the WHO on the initiative of researchers at Karolinska Institutet published in The New England Journal of Medicine.

Continuous skin-to-skin contact between infant and mother, or "Kangaroo Mother Care" (KMC), is one of the most effective ways to prevent infant mortality globally. The current recommendation from the World Health Organization (WHO) is that skin-to-skin contact should commence as soon as a low weight baby is sufficiently stable, which for those weighing under 2 kg at birth normally takes several days.

"The idea of giving skin-to-skin contact immediately after delivery to very small, unstable babies has encountered quite strong resistance, but about 75 per cent of deaths occur before the infant has been judged sufficiently stable," says Nils Bergman, doctor and researcher at the Department of Women's and Children's Health, Karolinska Institutet, Sweden, and one of the initiators of the study.

The new study, financed by the Bill & Melinda Gates Foundation and led by WHO, has examined whether immediate Kangaroo Mother Care, iKMC, after delivery leads to even better survival rates for infants with a birth weight of 1 to 1.8 kg in low- and middle-income countries. The study was conducted at five university hospitals in Ghana, India, Malawi, Nigeria and Tanzania, where mortality for these babies, prior to the study, varied between 20 and 30 per cent.

To improve and align the care to the greatest possible extent between study hospitals before the start of the study, training was provided in basic neonatal care and basic equipment was procured for measuring the babies' oxygen levels and to provide assisted ventilation. The participating hospitals were also trained in safe skin-to-skin contact for unstable infants. The KI researchers, supported by a colleague from the University of Stavanger, Norway, were responsible for the training and, by frequent visits to the study sites, the assurance of quality of the basic care in both groups and iKMC technique in the intervention group.

In the study, 3,211 infants were randomly assigned to two groups, one that received iKMC and continued skin-to-skin contact at the neonatal unit, where the mothers also received their medical care, and a control group that received standard care, whereby mothers and babies are cared for in separate units and are only reunited during infant feeding. As soon as the babies had stabilised sufficiently, mothers and babies from both groups were transferred to the regular KMC unit. During the first 72 hours, the infants in the iKMC group received approximately 17 hours of skin-to-skin contact per day, compared with 1.5 hours in the control group.

Mortality during the first 28 days was 12 per cent in the iKMC group compared to 15.7 per cent in the control group, which corresponds to a reduction of 25 per cent. There were also significantly fewer babies in the iKMC group with a low body temperature or bacterial blood poisoning.

"The main message is that low weight newborns should receive skin-to-skin contact immediately after birth and subsequently at a mother-infant couplet care unit, where mothers and babies are looked after together without having to be separated," says Björn Westrup, consultant and researcher at the Department of Women's and Children's Health, Karolinska Institutet and co-initiator of the study with Nils Bergman. "Our results suggest that this care model, which in itself isn't resource-demanding, could have significant health effects."

The researchers estimate that iKMC has the potential to save the lives of an additional 150,000 small newborns each year.

"Keeping the mother and baby together right from birth, with zero separation, will revolutionise the way neonatal intensive care is practiced for babies born early or small," says Dr Rajiv Bahl, Head of Maternal and Newborn Health Research and Development at WHO and the coordinator of the study. "This study illustrates that kangaroo mother care has the potential to save many more lives if it is started immediately after birth, a finding with relevance for countries of all income levels."

WHO is in the process of reviewing its current recommendations on kangaroo mother care, published in 2015, in light of new evidence. WHO recommends KMC for all babies, but the new study gives important evidence on the lifesaving role of immediate KMC for unstable small babies.

The opioid epidemic is taking a deadly toll on people in disproportionate clusters from Cape Cod to San Diego, according to a new study by the University of Cincinnati.

Fatal opiate overdoses are most prevalent among six states: Ohio, Pennsylvania, Kentucky, West Virginia, Indiana and Tennessee. But researchers identified 25 hot spots of fatal opioid overdoses nationwide using data from the Centers for Disease Control and Prevention.

The study demonstrates how both widespread and localized the problem of substance use disorders can be, UC assistant professor and co-author Diego Cuadros said.

Cuadros is director of UC's Health Geography and Disease Modeling Laboratory, which applies geographical information, perspectives and methods to the study of health, disease and health care. As an epidemiologist, he studies the impacts of diseases such as malaria, HIV and COVID-19.

"Not everyone is similarly at risk," Cuadros said. "We wanted to identify characteristics that put people at higher risk of a fatal overdose."

Health interventions for opiates have focused largely on treatments such as the distribution of naloxone and other lifesaving remedies. But Cuadros said prevention could be effective if vulnerable populations can be identified. To that end, researchers found that white males ages 25 to 29 were most at risk of fatal opioid overdose followed by white males ages 30 to 34. The study also identified an increasing risk to black males ages 30 to 34.

The study also found a correlation between fatal overdoses and mental and physical distress using surveys of physically and mentally unhealthy days. Mental distress increases the relative risk of dying from a drug overdose by as much as 39%.

"We saw a strong association with mental health and substance abuse disorders, particularly opiates," Cuadros said. "What's happening now is we're more than a year into a pandemic. Mental health has deteriorated for the entire population, which means we'll see a surge in opiate overdoses."

Researchers are trying to understand why men are more likely than women to suffer a fatal overdose and what it is about the period of life between age 30 and 45 that makes people more susceptible to the epidemic.

"Maybe you have more responsibilities, financial responsibilities or stress at that time. Maybe there are physiological changes or changes in our brain that we don't know yet," Cuadros said. 

"This is a complex epidemic. For HIV we have one virus or agent. Same with malaria. Same with COVID-19. It's a virus," Cuadros said. "But with opioids, we have several agents. At the beginning of the epidemic it was heroin. By 2010 it switched to prescription opiates."

Now states are seeing more overdoses from synthetic opioids such as fentanyl.

The study also tracked the migration of overdoses between 2005 and 2017 from Southwest states to the Northeast. Many of the clusters UC identified in the Southwest and Northeast had comparatively higher levels of physical and mental distress.

Co-author Neil MacKinnon, former dean of UC's James L. Winkle College of Pharmacy, said the analysis could help health policymakers and clinicians by identifying individual and community-level factors associated with an increased risk of death due to substance use disorder. He is provost now at Augusta University, Georgia. 

"We hope the risk factors we identified in this analysis will be used by agencies like RecoveryOhio to plan proactive strategies and allocate resources to address this epidemic," MacKinnon said.

Previously, UC researchers identified 12 regions in Ohio that had disproportionately high rates of fatal overdoses from opioids.

"We started in Ohio. We know that in this state we're suffering one of the highest burdens of the problem," Cuadros said.

Likewise, he said it would be worthwhile to study populations in the United States where opioids are not exacting a horrible toll on families to understand the problem.

"Sometimes we focus too much on where the problem is focused. It's useful to look at the areas where the problem is not as pressing," Cuadros said.

What The Study Did: This study included data from more than 11,000 emergency medical services (EMS) agencies in 49 states to describe racial/ethnic, social and geographic changes in EMS-observed overdose-associated cardiac arrests during the COVID-19 pandemic through 2020 in the United States.

Authors: Joseph Friedman, M.P.H., of the University of California, Los Angeles, is the corresponding author.

To access the embargoed study: Visit our For The Media website at this link https://media.jamanetwork.com/

(10.1001/jamapsychiatry.2021.0967)

Editor's Note: The article includes funding/support disclosures. Please see the article for additional information, including other authors, author contributions and affiliations, conflict of interest and financial disclosures, and funding and support.

What The Study Did: Researchers analyzed each state's department of health website for accessibility and usability challenges. Findings suggest state health department COVID-19 vaccine website accessibility and usability challenges create frustration, may promote health disparities and contribute to overall ineffective and inequitable distribution.

Authors: Raj M. Ratwani, Ph.D., of the Medstar Health National Center for Human Factors in Healthcare in Washington, D.C., is the corresponding author.

To access the embargoed study: Visit our For The Media website at this link https://media.jamanetwork.com/

(doi:10.1001/jamanetworkopen.2021.14861)

Editor's Note: The article includes conflict of interest disclosures. Please see the article for additional information, including other authors, author contributions and affiliations, conflict of interest and financial disclosures, and funding and support.

In a new study published online in spring 2021 and in the July issue of the journal Contraception, University of Chicago Medicine investigators and colleagues interviewed primary care providers in Illinois about their interest in providing medication abortion care and found that lifting FDA restrictions on mifepristone to allow pharmacy dispensing could normalize medication abortion, facilitate its use in primary care facilities, and address disparities in reproductive health access.

"Mifepristone is used in combination with misoprostol to end early pregnancies, during the first trimester," said senior author Debra Stulberg, MD, MAPP, Chair of the Department of Family Medicine at the UChicago Medicine. "The two-drug regimen is safe and highly effective, but access is limited by a strict Risk Evaluation and Mitigation Strategy (REMS) that prohibits pharmacy dispensing of mifepristone."

Together with students at UChicago and collaborators at Harvard Medical School, Stulberg interviewed 19 primary care providers and administrators, including family medicine physicians, nurse practitioners, certified nurse midwives and clinical directors.

In describing barriers and facilitators to providing medication abortion care in their practices, participants expressed strong support for removal of the mifepristone REMS to align medication abortion care with evidence-based practice.

"In interviews, study participants described how the restrictions around mifepristone contribute to the stigmatization of abortion care," said first author Kayla Rasmussen, a medical student at the Pritzker School of Medicine. "For example, one of the midwives we spoke to expressed that having a drug that can only be prescribed if you are 'a special someone,' it makes mifepristone seem like a mysterious thing. Since it can't be readily prescribed, it feels very restricted and specialized."

This sentiment was shared by multiple participants, who expressed hope that lifting the mifepristone REMS would shift perceptions of some colleagues and organizational leaders that abortion care requires a specialty referral to instead embrace it as an integral component of comprehensive primary care. Normalizing medication abortion would align practice with current scientific evidence of its safety, while making care more accessible for patients who face barriers to getting to an abortion clinic.

"Providers shared that allowing pharmacy dispensing of mifepristone would reduce the logistical barriers toward accessing medication abortion and allow clinicians to provide care remotely, via telemedicine," said Elizabeth Janiak, ScD, an assistant professor at Harvard Medical School. "Expanding these services could reduce geographic disparities in abortion access and increase patient autonomy over where and how to receive care, whether it be for an abortion or a miscarriage."

The research team also wrote a related commentary, published in the same issue of Contraception, to explain in more depth how the REMS restrictions perpetuate the stigmatization of mifepristone use in primary care.

"The REMS creates the false perception that mifepristone is difficult to use, which leads to institutions feeling afraid to stock or use the medication," said Danielle Calloway, an undergraduate student at UChicago and lead author on the commentary. "When institutions create barriers that prevent their providers from integrating mifepristone into their care practices, it affects access to not only early abortions, but also early pregnancy loss management, which uses the same medications."

The team seeks to highlight the importance of promoting equitable access to abortion care, especially during the COVID-19 pandemic, which made it difficult for many patients to receive in-person medical care.

"Leading medical organizations, including the American College of Obstetricians and Gynecologists (ACOG) and American Academy of Family Physicians, have long supported removal of the mifepristone REMS," said Stulberg. "In 2020, ACOG sued the FDA over these restrictions, resulting in a temporary suspension of the in-person requirements for the duration of the pandemic. While providers can now mail mifepristone to patients, pharmacy dispensing is still prohibited, despite evidence supporting the safety and efficacy of mifepristone. This means that patients have to wait for someone to send them the medication, rather than being able to pick it up as soon as possible after it's been prescribed."

While study participants acknowledged further challenges that will remain to be addressed if the mifepristone REMS is lifted, such as pharmacist refusal to dispense the drug, these were not perceived as justifications for the restriction of abortion care. "Our study adds to the growing body of evidence that the current policy barriers to providing mifepristone cause more harm to patients than good," said Stulberg. "Primary care clinicians can help ensure equitable access to safe, effective abortion care, but the REMS restrictions make it unnecessarily hard."

In response to this growing body of evidence and the ongoing litigation, on Friday, May 7, the FDA announced that the agency will undertake a full review of the mifepristone REMS by the end of calendar year 2021. "This research makes it clear that the REMS unjustly restricts abortion provision without any tradeoffs in patient safety or efficacy," said Rasmussen. "It's time to reevaluate the basis for these restrictions and expand equitable access to abortion care."

COLUMBUS, Ohio - Thermoelectric power generators that make electrical power from waste heat would be a useful tool to reduce greenhouse gas emissions if it weren't for a most vexing problem: the need to make electrical contacts to their hot side, which is often just too hot for materials that can generate a current.

The heat causes devices to fail over time.

Devices known as transverse thermoelectrics avoid this problem by producing a current that runs perpendicular to the conducting device, requiring contacts only on the cold end of the generator. Though considered a promising technology, the materials known to create this sideways voltage are impractically inefficient - or so scientists thought.

Ohio State University researchers show in a new study that a single material, a layered crystal consisting of the elements rhenium and silicon, turns out to be the gold standard of transverse thermoelectric devices.

The scientists demonstrated that this single compound functions as a highly effective thermoelectric generator because of a rare property: simultaneously carrying both positive and negative charges that can move independently rather than running parallel to each other, which forces them to zig-zag their way to the contacts to generate an electrical current.

By building a thermoelectric generator with a crystal about two inches long, the researchers also determined that when the crystal is situated at a specific angle in the device, it can churn out an impressive amount of power.

"We showed that these materials are as effective as conventional thermoelectric generator technology, but overcome its major disadvantages," said study co-author Joshua Goldberger, professor of chemistry and biochemistry at Ohio State.

"This is the first time this kind of device has ever been shown to be feasible. With efficiencies that are orders of magnitude higher than any previous transverse device, this compound is just as good as what you can buy commercially, but promises to be much simpler and more reliable."

The research is published online in the journal Energy & Environmental Science.

While 97% of energy is generated from heat, we throw most heat away, letting it escape from smokestacks, car exhaust pipes and the like.

"Waste heat is really important. Forever and ever there has been a quest to improve the efficiency of all engines that make power from heat - the amount of work you can get out of them that you can use," said study co-author Joseph Heremans, professor of mechanical and aerospace engineering and Ohio Eminent Scholar in Nanotechnology at Ohio State.

"For a long time, we've dreamt of finding little engines that would not have moving parts that can take heat and make electricity."

And now they have.

Most materials conduct only one type of charge, causing most thermoelectric devices to be composed of multiple compounds - yet the complexity of making contacts to them has hampered efforts to build an efficient and effective thermoelectric generator that is easy to construct and can withstand high temperatures.

Two years ago, this research team discovered unexpected properties in a different compound that allowed electrons and holes, the sources of the negative and positive charges, respectively, that generate an electrical current, to run along what might resemble a north-south highway for one charge and an east-west highway for the other.

After that discovery, the researchers combed through existing research on other crystals that had been found by other scientists to do the same thing.

"We got interested in this because at first, we didn't realize it could exist. When we figured out it could exist, we've been really pushing to find these materials," Goldberger said. To date, they've experimentally confirmed 15 materials with these properties - out of the over 110,000 crystal structures discovered and cataloged in an international database.

"A few had been discovered, but none was exploited for functionality. What we have found is that we can actually do something with it," said Wolfgang Windl, a professor of materials science and engineering at Ohio State and co-author of the study.

"All we have to do is put wires to one end and orient the crystal a certain way and suddenly we have a power generator with no moving parts. And you make it warm with whatever waste heat you have in your home, car or rocket, and this will generate emission-free power all by itself and basically endlessly. It's a little bit like black magic to me."

Theoretically, a generator made with this compound could be put to use any place heat is generated - the size of the crystal can be variable, and in this study was dictated by the size of the furnace in which it was grown.

Heremans said the generator could produce enough electricity from car exhaust to propel the vehicle forward, but he favors the idea of using this technology on a smaller scale: "The smaller-scale applications are where complex solutions are not welcome because they're too expensive," he said. "That's where a simple solution like this one is probably best."

The COVID-19 pandemic has seen scientists perform incredible feats in a short amount of time, from developing tests to new types of vaccines. Despite these victories, experts are still working to develop an effective antiviral drug to kill the SARS-CoV-2 virus. A cover story in Chemical & Engineering News, the weekly newsmagazine of the American Chemical Society, details the challenges of and progress toward creating a drug that would help the world conquer COVID-19.

Creating a new antiviral drug is a tricky business. Viruses mutate and replicate quickly, and their structures differ greatly even within the same class, writes Senior Editor Laura Howes. Most antivirals need to target a specific viral protein to be effective, meaning that each virus often requires its own drug to treat it. Another challenge is proving that the drug works, first in cells and animals, then humans. And while diseases like HIV, AIDS and hepatitis C have led to new advances in antiviral development, there is less of a market for other acute viral infections because of cost and need. The current pandemic has created a sense of urgency in creating new antivirals, but progress is still relatively slow compared with other developments, such as testing and vaccines.

While vaccination efforts are in full swing around the world, experts believe that an oral antiviral is the key to fully eradicating COVID-19, writes Senior Correspondent Bethany Halford. This would allow doctors to treat patients early in the course of infection, which would prevent hospitalizations and fatalities. However, most antivirals are only effective during a brief window after infection, and they can take years to develop and bring to market. Researchers have made some progress in the last year, such as Gilead Sciences' intravenous remdesivir, but an oral version would make treatment more accessible and effective in the early stage of infection. Scientists are also working on broad spectrum antivirals that could treat many types of viruses, including coronaviruses as a whole and novel strains of the flu, which they hope will help mitigate future outbreaks.

WASHINGTON--People who eat too many refined carbs and fatty meats for dinner have a higher risk of heart disease than those who eat a similar diet for breakfast, according to a nationwide study published in the Endocrine Society's Journal of Clinical Endocrinology & Metabolism.

Cardiovascular diseases like congestive heart failure, heart attack and stroke are the number one cause of death globally, taking an estimated 17.9 million lives each year. Eating lots of saturated fat, processed meats and added sugars can raise your cholesterol and increase your risk of heart disease. Eating a heart-healthy diet with more whole carbohydrates like vegetables and grains and less meat can significantly offset the risk of cardiovascular disease.

"Meal timing along with food quality are important factors to consider when looking for ways to lower your risk of heart disease. Our study found people who eat a plant-based dinner with more whole carbs and unsaturated fats reduced their risk of heart disease by ten percent," said study author Ying Li of the Harbin Medical University in Harbin, China. "It's always recommended to eat a healthy diet, especially for those at high risk for heart disease, but we found that eating meat and refined carbs for breakfast instead of dinner was associated with a lower risk."

The researchers studied 27,911 U.S. adults' data from the National Health and Nutrition Examination Survey (NHANES) and analyzed dietary information collected during interviews with the participants over two non-consecutive days. They examined the association between eating different fats, carbohydrates and proteins at breakfast or dinner with participants' rates of heart disease. The analysis found eating a plant-based dinner reduced heart disease risk by ten percent.

CLEVELAND, Ohio (May 26, 2021)--Carpal tunnel syndrome (CTS), which causes tingling and numbness in the hand, more commonly affects women than men and tends to peak around the age of menopause. A new study suggests the risk of severe CTS increases in women who underwent bilateral oophorectomy before menopause, and estrogen therapy didn't provide a protective effect. Study results are published online today in Menopause, the journal of The North American Menopause Society (NAMS).

Carpal tunnel syndrome is the most common nerve disorder in the upper body. Although predominately idiopathic in nature, an association with sex hormones has been suggested because of a higher incidence in women compared with men at all ages. The peak frequency for women is around the age of menopause, which is 50 to 59 years, but for men the peak is 70 to 79 years. In addition, estrogen therapy has been shown in other clinical trials to reduce the risk of CTS in postmenopausal women.

In this study, 1,653 premenopausal women who underwent bilateral oophorectomy between 1988 and 2007 were compared with a sample of 1,653 age-matched women who did not undergo the same surgery. Both groups were assessed for CTS in subsequent years using diagnostic codes.

This study is one of the first to demonstrate an increased long-term risk of de novo severe CTS in women who underwent bilateral oophorectomy before menopause. The risk was greater in women with lower body mass index, women who had never given birth to a child or carried a pregnancy, and in those with a benign ovarian indication for oophorectomy. The study did not find a protective effect of estrogen therapy after the surgery.

It remains unclear whether oophorectomy increases the risk of CTS because it causes abrupt estrogen deficiency because of another endocrine disruption or because of some confounding mechanism such as shared risk factors or a lower threshold to pain.

Results are published in the article "Risk of de novo severe carpal tunnel syndrome after bilateral oophorectomy: a population-based cohort study."

"This study highlights yet another risk associated with bilateral oophorectomy before natural menopause. Together, the findings of this study and others showing increased risk for disease outcomes, such as heart disease and dementia, should prompt reassessment of bilateral oophorectomy before menopause in women who are not at high risk for ovarian cancer," says Dr. Stephanie Faubion, NAMS medical director.

Even among a large group of cancer survivors who were mostly insured, college educated and had annual incomes above the national average, up to 10% delayed care in the previous 12 months because they simply could not afford out of pocket expenses like copays and deductibles, investigators report.

Being unable to get time off from work and being "nervous" about seeing a health care provider, were among the other frequently cited reasons for not always getting timely survivorship care, investigators at the Medical College of Georgia and Georgia Cancer Center report in the journal Cancer Medicine.

Investigators analyzed data from 5,426 cancer survivors who volunteered to share their information with the National Institutes of Health's All of Us Research Program, a historic effort to collect and study health data over many years from at least one million people living in the United States. The cancer survivors were a mean age of 67, mostly female and white with a history of a variety of cancers.

"It is likely that these percentages are much higher among cancer survivors in the general population, and particularly among minorities and other populations suffering significant health disparities in general," Dr. Steven S. Coughlin, interim chief of the Division of Epidemiology in the MCG Department of Population Health Sciences, and his colleagues report.

Survivorship care may need to continue throughout a patient's lifetime, and populations at particular risk for being unable to afford the care include racial minorities as well as women, younger individuals and those with lower incomes struggling most to make ends meet.

"There are subgroups of the population who are at higher risk for poor access, for financial hardship and for cancer in the first place," Coughlin says. "Those are the individuals we are particularly worried about."

"You can imagine that if you go to these populations that are still grossly under-represented in many of these types of surveys, such as African Americans, Hispanics, and individuals who live in more rural communities, these problems are probably magnified tenfold if not more," says Dr. Jorge E. Cortes, director of the Georgia Cancer Center and a study coauthor.

"Some people have lifelong commitments because of the investment they had to make to pay for their treatment, so now they are cured but they are in debt, they may have lost their job, there may be strains that developed in their personal and family relationships. Assessment and management of all these aspects of the patient as a whole have been incorporated into this science of survivorship, which is an integral part of cancer care nowadays," Cortes says.

There were an estimated 16.9 million cancer survivors in the U.S. as of January 2019, a number that is expected to increase to 22.2 million by 2030, according to the National Cancer Institute.

Improved cancer treatment and resulting improved survival rates have oncologists thinking about and talking with their patients about survivorship as early as the time of diagnosis, rather than working reactively, Cortes says, with the goals of preventing or at least minimizing collateral problems on the survivors' financial and emotional health.

"You cannot prevent the impact that a diagnosis of cancer can have emotionally on somebody," Cortes says. "We are all humans and it has a big impact, but maybe you can provide the assistance to help the patient navigate the impact that it can have."

An important aspect of these types of published analyses is to increase awareness of the impact of all these factors, Cortes says. "It is an important component to managing cancer. What this analysis, as well as other assessments that Drs. Coughlin and (Jie) Chen and others have done, is bring that to the forefront."

One goal of the All of Us program is to ultimately build a database that reflects the country's diversity, so that good data will be available for groups, like Blacks, women and eventually children, who have historically been underrepresented in medical research.

The uniqueness of this growing national database is that we are able to collect information from people who volunteer to participate, and use data analytics to extract information from the sophisticated database to answer relevant research questions, says coauthor Chen, chief of the MCG Division of Biostatistics and Data Science. More volunteers are needed along with good data science, which enables investigators to extract the insights the data provide, to fully answer questions like those Coughlin and Cortes are asking and to better help patients and families navigate the aftermath of a cancer diagnosis, she says.

Coughlin and his colleagues Cortes and Chen plan to look again at the survivorship data as the 6-year-old database grows and diversifies.

In the current analysis, MCG investigators looked at demographic factors and other personal characteristics like insured and employment status, personal medical history of cancer, health care use and access in the national database. The most common cancers were breast, prostate and colorectal, which are among the top five cancers in the U.S. Patients with skin cancer, the most common cancer, were excluded from their study because their follow up care needs are more often comparatively minor.

About half those studied had an annual income of $75,000 or more while the median household income was $68,703 in 2019, according to the U.S. Census Bureau. About 47% had private health insurance, 41% had Medicare, 6% had Medicaid, and the rest were insured through the military or the Department of Veterans Affairs, other insurers or were uninsured.

12.1% of people in the U.S. under the age of 65 are uninsured, according to the Centers for Disease Control and Prevention, and about 64% have private insurance. Medicare is available for those 65 and older, according to the U.S. Department of Health and Human Services.

At least in the current dataset, minorities were not significantly more likely to report delaying care in the past 12 months, and just a small percentage were uninsured. The investigators note again there was likely an underrepresentation of individuals most at risk for these problems in the database which patients opt to participate in.

Previous studies have shown that uninsured cancer survivors are more likely to avoid care, including prescription medications, actions associated with poorer outcomes, the investigators write. Studies have also shown that Black, Hispanic and other minority cancer survivors were more likely than whites to have no cancer-related medical visit within the past year, and another found survivors who are Hispanic had the lowest insured rates and did not have even routine medical care in the previous year. Younger cancer survivors also are more likely to forgo health care because of cost.

Based on these kinds of previous findings, the MCG investigators also expected to find survivors who are Black or Hispanic would be least likely to receive health care and experience greater barriers to care than whites, they write.

"Health disparities are pervasive, people across the country struggle to make ends meet and to afford their survivorship care," says Coughlin, who worked for more than a decade at the Division of Cancer Prevention and Control at the Centers for Disease Control and Prevention and has a longstanding interest in better addressing cancer survivorship.

Survivors often have lifelong health care needs that include preventive care, watching for recurrence of the treated cancer or a new malignancy, and cancer treatment related morbidity, which can include problems like infection and bleeding, and the impact of treatment on other body organs like the heart, as well as management of chronic health problems that make them more vulnerable. As examples, 10-20% of breast cancer survivors have diabetes, sometimes because of overlapping risk factors like inactivity and obesity, and some prostate cancer therapies can precipitate diabetes in males, Coughlin says.

Improving survival rates from a variety of cancers, have prompted oncologists to think more about things like the costs of the drugs they are prescribing, and refer patients earlier to a psychologist or psychiatrist, particularly patients already dealing with problems like depression or stress even before their cancer diagnosis. There is also an increasing use of social workers as well as financial advisors to work with families early on, Cortes says.

This more aggressive emphasis on survival reflects the positive reality that more patients are surviving, the investigators say.

The pandemic has increased older adults' willingness to receive the flu shot, new research shows.

The study analyzed survey results of 4,501 Canadians over the age of 50 from ten provinces.

Twenty per cent of 1,001 research participants aged 50 to 64 indicated they had not considered getting a flu shot, but were now more likely to given the impact of COVID-19. Of these respondents, 92 per cent inducated that they had not been vaccinated against influenza the year before.

Of the 3,500 participants aged 65 and older, eight per cent reported that they had not originally planned to get a flu shot but were now more likely to receive it.

"The pandemic has been a sobering demonstration of the dangers of infectious diseases," said Nancy Waite, a professor at the School of Pharmacy and the lead author on the study. "We've seen changing perceptions of the value of vaccines and a documented change in people's willingness to consider getting vaccinated."

Participants who said they would get the influenza vaccine--both those who got it before and those who had not--cited various reasons that reinforced their decision. For some, COVID-19 has demonstrated the devastating potential of viruses, and this awareness sparked the realization that there are severe outcomes of influenza due to risk factors including age. Others also cited the increased risks due to COVID-19 and influenza circulating simultaneously, or a desire to reduce vulnerability to COVID by protecting against influenza.

Just over two per cent of 50- to 64-year-olds and 0.8 per cent of respondents 65 years and older indicated that although they had previously received the influenza vaccine, during the COVID-19 pandemic they were less likely to consider influenza vaccination. This smaller group of participants cited fear of being exposed to COVID-19 when receiving their influenza vaccination and decreased anticipated risk of contracting influenza due to social distancing, as reasons.

"It is helpful for health-care providers who have vaccine conversations with the public to understand the context in which individuals are making decisions. These contexts are fluid, and we need to answer the questions individuals currently have to help them make informed decisions," Waite said. "Our findings demonstrate that the pandemic has created new motivations for many older adults to be accepting of the influenza vaccine but has also created concerns for a small group that health care professionals should be prepared to address."

New research could enable better healthcare for patients with benign tumours of the adrenal glands. Researchers at Lund University in Sweden have identified the levels of cortisol produced by the tumours which are associated with higher mortality rates.

Up to half of benign adrenal tumours produce excessive amounts of the hormone cortisol. Until now, researchers did not know at which levels the cortisol could be harmful or even fatal for the patient.

In a study published in the Annals of Internal Medicine, researchers at Lund University and Skåne University Hospital followed up all patients diagnosed with benign adrenal tumours who came into contact with Skåne University Hospital or Helsingborg Hospital between 2005 and 2015, a total of just over 1 000 patients.

The researchers collected data about the degree of cortisol production in the tumours. The patients were then divided into four groups, based on the degree of cortisol overproduction, from no overproduction to high. The difference in mortality between the groups was investigated using national registers on cause of death.

"The results show a clearly increased risk of death in the two groups with the highest production of cortisol. The risk is 2-3 times higher than for patients with normal cortisol production and the main cause of increased risk is cardiovascular disease", says Albin Kjellbom, consultant physician in endocrinology and diabetology at Skåne University Hospital and research student at Lund University.

The groups with increased risk make up around 20 per cent of patients in the study, i.e. about 200 people.

The results also show that many patients whose tumours have a lower level of cortisol production do not have an increased risk of death.

"In the future, we will be able to identify the patients with an increased risk of death and concentrate our efforts on them, while being able to reassure a large group of patients. This also means a better use of public healthcare resources", says Albin Kjellbom.

There are currently two treatment strategies available for patients with benign adrenal tumours. Either the tumours are surgically removed, or treatment focuses on the known risk factors for cardiovascular disease such as high blood pressure and diabetes.

"We actually know very little about which treatment is effective for these patients; so far, this has not been sufficiently studied. Nor is this something that our study can answer, but now that we are able to identify the patients with an increased risk of death, future studies can investigate which treatment is effective in reducing risk in this patient group", concludes Albin Kjellbom.

A paper published in the Journal of Clinical Medicine presents the results from a study which examined the use of an infrared thermal imaging camera as a novel non-invasive point-of-care tool for lymphatic filariasis lower-limb lymphoedema.

Thermal imaging has been used for several decades in a wide range of medical disciplines, but this is the first time it has been used for filariasis or any skin neglected tropical disease (NTD).

LSTM's Dr Louise Kelly-Hope led the research. She said: "Infrared thermal imaging presents an innovative and objective method for quantifying clinical change in filarial lymphoedema status by using naturally emitting infrared radiation to capture skin surface temperatures. This tool will help to objectively monitor progression of disease or detect new and sub-clinical cases in the field."

The LSTM team first trialled the use of the thermal imaging in Malawi in 2019 with the lymphatic filariasis elimination programme team using an FLIR iPhone thermal camera, which provided important insights into its utility as a non-invasive diagnostic.

This helped to design a multi-country prospective cohort study in Bangladesh, Ethiopia and Malawi using the robust compact FLIR C3 thermal camera, which is ongoing and includes ~750 people affected by lymphatic filariasis. The study aims to assess the impact of the enhanced self-care morbidity management protocol on lymphoedema patients with mild, moderate and severe conditions.

This paper present results from the first baseline survey conducted in Bangladesh in October 2020, which included 153 people affected by lymphoedema.

The images show clear significant differences by the severity of lymphoedema - it helps to 'see' the 'unseeable' and highlights that the 'affected legs' are hotter, especially in people with more severe conditions, which is associated with inflammation, damage and disease progression.

It also helps to show the extent to which limbs are affected - people with milder conditions tended to have high temperatures in selected areas of the limb, whereas people with severe conditions had high temperatures affecting most of their limb

The temperature data indicated significantly higher limb temperatures in people who suffered from secondary bacterial infections know as 'acute dermatolymphangioadenitis' (ADLAs) or acute attacks

The team feel that this novel tool has great potential to be used by field researchers and local health workers to detect subclinical cases, predict progression of disease, and monitor pathological tissue changes and stage severity following enhanced care packages or other interventions in people affected by lymphoedema.

Professor Mark Taylor, Director of LSTM's CNTD, said:"I believe Louise's research has delivered an important new tool to improve the care for this devastating tropical disease. It will give local health care workers and researchers a new opportunity to improve the diagnosis and monitoring of filarial lymphoedema in an affordable and useable format. To be able to show the patients themselves, the improvements gained by enhanced care packages and other interventions will go a long way to relieve the physical and mental suffering of those affected by filarial lymphoedema."

Researchers from the Danish psychiatry research-project iPSYCH have contributed to identify 33 new genetic variants which, as it turns out, play a role in bipolar disorder. To achieve this, they have examined DNA profiles from 413,000 people.

A number of scientific working groups are currently attempting to identify the genetic architecture underlying heritable and severe psychiatric disorders such as schizophrenia, depression and bipolar disorder.

One of these working groups is iPSYCH, Denmark's largest research project focusing on psychiatric disorders. Together with international colleagues, they have recently examined the genetic risk factors behind bipolar disorder. The research groups have examined DNA profiles from a total of 413,000 people of European descent.

These comprise 42,000 patients with bipolar disorder together with 371,000 individuals without the disorder. By comparing the results from these two groups, the researchers have succeeded in identifying 33 genetic variants which, as it turns out, play a role in the risk of developing bipolar disorder.

More knowledge about the disorder

This means that the number of mapped genetic variants - genetic risk factors - behind bipolar disorder has more than doubled, explains one of the Danish participants in the project, Associate Professor Thomas Damm Als from the Department of Biomedicine at Aarhus University:

"In the international collaboration that we're part of and which is focused on mapping genetic risk factors behind bipolar disorder, we've carried out three studies. Before we began the third study, we had knowledge of 31 risk variants - so this is a really significant increase in our knowledge of the genetic architecture of the disease."

The results have been published in the scientific journal Nature Genetics.

The 413,000 DNA profiles that the research group has examined stem from a total of 57 European health databases - with around 7,000 profiles from iPSYCH, the Lundbeck Foundation's Initiative for Integrated Psychiatric Research.

But what exactly are the researchers examining when they map out genetic variants in connection with a psychiatric disorder?

"On a general level we're looking for certain patterns in the prevalence of large pieces of DNA with several variants. Over time a whole 'library' of these genetic variants, which can appear in different places in the genome - our DNA that is - has been built up," says Thomas Damm Als.

Ideas for new treatment

By examining DNA from people who have a particular disease - and then comparing the results with DNA from people who are not affected by it - it is therefore possible to utilise the 'library' to see whether certain genetic variants are especially present in connection with the disease.

"This was how we found the 33 variants," says Thomas Damm Als: "But before we got to this point, we had to take all 413,000 DNA samples and look for variants at eight million places in the genome. It was a huge analysis, and it was only possible because more than two hundred researchers participated in the work."

However, the genetic variants do not provide the complete explanation of how a person develops bipolar disorder.

"They are various contributory factors, environmental factors, however, also play a role - and a similar 'cocktail' of hereditary and environmental factors are also underlying other psychiatric disorders such as schizophrenia and depression," explains the researcher.

In a broad sense, the identified genetic variants can be related to brain functions. Some of the variants are thus involved in genes expressed in the brain, while others influence the signalling between nerve cells in the brain.

This knowledge broadens our understanding of bipolar disorder and may also generate ideas for the development of new medical treatments. But as the researcher emphasizes, this is in no way a more detailed explanation of bipolar disorder,

"Today, we know that bipolar disorder appear to be more heritable than e.g. depression - but how these genetic factors and environmental factors interact is something we still need to understand. And we haven't yet identified all of the relevant genetic variants."

The road to a better understanding of the disorder involves even more DNA studies, as a similar mapping of depression which is also presently being carried out by a large team of international researchers has demonstrated. In this study it took a long time to find genetic variants specific to depression. Only when the research group had analysed approximately 500,000 DNA profiles did they really begin to see a clearer picture.

"It's true for all psychiatric disorders, that you need to have a certain study size to have any hope of finding genetic variants that can be considered risk factors," says Thomas Damm Als.

Poor sleep impacts the risk of long-term cognitive decline in Hispanic/Latino middle aged and older adults differently than it does in non-Hispanic adults, according to research led by University of Miami Miller School of Medicine neurology faculty and the largest long-term study of U.S. Hispanic/Latinos to date.

During seven years of follow-up, Hispanics/Latinos were more likely to develop cognitive declines in processing speed, mental flexibility, and verbal memory, if they had sleep disordered breathing, such as obstructive sleep apnea, and long sleep duration of nine or more hours. The risk was especially high in middle-aged adults without metabolic syndrome and women without obesity or metabolic syndrome according to the paper recently published in Alzheimer's & Dementia, the Journal of the Alzheimer's Association.

"A surprising finding of this study of 5,500 U.S. Hispanic/Latino adults was that participants without obesity that had sleep apnea and long sleep duration had worse cognitive decline," said senior author Alberto Ramos, M.D., M.S.P.H., associate professor of neurology, and research director of the Sleep Disorders Program. "To some extent, this was like a natural experiment where we removed the effect that obesity has on cognition and saw 'the pure effect' of sleep difficulties, such as sleep apnea, and long sleep duration on cognitive health."

The work shows that the metabolic risk factors that predict neurocognitive decline in non-Hispanics are not generalizable to Hispanics, according to Sonya Kaur, Ph.D., instructor in the Division of Neuropsychology at the Miller School.

"In general, the relationship between sleep and cognition was not mediated by metabolic syndrome and obesity in Hispanics like it is in non-Hispanics," Dr. Kaur said. "For Hispanics, sleep seems to be a much stronger predictor than obesity and metabolic syndrome that are traditionally thought as predictors in terms of what causes cognitive decline in non-Hispanics."

This is important given that, compared to non-Hispanic whites, Hispanics/Latinos are at greater risk for metabolic syndrome and are at 4 times the risk of Alzheimer's disease and related dementias, according to Dr. Kaur.

The findings highlight the importance of a precision medicine approach in studying and treating Hispanic/Latino patients.

"In the big picture, these findings have implications for how we can personalize treatment of sleep disorders to more effectively lessen cognitive decline, prevent neurocognitive disorders such as Alzheimer's disease and preserve brain health," Dr. Ramos said.
The Miller School has long been a leader in identifying disorders and risk factors associated with dementia and Alzheimer's and Hispanic health.

"We are conducting ongoing research on the cognitive effects of migration factors and genetic risk factors in Hispanic patients, because there is evidence that genetic risk factors in non-Hispanic whites do not predict cognition decline in the same way as in Hispanics," Dr. Kaur said.

Previously, Dr. Ramos and colleagues published data showing a high prevalence of sleep disorders associated with neurocognitive dysfunction, including memory decline, in a diverse population of Hispanic/Latino participants.

"This study builds on our previous work," said Dr. Ramos, who recently was awarded a five-year $13 million grant from the National Institute on Aging (NIA) to study "Sleep in Neurocognitive Aging and Alzheimer's Research."