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Quality of life relating to physical and mental health can be a key element in the treatment of obese adults. For this reason, interdisciplinary clinical measures including cognitive and behavioral therapy may produce more significant outcomes for these people, reducing not just weight but also symptoms of depression.

This is the main conclusion of a study conducted in Brazil by the Obesity Research Group at the Federal University of São Paulo (UNIFESP) in Santos, São Paulo state, and published in the journal Frontiers in Nutrition.

Considered one of the world’s major public health problems, obesity has more than doubled in Brazil in 17 years and is now increasingly frequent among children and young adults. Between 2002 and 2019, the proportion of obese adults rose from 12.2% to 26.8%. Among women, it reached 29.5% (versus 21.8% among men). The proportion of overweight adults rose from 43.3% to 62.1%, or almost two-thirds of all Brazilians, according to the 2019 National Health Survey.

“The interdisciplinary and cognitive-behavioral therapy program was more effective than the physical exercise and education and health programs. It promoted greater behavioral changes than the other two programs in factors relevant to weight control, such as activity level and dietary intake, resulting in more weight loss. Changes in almost all the variables investigated were observed, including reductions in weight, body mass index, absolute fat mass, waist circumference, hip circumference, and neck circumference. The program was shown to be effective in increasing quality of life in all domains (physical, psychological, social, environmental), and reducing symptoms of depression,” the researchers conclude in the article.

The study involved professionals in the areas of nutrition, psychology, physical education and physical therapy. It was supported by FAPESP via two projects (11/51723-7 and 15/06630-1). It also received funding from the Ministry of Education’s Coordination for the Improvement of Higher Education Personel (CAPES) and the National Council for Scientific and Technological Development (CNPq), an arm of the Ministry of Science, Technology and Innovation (MCTI).

For Amanda dos Santos Moraes, first author of the published study, psychological aspects are proving to be essential in the treatment of obesity. “This is an innovative factor, combining interdisciplinary therapy with the cognitive-behavioral approach to the treatment of obesity. Cognitive aspects are increasingly being taken into account for the treatment of adults with obesity,” she said.

“Cognitive-behavioral therapy is the most widely accepted intervention for weight loss in the psychologist’s clinical practice. This approach focuses on the central thoughts and belief systems of individuals who may have inadequate feelings and behaviors triggered by dysfunctional thoughts about body weight and obesity. In our study, we observed more frequent interventions and a greater reduction in symptoms of depression for the group given cognitive-behavioral therapy than the other two groups.”

According to Danielle Arisa Caranti, co-principal investigator for the study alongside Ricardo José Gomes, interdisciplinary therapy is rarely used by professionals affiliated with the SUS, Brazil’s national health system, but focusing on interprofessionality and mental health should be a priority in future public policy to address the obesity epidemic.

“The reality in the SUS is very different now,” Caranti said. “We have few physical education professionals, for example. Interdisciplinary therapy costs more and also requires knowledge of interprofessionality so that all those involved can work toward the same goals and use collaborative practices. As far as the applicability of the study is concerned, this is an aspect that needs to be taken up by healthcare services and for treatment of chronic diseases.”

In the article, the researchers note the high cost of treating obesity for health systems in many countries. The World Obesity Federation estimates that there are some 800 million people with obesity in the world and projects that the medical consequences of the disease will cost more than USD 1 trillion in 2025.

In Brazil, the cost of the procedures associated with overweight and obesity is estimated at USD 2.1 billion per year. In 2019 alone, for example, high blood pressure accounted for 20.6% of the conditions or problems assessed in over 105 million patient visits, while 8.3% related to diabetes and 2.5% to obesity.

Characteristics

Obesity is a chronic disease characterized by an excessive accumulation of body fat. The most widely used diagnostic criterion for adults is body mass index (weight over height squared). According to the World Health Organization (WHO), a BMI in the range of 25-29.9 kg/m² is overweight, and 30 kg/m² or higher is obese.

A high BMI is a major risk factor for cardiovascular disease, musculoskeletal disorders (especially osteoarthritis), psychological problems and cancer. More recently it has been associated with severe conditions in COVID-19 patients.

The causes of obesity include genetic, behavioral and environmental factors. Other drivers of the rising prevalence of obesity are unhealthy eating and lack of regular exercise.

“The most commonly accepted paradigm in relation to weight loss has been that an imbalance between food intake and physical activity is the main cause of overweight and obesity. However, this simple view does not take into account many other factors related to the problem, such as the influence of the modern lifestyle that stimulates overeating, or the role of adipose tissue in body homeostasis and energy balance,” the authors state in the article.

According to the researchers, “It is essential to develop more powerful strategies to address this obesity epidemic and help individuals lose weight, as well as assist them in adopting and maintaining a healthy lifestyle in a ‘toxic’ environment that promotes excessive food consumption.”

A recent meta-analysis that examined the worldwide prevalence of attempts to control weight showed that 42% of the general population of adults were trying to lose weight, while 23% were trying to maintain their weight. Other studies have shown that a 5% weight reduction is sufficient to improve health.

Methodology

The study conducted by the Brazilian group included a quantitative and qualitative survey as well as a randomized clinical trial. It analyzed and compared the effects of three different long-term treatments on anthropometric profiles, eating behavior, anxiety and depression, and quality of life.

The Obesity Research Group at UNIFESP’s Interdisciplinary Laboratory on Metabolic Diseases recruited the volunteers. Of the 150 who initially agreed to participate in the study, 98 were selected on the basis of the study criteria. They were aged between 30 and 50, and had BMIs between 30 and 39.9 kg/m². Most were women, generally more disposed to seek treatment for obesity than men.

The volunteers were divided randomly into three groups: one for education and health (basically lectures on health), another for physical exercise (according to a training program), and a third for interdisciplinary and cognitive-behavioral therapies (including resistance training, nutritional guidance, and physical and psychological therapy).

Forty-three volunteers remained until the end of the program, which lasted 30 weeks. In the education and health group, quality of life improved significantly. The exercise group lost a considerable amount of weight and quality of life also improved.

The interdisciplinary and cognitive-behavioral therapy group achieved the most substantial progress, with improved anthropometrics and quality of life in all domains (physical, psychological, social, and environmental), as well as positive changes in eating behavior and less depression. This group had the lowest dropout rate (42%).

The article “Cognitive behavioral approach to treat obesity: a randomized clinical trial” by Amanda dos Santos Moraes, Ricardo da Costa Padovani, Cauê Vazquez La Scala Teixeira, Maria Gabriela Soria Cuesta, Silvandro dos Santos Gil, Bárbara de Paula, Gilberto Monteiro dos Santos, Rodrigo Tributino Gonçalves, Ana Raimunda Dâmaso, Lila Missae Oyama, Ricardo José Gomes and Danielle Arisa Caranti is at: www.frontiersin.org/articles/10.3389/fnut.2021.611217/full.

Journal

Frontiers in Nutrition

DOI

10.3389/fnut.2021.611217

COLUMBUS, Ohio - Though obesity in midlife is linked to an increased risk for Alzheimer's disease, new research suggests that a high body mass index later in life doesn't necessarily translate to greater chances of developing the brain disease.

In the study, researchers compared data from two groups of people who had been diagnosed with mild cognitive impairment - half whose disease progressed to Alzheimer's in 24 months and half whose condition did not worsen.

The researchers zeroed in on two risk factors: body mass index (BMI) and a cluster of genetic variants associated with higher risk for Alzheimer's disease.

Their analysis showed that a higher genetic risk combined with a lower BMI was associated with a higher likelihood for progression to Alzheimer's, and that the association was strongest in men.

The finding does not suggest people should consider gaining weight in their later years as a preventive effort - instead, researchers speculate that lower BMI in these patients was likely a consequence of neurodegeneration, the progressive damage to the brain that is a hallmark of Alzheimer's. Brain regions affected by Alzheimer's are also involved in controlling eating behaviors and weight regulation.

"We don't want people to think they can eat everything they want because of this lower BMI association," said senior study author Jasmeet Hayes, assistant professor of psychology at The Ohio State University.

"We know that maintaining a healthy weight and having a healthy diet are extremely important to keeping inflammation and oxidative stress down - that's a risk factor that is modifiable, and it's something you can do to help improve your life and prevent neurodegenerative processes as much as possible," she said. "If you start to notice rapid weight loss in an older individual, that could actually be a reflection of a potential neurodegenerative disease process."

The study was published online recently in the Journals of Gerontology: Series A.

Previous research has found a link between obesity and negative cognitive outcomes, but in older adults closer to the age at which Alzheimer's disease is diagnosed, the results have been mixed, Hayes said. And though a variant to the gene known as APOE4 is the strongest single genetic risk factor for Alzheimer's, it explains only about 10 to 15% of overall risk, she said.

Hayes has focused her research program on looking at multiple risk factors at the same time to see how they might interact to influence risk - and to identify health behaviors that may help reduce the risk.

"We're trying to add more and more factors. That is my goal, to one day build a more precise and better model of the different combinations of risk factors," said Hayes, also an investigator in Ohio State's Chronic Brain Injury Initiative. "Genetic risk is important, but it really explains only a small part of Alzheimer's disease, so we're really interested in looking at other factors that we can control."

For this study, the research team obtained data from the Alzheimer's Disease Neuroimaging Initiative, compiling a sample of 104 people for whom BMI and polygenic risk scores were available. Fifty-two individuals whose mild cognitive impairment (MCI) had progressed to Alzheimer's in 24 months were matched against demographically similar people whose MCI diagnosis did not change over two years. Their average age was 73.

Statistical analysis showed that individuals with mild cognitive impairment who had both a lower BMI and higher genetic risk for Alzheimer's were more likely to progress to Alzheimer's disease within 24 months compared to people with a higher BMI.

"We think there's interaction between the genetics and lower BMI, and having both of these risk factors causes more degeneration in certain brain regions to increase the likelihood of developing Alzheimer's disease," said Jena Moody, a graduate student in psychology at Ohio State and first author of the paper.

The effect of the BMI-genetic risk interaction was significant even after taking into account the presence of beta-amyloid and tau proteins in the patients' cerebrospinal fluid - the core biomarkers of Alzheimer's disease.

The relationship between low BMI and high genetic risk and progression to Alzheimer's was stronger in males than in females, but a larger sample size and additional biological data would be needed to expand on that finding, the researchers said.

Because brain changes can begin long before cognitive symptoms surface, a better understanding of the multiple risk factors for Alzheimer's could open the door to better prevention options, Moody said.

"If you can identify people at higher risk before symptoms manifest, you could implement interventions and prevention techniques to either slow or prevent that progression from happening altogether," she said.

To date, scientists have suggested preventive steps include maintaining a healthy weight and diet and participating in activities that reduce inflammation and promote neurofunctioning, such as exercise and mentally stimulating activities.

"We're finding again and again how important inflammation is in the process," Hayes said. "Especially in midlife, trying to keep that inflammation down is such an important aspect of maintaining a healthy lifestyle and preventing accelerated aging."

SAN ANTONIO (May 19, 2021) -- Four months of multi-drug therapy that included rifapentine and moxifloxacin treated active tuberculosis (TB) as effectively as the standard six-month regimen in a multinational study, cutting treatment time by a third. Coauthors including Marc Weiner, MD, of The University of Texas Health Science Center at San Antonio, reported the findings May 6 in the New England Journal of Medicine.

"Shorter treatment would be easier for people to complete without missing doses, and ultimately may be cost-effective," said Dr. Weiner, associate professor in the health science center's Joe R. and Teresa Lozano Long School of Medicine and infectious diseases physician in the South Texas Veterans Health Care System. "These drugs have been around for more than 20 years and are widely available. This study demonstrates a new and feasible way to treat what is a global pandemic of tuberculosis."

Risk of spread with active disease

According to the World Health Organization, a quarter of the world's population has latent TB, which means the people are infected but don't have signs and symptoms of illness. "However, with active disease, people become sicker and TB can more easily spread to other people," Dr. Weiner said. Participants in the newly reported trial all had active TB disease.

The standard TB regimen consists of four drugs -- rifampin, isoniazid, pyrazinamide and ethambutol. It is a successful therapy; approximately 95% of recipients are cured of TB disease with this treatment. The rifapentine-moxifloxacin regimen, while being meaningfully shorter in treatment duration, was non-inferior to and was safe and well tolerated compared to the standard therapy, Dr. Weiner said.

The study enrolled more than 2,500 participants in 13 countries, including nearly 200 people living with HIV (human immunodeficiency virus). HIV greatly increases the risk of patients with latent TB infection progressing to active TB disease. Other risk factors for progression to active disease include recent infection, diabetes and chronic renal disease. Participants were registered at 34 trial sites in Brazil, China (Hong Kong), Haiti, India, Kenya, Malawi, Peru, South Africa, Thailand, Uganda, the United States, Vietnam and Zimbabwe.

The study population was divided randomly into a group that received the standard regimen, and two experimental multidrug arms, one with rifapentine and another with rifapentine and moxifloxacin. Participants were followed for up to 18 months, and the primary outcome was survival free of tuberculosis at a year after study randomization.

Cost savings will be evaluated, Dr. Weiner said, as a generic version of rifapentine is being developed. "However, drug costs are just one component of the expenses of active TB treatment," he said. "In general, TB drugs are taken daily, and five days a week, a health care provider observes the individual taking the medicine. In the U.S., there is substantial cost for personnel to administer this directly observed therapy to patients."

COVID-19 pandemic complicates the TB problem

India, Indonesia, the Philippines and South Africa have high numbers of people with active TB. The Stop TB Partnership has suggested that because of a delay in diagnosis and treatment of TB in high-burden countries, the COVID-19 pandemic could cause an additional 6.3 million TB cases worldwide between 2020 and 2025.

TB is an infection of Mycobacterium tuberculosis (MTB). This bacterium usually first infects the lungs after airborne transmission. It is encased in a granuloma, a small area of inflammation, and for months or years, the body may be able to contain the infection. However, if the immune system weakens or something else affects the granuloma, MTB proliferates, and the patient usually develops signs and symptoms that can include fever, cough with or without sputum production, weight loss or fatigue.

Leesburg, VA, May 19, 2021--According to an open-access article in ARRS' American Journal of Roentgenology (AJR), increased axillary lymph node or ipsilateral deltoid uptake is occasionally observed on FDG or 11C-choline PET performed after Pfizer-BioNTech or Moderna COVID-19 vaccination.

"Recognition of occasional abnormal axillary lymph node or deltoid uptake on PET examinations performed after COVID-19 vaccination will aid interpreting physicians and reduce unnecessary biopsies," wrote corresponding author Jason R. Young from the department of radiology at Mayo Clinic in Rochester, MN.

Young and colleagues' retrospective study included 67 patients (43 men, 24 women; mean age, 75.6 years) who underwent PET examination (PET/CT in 66, PET/MRI in 1; FDG in 54, 11C-choline in 13) between December 14, 2020 and March 10, 2021 following COVID-19 vaccination (Pfizer-BioNTech vaccine in 52, Moderna vaccine in 15) and who had undergone pre-vaccination PET without visible axillary node uptake. PET was performed a median of 13 and 10 days after vaccination in patients who had received one (n = 44) and two (n = 23) doses, respectively.

"We observed positive axillary lymph nodes in 7.4% of FDG and 23.1% of 11C-choline PET examinations performed after COVID-19 vaccination (10.4% of PET examinations) in patients without visible axillary nodal uptake on PET performed before vaccination," Young et al. concluded. Ipsilateral deltoid uptake with a characteristic appearance was observed in 14.5% of examinations, and one patient exhibited extraaxillary lymph node uptake (ipsilateral supraclavicular uptake on FDG PET).

"All examinations showing positive axillary lymph nodes were performed within 24 days of vaccination," the authors of this AJR article added.

Updated Criteria Also Released for Legius Syndrome and Mosaic NF

NF2 and Schwannomatosis Diagnostic Criteria to Be Released Later This Year

The Children's Tumor Foundation (CTF) today announced the publication of updated diagnostic criteria for the genetic disorder neurofibromatosis type 1 (NF1) in Genetics in Medicine, the official journal of the American College of Medical Genetics and Genomics. The new publication is the result of an extensive, multi-year collaborative effort of over 90 leading neurofibromatosis (NF) experts from around the globe, and is aimed at improving the accuracy and earlier diagnosis of NF1 in patients, thus ultimately leading to improved care and quality of life for those patients. Today's announcement is being made on the occasion of NF Awareness Month, a global awareness initiative focused on increasing recognition of all the forms of neurofibromatosis and schwannomatosis.

The original diagnostic criteria for NF1 and NF2 were established at the National Institutes of Health (NIH) consensus meeting in 1987, and the diagnostic criteria for schwannomatosis was established in 2005. Since that time, there has been an explosion of knowledge about these genetic disorders, including the discovery of the genes that cause NF1, NF2, and schwannomatosis, as well as the technological development of genetic testing. In recent years, NF clinicians have noted that an updated consensus was needed to better communicate (for both medical professionals and patients) the distinctions between NF1, NF2, and schwannomatosis, as patients were at times being misdiagnosed or receiving delayed diagnosis and care.

As a result, in 2017 a group of NF investigators reached out to the Children's Tumor Foundation, the largest nongovernmental funder of all forms of NF research in the world, to sponsor a review and potential revision of the NF diagnostic criteria. That group of investigators grew into a worldwide effort that utilized the following guiding principles in the development of the updated criteria:

Formulate a clear delineation between NF1, NF2, and schwannomatosis criteria
* Represent the best consensus among NF experts
* Reflect input from patients, caregivers, families, foundations, and advocacy groups
* Exclusively address the issues of diagnosis (rather than clinical management)
* Be broadly representative of medical specialties
* Be usable by general doctors as well as NF specialists
* Recognize advances in genetics without requiring genetic analysis for diagnosis
* Be relevant in different countries and health care systems, now and in coming years

While the review of all forms of NF were conducted concurrently by the expert groups, it is the updated NF1, Legius syndrome, and mosaic NF criteria that are available at this time, with the NF2 and schwannomatosis criteria release to come later this year.

The results of today's update are now publicly available in the publication Genetics in Medicine, in an article entitled "Revised Diagnostic Criteria for Neurofibromatosis Type 1 and Legius Syndrome: An International Consensus Recommendation". The article can be found at https://www.nature.com/articles/s41436-021-01170-5. All the names of the participants in the International Consensus Group on Neurofibromatosis Diagnostic Criteria can be found in the paper.

In the article, the authors outline the following:

Purpose: by incorporating major developments in genetics, ophthalmology, dermatology, and neuroimaging, to revise the diagnostic criteria for neurofibromatosis type 1 (NF1) and to establish diagnostic criteria for Legius syndrome (LGSS).

Methods: using a multistep process, beginning with a Delphi method involving global experts and subsequently involving non-NF experts, patients, and foundations/patient advocacy groups.

Results: reached consensus on the minimal clinical and genetic criteria for diagnosing and differentiating NF1 and LGSS, which have phenotypic overlap in young patients with pigmentary findings. Criteria for the mosaic forms of these conditions are also provided.

Conclusion: the revised criteria for NF1 incorporate new clinical features and genetic testing, whereas the criteria for LGSS were created to differentiate the two conditions. It is likely that continued refinement of these new criteria will be necessary as investigators (1) study the diagnostic properties of the revised criteria, (2) reconsider criteria not included in this process, and (3) identify new clinical and other features of NF and related disorders.

In coming months, the Clinical Care Advisory Board of the Children's Tumor Foundation, in partnership with NF clinics, medical groups, and other NF organizations, will roll out a multi-format education program of the updated criteria for both general physicians and NF experts, to increase knowledge and advance care of the various forms of neurofibromatosis.

Pregnant women made only modest dietary changes after being diagnosed with gestational diabetes, according to a study by researchers at the National Institutes of Health. Women with gestational diabetes are generally advised to reduce their carbohydrate intake, and the women in the study did cut their daily intake of juice and added sugars. They also increased their intake of cheese and artificially sweetened beverages. However, certain groups of women did not reduce their carbohydrate intake, including women with obesity, had more than one child, were Hispanic, had a high school degree or less, or were between the ages of 35-41 years.

The study was led by Stefanie N. Hinkle, Ph.D., of the Epidemiology Branch at NIH's Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). The study appears in the Journal of the Academy of Nutrition and Dietetics.

Patients with gestational (or pregnancy-related) diabetes have a higher risk of maternal high blood pressure, larger babies, cesarean delivery, low blood sugar in newborns, and development of chronic diabetes later in life.

"The improvements in diet that we observed were not equitable across all groups of women," said Dr. Hinkle. "This research highlights the importance of creating individualized programs to ensure that all women with gestational diabetes are successful at modifying their diet and optimizing their health."

The study team analyzed an existing set of data from the NICHD Fetal Growth Studies, which included surveys on diet and exercise from a diverse group of women at 12 hospital centers across the country. The analysis on diet included 1,371 women, of which 72 had gestational diabetes. The study team also examined exercise routines and that analysis included 1,875 women, of which 84 had gestational diabetes.

In the study, women with gestational diabetes limited their daily carbohydrate intake by 48 grams primarily by reducing their juice consumption by about 0.4 cups per day and reducing their added sugar consumption by about 3.2 teaspoons per day. Their consumption of cheese increased by 0.3 cups per day and artificially sweetened beverages increased by 0.2 cups per day.

In addition, the team found that women with gestational diabetes did not reduce their consumption of whole grains or whole fruit, nor did they compensate for their dietary changes by increasing saturated fats. The authors write that these observations are reassuring given that complex carbohydrates from whole grains or fruits may be beneficial for gestational diabetes, while saturated fats can worsen health outcomes by promoting excessive fetal growth.

The researchers also found that women with gestational diabetes maintained the same amount of time in moderate or vigorous exercises into their third trimester. However, women who did not have gestational diabetes reduced their moderate exercise activities during their third trimester by approximately 20 minutes per week and their vigorous exercise by approximately 9 minutes per week.

According to the study authors, the findings show that healthcare providers still have many opportunities to help women with gestational diabetes make greater gains and changes in diet and exercise. The authors called for more research to identify innovative approaches that are more effective in changing nutrition and exercise-related behaviors.

DALLAS, May 19, 2021 — Steps to ensure safety and mitigate the spread of COVID-19 have had some unintended consequences on the management of chronic conditions such as high blood pressure, a leading cause of heart disease and health disparities in the United States. COVID-19 has disproportionately affected people from different racial and ethnic groups, those who are from under-resourced populations and communities that face historic or systemic disadvantages. Discussions and research are ongoing to address what many experts label as long-existing inequities in the U.S. health system, according to information published today in the Journal of the American Heart Association, an open access journal of the American Heart Association.

“Media coverage has examined how and why COVID-19 is disproportionately impacting communities of color to some degree. However, it is critical that we continue to examine and explain the degree to which the pandemic has widened the divide among race/ethnic and class groups in the U.S. and exposed the systemic and institutional cracks in our health care system in terms of health care equity for people who are under-represented and populations that face disadvantages,” said Adam Bress, Pharm.D., M.S., lead author of the paper, an associate professor of population health science in the Division of Health System Innovation and Research at the University of Utah School of Medicine in Salt Lake City and an investigator at the VA Salt Lake City Health Care System. “COVID-19 has also reminded us that when we design interventions, it is important to consider health equity from the beginning rather than as an afterthought.”

A panel of frontline clinicians, researchers and leaders from diverse backgrounds recently convened virtually at the 4th Annual University of Utah Translational Hypertension Symposium to discuss how the pandemic has worsened inequities in blood pressure control and to highlight the environmental and socioeconomic factors contributing to disparities within the health care system, as well as strategies to help close the gap going forward.

The group also discussed the latest research on trends in hypertension care and effective ways to improve outcomes, and this study reflects a comparison on hypertension statistics before and during the COVID-19 pandemic outlined in previously published research.

One large nationwide study of over 50,000 adults indicated the number of people maintaining healthy blood pressure levels had been declining even prior to the pandemic, with lack of health insurance and access to health care being key factors. High blood pressure in this study was defined as greater than 140/90 mm Hg (the current American Heart Association guidelines define high blood pressure as 130/80 mm Hg). The research showed that from 2017-2018, only 22% of uninsured people in the study had healthy blood pressure levels, compared to 40-46% of the people who had some form of health insurance. Additionally, among the people who had not seen a health care professional in the previous year, only 8% had their blood pressure under control, compared to 47% of those who reported seeing a health care professional. The results also indicated Black adults were 12% less likely to have healthy blood pressure levels compared to white adults.

One nationally representative audit of practices in the U.S. shows that during the second quarter of 2020, new health care visits for the purpose of managing high blood pressure, both in-person and virtual, decreased by 39% compared to the same quarter in 2018 and 2019. A dangerous decrease in hospitalizations due to heart attacks, strokes and heart failure since COVID-19 was noted in another study of hospitalizations, yet it also found a 20% increase in out-of-hospital deaths during the same time period.

The COVID-19 pandemic caused a substantial shift in health care for hypertension – from in-person office visits to primarily virtual appointments. As the number of virtual health care appointments increased substantially since March 2020, many patients did not have access to validated home blood pressure monitors to regularly check their blood pressure. The lack of access to devices needed to monitor blood pressure, as well as the lack of internet access and/or inadequate or limited digital literacy to participate in virtual appointments posed significant barriers.

Additional obstacles to achieving healthy blood pressure levels are the challenges of adherence to medication regimens and lifestyle modifications. Lack of access to healthy foods or health care facilities, along with the costs of medications and, in some cases, a lack of understanding of the importance of medication, can all have a negative impact on hypertension.

Research shows health care professionals may also have biases, some based upon personal beliefs and/or stereotypes, leading to a difference in quality of care and clinical inertia. One study determined clinicians’ biases about their perceptions of medical agreeableness or acceptance of medication recommendations among Black patients versus white patients potentially had a negative effect on which treatment options were offered and/or implemented. Clinical inertia — clinicians’ failure to initiate or intensify antihypertensive therapy when blood pressure goals are unmet — can also result in high rates of inadequate blood pressure control.

The researchers note another concerning trend is a patient’s distrust of the health care system, fueled by years of institutional racism, historical atrocities in medical care and research such as the Tuskegee study of syphilis in Black men, and inadequate representation of people from diverse racial and ethnic groups in clinical trials and as health care professionals. Community-based interventions can help to foster patient trust and improve health care access. One trial highlighted was the highly successful BARBER trial, where barbershops in predominantly Black neighborhoods in Los Angeles encouraged people 1) to meet with pharmacists embedded in the BARBER shops regularly to discuss and manage their blood pressure, or 2) promoted healthy lifestyle choices with routine care by a physician. At six months, people who participated in the pharmacist-led intervention achieved a 21.6 mm Hg greater reduction in systolic blood pressure and had a 51.9% greater increase in blood pressure control compared to those who did not receive any intervention. At 12 months, the results were sustained.          

There is also a low proportion of medical school students, researchers and participants in health care research who are from diverse racial and ethnic groups, particularly from under-represented and under-resourced communities. One analysis found that among all blood pressure trials registered in the U.S. at ClinicalTrials.gov, only 5.4% had enrolled exclusively Black adults. This suggests there are few interventions and therapies being studied and designed specifically for Black adults with hypertension.

“Too often, individuals are blamed for their health care conditions, without considering the multiple levels of social factors and context that contribute to persistent and pervasive health inequities” added Bress. “Health inequities are a social justice issue. We need to be more direct and honest about the reasons for health disparities today and commit to structural solutions to begin to address them. These factors include historic structural and interpersonal racism; the different lived experiences for people of color and other groups facing disadvantages; the unacceptably low levels of public investment in public health, universal health care, and science; and the long-term effects of unequal access to affordable and high-quality health care among many others. We need to ensure that these meaningful conversations and changes in policy, research, health care and education persist after the COVID-19 pandemic in order for there to be sustained progress in achieving greater health equity.”

A new article from Liverpool ocular researchers demonstrates that small uveal (intraocular) melanomas are not always harmless, as the current paradigm suggests.

Instead, a reasonable proportion of them have molecular genetic alterations, which categorises them as highly metastatic tumours. The article recommends that they should not be observed but rather treated immediately, to improve patients' chances of survival.

The paper shows that uveal melanoma patients with small tumours, when treated within a certain time frame in Liverpool, do indeed have improved outcomes.

The study was undertaken by researchers at Liverpool Ocular Oncology Centre based at Liverpool University Hospitals NHS Foundation Trust, the Liverpool Ocular Oncology Research Group (LOORG) at the University of Liverpool and with Professor Bertil Damato, formerly of Liverpool and now based at the Ocular Oncology Service at Moorfields Eye Hospital, London.

First author Dr Rumana Hussain, of Liverpool Ocular Oncology Centre, said: "Uveal melanoma is a potentially lethal disease, with a 50% mortality rate from metastatic disease. However, traditionally, small lesions have been monitored rather than treated as it was considered that these are less likely to cause metastatic spread and that local treatment does not influence outcome.

"Liverpool is one of the only ocular oncology centres in the world that offers prognostic biopsies to all of its melanoma patients, and we have therefore collected a large molecular genetic cohort of small tumours. This is the first study to show that over a quarter of these smaller uveal melanomas have lethal genetic mutations, and suggests that we may be able to influence patient survival and mortality outcomes with earlier treatment of these small melanomas. This will cause a massive shift in the approach to such patients, both in terms of management of their primary tumour, but also in terms of the consideration of prognostic biopsies in small ocular cancers."

The Liverpool Ocular Oncology Research Group's mission is to conduct high quality basic, translational and clinical research into the pathogenesis and treatment of adult ocular tumours that will improve patient care and survival.

Together with Dr Helen Kalirai, Professor Sarah Coupland leads the basic science and translational research portfolio, in addition to being a diagnostic Consultant Pathologist at the Liverpool University Hospitals Foundation Trust. Sarah leads one of the four NHSE supra-regional Ophthalmic Pathology services, and has led the molecular oncology prognostication service for around 10 years. Professor Heinrich Heimann leads the clinical research portfolio of the LOORG and heads the Liverpool Ocular Oncology Centre.

Professor Sarah Coupland said: "Since the early 1990s it was clear that uveal melanomas could be divided into differing genetic prognostic groups. This has become even more definitive through studies such as The Cancer Genome Atlas Uveal Melanoma study, to which LOORG significantly contributed. These past analyses, however, were based mainly on large tumours, and very few genetic investigations have been undertaken on small uveal melanomas, which erroneously have all been labelled as 'safe'. Our study using a unique collection of tiny intraocular biopsies of small uveal melanomas with follow-up clinical data, shows that they too can be broken down into 'good' and 'bad' tumours. Instead of watching the latter, they can be treated earlier and thereby increase significantly the chance of cure for these patients".

Traditionally, an infection is thought to happen when microbes - bacteria, fungi, or viruses - enter and multiply in the body, and its severity is associated with how prevalent the microbes are in the body.

Now, an international research team led by Nanyang Technological University, Singapore (NTU Singapore) has proposed a new way of understanding infections. Their study of close to 400 respiratory samples from patients with bronchiectasis, a chronic lung condition, has shown that microbes in the body exist as a network, and that an infection's severity could be a result of interactions between these microbes.

Through statistical modelling of data from these respiratory samples, the scientists found that flare-ups of coughs and breathlessness (known as exacerbations) occurred more often when there were 'negative interactions' between communities of bacteria, viruses and fungi in the airways. A negative interaction occurs when the microbes compete rather than cooperate with one another.

These findings, published in one of the world's leading scientific journals Nature Medicine in April, bring the scientists one step closer to developing a new way of tackling infections, by targeting microbial interactions rather than the specific microbes.

Assistant Professor Sanjay Haresh Chotirmall from the NTU Lee Kong Chian School of Medicine, who led the study, said: "Our current understanding of infections is that they occur when harmful microbes enter our bodies. This model of understanding, however, fails to account for resident microbes or explain why some patients with infection respond to antibiotics to which the microbe is resistant in laboratory testing. We are therefore proposing that microbes exist as networks, where interactions happen and that the resistant antibiotic in this case targets another microbe with which the culprit is interacting. We therefore can potentially improve clinical outcomes by breaking such crosstalk.

"The findings of our study are the first steps in providing a more holistic view of how infections occur. While our study looked at patients with bronchiectasis, we believe this concept applies to all forms of infection - whether skin, lung, or a gastrointestinal infection. This way of looking at infections potentially changes our understanding of infection and may offer fresh ways of treating them."

Associate Professor John Abisheganaden, co-author of the study and Head of Department of Respiratory & Critical Care Medicine at Tan Tock Seng Hospital, said: "By applying an integrated and holistic method, this study provides a new and fresh approach to our understanding of respiratory infection. Applying this precision-medicine approach can help the managing physician better understand and choose the most appropriate antibiotic or other therapy to confer clinical benefit - in short, to guide us to the right treatment at the right time, and for the best outcome."

Microbial interactions and infection

For their study, the scientists looked at patients with bronchiectasis, a disease of high Asian prevalence, where airways dilate irreversibly and, where infection promotes progression. Targeting bacteria with antibiotics reduces bacterial load and accompanying inflammation, which in turn alleviates symptoms and improves clinical outcomes.

To investigate interactions between microbes in the airways of patients with bronchiectasis, the team collected respiratory (sputum) samples from 383 patients from Singapore, Malaysia, Italy, and Scotland, including samples before, during and after bronchiectasis flare-ups.

After analysing the genetic material from bacteria, fungi and viruses in the samples, the scientists assessed for possible microbial interactions and found that patients with frequent flare-ups had more negative interactions, where microbes compete rather than cooperate, and that the number of such negative interactions increased even further during a flare-up. While changes to interactions between microbes during flare-ups was detected, there was surprisingly minimal change to the type and quantity of microbes present during a flare-up, and even after antibiotics were administered.

New treatment possibilities

The scientists believe that these findings suggest that microbial interactions potentially drive frequent flare-ups in patients.

Using these findings, the scientists have developed an online tool
to help other researchers and physicians analyse microbial interactions in their own patient samples through the microbes' genetic sequences.

Asst Prof Chotirmall, who is also NTU Provost's Chair in Molecular Medicine, said: "We are proposing a fresh way to view infection, as networks rather than individual microbes. Targeting microbial interactions within an established network may promote more judicious antibiotic use and help curb rising antimicrobial resistance."

The team is currently exploring the use of probiotics to treat bronchiectasis by regulating microbiomes within the air passages.

LA JOLLA, CALIF. - May 19, 2021 - A study led by scientists at Sanford Burnham Prebys Medical Discovery Institute has identified a tumor marker that may be used to predict which breast cancer patients will experience resistance to endocrine therapy. The research offers a new approach to selecting patients for therapy that targets HER2, a protein that promotes the growth of cancer cells, to help avoid disease relapse or progression of endocrine-sensitive disease.

The study was published in the journal Nature Communications.

Nearly 80% of breast tumors are estrogen receptor (ER)-positive. For decades, these tumors have been treated with anti-estrogen (endocrine) therapies to lower estrogen levels and help slow the cancer's growth. About 20% of breast cancers are also HER2-positive at diagnosis, and these tumors tend to be more aggressive and fast-growing, as HER2 is a receptor that when active, promotes the rapid growth of breast cancer cells.

"We know there is a subset of patients who are initially diagnosed with ER-positive, HER2-negative breast tumors, but their tumors convert to HER2-positive after they receive endocrine therapy," says Svasti Haricharan, Ph.D., assistant professor in the Aging, Cancer and Immuno-oncology Program at Sanford Burnham Prebys and senior author of the study. "Unfortunately, this unleashes the detrimental effects of HER2, and patients become resistant to endocrine therapy--resulting in relapse, metastasis and death."

With conventional endocrine therapy being unhelpful for these patients, Haricharan's team examined how two genes, MLH1 and PMS2, affect HER2 activity. These genes are part of a biological system to "fix" DNA errors--but they also play a critical role in suppressing HER2. When these genes are turned off, HER2 becomes activated as soon as patients receive standard care endocrine therapy.

"Fortunately, there are tests for MLH1 and PMS2 activity that are now done routinely for colorectal and endometrial cancers," says Nindo Punturi, a research assistant in the Haricharan lab and first author of the paper. "If we were to transition these tests to newly diagnosed cases of breast cancer, we could identify patients who may benefit from early HER2 targeted treatment--essentially shutting the door to HER2 activity before it gets started."

The National Cancer Institute (NCI) estimates that 281,550 women in the U.S. will be diagnosed with breast cancer in 2021, and 43,600 women will eventually die from the disease. Some women whose MLH1 and PMS2 gene expression is low or absent may have an even greater risk of death.

"Our research efforts are all about getting the right treatments to the right people as soon as possible," says Haricharan. "With so many excellent drugs at our disposal to treat breast cancer--including those that target HER2--it's more a matter of selecting the available, appropriate drugs than searching for new ones. This research effort is an important step in that direction."

Monroe Carell Jr. Children's Hospital at Vanderbilt has launched a study to determine the impact of a predictive model for identifying pediatric patients at risk for developing blood clots or venous thromboembolisms (VTEs).

The study uses advanced predictive analytics to inform medical teams of patients at risk for blood clots before they happen.

"Hospital-associated blood clots are an increasing cause of morbidity in pediatrics," said the study's principal investigator, Shannon Walker, MD, clinical fellow of Pediatric Hematology-Oncology at Children's Hospital.

While these events are more rare among children than they are among adults, Walker noticed that blood clot development was on the rise.

"The reason children get blood clots is very different from adults," said Walker, who worked with mentors Allison Wheeler, MD, MSCI, assistant professor of Pediatrics and Pathology, Microbiology and Immunology, and C. Buddy Creech, MD, MPH, director of the Vanderbilt Vaccine Research Program and associate professor of Pediatric Infectious Diseases.

"There was no standardized protocol for preventing clots in pediatric patients. As we noticed that the rate of blood clots was going up and recognized that the adult strategy wasn't going to work for our patients, we wanted to look at each patient's individual risk factors and see how we could focus our attention on targeted blood clot prevention."

The study, set to be published in Pediatrics, describes how the team built and validated a predictive model that can be automated to run within the electronic health record of each patient admitted to the hospital.

The model includes 11 risk factors and was based on an analysis of more than 110,000 admissions to Children's Hospital and has been validated on more than 44,000 separate admissions.

Currently the team is studying using this model along with targeted intervention in the clinical setting in a trial called "Children's Likelihood of Thrombosis," or CLOT.

The prediction model is used in this way: every child admitted to the hospital has a risk score calculated. The patients are randomized, so in half of the patients, elevated scores are reviewed by a hematologist, and then discussed with each patient's medical team and family to determine a personalized prevention plan. All patients, regardless of randomization, continue to receive the current standard of care.

"We are not utilizing a one-size-fits-all plan," Walker said. "This is an extra level of review allowing for a very personalized recommendation for each patient with an elevated score. Each day the score is updated, so as risk factors change, the scores change accordingly.

"We are, in real-time, assessing the use of this model as a clinical support tool. We saw a clinical opportunity of something we could improve and have moved forward with building the model -- to identify high-risk patients and are currently performing the CLOT trial, which will run through the end of the year."

Walker's study was possible with the help of the Advanced Vanderbilt Artificial Intelligence Laboratory, or AVAIL. Only in its second year, the program is leading the way supporting artificial intelligence tools at VUMC through project incubation and curation, including facilitating clinical trials to assess their effectiveness.

"AVAIL served as a catalyst, in this instance by bringing experts in a complex trial development into proximity so that a great synthesis could happen," said Warren Sandberg, MD, PhD, executive sponsor of AVAIL, along with Kevin Johnson, MD.

"What is unique about this particular project is that we were not only able to predict complications but also able to test the model in a rigorous, pragmatic, randomized, controlled trial to see if it benefits patients," said Dan Byrne, senior biostatistician for the project and director of artificial intelligence research for AVAIL.

"The future of this kind of work is unlimited," he said. "We can hopefully use this approach to predict and prevent pressure injuries, sepsis, falls, readmissions or most any complication before they happen. At Vanderbilt, we are raising the bar when it comes to the science of personalized medicine and application of artificial intelligence in medicine in a way that is both ethical and safe."

CORVALLIS, Ore. - Researchers at Oregon State University have found a key new piece of the puzzle in the quest to use gene therapy to enable people born deaf to hear.

The work centers around a large gene responsible for an inner-ear protein, otoferlin. Mutations in otoferlin are linked to severe congenital hearing loss, a common type of deafness in which patients can hear almost nothing.

"For a long time otoferlin seemed to be a one-trick pony of a protein," said Colin Johnson, associate professor of biochemistry and biophysics in the OSU College of Science. "A lot of genes will find various things to do, but the otoferlin gene had appeared only to have one purpose and that was to encode sound in the sensory hair cells in the inner ear. Small mutations in otoferlin render people profoundly deaf."

In its regular form, the otoferlin gene is too big to package into a delivery vehicle for molecular therapy, so Johnson's team is looking at using a truncated version instead.

Research led by graduate student Aayushi Manchanda showed the shortened version needs to include a part of the gene known as the transmembrane domain, and one of the reasons for that was unexpected: Without the transmembrane domain, the sensory cells were slow to mature.

"That was surprising since otoferlin was known to help encode hearing information but had not been thought to be involved in sensory cell development," Johnson said.

Findings were published today in Molecular Biology of the Cell.

Scientists in Johnson's lab have been working for years with the otoferlin molecule and in 2017 they identified a truncated form of the gene that can function in the encoding of sound.

To test whether the transmembrane domain of otoferlin needed to be part of the shortened version of the gene, Manchanda introduced a mutation that truncated the transmembrane domain in zebrafish.

Zebrafish, a small freshwater species that go from a cell to a swimming fish in about five days, share a remarkable similarity to humans at the molecular, genetic and cellular levels, meaning many zebrafish findings are immediately relevant to humans. Embryonic zebrafish are transparent and can be easily maintained in small amounts of water.

"The transmembrane domain tethers otoferlin to the cell membrane and intracellular vesicles but it was not clear if this was essential and had to be included in a shortened form of otoferlin," Manchanda said. "We found that the loss of the transmembrane domain results in the sensory hair cells producing less otoferlin as well as deficits in hair cell activity. The mutation also caused a delay in the maturation of the sensory cells, which was a surprise. Overall the results argue that the transmembrane domain must be included in any gene therapy construct."

At the molecular level, Manchanda found that a lack of transmembrane domain led to otoferlin failing to properly link the synaptic vesicles filled with neurotransmitter to the cell membrane, causing less neurotransmitter to be released.

"Our study suggests otoferlin's ability to tether the vesicles to the cell membrane is a key mechanistic step for neurotransmitter release during the encoding of sound," Manchanda said.

New research from BYU published in PLOS Medicine found that providing medical patients with social support leads to an increased chance of survival and elongation of life. Such findings come at a critical time as doctors and healthcare professionals seek new ways to improve care and decrease mortality.

"The premise of the research is that everyone is strongly influenced by their social context," said BYU counseling psychology professor Timothy B. Smith, lead author of the study. "Relationships influence our behavior and our physical health. We now know that it is possible to prolong life by fostering coping and reducing distress."

Julianne Holt-Lunstad, BYU psychology professor and co-author of the study, said the findings support other research published by the National Academy of Science and that there is now ample evidence that social needs should be addressed within medical settings.

"From pediatrics to geriatrics, physicians may encounter patients who are struggling. These data suggest that social interventions integrated within clinical treatments that help patients cope and reduce distress also improve their survival," she said.

The research analyzed data from 106 randomized controlled trials including over 40,000 patients to study the effects of having psychosocial support. Such group meetings or family sessions that promoted healthy behaviors by giving motivation to exercise, encouragement to complete medical treatments, or group support for diet adherence resulted in a 29% increased probability of survival over time.

"Providing medical patients with social support can be just as helpful as providing cardiac rehabilitation for someone recovering from heart disease," said Smith. "It can be just as helpful as a diet or lifestyle program for obese patients or treatment for alcoholism among patients with alcoholism."

The findings hold major implications for hospitals and healthcare administrators striving to improve patient care and survival. The research could be used to implement support programs in hospitals and clinics for patients, particularly those at risk of not completing treatments. It could also influence programs for family members or caregivers.

"We already had robust evidence that social connection and other social factors significantly influence health outcomes including risk for premature mortality, but it was unclear what can be done about it to reduce risk," said Holt-Lunstad. "Is it the role of healthcare, or should this be addressed outside the healthcare system? This research combined with the other consensus reports suggests that it is a role of the healthcare system."

"Ultimately, these data should be used to foster collaboration between medical professionals and mental health professionals," said Smith. "About half of all patient medical visits are about conditions that entail psychological considerations. Large hospitals now routinely hire psychologists to consult with physicians and to evaluate or work with patients, but more integration is needed in smaller hospitals and clinics."

The findings also hold important implications for medical patients. People respond differently to medical conditions. While some will immediately take action in rehabilitation or preventative measures, others might delay or even avoid engaging in prescribed healthy behaviors. On top of that, depression and anxiety rates can be high among patients, which can limit responsiveness to treatments, making social support efforts even more critical.

"We know that when hospitals implement a social support group, people simply live longer," said Connor Workman, a BYU student who assisted with the research during his undergraduate years. "The data show that relationships have a tangible effect on a person's mortality and health. This will give decision-makers at hospitals the information they need to start pushing out programs and implementing the right social connections for patients."

Workman was one of twenty BYU students who spent years of their undergraduate education at BYU working on this research project alongside Smith and Holt-Lunstad -- a mentored learning experience that will shape their future educational endeavors as well as their careers.

"It was pretty special to be part of the research team," said Bonnie Barton, another student who participated in the study. "I feel like I've gained more knowledge than my peers who weren't doing research like this. This has helped me feel more prepared for graduate school. I got way more out of my undergraduate experience because of this."

What The Study Did: Demographic information from 105 randomized clinical trials for primary open-angle glaucoma was combined to compare the rate of participation between individuals from racial/ethnic minority groups with white individuals.

Authors: Deepkumar G. Patel, D.D.S., M.P.H., of New York Ophthalmology Associates in Manhattan, 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.2021.8348)

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

Fields of opium poppies once bloomed where the Zurich Opera House underground garage now stands. Through a new analysis of archaeological seeds, researchers at the University of Basel have been able to bolster the hypothesis that prehistoric farmers throughout the Alps participated in domesticating the opium poppy.

Although known today primarily as the source of opium and opiates, the poppy is also a valuable food and medicinal plant. Its seeds can be used to make porridge and cooking oil. Unlike all other previously domesticated crops, which are assumed to have been domesticated in south-west Asia (various grains, legumes and flax), experts believe that the opium poppy (Papaver somniferum L.) was domesticated in the western Mediterranean, where its presumed progenitor Papaver somniferum subsp. setigerum (DC.) Arcang is native and still grows wild today.

Using a new method of analysis, researchers from the universities of Basel and Montpellier have now been able to strengthen the hypothesis that prehistoric farmers living in pile dwellings around the Alps began to cultivate and use the opium poppy on a large scale from about 5500 BCE. By doing so, they contributed to its domestication, as the team reports in the journal Scientific Reports.

"When and where the opium poppy was domesticated has been impossible to determine exactly until now," says the study's leader, Dr. Ferran Antolín of the University of Basel and the German Archaeological Institute in Berlin. "There were no methods of identifying archaeological findings of poppy seeds either as domesticated or as a wild subspecies."

This has now been achieved thanks to a method developed by archaeologist Ana Jesus as part of her doctoral work. The method involves measuring the number of cells and the size and shape of the seed using contour analysis in order to capture the subtle differences between the domestic and wild variants. The researchers tested their method using 270 seeds from a total of nine poppy species (30 seeds per species) taken from the seed collections of the University of Basel and the National Museum of Natural History (MNHN) in Paris. These tests showed that classification of the seeds as the wild or domestic variant of the opium poppy was reliable in 87 percent of cases.

Finally, the team applied the method to archaeological findings of seeds discovered during the excavation of the 5,000-year-old pile dwelling site at Zurich Opera House's underground garage. The analysis of the poppy seeds showed that about half were the wild form and the other half domesticated. "There are two possible explanations for this," says Jesus. "Farmers could have mixed these two variants, or the pressure of selection due to cultivation led to the opium poppy gradually becoming the variant we now know as the domesticated opium poppy."

The latter explanation would mean that the opium poppy still had wild-type seeds when it came to central Europe, and that the farmers - knowingly or unknowingly - contributed to the changes in seed size and shape, i.e. to the domestication process.

The researchers now want to apply the method to other archaeological finds of sufficiently well-preserved poppy seeds. The international team's goal is to reconstruct the full domestication process of the opium poppy. This may make it possible to draw general conclusions about plant domestication and to identify the role played by cultivation in climate regions other than the plant's native area.