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Researchers from the Musculoskeletal Research Unit at the University of Bristol have identified the most important risk factors for developing severe infection after hip replacement. Patients who are under 60 years of age, males, those with chronic pulmonary disease, diabetes and a higher body mass index are at increased risk of having the joint replacement redone (known as revision) due to infection. The research also showed that some patients are at risk of early infection whilst others are more prone to late infection after hip replacement.

The study, published in The Lancet Infectious Diseases, and funded by the National Institute for Health Research (NIHR), considered the risk of infection following first-time (primary) hip replacement. This study used data from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man linked to the Hospital Episode Statistics database and is the largest study to analyse data from over 600,000 primary hip replacement patients, of whom 2,705 underwent revision for infection.

Total hip replacement, used mainly to treat pain and disability caused by osteoarthritis, is a common procedure with over 100,000 operations performed annually in the UK. A rare but serious complication affecting about one per cent of patients is deep infection. This causes considerable distress and frequently requires long and protracted treatments including revision.

This study showed the surgical approach used by the surgeon and the implant materials influenced the risk of needing revision surgery for infection. Hip replacements performed via a posterior surgical approach and those that used implant bearings that contained ceramic were less likely to be revised for an infection. Hip replacements performed for a hip fracture were at higher risk of infection. Interestingly, the experience of the surgeon and the size of the orthopaedic centre had no or only small effects on risk of revision for infection.

Uniquely, the research identified that these important factors have a different effect according to the post-operative period considered, with co-morbidities such as dementia influencing early revision for prosthetic joint infection and liver diseases influencing long-term revision. This is an important factor to consider when conducting further research in this area as just considering overall risk or short-term risk may mean important effects are missed entirely.

Mr Michael Whitehouse, Consultant Senior Lecturer in Trauma and Orthopaedic Surgery in the Musculoskeletal Research Unit of the Bristol Medical School: Translational Health Sciences (THS), said: "The results of this work are very useful to me as a surgeon and to my patients. It gives me the information I need to accurately advise patients about their risk of this devastating complication when undergoing hip replacement. The study also enables me to plan my surgery to minimise the risk for patients, for example using the posterior approach and ceramic heads. It will also provide information for the development of new patient resources to provide patients with better information to make decisions about their treatment."

Dr Erik Lenguerrand, Research Fellow in the Musculoskeletal Research Unit and lead author of the study, added: "We have shown that certain types of patients, such as those with liver disease, are at particular risk of long-term infection and they would benefit from extra surveillance and tailored information following their discharge from hospital to reduce this risk."

The researchers found that the risk of revision for infection following primary hip replacement is mainly driven by patient and surgical factors. The potentially modifiable factors identified in this study should be considered by clinicians when preparing patients for hip replacement surgery. It will be important to carry out research to establish if changes to the management of these conditions changes the risk of infection. It is equally important for clinicians to consider the factors that can't be changed and the factors that exhibit time specific effects on the risk of prosthetic joint infection, to support and inform patients appropriately pre-operatively.

The research team will carry out further work to determine if similar patterns and risk factors are also seen for knee replacement. Finally, the researchers will also be looking at the treatment of infection when it does occur to see what treatment results in the best outcomes for patients. They will analyse further data from the National Joint Registry and are currently conducting a large multinational randomised controlled trial to generate the best evidence possible in this area.

MONTREAL, JULY 25, 2018 - Trying to determine how best to treat a patient, doctors often look to randomized clinical trials to guide their choice of what drug to prescribe. One of the most common illnesses is heart disease, and in recent years it's been proven that, contrary to popular belief, more women have heart problems than men do; similarly, it's more common for older people to have a heart condition than younger people. But do clinical trials reflect this reality?

Apparently not. According to a new study published in Circulation: Cardiovascular Quality and Outcomes by Quoc Dinh Nguyen, a professor at Université de Montreal's Faculty of Medicine, researchers continue to test new heart drugs mostly on men (71 per cent), even though the majority of people affected by heart disease are women. Moreover, the male subjects have an average age of 63, when in fact the average age of people with the two most common heart diseases is between 68 to 69.

In the last 20 years, the sex-and-age gap in drug trials has barely diminished, even though the population is ageing rapidly, said Nguyen, a geriatrician at the Centre Hospitalier de l'Université de Montréal (University of Montreal Hospital Center).

"This under-representation of women and older people in clinical trials could have adverse consequences on care for both of these patient groups. The body of an older person doesn't respond to many treatments and medications like that of a younger person. The correct dosage or intervention are often different for older patients and so, too, are the side effects, but we can't know the specifics unless clinical trials are performed on a significant number of older people. This is also true for women."

"The current lack of representation means that physicians have to apply findings based on a male dominant and younger population without being sure that these results should be extrapolated to women or older people in general."

Nguyen decided to look into the issue while still a resident in geriatric medicine, prompted by discussions with colleagues and the concern they shared about effective treatment of heart disease. Resident physicians in other fields such as anaesthesiology, psychiatry, emergency medicine and cardiology joined him in the effort.

A closer look

Already, 20 years ago, researchers had begun to raise the alarm that the under-representation of many segments of the population, especially women, in clinical trials was problematic. "Our research team wanted to know whether practices had significantly improved since then," Nguyen said.

To find out, his team of residents took a close look at the 25 most frequently cited (i.e. most influential) clinical trials for each year in the 20-year period from 1996 to 2015. They compared the age and sex of participants to data published in the U.S. National Health and Nutrition Examination Survey 2015-2016 on the prevalence of cardiovascular disease in America.

The research team examined data on coronary artery disease, atrial fibrillation, heart failure and hypertension, along with cardiovascular risk factors. It also looked at diabetes, since people with that disease are two to four times more likely to suffer from heart disease as well.

Disappointing results

"Our research team was disappointed to see that, although the situation has improved slightly, it will still take decades to eliminate representational bias in clinical trials," said Eric Peters, an anaesthesiologist at CHU Saint-Justine children's hospital who is the new study's second author. "Based on our calculations, it'll be another 90 years before parity is achieved in studies on coronary heart disease. And that's before we factor in population-ageing, which is accelerating."

In the 500 clinical studies they analyzed, the team found that women represented a median of only 29 per cent of participants and that the average age of participants was only 63. "This is nowhere near the reality of what we see in hospital emergency rooms and departments of internal medicine, cardiology and geriatric medicine," said Nguyen.

Women and older people were least represented in clinical trials for coronary artery disease (CAD) and heart failure, the study shows. Although 54.6 per cent of CAD patients in the U.S. are women, only 27.4 per cent of participants in clinical trials for CAD are women.

Heart disease: a man thing?

It's a myth that heart disease primarily affects men; medical research has proven otherwise. As the second leading cause of death in Canada, heart disease kills more women than men. And it affects women later in life - in the case of coronary artery disease and heart failure, about 10 years later.

While death from heart disease has been falling among women, it has been falling at a faster rate among men. One of the most plausible hypothesis, according to the scientific literature: physicians underestimate the risk for women, and so treat them less often than men.

Why the gap?

Historically, women have long been excluded from drug trials due to the fact they could become pregnant while on medication. But this shouldn't apply to trials of heart drugs, since participants are already over 60 years old. Age also plays a factor in how women get selected. If researchers want to make sure women are adequately represented, they would need to recruit older participants, since cardiovascular disease afflicts women later in life than men.

But recruiting older people makes things more complicated for clinical researchers. Older people often have more difficulty getting around, making it harder for them to come in for testing. Furthermore, the older they are, the more likely they have a variety of ailments that require taking other medications; researchers often prefer to exclude them from clinical trials so as not to confuse the results. Also, older people are generally more fragile and less able to tolerate the side effects of the drugs tested.

Baby boomers: the next wave

In the U.S., it's estimated the number of people aged 65 and older will double over the next 30 years. With the first baby boomers now turning 73, the demand for cardiac care is expected to skyrocket, not just in the U.S. but in Canada and elsewhere as well.

"We have to do better," Nguyen said. "We must recruit more women and older people for clinical trials by relaxing eligibility criteria and adopting measures that encourage them to participate, such as arranging transportation and asking their families to help. As well, regulatory agencies should be more stringent in order to improve representation of both groups."

"It's a question of quality of care."

About this study

"Evolution of Age and Female Representation in the Most-Cited Randomized Controlled Trials of Cardiology of the Last 20 Years," by Quoc Dinh Nguyen, Eric Peters, Andréanne Wassef, Philippe Desmarais, Delphine Rémillard-Labrosse and Maxime Tremblay-Gravel, was published in Circulation: Cardiovascular Quality and Outcomes onJune 9, 2018. doi.org/10.1161/CIRCOUTCOMES.118.004713

This study was financed by two research grants from the Fondation du CHUM and a grant from the Montreal Heart Institute Foundation.

For the first time in the U.S., a blood test will be available to help doctors determine if people who've experienced a blow to the head could have a traumatic brain injury such as brain bleeding or bruising.

Until this point, physicians have relied on subjective markers - mainly patient-reported symptoms such as headaches, nausea, or light sensitivity - to make an educated "guess" on which individuals have brain trauma and require a head CT scan. Particularly among athletes who may hide symptoms in order to keep playing, a subjective assessment is not always reliable. The new test provides an objective indicator of injury that can potentially be obtained quickly and easily in busy emergency departments.

In February 2018, the U.S. Food and Drug Administration approved the test as part of a fast track program to get breakthrough technologies to patients more quickly. Called the Banyan Brain Trauma Indicator®, the test aids in the evaluation of patients with a suspected traumatic brain injury or concussion, also known as a mild traumatic brain injury.

Today, the major study that led to approval of the test was published in The Lancet Neurology. The clinical trial included close to 2,000 individuals presenting with a head injury to 22 emergency departments in the U.S. and Europe. Banyan Biomarkers, Inc., the company that developed the test, is working with its commercial partners to make the test available in hospitals and emergency departments.

"Many concussion patients don't seek medical care for their injury, a decision due in part to the perception that emergency departments have nothing to offer in terms of diagnosis," said lead study author Jeffrey J. Bazarian, M.D., M.P.H., professor of Emergency Medicine at the University of Rochester Medical Center. "The results of this study show that we now have something to offer--a brain biomarker blood test. The ability of this test to predict traumatic injuries on head CT scan will soon allow emergency physicians to provide patients with an unbiased report on the status of their brain."

Bazarian, who's conducted research on concussions and mild traumatic brain injury for more than 20 years, believes the tool will be valuable for emergency room physicians and reassuring for concerned patients and families.

The test detects two brain proteins that are present in the blood soon after a hit to the head. The new study shows that if the test is negative - meaning that the brain proteins aren't present - it is highly unlikely that a traumatic intracranial injury exists and that a head CT scan can be safely avoided. If the test is positive, a brain injury may be present and the patient should receive a head CT scan to further assess the damage and guide treatment.

Approved for use in individuals 18 years and older, the test has the potential to reduce CT scans and the radiation exposure that comes with them. They're commonly used to evaluate brain injuries, but research shows that less than 10 percent of head CTs show any injury. Limiting scans to patients with a positive blood test could eliminate needless radiation; allow people to get in and out of the emergency room faster; and lower health care costs.

The blood test is effective up to 12 hours following injury and picks up the presence of the brain proteins UCH-L1 and GFAP. Bazarian says these are useful markers because they aren't elevated when someone gets hit outside the head, such as the shoulder or abdomen.

The U.S. Centers for Disease Control and Prevention estimates that traumatic brain injury results in more than 2.5 million emergency department visits annually in the U.S. Falls, sports-related injuries, car accidents, assaults, and combat wounds for members of the military are common causes of brain injury.

San Antonio, Texas (July 24, 2018) - A group of scientists at Texas Biomedical Research Institute have zeroed in on a new defense against HIV-1, the virus that causes AIDS. Led by Ruth Ruprecht, M.D., Ph.D., the team used an animal model to show for the first time that an antibody called Immunoglobulin M (IgM) was effective in preventing infection after mucosal AIDS virus exposure. Worldwide, an estimated 90% of new cases of HIV-1 are caused through exposure in the mucosal cavities like the inside lining of the rectum or vagina.

"IgM is sort of the forgotten antibody," Dr. Ruprecht, Scientist and Director of Texas Biomed's AIDS Research Program, said. "Most scientists believed its protective effect was too short-lived to be leveraged as any kind of protective shield against an invading pathogen like HIV-1."

The study is published in the July 17, 2018 edition of the journal AIDS. The article is listed as "Fast Track," indicating these new and exciting data should get special attention.

Rhesus monkeys at the Southwest National Primate Research Center on the Texas Biomed campus served as models for the in vivo study. Scientists first treated the animals with a man-made version of IgM, which is naturally produced by plasma cells located under the epithelium (the surface lining of body cavities). Half an hour later, the same animals were exposed to SHIV (simian-human immunodeficiency virus). Four out of the six animals treated this way were fully protected against the virus. The animals were monitored for 82 days.

Dr. Ruprecht's team found that applying the IgM antibodies resulted in what is called immune exclusion. IgM clumped up the virus, preventing it from crossing the mucosal barrier and spreading to the rest of the body. The technique of introducing pre-formed antibodies into the body to create immunity is known as passive immunization.

IgM has a high affinity for its antigens and "grabs them very quickly and does not let go," Dr. Ruprecht explained. "Our study reveals for the first time the protective potential of mucosal anti-HIV-1 IgM. IgM has a five-times higher ability to bind to virus particles compared to the standard antibody form called IgG. It basically opens up a new area of research. IgM can do more than it has been given credit."

An accompanying editorial says Dr. Ruprecht has "set off a new wave in evaluating the activity of IgM antibodies in neutralizing HIV-1...[and she and her group] have largely broadened the horizon of neutralizing HIV-1 antibodies, which, as single or combined agents, may be used for HIV-1 prevention and treatment."

This investigation used resources that were supported by the Southwest National Primate Research Center grant P51 OD011133 from the Office of Research Infrastructure Programs, National Institutes of Health.

LONDON, ON - An international collaborative study between Lawson Health Research Institute, Memorial Sloan Kettering Cancer Center, the Royal Marsden and Epic Sciences is one of the first to demonstrate that a blood test can predict how patients with advanced prostate cancer will respond to specific treatments, leading to improved survival.

The study used a liquid biopsy test developed by molecular diagnostics company Epic Sciences that examines circulating tumour cells (CTCs) in blood samples from patients with advanced prostate cancer who are deciding whether to switch from hormone-targeting therapy to chemotherapy. CTCs are cancer cells that leave a tumour, enter the blood stream and invade other parts of the body, causing the spread of cancer.

The test identifies whether or not a patient's CTCs contain a protein called AR-V7 in the cell's nucleus. The research team set out to determine whether the presence of this protein predicted which treatment would best prolong a patient's life. They found that patients who tested positive for the protein responded best to taxane-based chemotherapy while those who tested negative for the protein responded best to hormone-targeting therapy with drugs called androgen-receptor signaling (ARS) inhibitors. These are the two most widely used drug classes to treat advanced prostate cancer.

"The study focused on a critical decision point when patients and their oncologists are choosing what therapy to pursue next," says Dr. Alison Allan, a scientist at Lawson and Chair, Department of Anatomy & Cell Biology at Western University's Schulich School of Medicine & Dentistry. "We are addressing a critical unmet need by validating that a blood test or liquid biopsy can be used to select a therapy most likely to extend a patient's life."

Research participants included 142 patients with advanced prostate cancer from the London Regional Cancer Program at London Health Sciences Centre (LHSC) in London, Ontario; Memorial Sloan Kettering Cancer Center in New York; and the Royal Marsden in London, England. The patients had already undergone at least one round of hormone-targeting therapy without success and were working with their oncologist to decide whether to switch to a different hormone-targeting therapy or to chemotherapy as their next line of treatment.

Hormone-targeting therapies like ARS inhibitors work by slowing or stopping the growth of cancers that use hormones to grow. Prostate cancer growth relies on hormones called androgens, which include testosterone. Androgen deprivation therapy like ARS inhibitors blocks the production of male hormones to treat the recurrence or spread of prostate cancer.

"ARS inhibitors are the preferred first line of treatment because they target the hormones that provide the fuel for prostate cancer cells to grow," explains Dr. Allan. "However, at some point, cancer cells can figure out a way to survive without this fuel and become resistant to ARS inhibitors, in many cases through production of the AR-V7 protein. That's why chemotherapy is sometimes used a second line therapy."

While this study looked at predicting the best treatment for patients who had already undergone at least one round of hormone-targeting therapy, a future goal of the team is to assess the use of this test or similar CTC blood tests in determining optimal therapy at earlier decision points in advanced prostate cancer care. The team also plans to collaborate further with Epic Sciences to evaluate different versions of the CTC blood test for other types of cancer, such as lung cancer.

Through Epic Sciences' partnership with Genomic Health, the CTC blood test is now commercially available in the United States as the Oncotype DX AR-V7 Nucleus Detect.

In addition to facing new concerns about their health, individuals who are diagnosed with cancer often worry about the financial burdens of treatment. A new study indicates that many patients feel that such 'financial toxicity' is not adequately addressed by their doctors and other clinicians. The findings are published early online in CANCER, a peer-reviewed journal of the American Cancer Society.

There is growing awareness that cancer diagnosis and treatment can create financial difficulties even for patients with health insurance, but it is unclear whether patients today are being helped by their doctors or staff with these challenges. To investigate, Reshma Jagsi, MD, DPhil, of the University of Michigan in Ann Arbor, and her colleagues surveyed patients with early-stage breast cancer and their physicians: 2502 patients, 370 surgeons, 306 medical oncologists, and 169 radiation oncologists.

Half of responding medical oncologists reported that someone in their practice often or always discusses financial burden with patients, as did 15.6 percent of surgeons and 43.2 percent of radiation oncologists. Patients indicated that financial toxicity remains common: 21.5 percent of whites and 22.5 percent of Asians had to cut down spending on food, as did 45.2 percent of blacks and 35.8 percent of Latinas.

The survey also revealed that many patients desired to talk to providers about the financial impact of cancer: 15.2 percent of whites, 31.1 percent of blacks, 30.3 percent of Latinas, and 25.4 percent of Asians. Unmet patient needs for engagement with doctors about financial concerns were common. Of 945 women who worried about finances, 679 (72.8 percent) indicated that doctors and their staff did not help. Of 523 women who desired to talk to providers about the impact of breast cancer on employment or finances, 283 (55.4 percent) reported no relevant discussion.

"We found that even though many doctors reported that they routinely make services available to their patients to help with financial concerns, many patients still reported unmet needs," said Dr. Jagsi.

The investigators noted that although advances in detection and treatment have transformed how breast cancer is perceived and managed, this study reveals an important aspect that cannot be overlooked or addressed as an afterthought. "Efforts must now turn to confront the financial devastation that many patients face, particularly as they progress into survivorship," said Dr. Jagsi. "The first steps for clinical practice and policy are clear: all physicians must assess patients for financial toxicity and learn how to communicate effectively about it. To cure a patient's disease at the cost of financial ruin falls short of the physician's duty to serve--and failure to recognize and mitigate a patient's financial distress is no longer acceptable."

ORLANDO (July 23, 2018): An academic medical center's weight-loss surgery program greatly lowered its rates of several postoperative complications, including rehospitalization in the first month, surgical site and urinary tract infections, and bleeding, despite almost doubling its surgical volume over five years. Results of this multiyear quality improvement project were presented today at the American College of Surgeons (ACS) 2018 Quality and Safety Conference.

This quality improvement project took place at California-based Stanford Bariatric, one of more than 800 centers in the country that have earned accreditation through the Metabolic Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP®). Maintaining this voluntary credential, awarded jointly by the ACS and the American Society for Metabolic and Bariatric Surgery (ASMBS) since 2012, requires accredited centers to perform an annual quality improvement project.

"MBSAQIP accreditation drives quality improvement," said principal investigator John Morton, MD, MPH, FACS, FASMBS, chief of bariatric and minimally invasive surgery, Stanford (Calif.) University School of Medicine. "Accreditation at hospitals performing bariatric surgery has been shown to decrease complications, costs, and deaths."

Stanford's bariatric surgery program identified complications needing improvement by reviewing the MBSAQIP Semiannual Report, which Dr. Morton likened to a report card. This risk-adjusted report contains participating centers' combined outcomes as well as center-specific data, explained Dr. Morton, who is the Chair of the Committee for Metabolic and Bariatric Surgery (CMBS), the surgeon oversight committee of MBSAQIP, Although MBSAQIP ranked Stanford as "exemplary" in most categories in 2013, "we wanted to do better. We wanted to provide the best care possible for patients."

The Stanford project committee chose reducing surgical site infections (SSIs) for their first improvement effort in 2013. They instituted "lean" methods of process improvement involving standardization and follow-up. Team members educated personnel in the operating room, emergency department, inpatient wards, and outpatient clinics about the improvement initiative. In monthly meetings, the entire bariatric program staff reviewed outcomes data, identified the root causes of SSIs that occurred, and discussed how to prevent these complications. In each of the four subsequent years, the committee followed the same processes for the other selected outcome measures: bleeding, medication reconciliation, unplanned readmissions in the first 30 days after discharge from the hospital, and urinary tract infections (UTIs).

Medication reconciliation involves comparing a patient's current medicines with new prescription orders and the patient's medical record to resolve discrepancies at transitions in care: hospital admission, transfer, discharge, and outpatient follow-up appointments. This process aims to decrease medication errors and overuse.

Medication reconciliation is important for bariatric surgical patients, who usually require multiple medicines to treat obesity-related illnesses, Dr. Morton said. Because substantial weight loss after a bariatric operation often improves or resolves co-existing illnesses such as Type 2 diabetes, high blood pressure, high cholesterol, and obstructive sleep apnea,1 patients may no longer need some of their medications.

From 2013 to 2017, the number of bariatric operations performed annually at Stanford rose from 234 to 438, Dr. Morton reported. Yet, over the same five-year period, the bariatric surgery program reportedly saw the following improvements:

30-day readmissions: dropped from 4.7 percent to 2.1 percent of surgical cases
Medication reconciliation compliance: increased from 83 percent to 100 percent of surgical cases
Bleeding: decreased from 0.9 percent to zero
UTIs: reduced from 1.1 percent to zero
SSIs: reduced from 2.5 percent to 0.5 percent

To lower the readmission rate, the project team implemented a policy whereby nurses would contact each patient by phone after discharge. These phone calls allowed staff to identify problems and schedule follow-up appointments before a potential complication became severe enough to require rehospitalization.

The committee achieved full compliance with medication reconciliation, according to Dr. Morton, by requiring completion of that task in the patient's electronic health record before the health care provider could continue or close the record.

Bleeding is uncommon after bariatric surgical procedures, Dr. Morton said. However, it can occur where the surgeon attaches, often with staples, the newly reduced stomach pouch to the intestine. He said adding several sutures to the staple line helped lower the chance of bleeding in their patients.

Despite Stanford Bariatric's prior success in eliminating catheter-associated urinary tract infections (UTIs), they later encountered two patients with UTIs, Dr. Morton said. After investigation, the researchers discovered that UTIs were already present at admission in one-third of bariatric surgical patients. This finding, he said, led them to evaluate patients for potential UTIs preoperatively so that antibiotic therapy could begin when needed.

For reduction in SSIs, the committee initiated multiple evidence-based guidelines, including those from the ACS and the Surgical Infection Society.2 Among other efforts, the surgical team encouraged diabetic patients to have optimal preoperative blood glucose (sugar) control, which can affect wound healing; they asked patients to clean the surgical site at home before the operation; and they gave weight-based doses of antibiotics for infection prevention.

Dr. Morton concluded that the MBSAQIP Semiannual Report is an advantage to accreditation because it helps identify opportunities for improvement.

Another key to their successful quality improvement, he added, was persistence. He said, "It paid off--like putting money in the bank and getting interest."

Chicago, July 22, 2018 - The first dementia prevalence data from a large population of lesbian, gay and bisexual older adults was reported today at the 2018 Alzheimer's Association International Conference in Chicago.

Researchers from University of California, San Francisco and Kaiser Permanente Division of Research, Oakland, CA, examined the prevalence of dementia among 3,718 sexual minority adults age 60+ who participated in the Kaiser Permanente Research Program on Genes, Environment, and Health (RPGEH). Dementia diagnoses were collected from medical records.

Over 9 years of follow-up, the overall crude prevalence of dementia was 7.4 percent for sexual minority older adults in this study population. For comparison, Alzheimer's Association 2018 Alzheimer's Disease Facts and Figures reports U.S. prevalence of Alzheimer's disease dementia and other dementias for age 65+ at approximately 10 percent. According to the researchers, significant rates of depression, hypertension, stroke and cardiovascular disease in the study population may be contributing factors to the level of dementia.

"Current estimates suggest that more than 200,000 sexual minorities in the U.S. are living with dementia, but -- before our study -- almost nothing was known about the prevalence of dementia among people in this group who do not have HIV/AIDS-related dementia," said Jason Flatt, PhD, MPH, Assistant Professor at the Institute for Health & Aging, School of Nursing, University of California, San Francisco. "Though our new findings provide important initial insights, future studies aimed at better understanding risk and risk factors for Alzheimer's and other dementias in older sexual minorities are greatly needed."

"With the growing prevalence of Alzheimer's disease dementia and the swelling population of LGBT older adults, we place a high priority on examining the intersections of Alzheimer's disease, sexual orientation, and gender identity and expression," said Sam Fazio, PhD, Alzheimer's Association Director of Quality Care and Psychosocial Research. "A more thorough and thoughtful understanding of this intersection will enable us to better meet the needs of LGBT elders living with dementia and their caregivers."

"Encouraging people to access healthcare services and make healthy lifestyle changes can have a positive impact on both LGBT and non-LGBT communities. Effective outreach to LGBT communities that is sensitive to racial, ethnic, and cultural differences could result in earlier diagnosis, which has been linked to better outcomes," Fazio added.

"Our findings highlight the need for culturally competent healthcare and practice for older sexual minorities at risk for, or currently living with, Alzheimer's disease or another dementia. There are also important implications for meeting the long-term care services and caregiving needs of this community. Given the concerns of social isolation and limited access to friend and family caregivers, there is a strong need to create a supportive healthcare environment and caregiving resources for sexual minority adults living with dementia," Flatt said.

The LGBT Community and Dementia

According to "Issue Brief: LGBT and Dementia," a co-publication of the Alzheimer's Association and SAGE (Services and Advocacy for GLBT Elders), there are 2.7 million LGBT people over age 50, and that number will likely double over the next 15 years. While the LGBT community faces similar health concerns as the general public, the LGBT population who receive a dementia diagnosis face uniquely challenging circumstances.

Even with recent advances in LGBT rights, LGBT older adults are often marginalized and face discrimination.

They are twice as likely to age without a spouse or partner, twice as likely to live alone and three to four times less likely to have children - greatly limiting their opportunities for support.

There's also a lack of transparency as forty percent of LGBT older people in their 60s and 70s say their healthcare providers don't know their sexual orientation (Out and Visible).

The Institute of Medicine identified the following pressing health issues for LGBT people: lower rates of accessing care (up to 30%); increased rates of depression; higher rates of obesity in the lesbian population; higher rates of alcohol and tobacco use; higher risk factors of cardiovascular disease for lesbians; and higher incidents of HIV/AIDS for gay and bisexual men (Brennan-Ing, Seidel, Larson, and Karpiak, 2014). Risk factors for heart disease -- including diabetes, tobacco use, high blood pressure and high cholesterol -- are also risk factors for Alzheimer's and stroke-related dementia.

Due to the healthcare-related challenges they and others have faced, an LGBT person may not reach out for services and support because they fear poor treatment due to their LGBT identity, because they fear the stigma of being diagnosed with dementia, or both. Several studies document that LGBT elders access essential services, including visiting nurses, food stamps, senior centers, and meal plans, much less frequently than the general aging population.

Among the 16 recommendations for organizations and service providers in their Issue Brief, the Alzheimer's Association and SAGE suggest:

Expand your definition of family.

Educate yourself and your staff on LGBT cultural competency.

Find or create support groups specifically for LGBT people.

Partner with local LGBT community groups and political organizations.

Help LGBT people and their families with legal and financial planning.

Dementia Survival Time is Short, Regardless of Age at Onset

Previous studies of survival times in persons with dementia have varied considerably, reporting between three and 12 years in elderly populations with either general dementia or Alzheimer's disease dementia. To better understand survival time in individuals of a relatively young age and with different types of dementia, Hanneke Rhodius-Meester, MD, PhD, of VU University Medical Center in Amsterdam, and colleagues investigated survival time of 4,495 early-onset dementia patients in a memory clinic (aged 66 ±10 years; 45 percent female) enrolled in the Amsterdam Dementia Cohort between 2000-2014, with any type of dementia (n=2,625), mild cognitive impairment (n=739) or subjective cognitive decline (n=1,131).

The study found that the median survival time across all groups was six years and varied based on dementia type: 6.4 years in frontotemporal lobe degeneration; 6.2 years in Alzheimer's disease; 5.7 years in vascular dementia; 5.1 years in dementia with Lewy bodies; and 3.6 years for rarer causes of dementia. Survival time hardly differed when comparing younger patients (age 65 or younger) to those older than 65. However, over time and compared to the general Dutch population, survival time in older patients showed a marginal increase, while survival time in younger patients remained unchanged.

"These findings suggest that, despite all efforts, and despite being younger and perhaps physically healthier' than older people, survival time in people with young-onset dementia has not improved since 2000," said Rhodius-Meester. "While these results still need to be replicated and confirmed, they do highlight the urgency of the need for better treatments and effective prevention strategies."

Prevalence of Dementia Increases with Age, Even in "Oldest Old"

Evaluating data from 17 centenarian studies conducted across 11 countries through the International Centenarian Consortium for Dementia (ICC-Dementia), Yvonne Leung, Ph.D., a postdoctoral fellow from the Centre for Healthy Brain Ageing (CHeBA), University of New South Wales in Sydney, and colleagues examined dementia prevalence, risk factors and cognitive and functional impairment in 4,121 centenarians and near-centenarians (aged 95-110).

When statistical predictive models were applied to examine impairment as a function of age, sex and education, researchers found that:

Prevalence increased with age (from 95-99 to ? 105 years) in all societies for dementia (from 35.75 to 75.61 percent), cognitive impairment (from 45.24 to 78.72 percent) and functional impairment (from 67.46 to 91.55 percent).

The risk of dementia, cognitive and functional impairment varied significantly between countries, suggesting cultural and lifestyle factors play a role in remaining physically and cognitively healthy as we age.

Participants with higher levels of education expressed lower prevalence of dementia and cognitive impairment than those with fewer years of education.

Women in this age group had a higher risk of dementia and cognitive impairment compared to men.

"This is the first study to define the global prevalence of dementia in this advanced age group using a set of common diagnostic criteria," said Dr. Leung. "These data, and this type of research, may help identify protective factors to reduce the risk of dementia, and provide insights into longevity and brain health."

When it comes to being fit, are genes or lifestyle -- nature or nurture -- more important? Researchers at San Francisco State University, CSU Fullerton and Cal Poly, Pomona removed the nature part of the equation by studying a pair of identical 52-year-old twins who had taken radically different fitness paths over three decades. "One of the twins became a truck driver and one started running," said Assistant Professor of Kinesiology Jimmy Bagley. The runner became an Ironman triathlete and track coach while the other remained relatively sedentary over the last 30 years. The study results, just published in the European Journal of Applied Physiology, demonstrate the impact exercise can have on health over time.

Bagley explains that because identical twins share over 99 percent of the same genes, studying them offers a perfect opportunity to gauge the importance of external influences on a person's health. To look at the effects of exercise on these two brothers, Bagley and his colleagues analyzed their physiques, blood profiles, cardiovascular and pulmonary health, skeletal muscle size, strength and power, and molecular markers of muscle health. Not surprisingly, the athletic twin exhibited much better overall health: lower body fat, lower resting heart rate and blood pressure, lower cholesterol, triglycerides and blood sugar, and greater aerobic capacity and endurance. There was one surprise, however. The truck driver had larger, stronger leg muscles.

"The untrained twin had been carrying around more weight his whole life, which can build bigger muscles," said Bagley. Because the athletic twin was a runner, his muscles were leaner and built more to move forward in space -- to run. If that twin wanted to build up those muscles, he could add some lower body resistance training, Bagley suggested. But he explains that in the one measurement that tells you the most about a person's overall health -- the "VO2 max," or the maximum rate of oxygen consumption during exercise -- the athletic twin came out far ahead. The VO2 max test (in this case done while riding an exercise bike) measures cardiovascular health, pulmonary health and muscle efficiency.

"VO2 max starts to drop off at age 65 or 70, and when it hits a certain low you are probably going to become dependent on someone else," he said. "As people get older, we try to keep them over that dependency limit."

The athletic twin's fitness as measured by the VO2 max test was equal to that of a 30-year old, much better than that of the sedentary twin, who was more typical for his age.

The athletic twin also had 55 percent more "slow-twitch" muscle fibers than the truck-driving twin, meaning that he could run for hours without getting fatigued. "He was like a machine," Bagley said.

The researchers plan to monitor the twins every five years. While the twins could end up having the same life span, Bagley thinks that a person's "health span" -- the ability to live longer in good health, independently -- may be more important.

Not everyone can be an Ironman athlete. But according to Bagley, the study could help researchers learn more about how much exercise you need, and in what "doses." "It shows your genes aren't a cop-out," he said. "If your parents are overweight, for example, it might be harder for you to get fit, but this study shows that it's not impossible." As for the lesser-fit twin? He's started walking a lot more.

The hormone cortisol rises and falls naturally throughout the day and can spike in response to stress, but current methods for measuring cortisol levels require waiting several days for results from a lab. By the time a person learns the results of a cortisol test - which may inform treatment for certain medical conditions - it is likely different from when the test was taken.

Now, a group led by materials scientist Alberto Salleo at Stanford University has created a stretchy patch that, applied directly to the skin, wicks up sweat and assesses how much cortisol a person is producing. A paper about the wearable sensor was published July 20 in Science Advances.

"We are particularly interested in sweat sensing, because it offers noninvasive and continuous monitoring of various biomarkers for a range of physiological conditions," said Onur Parlak, a post-doctoral scholar in the Salleo lab and lead author of the paper. "This offers a novel approach for the early detection of various diseases and evaluation of sports performance."

Clinical tests that measure cortisol provide an objective gauge of emotional or physical stress in research subjects and can help doctors tell if a patient's adrenal or pituitary gland is working properly. If the prototype version of the wearable device becomes a reality, it could allow people with an imbalance to monitor their own levels at home.

A fast-working test like this could also reveal the emotional state of young - even non-verbal - children, who might not otherwise be able to communicate that they feel stress.

The cortisol challenge

Parlak came to work with Salleo, who is associate professor of materials science and engineering, intending to develop wearable technologies. While discussing Parlak's work at a conference, someone suggested to Salleo that it would be great if a sensor could measure cortisol. Cortisol presents a special challenge to biosensors like the one Parlak was developing because these sensors detect a molecule's positive or negative charge - and cortisol has no charge.

To overcome this challenge, Parlak built his stretchy, rectangular sensor around a membrane that specifically binds only to cortisol. Stuck to the skin, it sucks in sweat passively through holes in the bottom of the patch. The sweat pools in a reservoir, which is topped by the cortisol-sensitive membrane. Charged ions like sodium or potassium, also found in sweat, pass through the membrane unless they are blocked by cortisol. It's those backed up charged ions the sensor detects, not the cortisol itself. On top of all this is a waterproof layer that protects the patch from contamination.

"I always get excited about a device, but the sweat collection system that Onur devised is really clever," Salleo said. "Without any active microfluidics, he's able to collect enough sweat to do the measurements."

All a user needs to see cortisol levels is to sweat (enough to glisten), apply the patch and connect it to a device for analysis, which gives results in seconds. In the future, the researchers hope the sensor could be part of a fully integrated system.

Optimizing and diversifying

Parlak first showed that the device measured up to the gold standard clinical test in the lab, then gave it a real world test. He strapped on his running shoes and recruited two volunteers, who all ran for 20 minutes with the patches on their arms. In both the lab and real world tests, the results were similar to the gold standard.

So far, the sensor appears to work as designed. But the researchers want to make it more reliable and accurate, and also make sure it is reusable. The prototype seems to work multiple times so long as it is not saturated with sweat. In the future, they may try the cortisol sensor on saliva, which would avoid patients needing to sweat.

The researchers, hoping to take advantage of their generalizable design, are also figuring out what biomarker they may want to study next. Eventually, the goal would be to have a device that measures several biomarkers at once, which would give a clearer and more individualized picture of what is going on in a person's body.

PHILADELPHIA -- Greening vacant urban land significantly reduces feelings of depression and improves overall mental health for the surrounding residents, researchers from the Perelman School of Medicine and the School of Arts & Sciences at the University of Pennsylvania and other institutions show in a new randomized, controlled study published in JAMA Network Open. The findings have implications for cities across the United States, where 15 percent of land is deemed "vacant" and often blighted or filled with trash and overgrown vegetation.

For the first time, the research team measured the mental health of Philadelphia residents before and after nearby vacant lots had been converted into green spaces, as well as residents living near untreated abandoned lots, and those that just received trash clean-up. They found that people living within a quarter of a mile radius of greened lots had a 41.5 percent decrease in feelings of depression compared to those who lived near the lots that had not been cleaned. Those living near green lots also experienced a nearly 63 percent decrease in self-reported poor mental health compared to those living near lots that received no intervention.

The findings add to the growing body of evidence showing how revitalized spaces in blighted urban areas can help improve safety and health, such as reducing crime, violence, and stress levels. The most recent study from the same team in February found up to a 29 percent decrease in gun violence near treated lots. This latest work is believed to be the first experimental study to test changes in the mental health of residents after nearby vacant lots were greened.

"Dilapidated and vacant spaces are factors that put residents at an increased risk of depression and stress, and may explain why socioeconomic disparities in mental illness persist," said lead author Eugenia C. South, MD, MSHP, an assistant professor of Emergency Medicine and a member of the Center for Emergency Care and Policy Research at Penn. "What these new data show us is that making structural changes, like greening lots, has a positive impact on the health of those living in these neighborhoods. And that it can be achieved in a cost-effective and scalable way - not only in Philadelphia but in other cities with the same harmful environmental surroundings."

For the trial, 541 vacant lots throughout Philadelphia were randomly assigned to one of three study arms: greening intervention, a trash clean-up intervention, or a control group with no intervention. The greening intervention involved removing trash, grading the land, planting new grass and a small number of trees, installing a low wooden perimeter fence, and regular monthly maintenance. The trash clean-up involved removing trash, limited grass mowing where possible, and regular monthly maintenance. The Pennsylvania Horticultural Society LandCare program performed the greening, trash clean-up, and maintenance.

Two sets of pre-intervention and post-intervention mental health surveys were performed among 342 people, 18 months before revitalization and 18 months after. Researchers used the Kessler Psychological Distress Scale (K6), a widely used community screening tool, to evaluate the prevalence of serious mental illness in the community. Participants were asked to indicate how often they felt nervous, hopeless, restless, depressed, that everything was an effort, and worthless.

Results were most pronounced when looking only at neighborhoods below the poverty line, with feelings of depression among residents who lived near green lots decreasing significantly--by more than 68 percent.

Analyses of the trash clean-up intervention compared to no intervention showed no significant changes in self-reported mental health.

"The lack of change in these groups is likely because the trash clean-up lots had no additional green space created," said co-author John MacDonald, PhD, a professor of criminology and sociology at Penn. "The findings support that exposure to more natural environments can be part of restoring mental health, particularly for people living in stressful and chaotic urban environments."

The study shows transforming blighted neighborhood environments into green space can improve the trajectory of the residents' mental health, the authors said. Adding green space to neighborhoods should be considered alongside individual treatments to address mental health problems in low resource communities. Additionally, greening is an affordable approach, costing about $1,600 per vacant lot and $180 per year to maintain. For these reasons, the authors said, vacant lot greening may be an extremely attractive intervention for policy makers seeking to address urban blight and promote health.

"Greening vacant land is a highly inexpensive and scalable way to improve cities and enhance people's health while encouraging them to remain in their home neighborhoods," said senior author Charles C. Branas, PhD, chair of Epidemiology at Columbia University and an adjunct professor in the department of Biostatistics and Epidemiology at Penn's Perelman School of Medicine. "While mental health therapies will always be a vital aspect of treatment, revitalizing the places where people live, work, and play, may have broad, population-level impact on mental health outcomes."

A global review involving almost 20 million people has shown that having diabetes significantly raises the risk of developing cancer, and for women the risk is even higher.

Researchers from The George Institute for Global Health also found diabetes (type 1 and type 2) conferred an additional risk for women, compared to men, for leukaemia and cancers of the stomach, mouth and kidney, but less risk for liver cancer.

The findings published in Diabetologia (the journal of the European Association for the Study of Diabetes [EASD]) highlight the need for more research into the role diabetes plays in developing cancer. They also demonstrate the increasing importance of sex specific research.

Lead author Dr Toshiaki Ohkuma, research fellow with The George Institute for Global Health, said: "The link between diabetes and the risk of developing cancer is now firmly established. We have also demonstrated for the first time that women with diabetes are more likely to develop any form of cancer, and have a significantly higher chance of developing kidney, oral and stomach cancers and leukaemia.

"The number of people with diabetes has doubled globally in the last 30 years but we still have much to learn about the condition. It's vital that we undertake more research into discovering what is driving this, and for both people with diabetes and the medical community to be aware of the heightened cancer risk for women and men with diabetes."

Key findings

Women with diabetes were 27 per cent more likely to develop cancer than women without diabetes. For men the risk was 19 per cent higher.

Researchers also found that diabetes was a risk factor for the majority of cancers of specific parts of the body for both men and women.

Overall, it was calculated that women with diabetes were six per cent more likely overall to develop any form of cancer than men with diabetes.

There were significantly higher risks for women with diabetes for developing cancer of the kidney (11 per cent higher), oral cancer (13 per cent higher), stomach cancer (14 per cent higher) and leukaemia (15 per cent higher) compared to men with the condition.

For liver cancer, the risk was 12 per cent lower for women with diabetes compared to men with diabetes.

Diabetes affects more than 415 million people worldwide, with five million deaths every year. In Australia, it's the fastest growing chronic condition with 280 people developing the disease every single day.

It is believed that heightened blood glucose may have cancer-causing effects by leading to DNA damage.

Co-author Dr Sanne Peters, of The George Institute for Global Health at the University of Oxford, said there were several possible reasons why women were subject to an excess risk of cancer including that they are in the pre-diabetic state of impaired glucose tolerance two years longer on average than men.

"Historically we know that women are often undertreated when they first present with symptoms of diabetes, are less likely to receive intensive care and are not taking the same levels of medications as men. All of these could go some way into explaining why women are at greater risk of developing cancer. But, without more research we can't be certain.

"The differences we found are not insignificant and need addressing. The more we look into gender specific research the more we are discovering that women are not only undertreated, they also have very different risk factors for a whole host of diseases, including stroke, heart disease and now diabetes, said Dr Peters.

HIV rates persist in high risk, marginalised populations and the Commission authors warn that a resurgence of the epidemic is likely as the largest generation of young people age into adolescence and adulthood.

Stalling of HIV funding in recent years endangers HIV control efforts.

Historic 'exceptionalism' of HIV treatment and care may no longer be sustainable; services will likely need to be part of wider health care supporting related diseases and conditions.

The authors call on HIV researchers, health care professionals and policy makers to collaborate and make common cause with their counterparts in global health.

The Commission will be launched at the AIDS 2018 conference between 6.30-8.30pm Amsterdam time on Thursday 26th July in Hall 10.

The HIV pandemic is not on track to end by 2030 and current approaches to HIV control are not enough to control it, according to a new Lancet Commission led by the International AIDS Society.

Changes to the HIV response are needed to win the global fight against HIV, and the authors propose that HIV researchers and health care professionals need to work more closely with their counterparts in global health, HIV services need to be included into wider health services, and global health policies need to incorporate HIV.

The report combines the expertise of more than 40 international experts who make recommendations for how HIV and global health can work together to advance global health and improve the HIV response. The report also models the impact of combining HIV within other health services in five countries, and is being presented at the AIDS 2018 conference in Amsterdam.

Growing threats in HIV and global health

HIV is the epidemic of our time, with up to 38.8 million people living with HIV worldwide in 2015-2016, and around two million new cases diagnosed in 2015. There were one million AIDS-related deaths in 2016, and overall more than 35 million people have died of AIDS-related causes since the start of the epidemic.

Worldwide, 44% of all new HIV infections occurred in people from marginalised groups (such as gay and bisexual men, people who inject drugs, sex workers, transgender people, and the sex partners of people in these groups), and health systems struggle to reach and engage these groups. Additionally, as health systems struggle to provide adolescent-friendly services, adolescents are at risk of HIV infection, particularly girls and young women. In sub-Saharan Africa, the risk of HIV infection peaks at age 15-24 years for adolescent girls and young women, and AIDS is the fourth leading cause of death for this group.

The HIV epidemic remains prevalent in these populations and in countries where health systems struggle to provide the necessary services. New infections are declining, but far too slowly to reach the UNAIDS target of 500,000 new infections by 2020. From 2010-2017, new infections declined by 16% to 1.8 million per year worldwide, but remained substantially higher for younger women then young men [1]. The Commission authors warn that a resurgence of the epidemic is likely as the largest generation of young people age into adolescence and adulthood.

At the same time, care for HIV is also changing as the population of people with HIV is steadily growing older due to the effectiveness of antiretroviral therapy (ART). Between 2012 and 2016, the number of people older than 50 years living with HIV increased by 36% worldwide. As this group have an increased risk of many age-related diseases (such as cardiovascular disease, neurocognitive disorders, renal disease and some cancers), a focus on prevention and management of non-communicable diseases (NCDs) for people with HIV is needed, creating a crossover with global health and wider health services.

HIV funding has remained flat in recent years, at about US$19.1 billion, roughly US$7 billion short of the estimated amount needed to achieve the UNAIDS 90-90-90 targets [2]. This is happening as a growing number of people are receiving ART and will require sustained access for decades to come - in June 2017 approximately 20.9 million people worldwide were receiving the drugs (57% of people with HIV), increasing from 680,000 people in 2000.

However, there are also wider issues in global health that add to these problems. "Global health is beginning to falter as democracy, civil society, and human rights deteriorate in many countries, and as development assistance for health has stalled. This loss of momentum comes as health systems need to become stronger to contend with the growing numbers of non-communicable diseases," says lead Commissioner Dr Linda-Gail Bekker, President of the International AIDS Society and Professor at University of Cape Town, South Africa.

"The HIV response and the broader global health field must work together. Despite the remarkable progress of the HIV response, the situation has stagnated in the past decade. Reinvigorating this work will be demanding, but the future health and wellbeing of millions of people require that we meet this challenge," she adds. [3]

Exceptionalism and the future

The authors call on HIV and global health researchers, health care professionals and policy makers to work together to improve the HIV response, arguing that this may be essential to achieve ambitious global HIV targets to end HIV by 2030 [4], maintain treatment access, and more effectively fund the HIV response to also benefit broader health outcomes. The authors call for immediate increased funding to avert another epidemic, and while they recognise that the 'exceptionalist' approach of the HIV response (where specific funding and health services have been provided for HIV alone) has been highly effective, they note that the approach may not be sustainable in the future.

They use mathematical models to examine the benefits of combining HIV with other health services, such as screening for HIV alongside screening for diabetes, high blood pressure and other NCDs, integration of HIV into reproductive and sexual health services, and harm reduction and overdose services.

In Kenya, approximately 1.6 million people are living with HIV, and around 30% of cases remain undiagnosed. At the same time, there is an increasing burden of NCDs (accounting for 27% of all deaths and 50% of all hospital admissions), which is largely due to a lack of early detection, meaning that people are diagnosed late and have poorer treatment outcomes.

The authors modelled combining screening for HIV, high blood pressure and diabetes. They estimate that, if the combined screening reached 10% of the Kenyan population every year over the next decade (2018 to 2028), and ART coverage reached 78% by 2028, over 216,000 new HIV cases and 244,000 AIDS deaths would be averted. This would also identify 686,000 individuals with untreated diabetes and 7.57 million people with untreated high blood pressure during this period. Setting up the screening programme would cost US$56.8 million for HIV testing and $3.2 million for NCD testing in the first year of the programme (2018). The authors estimate that the intervention would be cost-effective with respect to both HIV-related and NCD-related outcomes, but would require substantial health care resources to meet demand.

In India, if HIV testing, ART, and pre-exposure prophylaxis (PrEP) were combined with testing and treatment for syphilis for female sex workers and men who have sex with men (MSM), this could reduce the number of new HIV cases at a national-level by 7% between 2018-2028, potentially averting 51,000 new infections (including 43,000 in MSM, but fewer new infections in female sex workers as incidence is already projected to decrease rapidly). It could also avoid 81,000 AIDS-related deaths (including 59,000 in MSM, and 6,200 in female sex workers) between 2018-2028.

Adding PrEP into the intervention is estimated to have limited additional benefits due to the large preventive effects of ART. However, including testing and treatment of syphilis is estimated to diagnose and treat more than 510,000 new syphilis cases in female sex workers and MSM in 2018 alone, but the long-term effects would depend on infection and re-infection rates. Therefore, the authors estimate that combining HIV testing and treatment with syphilis screening and treatment would be highly cost-effective, but adding PrEP to this intervention is not cost-effective.

Finally, in Russia, increased medication-assisted treatment, needle and syringe programmes, and providing ART to 50% of people who inject drugs in the two high risk areas of Omsk and Ekaterinburg, could avert 53% and 36% of new HIV infections between 2018-2028, respectively. Integration of HIV services with medication-assisted treatment could also avert one-third of all fatal opioid overdoses - a major cause of mortality among people who inject drugs in Russia and globally. However, cost-effectiveness of this model was not estimated.

"Health systems must be designed to meet the needs of the people they serve, including having the capacity to address multiple health problems simultaneously. No one can be left behind in our efforts to achieve sustainable health. We must recognise health as an investment, and increase resources to support stronger, sustainable, and people-centred health systems," says co-chair of the Commission Professor Chris Beyrer, John Hopkins Bloomberg School of Public Health, USA, and past President of the International AIDS Society. "The HIV community must make common cause with the global health field. The HIV response's multidisciplinary, inclusive approach, its engagement of civil society, emphasis on human rights and equality, galvanisation of scientific innovation, and global collaboration are important elements that could revitalise global health's aim for sustainable health for all." [3]

Writing in a linked Comment, Peter Sands, Global Fund to Fight AIDS, Tuberculosis and Malaria, Switzerland, welcomes the Commission, but highlights that there will be barriers to be addressed in this integration. He says: "The challenge is how to achieve this deeper integration without diluting what has made the HIV response so successful. If mainstreaming HIV programmes into other health services makes them less focused on outcomes, or diffuses engagement, we will go backwards."

Writing in a Lancet Comment reflecting on the Commission, Dr Pamela Das, Senior Executive Editor, and Dr Richard Horton, Editor-in-Chief of The Lancet, say: "...it is now time to end the siloed and vertical response to AIDS, and, in the words of the Commission, to "make common cause with the global health field". That conclusion raises many questions about the existing instruments to address the AIDS epidemic - namely, UNAIDS, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the US President's Emergency Plan for AIDS Relief (PEPFAR). We invite these major institutions that are instrumental in driving the AIDS response to reconsider their purpose and their future. We encourage their respective leaderships to reassess their missions and to move towards a broader global health purpose, while at the same time sharpening their commitments to HIV/AIDS. With an upcoming replenishment in 2019, the Global Fund should continue to push hard for extra funding for HIV/AIDS. But the Global Fund should also think about how to broaden its response to include wider aspects of global health. This approach would support the idea that investing in the AIDS response is a means to building stronger health systems, getting to universal health coverage, and deepening access to services beyond HIV/AIDS."

Diabetes is a risk factor for all-site cancer for both men and women, but the increased risk is higher in women than in men, according to a new article in Diabetologia (the journal of the European Association for the Study of Diabetes).

Cancer is the second leading cause of death in the world. It is estimated that 1 in 4 women, and 1 in 3 men, develop cancer during their lifetime. In 2015 there were 17.5 million incident cancer cases and 8.7 million cancer deaths globally, and these figures are expected to increase in the next decades. Diabetes prevalence has also grown rapidly: 415 million adults were reported to have the condition in 2015, with 5 million deaths attributed. In the same year 12% of global health expenditure was spent on diabetes and its complications.

Previous studies have indicated that diabetes is associated with a risk of all-site and some site-specific cancers. For other conditions, such as stroke, coronary heart disease and dementia, there is published evidence (from these same authors) that excess risk of these conditions associated with diabetes is greater in women than in men. This study, conducted by Dr Toshiaki Ohkuma, Dr Sanne Peters and Professor Mark Woodward of the George Institute for Global Health at the University of New South Wales, Sydney, Australia and the University of Oxford, Oxford, UK, assessed whether there are sex differences in the association between diabetes and cancer.

In December 2016, the authors undertook a systematic search in PubMed MEDLINE to identify reports on the links between diabetes and cancer. Additional reports were identified from the reference lists of the relevant studies. Only those cohort studies providing relative risks (RRs) for the association between diabetes and cancer for both women and men were included - studies with data only for one sex were excluded, as were studies that had not adjusted for at least age as a confounder. In total, 107 relevant articles were identified, along with 36 cohorts of individual participant data.

Statistical analysis considered diabetes (types 1 and 2 combined) with all-site cancer events. Additionally, for those cancers that can occur in both sexes, site-specific cancer events were analysed. Relative risks (RRs) for cancer were obtained for those individuals with diabetes versus those without diabetes, for both men and women. The women-to-men ratios of these relative risk ratios (RRRs) were then calculated, to work out the excess risk in women if present.

Data on all-site cancer was available from 47 studies, involving 121 cohorts and 19,239,302 individuals. Women with diabetes had a 27% higher risk of all-site cancer compared to women without diabetes; for men with diabetes the risk was 19% higher than for men without. Calculation of the women-to-men ratio revealed that women with diabetes had a 6% greater excess risk of all-site cancer compared to men with diabetes.

Data on site-specific cancer were available for 50 sites. The women-to-men ratios showed statistically significant higher risks for women with diabetes for kidney (11% higher); oral (13% higher); stomach (14% higher); and leukaemia (15% higher) cancers, compared to men with diabetes. For liver cancer the risk for women with diabetes was 12% lower than for men with diabetes.*

The authors suggest that there are several possible explanations for the excess risk of all-site cancer conferred by diabetes in women. Hyperglycaemia (i.e. heightened blood glucose) may have carcinogenic effects by causing DNA damage - an effect that would be potentially more pronounced in women because historically women were likely to be undertreated, receive less intensive care, or show lower adherence to antidiabetic medication compared to men.

Alternatively, because the average duration of impaired glucose tolerance or impaired fasting glucose has been found to be over 2 years longer in women, they may have more exposure to untreated hyperinsulinaemia (high levels of insulin) in the prediabetic state - hyperinsulinaemia has been found to promote cancer cell proliferation. Another factor that may impact on the lower risk ratio for all-site cancer in men may be the apparent protective effect of diabetes in prostate cancer, a type that affects men only.

The authors also found that diabetes conferred a higher site-specific risk for women than men for oral, stomach and kidney cancers and leukaemia*, but a lower risk for liver cancer. The authors note that the literature around mechanisms underpinning the sex differences in site-specific cancers is scant. However, unmeasured confounding factors specific to each site, for example Helicobacter pylori infection for stomach cancer, and hepatitis virus infection for liver cancer may be involved."

Diabetes has been associated with the risk of all-site, and some site-specific, cancers in several systematic reviews and meta-analyses. Previously, however, there has been no systematic overview of the evidence available that sex differences may impact on this risk. This study confirms that diabetes is indeed a risk factor for all-site cancer in both sexes, but shows also that the effect is stronger in women than in men, and that this increase in risk for women varies with cancer site.

The authors stress "the importance of a sex-specific approach to quantification of the role of diabetes in cancer research, prevention and treatment," and conclude that "further studies are needed to clarify the mechanisms underlying the sex differences in the diabetes-cancer association."

LAWRENCE -- Individuals with disabilities are significantly more likely to be employed in states that have expanded Medicaid coverage as part of the Affordable Care Act, new research from the University of Kansas has found. Similarly, individuals who report not working because of a disability have significantly declined in expansion states, while neither trend happened in states that chose not to expand Medicaid.

The trends have broad policy implications as many states are considering work requirements for Medicaid eligibility, and they also have the potential to show similar employment benefits for individuals without disabilities. "In effect, Medicaid expansion is acting as an employment incentive for people with disabilities," the researchers wrote.

The study, authored by Jean Hall, professor of applied behavioral science and director of KU's Institute for Health and Disability Policy Studies; Adele Shartzer of the Urban Institute; Noelle Kurth, senior research assistant in KU's Institute for Health and Disability Policy Studies; and Kathleen Thomas of the University of North Carolina, was published in the American Journal of Public Health.

The analysis builds upon previous research that showed individuals with disabilities in Medicaid expansion states were more likely to be employed than those in nonexpansion states. The researchers analyzed data from the nationally representative Health Reform Monitoring Survey for both studies. In the most recent, they had another year of data to analyze, from 2013 after the ACA was implemented, to 2017. The data showed that in 2013, 41.3 percent of individuals with disabilities in expansion states reported being employed or self-employed. In 2017, that number rose to 47 percent. In the same timeframe, the percentage of the same population that reported not working because of disability dropped from 32 to 27 percent. Those trends were not present in nonexpansion states.

"We corrected for employment statistics in all states. If unemployment rates were already lower in a state, we controlled for that when looking at disability and employment," Hall said. "The takeaway is that, over time, these changes are becoming more robust. I would expect that to continue increasing over time. We also think you'd see the same trends for people without disabilities if you give it time."

Individuals with disabilities were often confined to lives of poverty and/or unemployment to qualify for Medicaid, as those whose earnings were too high were deemed ineligible. Yet those who surpassed income limitations were still often unable to afford health insurance on their own. In nonexpansion states, most adults with disabilities are required to apply for Supplemental Security Income and undergo a disability determination to affirm they cannot substantially work to be eligible for Medicaid. The researchers postulate that the incentive for employment could expand to individuals without disabilities as well. For example, a childless adult with a chronic illness cannot apply for Medicaid in nonexpansion states. In expansion states, they would be able to do so and move from having no health insurance to being covered by Medicaid.

"Our argument is that, over time, those who are better able to manage their health would have a better ability to be employed," Hall said.

The ability to work has benefits for individuals, their families and the state, the authors write. Having coverage and being able to gain employment makes individuals more independent, lowers unemployment and results in more people paying taxes and boosting state economies, while simultaneously reducing the number of people reliant on government programs such as food stamps, housing and child care subsidies and others.

The data analyzed for the study was from December 2014, when 26 states and the District of Columbia had expanded Medicaid. As of this month, 33 states and the District of Columbia have decided to expand coverage.

The findings come amidst continuing debates about the Affordable Care Act, health care in America and work requirements for Medicaid eligibility. They help illustrate the importance of coverage and independence, the researchers stated.

"First of all, having health insurance is very important in the ability to work," Hall said. "And I think we need to move away from a system where health coverage is predicated on living in poverty and not working. That's counterproductive."