Culture

When Stanford physicians Donna Zulman, MD, and Abraham Verghese, MD, set out more than two years ago to lead a team in finding ways to heal a growing fracture in doctor-patient relationships, they knew the task would be complicated.

In recent surveys, clinicians have reported that the current climate of medicine -- with limits on the amount of time they can spend with patients during appointments, an explosion of biomedical knowledge and increased demands to update and review electronic health records -- translates into less time for meaningful interactions with patients.

That, Stanford researchers contend in a paper to be published Jan. 7 in JAMA, isn't good for patients -- or for clinicians who are feeling increasingly disconnected from the reasons they got into medicine.

The goal of their research, which began 2½ years ago, was to identify evidence-based measures that clinicians can take to be fully engaged with patients and understand their perspectives, life circumstances and priorities. Ultimately, researchers wanted to generate a brief list of highly effective practices that clinicians could easily incorporate into their interactions with patients, Zulman said.

In their paper, researchers describe five evidence-based recommendations:

Prepare with intention: Familiarize yourself with the patient you are about to meet; create a ritual to focus your attention before a visit.

Listen intently and completely: Sit down, lean forward and position yourself to listen; don't interrupt; your patient is your most valuable source of information.

Agree on what matters most: Find out what your patient cares about and incorporate these priorities into the visit agenda.

Connect with the patient's story: Consider the circumstances that influence your patient's health; acknowledge your patient's efforts, and celebrate successes.

Explore emotional cues: Tune in, notice, name and validate your patient's emotions to become a trusted partner.

The research was conducted in conjunction with Presence, an interdisciplinary center at Stanford that promotes the art and science of human connection in medicine. The objective of the research project was to revise the critical moment when physicians and patients meet, shifting the emphasis from institutional procedure to an interaction focused on meaningful human interaction.

"We were looking for practices that would improve the experience of patients and lead to better care for them, but would also improve the experience of clinicians and help them to rediscover the joy of medicine," said Zulman, an assistant professor of medicine and the director of Stanford Presence 5, one of several Presence initiatives.

"As physicians, we are privileged to work with people in their most vulnerable moments," she said. "And in today's climate, particularly in primary care, it's easy to lose sight of that with all of the administrative demands, time pressures and technology distractions."

Zulman, a health services researcher at Stanford and the Veterans Affairs Health Care System, is the lead author of the paper. Verghese, an advocate for the importance of bedside medicine and physical exams, is senior author of the paper, which includes links to podcast interviews with him and Zulman.

Identifying strategies

The Presence 5 practices, as they are known, were identified through a systematic review of 73 studies of interpersonal interventions published between January 1997 and August 2017, as well as through observations of clinician-patient encounters, and interviews with clinicians and patients at Stanford internal medicine and family medicine clinics, the Ravenswood Family Health Center in East Palo Alto and the Veterans Affairs Palo Alto Health Care System. The team also interviewed professionals outside the field of medicine to learn about cross-cutting themes related to clinician presence and human connection.

The published studies were analyzed to measure how interventions improved health outcomes, costs and patient and physician experiences. The interviews and observations provided insights into best practices at the clinical level.

The information researchers gleaned from the studies, interviews and observations generated 31 ideas for practices physicians could implement, which were reviewed, rated and culled to five with input from a group of experts: physicians, researchers, a patient advocate, a caregiver advocate and health care leaders.

Zulman said the team's next step is to evaluate how using the five practices affects the experiences of patients and clinicians, with new research being conducted at Stanford primary care clinics, the MayView Community Health Center in Mountain View and the San Jose VA Clinic, which is part of the VA Palo Alto Health Care System.

Researchers are holding workshops to share their findings, as well as developing a curriculum for training medical students and residents. The team is also working to validate their findings with international collaborators and to determine whether the practices can be adapted for different clinical settings and models.

"The Presence 5 practices resonate because they speak to something that is timeless and central to medicine," said Verghese, the Linda R. Meier and John F. Lane Provostial Professor and director of the Presence Center. "Patients want us to be more present. And we as physicians want to be more present with our patients, because without that contact, our professional life loses much of its meaning."

Systematic change is needed

Zulman said the researchers see the Presence 5 measures as just one step to address frustrations with modern-day medicine.

"While we might not be able to change the system overnight, our study suggests there are some concrete, evidence-based strategies that we, as physicians, can use that will help preserve and foster the connections that are most healing for patients and for us as physicians," she said.

What The Study Did: Researchers pooled data from four large study groups with 250,000 women to estimate the association between using body powder in the genital area and risk of ovarian cancer.

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

Authors: Katie M. O'Brien, of the National Institute of Environmental Health Sciences in Research Triangle Park, North Carolina, is the corresponding author.

(doi:10.1001/jama.2019.20079)

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

WASHINGTON, D.C., January 7, 2020 -- Doctors have used focused ultrasound to destroy tumors without invasive surgery for some time. However, the therapeutic ultrasound used in clinics today indiscriminately damages cancer and healthy cells alike.

Most forms of ultrasound-based therapies either use high-intensity beams to heat and destroy cells or special contrast agents that are injected prior to ultrasound, which can shatter nearby cells. Heat can harm healthy cells as well as cancer cells, and contrast agents only work for a minority of tumors.

Researchers at the California Institute of Technology and City of Hope Beckman Research Institute have developed a low-intensity ultrasound approach that exploits the unique physical and structural properties of tumor cells to target them and provide a more selective, safer option. By scaling down the intensity and carefully tuning the frequency to match the target cells, the group was able to break apart several types of cancer cells without harming healthy blood cells.

Their findings, reported in Applied Physics Letters, from AIP Publishing, are a new step in the emerging field called oncotripsy, the singling out and killing of cancer cells based on their physical properties.

"This project shows that ultrasound can be used to target cancer cells based on their mechanical properties," said David Mittelstein, lead author on the paper. "This is an exciting proof of concept for a new kind of cancer therapy that doesn't require the cancer to have unique molecular markers or to be located separately from healthy cells to be targeted."

A solid mechanics lab at Caltech first developed the theory of oncotripsy, based on the idea that cells are vulnerable to ultrasound at specific frequencies -- like how a trained singer can shatter a wine glass by singing a specific note.

The Caltech team found at certain frequencies, low-intensity ultrasound caused the cellular skeleton of cancer cells to break down, while nearby healthy cells were unscathed.

"Just by tuning the frequency of stimulation, we saw a dramatic difference in how cancer and healthy cells responded," Mittelstein said. "There are many questions left to investigate about the precise mechanism, but our findings are very encouraging."

The researchers hope their work will inspire others to explore oncotripsy as a treatment that could one day be used alongside chemotherapy, immunotherapy, radiation and surgery. They plan to gain a better understanding of what specifically occurs in a cell impacted by this form of ultrasound.

AMES, Iowa - Researchers may have discovered a way to turn back the clock on aging heart muscles in fruit flies, a development that could lead to new therapies for older humans with heart disease.

Hua Bai, an assistant professor of genetics, development and cell biology at Iowa State University, led a study, published recently in the academic journal Autophagy, that explores the genetic mechanism that causes fly cardiac muscles to deteriorate with age. Bai said the research team restored much of the cardiac function in middle-aged flies, which experience many of the same heart maladies as middle-aged humans.

The researchers' approach starts with autophagy, a cellular "cleanup process" that removes and recycles damaged proteins and organelles. The autophagy process slows with age, which can lead to the weakening of cardiac muscles. Bai's research team looked at a key genetic pathway conserved in virtually all organisms on Earth related to autophagy that balances organism growth with nutrient intake. This pathway, called mechanistic target of rapamycin (or mTOR), has long been linked to tissue aging, Bai said. One of two complexes that underlie the mTOR pathway, referred to as mTORC2, decreases with age as autophagy declines. But the researchers found that transgenically boosting mTORC2 strengthens heart muscles of older fruit flies.

"Boosting the complex almost fully restored heart function," Bai said.

Implications for treatment in humans

The discovery that enhancing mTORC2 slows the decline of the critical autophagy process could have big implications for how doctors treat patients with heart disease, one of the leading causes of the death in the United States. While flies and humans might seem to be worlds apart evolutionarily, Bai said the two species' hearts age in a similar fashion. By middle age, cardiac muscles in both species tend to contract with less strength and regularity.

"The fly model can be useful for developing drug target discoveries that could have a big impact on human health," Bai said.

The researchers arrived at their conclusions after conducting thousands of video recordings on cardiac muscles in fruit flies of various ages. High-resolution, high-speed cameras measured the activity of the flies' cardiac muscles. The experiments showed that boosting mTORC2 could restore a five-to-six-week-old fly's heart function to that of a fly between one and two weeks old. That's like restoring a middle-aged heart to how it functioned during young adulthood, Bai said.

Because flies live only between two and three months, it's much easier for scientists to study aging and longevity in flies than in more long-lived species, he said. And the ability to manipulate the fly genome also makes them ideal for genetic study and a common model organism, he said.

Hospital ratings are intended to help patients decide where to get medical care and encourage hospitals to improve the quality of their services. They also can influence how insurance companies negotiate contracts for reimbursing hospitals.

But a University of Chicago Medicine analysis of the Centers for Medicare and Medicaid Services (CMS) Hospital Compare rating system shows that hospitals serving vulnerable communities may be judged on social factors outside of their control.

The CMS Hospital Compare program uses a variety of quality metrics and survey data to assign every Medicare-certified hospital in the U.S an overall rating of one-to-five stars. Since the inception of star ratings in 2016, however, hospital leaders and industry groups have criticized the program's methodology.

One criticism is that the CMS rating system does not account for social risk factors (SRFs) such as income, marital status, race, languages spoken, education and employment in the community that the hospital serves. However, these SRFs may make it more challenging for hospitals to improve certain quality outcomes.

UChicago Medicine researchers examined associations between neighborhood SRFs and seven CMS quality scores -- effectiveness of care, efficiency of care, hospital readmission, mortality, patient experience, safety of care and timelessness of care -- for 3,608 hospitals nationwide. The results showed that hospitals caring for patients in neighborhoods with higher social risks garnered lower quality scores, but largely in areas that hospitals may have little control over.

The impact of neighborhood SRFs was most evident in scores for timeliness of care, hospital readmissions, and patient experience. Timeliness of care, which mostly measures emergency department wait times, is heavily connected to regional access to emergency services.

Scores in safety, efficiency and effectiveness of care - measures that occur within the hospital walls -- were minimally affected by SRFs.

"Our study suggests that a hospital's quality rating may be tied to its geographic location -- its place," said Elizabeth Tung, MD, MS, senior author of the paper published in the journal Medical Care. "Living in a disadvantaged community can influence health directly through social factors like substandard housing conditions, inadequate access to food or transportation, and high levels of stress due to safety concerns. These factors work against well-being, so patients from these neighborhoods have more barriers to health to begin with."

John Fahrenbach, PhD, data scientist at UChicago Medicine and lead author on the paper, acknowledges that it is a challenge for CMS and other organizations that rate hospitals to come up with good quality metrics, but calls for more fairness and equity in their approach.

"What we are trying to say is, pay attention to -- and risk adjust for--the social determinants in the communities that we serve," he said. "Don't penalize hospitals that are taking care of less-resourced patients."

In 2006, more than 400 children under the age of 5 died during an outbreak of diarrheal disease in Botswana. In what was a 25-fold increase in diarrheal disease mortality for this age group, citizens of the country were devastated.

For more than 10 years, Kathleen Alexander, a professor of fish and wildlife conservation in the College of Natural Resources and Environment at Virginia Tech and the co-founder of Conservation of African Resources: Animals, Communities, and Land Use (CARACAL), has been researching similar diarrheal disease outbreaks across Botswana to determine if there are correlations between certain atmospheric conditions, local environmental variables, and diarrhea rates.

Together with Jeffrey Shaman, of Columbia University, and Alexandra Heaney, of the University of California Berkeley, Alexander discovered a critical link between environmental dynamics and human health. With this knowledge, researchers will have the capacity to begin to predict when diarrheal disease outbreaks will reoccur.

Their findings were recently published in Nature Communications.

Botswana is a dry country with only three sources of surface water. Alexander and her collaborators focused their work in the Chobe District, which is home to the Chobe River, the only permanent surface water that can be found in 12,000 square kilometers. Notably, it is also the only source of drinking water for eight villages, making it a critical region to study the additional influence of surface water on diarrheal disease.

Diarrheal disease remains a critical threat to children under 5 years of age across Africa but particularly in Chobe District. With case reports peaking annually in the wet season and again in the dry season, researchers were able to determine that certain meteorological conditions were directly responsible for these outbreaks.

El Niño-Southern Oscillation (ENSO) is an ocean-atmosphere system that causes temperature and precipitation fluctuations across the world. El Niño and La Niña are the two extremes of ENSO conditions, which alternate every three to seven years.

During La Niña, researchers found that the combination of cooler conditions and above-average rainfall contributed to increased flooding, which, in turn, increased the concentrations of organic material and diarrhea-causing pathogens within the Chobe River. El Niño conditions had the opposite effect on the climate and precipitation of the region.

"Human health is intimately connected to the landscape and the environmental conditions that prevail - connections that cross scales from local hydrometeriology and water quality dynamics to global atmospheric conditions," said Alexander, who is also an affiliated faculty member of the Fralin Life Sciences Institute at Virginia Tech.

In a previous paper, Alexander and her team concluded that Chobe's elephant populations, which happen to be the highest in the world, may have a critical influence on water quality in the region and, perhaps, diarrheal disease. In the dry season, large herds of elephants in the tens of thousands will move to the Chobe River, the only surface water to be found in the region. Development of infrastructure has limited wildlife access to the river. With such a large density of wildlife, sediment and fecal matter are carried downstream toward the district's water treatment plants.

"Landscape degradation and significant fluxes in sediment levels can influence the ability of water treatment plants to remove diarrhea-causing pathogens. These treatment plants work but not well in these highly dynamic systems. This is a clear example of how important it is to maintain protected areas - they are so central to human health," said Alexander.

Alexander is an advocate of "One Health," a concept that recognizes that human health is directly linked to the health of the environment. One Health also focuses on taking a bottom-up approach and puts education at the forefront. Alexander has an educational program in 12 schools within the Chobe District, teaching children exactly how important it is to take care of their environment and, ultimately, themselves.

Alexander maintains that working actively and intimately within grassroots environments provides a different perspective, and it is also the best way to collect data, gain novel insights, and develop solutions that work for the people who need them.

"It was a humbling experience in that you remember that no matter how much education you have, no matter how many degrees you have, you really need to stay connected to the people who have the problem," said Alexander. "What is their experience? What is their problem definition? What is the solution that they see? What do they understand is the issue?"

Overall, Alexander sees a long journey ahead. With its many facets, conquering childhood diarrhea is not an easy task. Although Botswana is committed to improving public health and dedicates significant resources to the aim, the country is still hit hard by diarrheal disease biannually. One of the first steps of disease eradication involves awareness and understanding cultural and social perceptions, which can turn the tide significantly.

"Diarrhea is not a complicated issue," Alexander explained. "But it is in so many ways in these low resource environments when you're trying to integrate cultural practices and beliefs with existing infrastructure limitations. If you've got five doctors and 20,000 people, how much can you really do? What are the tools that you can use in those environments? Where do you focus with what little you have? That's what we are really working toward trying to figure out."

Alexander and her team's findings provide a tool that can be used to predict diarrheal disease outbreaks and help regions to be better prepared. "Even if your resources are limited, if you can plan, you are one step ahead. We are working closely with the Botswana government and communities in this effort," said Alexander.

LEBANON, NH - For decades, theories have existed to explain patient reports of seeing light flashes during radiation therapy, even with their eyes closed. However, no one has been able to secure evidence of this sensation in humans to prove their theory. A team of researchers at Dartmouth's and Dartmouth-Hitchcock's Norris Cotton Cancer Center led by radiation oncologist Lesley Jarvis, MD, PhD and Irwin Tendler, MEng, have collected real-time data to show that during head and neck radiation therapy, enough light is produced inside the eye to elicit such a visual sensation. This evidence, and their explanation of it, "Experimentally Observed Cherenkov Light Generation in the Eye During Radiation Therapy," is newly published in The Red Journal (International Journal of Radiation Oncology, Biology, & Physics).

"Overall, the idea of imaging light emission from humans undergoing radiotherapy is novel and was also first suggested and developed at Dartmouth," says Tendler. "Our newest data is exciting because for the first time, light emission from the eye of a patient undergoing radiotherapy was captured. This data is also the first instance of evidence directly supporting that there is enough light produced inside the eye to cause a visual sensation and that this light resembles Cherenkov emission."

Light emission from the eye is very subtle, hard to detect, and likely why no one has been able to record evidence of this phenomenon. To accomplish this, the team leveraged special technology called the CDose camera imaging system, an engineering innovation manufactured by Dartmouth spin-off company, DoseOptics, LLC. The camera provides live views of light emission from biological systems (animal and human) during radiotherapy. "As the radiation beam passes through the eye, light is generated within the vitreous fluid. Our real-time data rigorously showed that the amount of light produced is sufficient to elicit a visual sensation--a topic that has been debated in the literature," explains Tendler. "By analyzing the spectral composition, we also show that this emission can be classified as Cherenkov light--again, another contested point in the literature."

The benefits of the team's finding to cancer treatment are several-fold:

The imaging technique could be used to monitor light emission from the eye during radiotherapy and directly determine whether radiation transects the eye. "In the case that the eye is a target, the method could provide confirmation of beam delivery; in the case that this is unintentional, it can provide evidence of an error or near miss - as a safety check," says Tendler.

The ability to provide the patient with a valid explanation of this phenomenon can help relieve treatment-related anxiety.

"Published work has shown that if a patient doesn't see light flashes during radiotherapy, there is a higher chance of expecting vision loss after irradiation," says Tendler. The method could help determine if any light was actually generated to potentially relate this to predicted vision loss as well as provide information about long-term visual outcome following radiotherapy.

The team's next steps are to correlate how recorded ocular Cherenkov light and delivered dose can provide information about long-term visual outcome, and to develop the tool to use in prediction and measurement of eye dose.

Zinc and folic acid, a pair of dietary supplements long touted as an effective treatment for male infertility, failed to improve pregnancy rates, sperm counts, and sperm potency in a new study conducted at University of Utah Health and other medical centers in conjunction with the National Institutes of Health. According to the researchers, the finding presents the most definitive evidence to date that so-called fertility supplements do not live up expectations.

"This is a landmark trial of male infertility supplements," says James M. Hotaling, M.D., co-author of the study and a U of U Health urologist specializing in male infertility. "The take-home message for men is that, for the first time, there is high-quality data that zinc and folic acid do not improve live birth outcomes or semen function."

The study, led by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), appears in JAMA.

Many fertility supplements contain zinc, a mineral essential for sperm development, and folate, the natural form of folic acid that helps form DNA in the sperm. These over-the-counter supplements, also known as nutraceuticals, are often promoted as a natural way to enhance sperm formation, sperm count, and movement. However, previous studies of these products have produced inconclusive results.

For this study, the researchers recruited 2,370 couples planning to undergo infertility treatments in Salt Lake City, Chicago, Minneapolis, and Iowa City, Iowa. Men were randomly assigned to either receive a placebo or a daily supplement consisting of 5 milligrams of folic acid and 30 milligrams of zinc for six months. Women were asked to complete questionnaires for up to 18 months following the beginning of the trial in order to track pregnancy outcomes.

Researchers found no significant differences in live births between the men who received the supplement (404 births, 34%) and the placebo group (416 births, 35%). Men in the two groups also had similar measures for total sperm count, mobility, and shape. However, men who took the supplements had a higher proportion of broken DNA in sperm than in the placebo group. Prior studies suggest that this phenomenon, known as DNA fragmentation, can contribute to male infertility.

Men in the supplement group also complained of more abdominal pain, nausea, vomiting, and other gastrointestinal symptoms than those in the placebo group.

"This large, well-controlled, randomized study shows us that nutraceuticals like zinc and folic acid really don't improve the chances of a couple getting pregnant and actually can cause side effects that are not beneficial," says C. Matthew Peterson, M.D., a U of U Health reproductive endocrinologist and one of the study's principal investigators. "It's important for men of all ages to eat a healthy diet to maintain fertility, but you don't necessarily need to take something extra to help you achieve better sperm parameters."

University of Cincinnati geography researchers have identified a tipping point for deforestation that leads to rapid forest loss.

Geography professor Tomasz Stepinski used high-resolution satellite images from the European Space Agency to study landscapes in 9-kilometer-wide blocks across every inch of the planet between 1992 and 2015. He found that deforestation occurs comparatively slowly in these blocks until about half of the forest is gone. Then the remaining forest disappears very quickly.

The study was published in the journal Geophysical Research Letters.

Stepinski and former UC postdoctoral researcher Jakub Nowosad, the lead author, discovered something surprising and fundamental: nature abhors mixed landscapes, at least on a scale of 81 square kilometers. The study showed that mixed landscapes (like agriculture and forest) are comparatively few and, more surprisingly, do not stay mixed for long. These mixed blocks tend to become homogeneous over time, regardless of the landscape type.

"I think it's very intuitive. It corresponds to the different climatic zones. The Earth before people was certainly like that. You had forests and mountains and wetlands and deserts," Stepinski said. "You would expect people would create more fragmentation, but as it turns out, people never stop. They convert the entire block on a large scale."

Stepinski said landscapes are always changing through natural or anthropological causes. Human causes are both direct, like clear-cutting, or indirect like climate change.

Last year, Stepinski used the same data to demonstrate that 22% of the Earth's habitable surface was altered in measurable ways between 1992 and 2015. The biggest change: forest to agriculture.

For the new study, Stepinski examined nearly 1.8 million blocks covering Earth's seven continents. Blocks were categorized by 64 landscape combinations. Researchers observed transitions in these blocks from predominantly one type to predominantly another in nearly 15% of the blocks between 1992 and 2015.

"The data we have covers 23 years. That's a relatively short period of time. But from that we can calculate change in the future," Stepinski said.

Deforestation was the most pronounced example of human-caused landscape change, researchers found. They used probability modeling known as Monte Carlo methods to determine the likelihood of different types of landscape change over time (in this case hundreds of years).

The result? Researchers found that the most likely trajectory of change was from one homogeneous type to another.

"Planet Earth wants to be homogeneous. The land wants to be the same in all these patches. And when they start to change, they don't stop until they convert everything into another homogeneous block," he said.

The authors did not examine why blocks change so quickly once a transition begins. But Stepinski said it's possible that development such as logging roads or drainage required to clear forest makes continued change that much easier.

"I can only speculate because that was not part of the study, but I would imagine two things are happening," he said. "If you are cutting forest, you have the infrastructure to finish it. It's so much easier to cut the rest. Second, the forest is more vulnerable to change when there has been a disturbance." 

Wildlife managers often try to preserve larger intact blocks to prevent fragmentation, said Martin McCallister, the Appalachian Forest project manager for the Edge of Appalachia Nature Preserve in southern Ohio. The preserve is managed by the Nature Conservancy, one of the world's largest wildlife conservation organizations.

"You'd be hard pressed to find land managers who wouldn't be strongly in favor of protecting larger tracts because they're more resilient to a variety of challenges, including invasive species and climate change," McCallister said. "Once a property gets fragmented by roads, it's easier to extract resources. It's also easier for invasive species and pests to get a foothold."

McCallister said woodlands can be fragmented on paper, too.

"In Ohio, 96 percent of our woodland owners have less than 50 acres. They represent a lot of small parcels," he said.

The UC study found that mixed land types don't stay mixed for long. 

"I think it is interesting that this property applies both to natural and human landscapes," said co-author Nowosad, a former UC postdoctoral researcher who now works as an assistant professor at the Adam Mickiewicz University in Poland.

Nowosad said the study provides a data-driven model of long-term landscape change. While researchers only looked at changes between forest and agriculture, Nowosad said it would be worthwhile to examine whether tipping points exist for other landscape transitions.

"This model can be used to help understand how landscapes evolved and are going to evolve in the future," Nowosad said.

Stepinski, a physicist who worked for NASA before coming to UC, said the principle borrows from other disciplines, particularly astrophysics.

"If you look at the evolution of stars, the principle is you predict a long-term path statistically from short-term knowledge," Stepinski said. "It's an idea that has been used elsewhere but never for environmental study."

While it's only a theory, it's one that could be borne out by time, he said.

"It's thought-provoking. My hope is that people will criticize it and come up with different ideas," Stepinski said.

Astronomers announced Monday the first discovery made by NASA's TESS mission of a two-star planetary system. Led by researchers at NASA's Goddard Space Flight Center and San Diego State University, with other collaborators, the telescope satellite's finding marks the start of a much better understanding of the population of such planetary systems.

On behalf of the international team of 60 investigators, the work was presented by researcher Veselin Kostov at the 235th meeting of the American Astronomical Society in Honolulu.

The new planet, called TOI-1338 b, is about 6.9 times larger than Earth. It orbits its pair of host stars every 95 days. One of the stars is more massive and much brighter than the other, and as the planet orbits around it blocks some of the light from the brighter star. This transit allows astronomers to measure the size of the planet. The transit was first found in the TESS data by a high school student working at NASA with Kostov over the summer.

"Our analysis confirmed the transit was caused by a circumbinary planet and we were able to measure the planet's properties," said SDSU astronomer Jerome Orosz.

A dozen such Tatooine-like planets--so named for the desert world in "Star Wars"-- were found with NASA's Kepler Mission, which ended in 2013. The orbiting TESS telescope, launched in 2018, will cover nearly the whole sky and enable many more discoveries, perhaps as many as 100 new circumbinary planets. A sample size that large will allow a statistical analysis of the population, which to date has not been possible because too few systems are known.

New Kepler planet

Helping to boost the numbers, SDSU astronomers at the AAS meeting also revealed a new Kepler circumbinary planet, called KOI-3152 b.

"We first noted convincing evidence for this planet in 2012, but confirmation required additional data and improvements in computer modeling," said SDSU astronomer William Welsh. "In particular, star spots on the primary host star and a weak eclipse signal from the second star made the analysis difficult."

In 2019, Welsh's master's thesis student Quentin Socia accepted the challenge and spearheaded the investigation.

KOI-3152 b is located 1,347 light-years away and is 3.9 times the size of the Earth. It orbits its binary stars every 175 days. Although KOI-3152 b straddles the hot edge of the habitable zone, it is a low-density gaseous planet and not able to support life as we know it. This work has been accepted for publication in The Astronomical Journal.

This finding marks the latest discovery made by the SDSU team using Kepler Mission data. Their pioneering work established this new type of planet and includes the discovery of the most interesting of the circumbinary planets, the Kepler-47 system, consisting of three planets orbiting two stars.

Honolulu -- The outskirts of the Milky Way are home to the galaxy's oldest stars. But astronomers have spotted something unexpected in this celestial retirement community: a flock of young stars.

More surprising still, spectral analysis suggests that the infant stars have an extragalactic origin. The stars seemingly formed not from material from the Milky Way, but from two nearby dwarf galaxies known as the Magellanic Clouds. Those galaxies are on a collision course with our own. The discovery suggests that a stream of gas extending from the galaxies is about half as far from crashing into the Milky Way as previously thought.

"This is a puny cluster of stars -- less than a few thousand in total -- but it has big implications beyond its local area of the Milky Way," says primary discoverer Adrian Price-Whelan, a research fellow at the Flatiron Institute's Center for Computational Astrophysics in New York City. (The cluster also bears his name: Price-Whelan 1.)

The newfound stars could reveal new insights into the Milky Way's history; they might, for example, tell if the Magellanic Clouds collided with our galaxy in the past.

Price-Whelan and his colleagues present their findings January 8 at the American Astronomical Society meeting in Honolulu. They previously reported the discovery of Price-Whelan 1 on December 5 in The Astrophysical Journal and their subsequent spectroscopic analysis of the stars on December 16, also in The Astrophysical Journal.

Identifying clusters of stars is tricky because our galaxy is chock-full of the radiant orbs. Some stars may appear to be close together in the sky but actually sit at drastically different distances from Earth. Other stars may temporarily neighbor one another but move on in opposite directions. Determining which stars are actually clustered together requires many precise measurements over time.

Price-Whelan started with the latest data collected by the Gaia spacecraft, which has measured and cataloged the distances and motions of 1.7 billion stars. He searched the Gaia dataset for very blue stars, which are rare in the universe, and identified clumps of stars moving alongside them. After cross-matching with and removing known clusters, one remained.

The newfound cluster is relatively young at 117 million years old and is on the far outskirts of the Milky Way. "It's really, really far away," Price-Whelan says. "It's further than any known young stars in the Milky Way, which are typically in the disk. So right away, I was like, 'Holy smokes, what is this?'"

The cluster inhabits a region near a river of gas, dubbed the Magellanic Stream, that forms the outmost edge of the Large and Small Magellanic Clouds and reaches toward the Milky Way. Gas in the stream doesn't contain much metal, unlike gases in the outer reaches of the Milky Way. David Nidever, assistant professor of physics at Montana State University in Bozeman, led an analysis of the metal content of the 27 brightest stars in the cluster. Just like the Magellanic Stream, the stars contain meager levels of metal.

The researchers propose that the cluster formed as gas from the Magellanic Stream passed through the gases surrounding the Milky Way. This pass-through created a drag force that compressed the Magellanic Stream gas. This drag, along with tidal forces from the Milky Way's gravitational tug, condensed the gas enough to trigger star formation. Over time, the stars zoomed ahead of the surrounding gas and joined the Milky Way.

The stars' presence presents a unique opportunity. Gauging the distance of gas from Earth is tricky and imprecise, so astronomers weren't sure how far the Magellanic Stream was from reaching the Milky Way. The distance of stars, on the other hand, is comparatively trivial. Using the current positions and movements of stars in the cluster, the researchers predict that the edge of the Magellanic Stream is 90,000 light-years away from the Milky Way. That's roughly half the distance previously predicted.

"If the Magellanic Stream is closer, especially the leading arm closest to our galaxy, then it's likely to be incorporated into the Milky Way sooner than the current model predicts," Nidever says. "Eventually, that gas will turn into new stars in the Milky Way's disk. Right now, our galaxy is using up gas faster than its being replenished. This extra gas coming in will help us replenish that reservoir and make sure that our galaxy continues to thrive and form new stars."

The updated distance to the Magellanic Stream will improve models of where the Magellanic Clouds have been and where they're going, Price-Whelan says. The improved numbers could even settle a debate over whether the Magellanic Clouds have crossed through the Milky Way before. Finding an answer to that question will help astronomers better understand the history and properties of our galaxy.

The most effective way to reduce HIV-related deaths and prevent onward transmission is to diagnose and treat all persons as soon as possible after HIV infection. According to a study published in Clinical Infectious Diseases, New Yorkers living with HIV are being treated sooner after infection. The time to treatment initiation was reduced in tandem with expanded HIV testing and treatment efforts in New York City.

An analysis of 28,162 New Yorkers diagnosed with HIV found considerable progress in rapid treatment initiation. The time from diagnosis to treatment initiation decreased by 60 percent from 2006 to 2015 and was a median of 0.2 years (~2.4 months) for people diagnosed in 2015. The time from estimated infection to diagnosis decreased by 28 percent to a median of 3.3 years among people diagnosed in 2015.

"The elapsed time from infection to diagnosis or treatment initiation matters because this represents time when an individual misses out on the benefits of treatment," says Dr. McKaylee Robertson, the study's lead author and an epidemiologist at the Institute for Implementation Science in Population Health (ISPH) at the CUNY Graduate School of Public Health and Health Policy (CUNY SPH). "If we can continue to reduce diagnosis and treatment delays, we may continue to see declines in HIV incidence and mortality. These results suggest that we need more effective implementation strategies for earlier HIV diagnosis and linkage."

An overwhelming body of scientific evidence has established that "HIV Undetectable=Untransmittable (U=U)" and people living with HIV who receive treatment to stably suppress the virus cannot transmit the virus to sexual partners. To eliminate HIV as a public health threat, the elapsed time between infection and treatment must be minimized.

The study was conducted by a team of investigators at the ISPH in collaboration with the New York City Department of Health and Mental Hygiene and used population-based HIV surveillance data.

"This study shows that NYC has made significant improvements in quickly getting people on treatment, and these improvements coincide with many citywide testing and treatment campaigns," says Dr. Sarah Braunstein, the study co-author and director of HIV epidemiology at the New York City Department of Health and Mental Hygiene. "New York's robust infrastructure for HIV prevention and treatment likely contributed to reductions in diagnosis and treatment delay."

Dr. Denis Nash, the study's senior author and distinguished professor of public health at CUNY SPH, says the new metrics developed as part of this study can better target HIV testing services towards those with longer standing undiagnosed HIV infection.

"The biggest potential for impact on public health going forward will be via much-needed gains in earlier HIV diagnosis," Nash says. "With more than half of people diagnosed with HIV three or more years after infection, there is much room for improvement in the impact of HIV testing services."

A new study provides convincing evidence that the use of peripherally inserted central catheters (PICCs) to administer medicine and draw blood in children is associated with a significantly increased risk of blood clots (known as venous thromboembolism or VTE) compared with central venous catheters (CVCs) placed directly into the neck or chest. The study results, published today in Blood, also reveal a significantly higher rate of CVC-related bloodstream infections and catheter malfunctions among pediatric patients receiving PICCs. Based on the findings, researchers are voicing concerns about the growing use of PICCs - and what appears to be a corresponding jump in VTE - in children who need a CVC.

Treating children with cancer, congenital heart disease, infections, or other serious health problems frequently requires the insertion of a catheter into a large central vein to allow medical teams to administer medications and draw blood for testing. PICCs have been used with increasing frequency because they can be quickly and easily inserted at the bedside by a nurse with light sedation. By contrast, insertion of a centrally placed line, or tunneled line (TL) is a more invasive, time-consuming and costly procedure in which a surgeon or interventional radiologist uses ultrasound or X-ray imaging to guide the insertion of the line, usually into the large vein in the neck, while the patient is under anesthesia.

The study, known as Clot Incidence Rates in Central Lines (CIRCLE), is the first multi-center, prospective, observational cohort study to compare VTEs in children with newly placed PICCs and TLs. The analysis included a total of 1,967 newly placed CVCs in 1,742 children aged six months to 18 years. CVC-related VTEs occurred in 6% of children overall within six months of follow up. Of the 94 VTEs observed, 75 (80%) were seen in children with PICCs. Children who received a PICC were 8.5 times more likely to develop a blood clot compared to those with a TL. The results corroborate evidence from an earlier interim analysis in a smaller cohort of patients that showed a disproportionally higher incidence of VTE in patients with PICCs versus those with TLs.

"Now we can say definitively that patients who have PICCs have a much higher rate of thrombosis as well as central line associated bloodstream infections and catheter malfunctions when compared to TLs," said senior study author Julie Jaffray, MD, of Children's Hospital Los Angeles and University of Southern California, adding that the research was conducted in response to a sharp increase over recent years in the incidence of VTE in children receiving CVCs. "PICCs are not as benign as we once thought."

She said this is also the first large study to take a comprehensive look at the incidence of VTE across multiple subgroups of children receiving CVCs in a real-world setting. Catheter-related blood clots were highest among patients with a prior history of VTE; VTE was also more likely among children receiving a larger caliber catheter carrying multiple lines (or lumens) and those with leukemia. Additionally, patients who had a line malfunction or an infection were more likely to have VTE.

Children who develop a VTE require anticoagulation therapy, which Dr. Jaffray explains is inconvenient to administer and carries an inherent risk of internal bleeding. VTE is also associated with prolonged hospitalizations, increased cost, and a higher likelihood of morbidity and death from pulmonary embolism. Dr. Jaffray said that as many as one in four pediatric patients with VTE develop post-thrombotic syndrome, a condition that can cause chronic pain, swelling, and other symptoms after a clot is resolved. Venous stenosis, in which the vein becomes constricted following VTE, is also a clinically significant complication as it can limit blood flow and make it harder to insert catheters in patients who need to undergo surgeries over the course of their treatment.

Dr. Jaffray says the observed incidence of PICC-related VTE is too high to justify their frequent use and adds that the results of the CIRCLE study should give pause to medical professionals who care for children requiring intravenous treatments, especially when central venous access is not absolutely necessary.

"Do all of the kids getting PICCs really need them?" asked Dr. Jaffray, whose work will help inform how CVCs are selected and used in children. The ultimate goal, she said, is to see if the use of PICCs can be reduced, perhaps in favor of using peripheral intravenous lines (those going into a vein in a limb) in patients who don't really need a CVC or using a more permanent central line in those whose medical condition demands ongoing access.

Dr. Jaffray and her team plan to conduct further additional analyses to assess whether the underlying reason for inserting the line - for example, chemotherapy, prolonged courses of antibiotics, or feeding - might play a role in the development of VTEs.

ANN ARBOR, Mich. - Children with public insurance are slightly more likely to receive medical services that they don't need than those with private insurance, a new study finds.

One in nine publicly insured and one in 11 privately insured children received low-value care in 2014, according to the findings published in journal Pediatrics.

Researchers evaluated data for 8.6 million children in 12 states to see whether having public or private insurance is associated with receiving low-value medical services.

"In a prior study, we showed that privately insured children frequently received low-value services that do not improve their health, but we didn't know if publicly insured children were more or less likely to receive wasteful care," says lead author Kao-Ping Chua, M.D., Ph.D., a pediatrician and researcher at Michigan Medicine's C.S. Mott Children's Hospital and the Susan B. Meister Child Health Evaluation and Research Center.

"While we found that publicly insured children were a little more likely to receive low-value services, the difference was not large. The more important finding is that children are highly likely to receive wasteful care regardless of what type of insurance they have. This means that efforts to reduce waste should be global in nature and target the care of all children."

Researchers estimated the prevalence of 20 low-value diagnostic tests, imaging tests, and prescription drugs, such as unnecessary vitamin D screening, imaging for acute sinus infections, and antibiotic prescriptions for colds.

Among publicly and privately insured children in the sample, respectively, 11% and 9% received unnecessary services at least once in 2014 while about 4% and 3% received low-value services at least twice.

About 1 in 33 publicly and privately insured kids received a low-value diagnostic test at least once in 2014. About 1 in 12 publicly insured and 1 in 20 privately insured children received a low-value prescription drug at least once.

"Our study shows that insurance type doesn't strongly predict whether a child is likely to receive wasteful care," says Chua, who's also a researcher at the University of Michigan Institute for Healthcare Policy and Innovation.

Chua points to several factors that may explain why some children still receive low-value services despite evidence that they don't work. High on the list is the difficulty in changing the interventionist culture of medicine.

"Parents understandably want to relieve their children's suffering and to rule out serious problems," Chua says. "Both parents and doctors sometimes have a tendency to believe that prescribing a drug or ordering a test is better than doing nothing, even though the right answer is often to do less.

"The expectation that something be done can be particularly high when parents miss work and children miss school to go to the doctor, or when children previously received an unnecessary intervention for the same condition, like an antibiotic for a cold."

Some interventions also stem from an overabundance of caution.

"Doctors have a strong fear of missing something," Chua says. "Some doctors would rather over-treat and risk the side effects of the intervention than undertreat and risk missing a catastrophic problem."

Unnecessary care has consequences, Chua says. Overuse of antibiotics, for example, can increase antibiotic resistance and the risk of allergic reactions. MRIs sometimes expose children to the risks of sedation while CT scans expose them to radiation, which can increase the lifetime risk of cancer.

All low-value services also come with wasteful healthcare spending, Chua says.

"These interventions waste healthcare dollars that could be devoted to other valuable causes, and also force many families to pay out-of-pocket for unnecessary care," Chua says. "Reducing wasteful care will improve child health and decrease the financial burden of health care spending on society and families."

Ann Arbor, January 7, 2020 - People are looking at e-cigarettes as a "healthy" alternative to cigarettes and we currently have an epidemic of e-cigarettes use. However, according to a new study in the American Journal of Preventive Medicine, published by Elsevier, young adults who smoke cigarettes plus use e-cigarettes are nearly two times more likely to have a stroke compared to current cigarette-only smokers and nearly three times more likely than non-smokers.

"It's long been known that smoking cigarettes is among the most significant risk factors for stroke. Our study shows that young smokers who also use e-cigarettes put themselves at an even greater risk," explained lead investigator Tarang Parekh, MBBS, MSc, Department of Health Administration and Policy, George Mason University, Fairfax, VA, USA. "This is an important message for young smokers who perceive e-cigarettes as less harmful and consider them a safer alternative. We have begun understanding the health impact of e-cigarettes and concomitant cigarette smoking, and it's not good."

E-cigarettes may not be a safe way to stop smoking, the claim made by their purveyors. Researchers are only beginning to understand the health consequences of e-cigarettes, but the case against them is mounting with recent instances of vaping-related lung injury, as well as studies showing their hazards as a gateway (e-cigarettes users are more likely to start smoking within a shorter period of time than non-users), long-term source of high nicotine concentration, and their role in an inflammatory signaling network that underlies cardiovascular disease.

"Our findings demonstrate an additive harmful effect of e-cigarettes on smokers' blood vessels, hearts and brains," explained Mr. Parekh. This study calculated the adjusted odds ratios (AORs) for cerebrovascular events among current smokers (compared to non-smokers) at 1.59, former smokers who have switched to e-cigarettes at 2.54, and those who use both at 2.91. Factors weighed in this ratio included frequency of use; demographic factors; hypertension, diabetes, and cholesterol levels; body mass index; physical activity; and alcohol use.

E-cigarette use by never-smokers is not associated with an increased stroke risk, which is potentially due to relatively young age of sole e-cigarette users with better socioeconomic status, higher insurance enrollment, and normal cardiovascular health that could overall undermine the stroke risk. Therefore, it remains important to analyze long-term effects of e-cigarette smoking on cerebrovascular metabolism before completely dismissing a higher stroke risk. This study also did not find any clear benefit from using e-cigarettes if users are switching from combustible cigarette smoking.

Investigators used data from the 2016-2017 Behavior Risk Factor Surveillance System (BRFSS), a national annual, cross-sectional health survey conducted jointly by the Centers for Disease Control and Prevention and all US states and territories to investigate the prevalence and effect of e-cigarette and combustible cigarette use among young adults. They analyzed responses on cigarette and e-cigarette use from 161,529 participants aged 18-44 years. A slight majority of the sample population was female (53.1 percent), white (50.6 percent), and unmarried (50.3 percent). Nearly half had annual incomes over $50,000 and just under a quarter identified as Hispanic. Compared with non-smokers, e-cigarette users (solo and concomitantly with smoking) reported higher rates of college dropout / terminal high-school, unmarried status, obesity, and binge drinking.

Although e-cigarettes are labeled by some as a "safer option" to active smoking cessation, nicotine dependence and toxicity remain a great concern in low-risk young adults who smoke e-cigarettes for flavors and fun. "Consider this study as a wake-up call for young vapers, clinicians, and healthcare policymakers. There is an urgency to regulate such products to avoid economic and population health consequences and a critical need to conduct further research on the benefits and risks of smoking-cessation alternatives," warned Mr. Parekh.