The use of a consensus-based preoperative risk stratification algorithm has been shown to significantly decrease unnecessary oophorectomies for benign ovarian neoplasms in pediatric patients, according to a study published in JAMA. Surgeon holding scalpel near ovary | Image Credit: shidlovski – stock.adobe.com The preoperative risk assessment algorithm can identify ovarian lesions with a strong likelihood of being non-cancerous and suitable for ovary-preserving surgery. According to the study authors, the adoption of such an algorithm has the potential to mitigate the risk of unnecessary oophorectomy—the surgical removal of one or both ovaries, also referred to as ovariectomy—during adolescence and subsequent lifelong consequences of the procedure. Additional research is required to investigate the obstacles that may hinder compliance with this algorithm. The study was conducted across 11 children’s hospitals in the United States, including 519 patients aged between 6 and 21 years with a median (IQR) age of 15.1 (13-16.8) years. The intervention consisted of 3 phases: 6 months of preintervention assessment, followed by 6 months of intervention adoption, and 18 months of active intervention. There were 96 children included in the preintervention phase, 105 in the adoption phase, and 318 in the intervention phase. The intervention adoption group was excluded from statistical comparisons. Nearly all children had a benign neoplasm, present in 93 (96.9%) children in the preintervention cohort and 298 (93.7%) in the intervention cohort. The study demonstrated a substantial decrease in unnecessary oophorectomies during the intervention phase, with a notable absolute reduction of 7.7% (95% CI, 0.4%-15.9%; P = .03). While 15 of the 93 (16.1%) children with a benign neoplasm in the preintervention group received an unnecessary oophorectomy, only 25 of 298 (8.4%) children underwent the surgery during the intervention period. The algorithm’s test performance in identifying benign lesions showed a sensitivity of 91.6% (95% CI, 88.5%-94.8%) and a specificity of 90.0% (95% CI, 76.9%-100%), underlining its accuracy in distinguishing between benign and malignant cases. The researchers also noted a positive predictive value of 99.3% (95% CI, 98.3%-100%) and a negative predictive value of 41.9% (95% CI, 27.1%-56.6%). During the intervention phase, there was a misclassification rate of 0.7%, referring to instances where malignant disease was mistakenly treated with ovary-sparing surgery. The algorithm demonstrated a strong adherence rate of 95.0% during this phase, indicating surgeons’ willingness to adhere to the algorithm, though the lower fidelity level of 81.8% suggests there were obstacles hindering complete implementation. “Adherent cases with incomplete fidelity with the algorithm were often due to a discrepancy between the initial and final interpretations of imaging,” the authors noted. “Additionally, many patients had an incomplete panel of tumor marker data available, which may have resulted from clinicians not having certain tumor markers evaluated based on clinical judgment.” On this note, the authors said further investigation is needed to explore ways to enhance algorithm implementation for the benefit of a larger patient population. For example, a notable finding was that among the 25 unnecessary oophorectomies during the intervention phase, 9 occurred in patients with suspected torsion. According to the authors, this implies that improved adherence to the algorithm’s directives for detorsion and the thorough completion of preoperative risk stratification, followed by a definitive procedure, could potentially further decrease the incidence of unnecessary oophorectomies. A short list of limitations was included in the study. First, the clinical practices at the participating sites started evolving during the study’s planning phase, which led to a reduction in the anticipated percentage of unnecessary oophorectomies from an expected 27% to 16% in the preintervention cohort. Second, this study was conducted exclusively at tertiary children’s hospitals with pediatric surgical subspecialists, which may limit the broader generalizability of the results. Reference Minneci PC, Bergus KC, Lutz C, et al. Reducing unnecessary oophorectomies for benign ovarian neoplasms in pediatric patients. JAMA. 2023;330(13):1247-1254. doi:10.1001/jama.2023.17183
Month: October 2023
1:14 Obesity and cardiovascular risk 3:28 Topline findings for semaglutide in the SELECT trial 7:15 CV risk reduction with semaglutide 8:54 Perspectives on cost-benefit for GLP-1 in obesity 14:14 Outcomes from STEP HFpEF trial 16:44 Considerations for using GLP-1 agonists 20:54 Need to address inequity in access to obesity medications 26:44 Investigational therapies for obesity with potential for CV benefits 30:00 Combination therapy for obesity and CV risk
Regular adherence to antimalarial medication among individuals with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) has been shown to significantly lower cardiovascular risk over time, according to study results published in Arthritis Care & Research. Chronic inflammatory autoimmune diseases such as RA and SLE are associated with an increased risk for inflammatory complications, notably, cardiovascular disease. Long term maintenance of these conditions consists mainly of treatment with antimalarial medications. The added lipid lowering, anti-inflammatory, and hypoglycemic effects of these drugs can further attenuate cardiovascular risk. To quantify this benefit, researchers investigated cardiovascular outcomes among patients with RA and SLE in relation to antimalarial adherence. A retrospective, longitudinal cohort study was conducted in British Columbia, Canada. Adult patients aged at least 18 years with newly diagnosed RA or SLE who were prescribed antimalarial medications at least once without experiencing a cardiovascular event were included in the analysis. Population Data BC (PopData), an electronic medical tracking record for all residents, was used to collect patient data on outpatient visits, hospitalizations, demographic information, and comprehensive information on prescription medications. Individuals were tracked for medical adherence based on the first day receiving an antimalarial drug and at 90-day interval windows thereafter. Adherence was calculated as a proportion of time when medication was taken as prescribed. The protective effect of antimalarial was found to be lost when adhering to less than 90% of the prescribed doses, and a greater degree of protection was observed in older patients. The composite primary study outcome was incident cardiovascular events, including myocardial infarction (MI), ischemic stroke, and venous thromboembolism (VTE). A total of 16,538 individuals treated with antimalarials, of whom 14,644 (88.5%) were diagnosed with RA and 1894 (11.5%) with SLE, were included in the study. The median number of 90-day follow-up windows for all patients was 33 (mean, 35). A cumulative 22% antimalarial adherence rate was noted for all 90-day windows of exposure among patients with RA and SLE, with 59% categorized as discontinuation, and 19% as nonadherence. Over the mean follow-up time of 9 years, 2174 (13.2%) patients experienced an incident cardiovascular event. A majority of those events were associated with antimalarial discontinuation (n=1394). The adjusted hazard ratio (aHR) for incident cardiovascular events for antimalarial adherence relative to discontinuation was 0.72 (95% CI, 0.64-0.81), and 1.01 (95% CI, 0.90-1.14) for nonadherence relative to discontinuation. Estimates were not statistically different between the antimalarial discontinuation and nonadherence groups. Patients with RA and SLE who did adhere to antimalarial therapy were found to have a 29% lower risk for incident cardiovascular events, compared against those who did not adhere to treatment (aHR, 0.71; 95% CI, 0.61-0.82). When stratified according to specific cardiovascular event, antimalarial adherence was found to have a comparable risk reduction, with a 38% lower risk for MI (aHR, 0.62; 95% CI, 0.51-0.75), a 55% lower risk for stroke (aHR, 0.45; 95% CI, 0.36-0.58), and a 35% lower risk for VTE (aHR, 0.65; 95% CI, 0.46-0.93), when compared with nonadherence. A secondary analysis using an 80% cut-off for antimalarial adherence was shown to have similar findings; the aHRs for incident cardiovascular events for antimalarial adherence compared with nonadherence was 0.74 (95% CI, 0.66-0.82) and 1.09 (95% CI, 0.96-1.24), respectively. Of note, stratified analyses by disease type and sex did not show any effect modification, except for age group. The relative risk reduction of incident cardiovascular events among patients aged at least 65 years was significantly greater compared with those aged less than 65 years, when comparing antimalarial adherence with nonadherence (risk reduction, 41% vs 17%; P =.02). This study was limited by a lack of data on reasons for antimalarial nonadherence and discontinuation, as well as unmeasured lifestyle factors contributing to adherence. Additional risk factors for cardiovascular events, such as disease activity, body mass index, smoking, and alcohol consumption were unavailable in the data. The study authors concluded, “The protective effect of antimalarial was found to be lost when adhering to less than 90% of the prescribed doses, and a greater degree of protection was observed in older patients. Therefore, enhancing medication adherence should be incorporated into appropriate screening strategies targeting high-risk populations (e.g., assessment for antiphospholipid antibodies in SLE) and encouraging compliance from patients to nonpharmacologic measures.” References: Hoque, MR, Avina-Zubeita JA, Lacaille D. Antimalarial adherence and risk of cardiovascular events in rheumatoid arthritis and systemic lupus erythematosus patients: a population-based study. Arthritis Care Res (Hoboken). Published online September 10, 2023. doi:10.1002/acr.25233.
BOISE, Idaho — 6.8 million people in America donate blood. However, one man has taken a different approach to donating. It’s six in the morning. Most are just waking up or are already getting ready for their day, but Pennsylvania man Vinton Smith is getting ready to donate blood. “When I think about donating blood, I think about the people who will be benefiting from receiving that blood. that motivates me more than anything else,” explained Smith. Smith has taken it upon himself to donate blood in all 50 states. This week’s trip to Idaho marked his 47th state. Smith said the remaining three on his checklist are Nevada, Alaska, and Hawaii. Idaho News 6 spoke with the American Red Cross Idaho District Manager for Donor Services, Stephen Dalmas about his thoughts on Smith’s journey. Dalmas said, “It’s the dedication. It’s the personal mission he has to help other people.” That is what is amazing,” said Dalmas. For the last 35 years, Smith has been donating blood. His first time was his senior year of high school. Smith says that his passion for giving back starts with his parents. Smith explained, “I grew up watching my dad donate blood every two months. I also saw my mother working in the community helping others. I think that idea of helping others was instilled in me as a young boy.” Both men explained that having the ability to donate in today’s world is so important. Smith said, “We may not know what tomorrow may bring. We may not know when we may be the ones who may need to receive blood or platelets. We don’t know when a family member is the one that needs it.” “It is just doing good for someone you might never meet,” said Dalmas Speaking with Dalmas, he said that there is a national blood and platelet shortage here in America and that it is more important than ever to go and donate. You can go to redcrossblood.org to find a blood donation center in your community.
WASHINGTON—Pushing back a black hood to reveal reddened, glowing eyes, Sen. Ron Darkness appeared on CNN Friday to try to garner support for a 1,000-year reign of blood. “In times of great tragedy, we as Americans must do all we can to enact many millennia of death and suffering,” the independent lawmaker from Hades said in an address delivered through all languages at once, reading off a teleprompter operated by Samael, Ruler of Hell, who reportedly left the studio floor peppered with unconscious and bleeding CNN crew members. “The harrowing images and rising death tolls coming out of the Middle East are, frankly, child’s play. Viscera must flow down every street. The oceans must blacken with blood and terror. We must crucify ourselves at the altar of death. That is why I am announcing my run for president.” Sen. Darkness went on to plead for all belligerents in the world’s conflicts to not relent until a 100% global casualty rate had been reached. This Week’s Most Viral News: October 13, 2023 Off English
Mumbai’s ‘October Heat’ Triggers Spike in Infections and Hospitalisations; Hot Weekend Incoming!
Traffic police personnel takes a water break on a hot day at CSMT, Mumbai. (SL Shanth Kumar/BCCL Mumbai) Friday, October 13: In Mumbai, October ushers in a peculiar weather shift, marking the transition from monsoon to winter. While Mumbaikars are no strangers to this ‘second summer’, the onset of what locals call ‘October heat’ has been particularly intense this year. After the southwest monsoon graciously bowed out of the city on October 6, a swift return of hot and dry weather has Mumbaikars sweltering, coughing and more. Throughout this week, the mercury levels have been consistently high, with maximum temperatures dancing between 34-36°C. This surge in heat is more than 2°C above Mumbai’s typical average of 32.7°C for this time of the year. The culprit behind this warmth is the arrival of easterly winds, ushering in dry air that’s keeping the heat locked in. According to the India Meteorological Department (IMD), daytime highs of 34-36°C are predicted to persist throughout the weekend. Any respite is unlikely until the start of next week, when the maximum temperatures may finally stabilise around 33°C, per the IMD’s early projections. While the city bakes in this heat, the air quality has remained relatively steady, clocking in at a ‘moderate’ 111 on the air quality index (AQI) today. No major fluctuations in the AQI are expected for the next three days, providing a silver lining amidst the rising temperatures. Advertisement Unfortunately, the sweltering conditions have triggered a spike in cases of viral fever, dehydration, giddiness and heat stroke across the city. Civic, state and private hospitals have all reported an upswing in the number of people seeking treatment over the past week. Extreme heat can create ideal conditions for viruses to thrive, while simultaneously weakening the body’s immune response. This makes people more susceptible to fevers, colds and other viral infections. As Mumbai navigates these uncomfortable weather patterns, the old adage ‘prevention is better than cure’ certainly holds true. Therefore, avoid direct sunlight and limit outdoor activities during the noon and afternoon hours unless absolutely necessary. For those unavoidable outings, don’t forget your sunscreen, protective headgear and umbrellas. Keeping wet wipes on hand can offer a refreshing break from the heat. Hydration is key, so along with water, consider sipping on fruit juices, coconut water and buttermilk, as they offer a rich supply of essential vitamins and minerals. ** For weather and science updates on the go, download The Weather Channel App (on Android and iOS store). It’s free!
The following is a summary of “Plasma Serotonin and Cardiovascular Outcomes in Chronic Kidney Disease,” published in the August 2023 issue of Cardiology by Edmonston et al. Researchers performed a prospective study to determine the relationship between platelet-poor plasma serotonin levels and cardiovascular outcomes in patients with chronic kidney disease. They assessed the association between plasma serotonin levels (categorized as undetectable, intermediate, and high ≥20 ng/mL) and echocardiographic findings, cardiovascular outcomes including heart failure hospitalization, atherosclerotic cardiovascular disease events (ASCVD), and mortality in 1,114 participants from the prospective CRIC (Chronic Renal Insufficiency Cohort) Study. The impact of selective serotonin reuptake inhibitors on the serotonin-outcome relationship was also assessed. The results showed plasma serotonin levels exhibited an inverse relationship with estimated glomerular filtration rate while directly correlating with blood pressure. Elevated plasma serotonin levels corresponded with left ventricular hypertrophy (adjusted odds ratio: 2.74 [95% CI: 1.11–7.41]). Conversely, having undetectable plasma serotonin levels correlated with the highest risk of heart failure (adjusted hazard ratio [HR]: 2.26 [95% CI: 1.40–3.66]) and ASCVD events (adjusted HR: 1.96 [95% CI: 1.15–3.32]). Investigators concluded low and high plasma serotonin levels were associated with ASCVD risk in people with chronic kidney disease. Source: ahajournals.org/doi/full/10.1161/JAHA.123.029785
It’s finally happened. Despite your speed, agility, cunning and many feats of strength, you’ve come down with a dreaded case of cooties. You probably have lots of questions. Do I have to go to the hospital to get my cootie shot? Does insurance cover circle circle, dot dots? What if my doctor has cooties, too?! Advertising Policy Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services. Policy Before you get too worried, it’s important we let you know: Cooties aren’t real. At least, not as we understand them today. So, why are we bothering to talk about cooties if they aren’t real? Simply put, it doesn’t matter that cooties are a figment of our collective imagination because they have a symbolic meaning in many cultures. This fictional disease is powerful because it can offer a chance to teach children how to behave in the face of real disease. We asked pediatric infectious disease specialist Frank Esper, MD, to help us dissect this imaginary communicable disease. Read on to learn why it exists and what it tells us about the ways societies respond to public health crises. The history of cooties That’s right: Cooties are fake, but they have a real — and important — history. It starts in the Pacific. Many different Austronesian languages use words that sound vaguely like “cootie” to describe parasitic insects. The word took on a life of its own when cultures came together. Origins of the word ‘cooties’ Unfortunately, there are few things that bring different cultures into contact like war. That’s exactly what happened with cooties. As you may have learned in history class, World War I soldiers did most of their fighting from trenches. Those muddy pits were hot beds for all sorts of creepy crawlies, many of which carried infectious diseases like typhus, malaria and yellow fever. In fact, more people died from disease and famine during World War I than died in battle. Soldiers used the word “cooties” to describe both the parasitic bugs that lived in the trenches with them and the illnesses the bugs gave them. In fact, they had another name for cooties: arithmetic bugs. Why? Because when the so-called cooties got on the soldiers, “They added to our troubles, subtracted from our pleasures, divided our attention, and multiplied like hell.” While we know people were speaking about cooties in the early 20th century, the term was popularized later, by American soldiers returning home from the South Pacific theaters of World War II. Their children heard it and starting using the term as a form of social rejection. In particular, you’d use cooties as a way to mock members of the opposite sex as “icky” or “dirty.” If little boys and girls get too close to each other, one is sure to give the other their cooties. Cooties spread throughout U.S. culture in part because — as serious as epidemic disease and social rejection may be — cooties also became the subject of many games, specifically, board games. The board game You might be surprised to know that there’s actually a board game version of the cooties game. In fact, there have been several. In every single version of the board game, there’s no ambivalence: Cooties are parasitic bugs. It’s that simple. But only some children encounter cooties on a tabletop. Most of us are first exposed to the concept of cooties in backyards and on playgrounds, where there’s a lot more room for interpretation … and invention. The playground version While its popularity waxes and wanes in response to current events, children in many different communities around the world have been playing free-form cooties games for generations now. In most versions of the game, one or more “infected” children chase the cootie-free children, spreading the fictional disease through some form of physical contact. Some children play the game zombie-style: The cootie-havers’ ranks grow and grow, making it increasingly difficult for the uninfected to win. Other children treat it more like a game of tag: Once the cootie-haver transfers the infection to another child, they’re cured. Real-world cooties Cooties may not be real, but are there any infections that you could call “cootie-esque”? Dr. Esper thinks so. “I’ve always felt scabies is most akin to cooties,” he muses. Scabies, also known as sarcoptic mange, is a common parasitic condition caused by mites burrowing under the skin and laying eggs there. Lice are similarly strong candidates. In fact, some scholars believe the word “cootie” originates from the Malay and Māori word for louse: “kutu.” There’s nothing “sexy” about parasites and parasitic bugs — and they don’t get nearly the same attention that viral and bacterial infections do — but they should. “There are many, many different parasites,” Dr. Esper says. “They fall under the umbrella of ‘infectious disease’ because an infectious disease is basically any organism that tries to take advantage of you, harming you in the process. “Parasites are fairly uncommon in the United States,” he continues, “but they are extremely common globally. In fact, parasitic infections are some of the most common infections worldwide.” He notes that you’ll find more parasites anywhere that doesn’t have substantial water sanitation or insect control. “Malaria is one of the most common parasitic infections worldwide that is transmitted by mosquitoes,” says Dr. Esper. “We eliminated malaria in the U.S. through a large-scale public health campaign in the 1950s,” he adds, “But after seven decades, we’re beginning to see local transmission again.” The lessons cooties teach us If you’ve ever watched a nature documentary before, you’ve probably heard that play is incredibly important. It’s almost like rehearsing for real life. A tiger cub, for example, learns how to hunt by stalking and “attacking” its siblings. Games are just as important for human children (and let’s be honest, for adults, too). Playing helps us confront things that would otherwise scare us in a safe environment. Is
Oct. 13, 2023 6:00 am ET Listen (2 min) More period-care brands are slowly replacing the blue liquid that has long been ubiquitous in the category’s advertising with more realistic red alternatives, despite pushback from some consumers and media companies. Copyright ©2023 Dow Jones & Company, Inc. All Rights Reserved. 87990cbe856818d5eddac44c7b1cdeb8
If you have ever gotten a vaccine or received an intravenous drug and did not come down with a potentially life-threatening fever, you can thank a horseshoe crab (Limulus polyphemus). How can animals that are often called living fossils, because they have barely changed over millions of years, be so important in modern medicine? Horseshoe crab blood is used to produce a substance called limulus amebocyte lysate, or LAL, which scientists use to test for toxic substances called endotoxins in intravenous drugs. These toxins, produced by bacteria, are ubiquitous in the environment and can’t be removed simply through sterilization. They can cause a reaction historically referred to as “injection fever.” A strong concentration can lead to shock and even death. Identifying LAL as a highly sensitive detector of endotoxins was a 20th-century medical safety breakthrough. Now, however, critics are raising questions about environmental impacts and the process for reviewing and approving synthetic alternatives to horseshoe crab blood. We study science, technology and public policy, and recently published a white paper examining social, political and economic issues associated with using horseshoe crabs to produce LAL. We see this issue as a test case for complicated problems that cut across multiple agencies and require attention to both nature and human health. An ocean solution Doctors began injecting patients with various solutions in the mid-1800s, but it was not until the 1920s that biochemist Florence Seibert discovered that febrile reactions were due to contaminated water in these solutions. She created a method for detecting and removing the substances that caused this reaction, and it became the medical standard in the 1940s. Known as the rabbit pyrogen test, it required scientists to inject intravenous drugs into rabbits, then monitor the animals. A feverish rabbit meant that a batch of drugs was contaminated. The LAL method was discovered by accident. Working with horseshoe crabs at the Marine Biological Laboratory at Woods Hole, Massachusetts, in the 1950s and ’60s, pathobiologist Frederik Bang and medical researcher Jack Levin noticed that the animals’ blue blood coagulated in a curious manner. Through a series of experiments, they isolated endotoxin as the coagulant and devised a method for extracting LAL from the blood. This compound would gel or clot nearly instantaneously in the presence of fever-inducing toxins. Academic researchers, biomedical companies and the U.S. Food and Drug Administration refined LAL production and measured it against the rabbit test. By the 1990s, LAL was the FDA-approved method for testing medicines for endotoxin, largely replacing rabbits. Producing LAL requires harvesting horseshoe crabs from oceans and beaches, draining up to 30% of their blood in a laboratory and returning the live crabs to the ocean. There’s dispute about how many crabs die in the process – estimates range from a few percent to 30% or more – and about possible harmful effects on survivors. Today there are five FDA-licensed LAL producers along the U.S. East Coast. The amount of LAL they produce, and its sales value, are proprietary. Bait versus biotech As biomedical LAL production ramped up in the 1990s, so did harvesting horseshoe crabs to use as bait for other species, particularly eel and whelk for foreign seafood markets. Over the past 25 years, hundreds of thousands – and in the early years, millions – of horseshoe crabs have been harvested each year for these purposes. Combined, the two fisheries kill over half a million horseshoe crabs every year. There’s no agreed total population estimate for Limulus, but the most recent federal assessment of horseshoe crab fisheries found the population was neither strongly growing nor declining. Conservationists are worried, and not just about the crabs. Millions of shorebirds migrate along the Atlantic coast, and many stop in spring, when horseshoe crabs spawn on mid-Atlantic beaches, to feed on the crabs’ eggs. Particularly for red knots – a species that can migrate up to 9,000 miles between the tip of South America and the Canadian Arctic – gorging on horseshoe crab eggs provides a critical energy-rich boost on their grueling journey. Red knots were listed as threatened under the Endangered Species Act in 2015, largely because horseshoe crab fishing threatened this key food source. As biomedical crab harvests came to equal or surpass bait harvests, conservation groups began calling on the LAL industry to find new sources. Biomedical alternatives Many important medicines are derived from living organisms. Penicillin, the first important antibiotic, was originally produced from molds. Other medicines currently in use come from sources including cows, pigs, chickens and fish. The ocean is a promising source for such products. When possible, synthesizing these substances in laboratories – especially widely used medications like insulin – offers many benefits. It’s typically cheaper and more efficient, and it avoids putting species at risk, as well as addressing concerns some patients have about using animal-derived medical products. In the 1990s, researchers at the National University of Singapore invented and patented the first process for creating a synthetic, endotoxin-detecting compound using horseshoe crab DNA and recombinant DNA technology. The result, dubbed recombinant Factor C (rFC), mimicked the first step in the three-part cascade reaction that occurs when LAL is exposed to endotoxin. Later, several biomedical firms produced their own versions of rFC and compounds called recombinant cascade reagents (rCRs), which reproduce the entire LAL reaction without using horseshoe crab blood. Yet, today, LAL remains the dominant technology for detecting endotoxins in medicine. The main reason is that the U.S. Pharmacopeia, a quasi-regulatory organization that sets safety standards for medical products, considers rFC and rCR as “alternative” methods for detecting endotoxins, so they require case-by-case validation for use – a potentially lengthy and expensive process. The FDA generally defers to the U.S. Pharmacopeia. A few large pharmaceutical companies with deep pockets have committed to switching from LAL to rFC. But most drug producers are sticking with the tried-and-true method. Conservation groups want the U.S. Pharmacopeia to fully certify rFC for use in industry with no extra testing or validation. In their view, LAL producers are stalling rFC