Month: September 2021

High Altitude Protects against Stroke Risk

Photo by Yura Lytkin on Unsplash

While there are well-known common lifestyle and health factors that contribute to stroke risk, including smoking, high blood pressure, high cholesterol, and lack of physical activity, there is another overlooked factor that could also affect stroke risk – altitude.

Higher altitude means less oxygen availability, to which people living there have adapted. However, how this environment affects someone’s risk for stroke is still unclear. Anecdotal evidence suggests that short-term exposure to low oxygen can contribute to increased blood clotting and stroke risk, but the risk among people who permanently live at high altitude is not clear.

Researchers in Ecuador are in a unique position to explore these phenomena, as the presence of the Ecuadorian Andes means that people in the country live at a wide array of altitudes. Study lead author Esteban Ortiz-Prado, and Professor, Universidad de las Americas, explained:

“The main motivation of our work was to raise awareness of a problem that is very little explored. That is, more than 160 million people live above 2500 metres and there is very little information regarding epidemiological differences in terms of stroke at altitude. We wanted to contribute to new knowledge in this population that is often considered to be the same as the population living at sea level, and from a physiological point of view we are very different.”

The researchers drew on hospital records in Ecuador from between 2001 and 2017, and analysed rates of stroke hospitalisation and mortality among people who live at four different elevation ranges: low altitude (under 1500m), moderate altitude (1500­–2500m), high altitude (2500–3500m) and very high altitude (3500–5500m).

Analysis showed that people who lived at higher altitudes (above 2500m) tended to experience stroke at a later age compared with those at lower altitudes. Intriguingly, people who lived at higher altitudes had a lower stroke hospitalisation or mortality risk. This protective effect was greater between 2000 and 3500m, tapering off somewhat above 3500m. In South Africa, Johannesburg sits above 1700m altitude.

One explanation for this finding may be that people who live at high altitude have adapted to the low oxygen conditions, and more readily grow new blood vessels to help overcome stroke-related damage. They may also have a more developed vascular network in their brains that helps them to make the most of the oxygen they take in, but this could also protect them from the worst effects of stroke.

Source: Medical Xpress

Gender Behavioural Differences Strengthened in Lockdown

Photo by Tim Mossholder on Unsplash

‘Stereotypical’ gender behaviour differences were exaggerated during the COVID lockdown in Austria, according to a recent study published in Scientific Reports

Men and women conducted themselves differently in the wake of the COVD lockdown in Austria, with women spending more time on the phone while men returned to crowded and public areas more quickly.

Using mobile phone data from 1.2 million devices in Austria (representing 15% of the population) across the first phase of the COVID pandemic, researchers quantified gender-specific patterns of communication intensity, mobility, and circadian rhythms. They noted the resilience of behavioural patterns with respect to the shock imposed by a strict nation-wide lock-down that Austria experienced in the beginning of the crisis with severe implications on public and private life. They found significant differences in gender-specific responses during the different phases of the pandemic. They found that following lockdown, gender differences in mobility and communication patterns increased massively, while circadian rhythms tended to synchronise.

In particular, women had fewer but longer phone calls than men during the lock-down. Phone calls involving women lasted significantly longer on average, with big differences depending on who was calling whom. After the first lockdown in Austria was imposed on March 16, calls between women were up to 1.5 times longer than before the crisis (140% increase), while calls from men to women lasted nearly twice as long. Conversely, when women called men, they talked 80 percent longer, while the duration of calls between men rose only by 66 percent.

“Of course, we don’t know the content or purpose of these calls,” says Georg Heiler, a researcher at CSH and TU Wien, who was responsible for data processing. “Yet, literature from the social sciences provides evidence — mostly from small surveys, polls, or interviews — that women tend to choose more active strategies to cope with stress, such as talking with others. Our study would confirm that.”

Mobility declined massively for both genders, however, women tended to restrict their movement stronger than men. Women also showed a stronger tendency to avoid shopping centres and more men frequented recreational areas. 

After the lockdown, males returned back to normal quicker than females; and young and adolescent age-cohorts returned much quicker. An age stratification highlights the role of retirement on behavioural differences. They found that the length of a day for men and women is reduced by one hour. 

Source: Complexity Science Hub Vienna

Is There a Wave of Teenage Lockdown Pregnancies in SA?

Image by Quicknews

An article in The Outlier examines whether the spike in teenage pregnancies in Gauteng could signal a tsunami of teenage pregnancies caused by the lockdown and increased sexual assaults.

In August the Gauteng MEC for health, Nomathemba Mokgethi, revealed that 23 226 teenage girls had fallen pregnant in the province between April 2020 and March 2021. This came in a written response to questions from the DA tabled in the Gauteng legislature. Alarmingly, 934 of them were between the ages of 10 and 14, where the age of consent is 16.

There were 20 250 babies born to teenage mothers aged 10 to 19, according to the Gauteng MEC in a response to a question in the Gauteng Legislature; 2976 pregnancies were terminated. From the start of the year to August, 118 babies were abandoned in public hospitals, some of them likely by teenage mothers.

A preliminary understanding of the impact of the pandemic on teen pregnancies can be seen through data from the annual District Health Barometer (DHB) report, which shows the number of deliveries recorded in public health facilities.

An increase in teenage births of 28% when comparing births to teenage mothers in Gauteng reported in the DBH for 2019/2020 with the Gauteng health department’s number, 
The Gauteng health department also provided a monthly breakdown of the teenage deliveries from April 2020 to March 2021. The months with the highest number of deliveries were May, June, July and August: most of these teenage mothers would have fallen pregnant before COVID hit South Africa.

In the early stages of the COVID pandemic, schools were closed on 18 March 2020, with the hard lockdown starting on 26 March, meaning that pregnancies from that time would be delivered around December 2020, which would likely not be reflected in the DBH for 2019/2020.

Catherine Mathews, director in the Health Systems Research Unit of the South African Medical Research Council (SAMRC) said it would take time to assess the full impact school closures had on teen pregnancies.  

“We do know that schools can be an important, safe, protective environment for girls, and when schools close, children are often left unsupervised and can be more at risk of sexual violence.”

Contraception has not been readily available to girls and women, with the District Health Barometer 2019/20 noting persistent stock-outs of contraception have been reported since 2018.

The SAMRC surveyed adolescent girls, aged 15 to 24, between 1 December 2020 and 28 February 2021, to find out how they were affected by the pandemic. The Outlier looked at the results for the 15 to 19 age group. Out of the 264 participants in this age group, 23.5% stated that they were unable to obtain contraceptives, while 18.8% reported challenges in accessing condoms due to the pandemic.

But, to connect the increase in teen pregnancies to the inaccessibility of condoms and contraception alone would be to assume that the 23 226 pregnancies were a product of consensual sex, when that may not always have been the case.

Mathews said: “Violence against women and girls in the country is so pervasive in South Africa and we can’t ignore its impact on teenage pregnancy.”

The MEC Mokgethi said, “Cases of statutory rape are reported by healthcare social workers at hospitals and clinics to the Department of Social Development and SAPS,” adding that no cases of statutory rape were collected by the health department.

Data for 2020/21 for the other eight provinces are not available, so it hasn’t been possible to see if this trend is reflected there,
However, the province with the highest percentage of teenagers of mothers giving birth is the Northern Cape at 18% in 2019/20. The Eastern Cape and KwaZulu-Natal follow with 16.7% and 16.4% respectively. Gauteng’s teenage birth rate was 7.5%, the lowest of the provinces.

According to World Bank data on births among women aged 15 to 19 years, South Africa’s 68 births per 1000 women was lower than other Sub-Saharan African countries, it remains higher than the world average of 42 births per 1000 women in that age group.

Source: The Outlier

No Dementia Risk with Hormone Replacement Therapy

Photo by Loren Joseph on Unsplash

A large UK study found that use of menopausal hormone therapy (MHT, also known as hormone replacement therapy, HRT) is not associated with increased dementia risk.

The study, published in the BMJ, found within the subgroup of women with a specific diagnosis for Alzheimer’s disease, a slight increasing risk association was found with use of oestrogen-progestogen treatments, but only seen for long-term usage (5 years or more).

This study “brings clarity to previously inconsistent findings and should reassure women in need of menopausal hormonal therapy,” said the researchers.

MHT relieves menopausal symptoms such as hot flushes, sleep disturbance, mood swings, memory losses and depression. Treatment includes oral tablets with oestrogen only, or oestrogen and progestogen combined, as well as patches, gels and creams.

Early signs of dementia are similar to some menopausal symptoms. Research has shown a beneficial link between oestrogen and age-related brain decline. However, in the largest trial of MHT, the Women’s Health Initiative Memory Study, an increased dementia risk was found among users of oestrogen-progestogen treatments. A recent study picked up a possible link to Alzheimer’s disease among users of both oestrogen-only and oestrogen-progestogen treatments, though the study has some issues.

To address this uncertainty, researchers set out to investigate the risks of developing dementia for women using commonly available menopausal hormone therapy treatments.

They used two UK primary care databases to analyse MHT prescriptions for the 118 501 women aged 55 and older diagnosed with dementia between 1998 and 2020 (cases), and 497 416 matched women without dementia (controls).

After adjusting for confounding factors, no overall associations were found between use of hormone therapy and risk of dementia, regardless of hormone type, application, dose, or duration of treatment. Only a slightly decreased risk of dementia was found in one subgroup: those under 80 years who had been taking oestrogen-only therapy for 10 years or more.
Analysis of cases with a specific diagnosis of Alzheimer’s disease showed a slight increase in risk associated with oestrogen-progestogen therapy. This rose gradually with each year of exposure, reaching an average 11% increased risk for use of between 5 and 9 years and an average 19% for use of 10 years or more, equivalent to, respectively, five and seven extra cases per 10 000 woman years.

As this is an observational study it cannot establish cause, and some limitations include incomplete recording of menopausal symptoms, particularly for women registered after their menopause. However, its large size counts in its favour.
According to the researchers, this study provides the most detailed estimates of risk for individual treatments, and their results are in line with existing concerns in guidelines about long term exposures to combined hormone therapy treatments.

“The findings will be helpful to policy makers, doctors, and patients when making choices about hormone therapy,” they concluded.

The findings do not change the recommendation that menopausal hormone therapy should not be used to prevent dementia, US researchers commented in a linked opinion article. However, it is helpful for providers to put dementia findings in context for patients, they added.

“The primary indication for hormone therapy continues to be the treatment of vasomotor symptoms, and the current study should provide reassurance for women and their providers when treatment is prescribed for that reason,” they concluded.

Source: News-Medical.Net

Basic Toothbrush Still Tops for Gingivitis Prevention

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In a review of evidence for dental hygiene techniques, only a few were able to provide additional protection against gingivitis and periodontitis beyond brushing one’s teeth with a basic toothbrush.

The paper was published in the Journal of the International Academy of Periodontology and examines the effectiveness of various oral hygiene devices.

At the moment, all other oral hygiene interventions are only supported by insufficient evidence, said principal investigator Frank Scannapieco, DMD, PhD, professor of oral biology in the UB School of Dental Medicine. The findings, he said, will help identify best practices for preventing gum disease.

“Patients can be confident that the oral care tools and practices supported by research, as described in the paper, will prevent the initiation and progression of periodontal disease, if they are performed regularly and properly,” said Prof Scannapieco.

The list of proven techniques includes: basic toothbrush; interdental brush; water pick; chlorhexidine gluconate (CHX), cetylpyridinium chloride (CPC) and essential oil (Listerine) mouth rinses.
Tooth brushing is the cornerstone of daily oral hygiene and is a reliable way to control dental plaque, said Scannapieco. Interdental brushes and water picks also performed better than other interdental oral hygiene devices at reducing gingivitis, and both should be used in combination with daily tooth brushing to prevent gum disease.

Mouth rinses based on CHX, CPC, and essential oils (such as Listerine) were proven to be effective at significantly reducing plaque and gingivitis.

While not effective at fighting gingivitis, toothpicks were useful for monitoring gum health, said Prof Scannapieco. By gently prodding the gums with a toothpick and monitoring for bleeding, patients could detect signs of gum disease.

While triclosan toothpastes and mouth rinses significantly reduced plaque and gingivitis, the compound is linked to cancer development and reproductive defects, and has been removed from most toothpastes in the US.
Unfortunately for those who invested in one, electric-powered toothbrushes are no more effective at reducing plaque and gingivitis than a basic toothbrush,  the researchers found. And little evidence has been published in support of dental floss – the mainstay of interdental cleaning – to reduce plaque and gingivitis. However, Prof Scannapieco said that flossing is still necessary:
“While there are few studies available that specifically examined toothbrushes or floss alone, both are still essential. Floss is especially useful to remove interdental plaque for people who have tight space between their teeth. Floss also likely reduces the risk for cavities that from between the teeth.”
Evidence was lacking for mouthwashes based on tea tree oil, green tea, anti-inflammatory agents, hydrogen peroxide, sodium benzoate, stannous fluoride, hexetidine or delmopinol reduced gingivitis.

Though promising as a preventive strategy against gum disease, the effectiveness of probiotics was unproven. There was also little evidence for dietary supplements improving gum health. The investigators also found insufficient evidence that professional plaque removal (known as scaling, the process of removing plaque with a scraper) prevents gum disease.

Source: University at Buffalo

New Migraine Prevention Drug Gets The Green Light from FDA

Source: Usman Yousaf on Unsplash

Atogepant (Qulipta) has become the first oral calcitonin gene-related peptide (CGRP) receptor antagonist (gepant) specifically developed for migraine prevention to win FDA approval, manufacturer AbbVie announced on Monday.

Following on after rimegepant, which is also indicated by the FDA for acute migraine treatment, atogepant became the second gepant approved for prevention of episodic migraine in adults.

The atogepant decision “reflects a broader shift in the treatment and management paradigm for the migraine community,” noted Peter Goadsby, MD, PhD, DSc, of the University of California Los Angeles and King’s College London.

“Qulipta provides a simple oral treatment option specifically developed to prevent migraine attacks and target CGRP, which is believed to be crucially involved in migraine in many patients,” said Dr Goadsby in a statement.
Atogepant has a high affinity at the CGRP receptor, and being a small-molecule drug it can be taken orally, unlike injectable anti-CGRP monoclonal antibodies approved for migraine prevention.
An oral CGRP-receptor antagonist is easier for patients, Goadsby noted when he presented data from atogepant’s pivotal phase IIb/III trial at the 2019 American Academy of Neurology annual meeting. “It could facilitate, with time, the greater use of this mechanism in primary care,” he told MedPage Today. “Primary care doctors will more easily use a medicine that’s relatively simple to use and well-tolerated, and that means more migraine patients can get treated.”

In the phase III ADVANCE trial, 873 participants were randomised to receive a once-daily dose of oral atogepant (10mg, 30mg, or 60mg) or placebo. After 12 weeks, average days with migraine per month dropped from baseline by 3.7 days with atogepant 10mg, 3.9 days with atogepant 30mg, 4.2 days with atogepant 60mg, and 2.5 days with placebo. The most common adverse events with atogepant were constipation and nausea, along with fatigue. 
Patients should notify their healthcare provider if they have kidney problems or are on dialysis, have liver problems, are pregnant or plan to become pregnant, or are breastfeeding or plan to breastfeed, AbbVie said.

Source: MedPage Today

New Connection Found Between Diabetes and Alzheimer’s

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Researchers have added to the body of evidence linking Type 2 diabetes to Alzheimer’s disease.

In a study published in Communications Biology, researchers show that chronic hyperglycaemia impairs working memory performance and also alters key aspects of working memory networks. Insulin insensitivity has been linked to memory deficits, cognitive decline, and many of the characteristic symptoms that have been displayed in Alzheimer’s disease. At the same time, Type 2 diabetes has remained one of the most adjustable risk factors for the development of Alzheimer’s disease.

“Diabetes is a major risk factor for developing Alzheimer’s disease, but it is not clear why,” said James Hyman, study author and associate professor of psychology at UNLV. “We show that a central feature of diabetes, hyperglycaemia, impairs neural activity in ways that are similar to what is observed in preclinical Alzheimer’s disease models. This is the first evidence showing neural activity changes due to hyperglycemia overlap with what is observed in Alzheimer’s systems.”

“As the number of Alzheimer’s disease diagnoses rapidly rises and the incidence of diabetes and pre-diabetes has accelerated, it’s crucial that we understand what connects these two disorders,” said coauthor Jefferson Kinney, chair and professor in UNLV’s Department of Brain Health.

The researchers found that two parts of the brain crucial for memory, the hippocampus and the anterior cingulate cortex, were over-connected, or hyper-synchronised. When it came time to recall the information and complete a task, these two parts of the brain – which are affected early in Alzheimer’s progression – were over-communicating with each other, resulting in errors.

“We know synchrony is important for different parts of the brain to work together. But, we’re finding more and more these days, that the key with neural synchrony is it has to happen at the right time, and it has to happen with control,” Prof Hyman said. “Sometimes, there’s just too much ‘talking’ between certain areas and we think this leads to memory difficulties, among other things.”

Prof Hyman likens the situation to a CEO who hands over a majority of the company’s business operations to their son, who then decides to upend previous communication structures and become the sole gatekeeper of information.

“The only communication the CEO has is with one person, as opposed to talking with all of the other people in the office,” Prof Hyman explained. “It is possible that in Alzheimer’s patients there’s over-connection in certain areas where there should be flexibility. And in the models in our study, we’re seeing evidence of that in real-time at these crucial moments to do the task.”

This discovery not only provides new insights into brain activity in the hyperglycaemia model, it also provides an important new measure which can be used in future research.

“Our next step is to combine the biochemical markers and electrophysiology data to test specific mechanisms responsible and potential treatments,” said Prof Kinney. “This research will now be able to work towards understanding the risk as well as what may be able to be done to help.”

Source: University of Nevada, Las Vegas

Impact of Pandemic Delay to Cardiac Procedures

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A Canadian study found that after the onset of the COVID pandemic, there was a significant decline in referrals and procedures for common cardiac interventions. 

Patients awaiting coronary bypass surgery or stenting were at higher risk of dying while waiting for their procedure compared to before the pandemic, despite wait times not being longer. The study was published in the Canadian Journal of Cardiology.

“In the first wave of the COVID pandemic, we kept hearing stories from patients and other doctors that there were delays in care for patients with heart disease,” explained lead investigator Harindra C. Wijeysundera, MD, PhD, University of Toronto. “We decided to look into these claims using the Ontario database that keeps track of wait lists and wait times for individuals with heart disease who require a procedure or surgery.”

The researchers were able to link multiple population-based administrative data sources and clinical registries. The study looked at adult patients who were referred for four commonly performed cardiac procedures: percutaneous coronary intervention; isolated coronary bypass grafting; valve surgery; or transcatheter aortic valve implantation from January 1, 2014 to September 30, 2020, and the start of the pandemic was put at March 31 2020. Outcomes were defined as death while awaiting procedure and hospitalisation while waiting for procedure.

Of 584 341 patients identified, 37 718 were referred during the pandemic. As expected, a decline in referrals was observed at the outset of the pandemic, although those numbers steadily increased throughout the pandemic period, along with an initial decline in the number of procedures performed. Individuals waiting for coronary bypass surgery or stenting were at higher risk of dying while waiting for their procedure compared to before the pandemic. Mortality rates increased even though wait times did not during the pandemic, suggesting patients may have delayed in presenting to their doctors with symptoms.

“We found that the increase in wait list mortality was consistent across patients with stable coronary artery disease, acute coronary syndrome, or emergency referral,” said Dr Wijeysundera. “Coupled with reduced referrals, this raises concerns of a care deficit due to delays in diagnosis and wait list referral.”

A number of potential explanations were suggested by the researchers for the decline in referrals during the pandemic, from patient factors such as fear of contracting COVID in the hospital or concerns about missing work, to system factors including testing delays and pressures on hospital beds and staffing.

Source: EurekAlert!

Amoxicillin Flops in Simple Paediatric Chest Infections

Photo by Andrea Piacquadio from Pexels

The largest randomised placebo-controlled trial of the antibiotic amoxicillin for treating paediatric chest infections has found it is little more effective at relieving symptoms than placebo. 

While viruses are believed to cause many chest infections in children, whether antibiotics are effective in treating chest infections in children is still debated. In adults, research has shown that antibiotics are not effective for uncomplicated chest infections.

In the study, published in The Lancet, researchers sought to test whether amoxicillin reduces the duration of moderately bad symptoms in children presenting with uncomplicated (non-pneumonic) lower respiratory tract chest infections in primary care. The trial recruited 432 children aged six months to 12 years-old with acute uncomplicated chest infections from primary care practices, randomised to receive either amoxicillin or a placebo three times a day for seven days. Doctors or nurse-prescribers assessed symptoms at the start of the study and parents, with help from their children where possible, completed a daily symptom diary.

Only a small, non-significant, difference in symptom duration was seen between the two groups: children given the placebo had symptoms which were rated moderately bad or worse for around 6 days on average after seeing the doctor, and those given antibiotics only recovered 13% faster.

This held true even for groups where chest sounds were present, there was a fever, was rated more unwell by a doctor, coughing up phlegm or had a rattly chest, or the child was short of breath.

Just four children in the placebo group and five in the antibiotic group required further assessment at hospital. Parental costs such as leave taken or over-the-counter remedies, were very similar in both groups.

The study lead author, Professor Paul Little, said: “”Children given amoxycillin for chest infections where the doctor does not think the child has pneumonia do not recover much more quickly.

“Indeed, using amoxicillin to treat chest infections in children not suspected of having pneumonia is not likely to help and could be harmful. Overuse of antibiotics, which is dominated by prescribing of antibiotics in primary care, particularly when they are ineffective, can lead to side effects and the development of antibiotic resistance.”

Study co-author Alastair Hay, a GP and University of Bristol professor, added: “The ARTIC PC trial is one of the very few studies to report on the effectiveness of prescribing antibiotics among younger children presenting with chest infections in primary care. It was designed to be able to detect a clinically important 3-day improvement in symptom duration.

“Our results suggest that unless pneumonia is suspected, clinicians should provide ‘safety-netting’ advice such as explaining what illness course to expect and when it would be necessary to re-attend but not prescribe antibiotics for most children presenting with chest infections.”

Source: University of Bristol

Radiation after Breast-conserving Surgery Reduces Cancer Recurrence

Source: National Cancer Institute

A long-term follow up analysis of a trial has shown that breast radiation following lumpectomy significantly reduces incidence of ipsilateral breast recurrence (IBR) for “low risk” DCIS.

NRG-RTOG 9804 is a clinical study conducted by the National Cancer Institute National Clinical Trials Network group NRG Oncology. These results were recently published in JCO.

IBR occurs at a rate of 5-10% after breast-conserving surgery. The NRG-RTOG 9804 study enrolled 636 women with a median age of 58 between December 1999 and July 2006. Patients were randomised to breast radiation (RT) or observation (OBS) treatment groups. All patients who participated in the trial underwent annual mammography and specified clinical exam intervals. For this analysis, the median follow up time was 13.9 years.

Analysis focused on the long-term cumulative incidence of IBR, the primary endpoint in the study. The study hypothesised that radiation would significantly reduce IBR from 6% to 3.5% at 5 years, assuming that the reduction in IBR from RT would be less than previous trials that included higher grades and larger sizes of DCIS. With long-term follow-up, cumulative incidence of IBR remained statistically significantly lower with RT, as compared to OBS. At 10 and 15 years, the cumulative incidence of IBR with OBS was 9.2% and 15.1%, respectively, and was 1.5% and 7.1%, respectively, with RT. The 10 and 15 year invasive IBR incidence, respectively, was 0.4% and 5.4%  with RT; 4.3%  and 9.5% with OBS. A total of 52 IBRs were observed; 14 in the RT arm and 38 in the OBS arm.

No statistically significant differences in mastectomy, distant metastasis, overall or disease-free survival were seen between the two treatment arms.

“Since IBR risk continues to increase through at least 15 years, with radiation conferring both a delay and decrease in this risk, the data presented support the decision to treat patients who wish to minimise their IBR and particularly the invasive cancer risk long term. Factors such as age, life expectancy, and willingness (if oestrogen receptor–positive) to take antioestrogen therapy should be taken into consideration in this patient-doctor shared decision,” stated lead author Beryl McCormick, MD, of the Memorial Sloan Kettering Cancer Center.

Source: NRG Oncology