A University of Minnesota Medical School research team has found that giving iron supplements to children living with human immunodeficiency virus (HIV) in sub-Saharan Africa could be an important first step in optimising brain development.
The study, published in Lancet HIV, demonstrates that iron, while often withheld from children with HIV due to fear of increasing infection risk, is in fact beneficial. This finding paves the way for future research examining iron’s role in neurodevelopmental outcomes in children with HIV.
“With the success and widespread availability of antiretroviral therapy (ART), children with HIV in sub-Saharan Africa are living longer, and optimising their brain development is a new public health imperative,” said Sarah Cusick, PhD, associate professor at the U of M Medical School and a member of the Masonic Institute for the Developing Brain.
Between May 2018 and November 2019, researchers enrolled 200 children with HIV and anaemia who had received ART for at least six months. The study participants were randomly chosen to receive either iron supplements or a placebo for three months. Children who received iron had higher haemoglobin concentrations and better markers of iron nutrition than those who received the placebo. There also was no evidence of increased risk of infection.
According to Dr Cusick, further research is needed to assess brain development and infection risk over a longer period of time.
A new study published in BJU International has found that the conventional, versatile open surgery approach to removal of the lymph nodes behind the intestines for patients whose testicular cancer has not advanced beyond the abdomen is the gold standard of care for men in this condition.
Open surgery involves making an incision on the abdomen for a direct view and access to the surgical area. In the appropriate patients, cancer cure rates are excellent with this surgery alone due to continued clinician experience and refinement of technique, particularly at high-volume centres.
The study, led by urologist and health services researcher Clint Cary, MD, MPH, MBA, of the Indiana University School of Medicine and the Regenstrief Institute, was conducted using information from the on 165 patients with clinical stage I or II testicular cancer and no prior chemotherapy. One of the highest-volume testicular cancer treatment groups in the US, IU School of Medicine’s Department of Urology is among those groups setting the bar for both better surgical results and fewer negative outcomes such as infertility. Study benchmarks included low blood loss, short hospital stay and rare major postoperative complications.
Dr Cary notes that the paper, which includes analysis of risk factors for complications, clearly indicates that prior to treatment, men and their families should have conversations with their local urologist about their experience level across risk factors, such as high body mass index (BMI), as well as have detailed discussions of complication rates. He adds that both patients and clinicians can use the findings of this paper as a bar for comparison as they make choices.
“In my clinical role at Indiana University in the operating room, I frequently perform lymph node dissections for men with a lower burden of metastatic cancer who have not had chemotherapy or may never receive it for this cancer. In my complementary role as a Regenstrief Institute health services researcher, I study the impact of clinical decisions,” said Dr Cary. “For this study, I wanted to know that this and other treatments I perform are making a difference and I want to know – whether we are continuing established treatments or introducing new approaches to surgery – how these decisions and the resulting care will impact patients’ quality of life and their cancer outcomes.
“This study is an example of how the benefit of providing clinical care and also being in a research environment enables us to learn from what we’re doing and to report it in a manner that is meaningful to both patients and physicians. We’re always looking for ways to improve upon surgical outcomes. Going beyond the scope of this paper, we are now expanding our work to begin a randomised trial comparing two surgical techniques for removing lymph nodes to understand if one is better than the other regarding postoperative recovery.”
The paper did not compare robot-assisted surgery with traditional open surgery, which may allow a more complete lymph node dissection. While robotic surgery in general offers potential benefits to both surgeons and patients, the authors note that the head to head comparison between these two approaches is limited due to small experiences with the robotic approach in testicular cancer.
The authors conclude that for patients undergoing removal of lymph nodes for testicular cancer and certainly more complex and challenging patients at higher risk of post-operative complications, the traditional open surgery remains the most effective approach and the gold standard.
Chronic pain, defined as daily or significant pain that lasts more than three month, can be complicated to diagnose and treat. Studies have shown that, since chronic pain conditions are clouded with uncertainties, patients often struggle with anxiety and depression – something challenging to for they and their doctors to discuss and manage.
A recent study of 200 chronic neck or back pain sufferers found that effective physician-patient communication during the initial consultation helps patients manage their uncertainties, including their fears, anxieties and confidence in their ability to cope with their condition.
Study leader Charee Thompson, communication professor at University of Illinois Urbana-Champaign, said: “We found that providers and patients who perceive themselves and each other as competent medical communicators during consultations can alleviate patients’ negative feelings of uncertainty such as distress and increase their positive feelings about uncertainties such as their sense of hope and beliefs in their pain-management self-efficacy. Providers and patients successfully manage patients’ uncertainty through two fundamental medical communication processes – informational and socioemotional, each of which can have important clinical implications.”
According to the study, informational competence reflects patients’ abilities to accurately describe their symptoms and verify their understanding of doctors’ explanations and instructions, as well as clinicians asking appropriate questions, providing clear explanations and confirming patients’ understanding. The extent to which doctors and patients establish a trusting relationship through open, honest communication and patients’ feelings of being emotionally supported by the physician reflects socioemotional communication competence.
Thompson and her co-authors — Manuel D. Pulido, a communication professor at California State University, Long Beach; and neurosurgery chair Dr. Paul M. Arnold and medical student Suma Ganjidi, both of the Carle Illinois College of Medicine — published their findings in the Journal of Health Communication.
The current study was based on uncertainty management theory, the hypothesis that people faced with uncertainty about a health condition appraise it and decide whether obtaining information is a benefit or a threat. For example, patients may seek information about the origins of a new symptom to mitigate their anxiety-related uncertainty — or, conversely, they might avoid information-seeking so they can maintain hopeful uncertainty about their prognosis, the team wrote.
The study was conducted at an institute in the Midwest composed of several clinics and programs that treat diseases and injuries of the brain, spinal cord and nervous system. Ranging in age from 18–75, those in the study sample had pain that included but was not limited to their neck, back, buttocks and lower extremities. About 59% of the patients were female.
Before the consultation, the patients completed surveys rating how they experienced and managed their pain and their certainty or uncertainty about it. They and the providers also completed post-consultation surveys rating themselves and each other on their communication skills.
The patients rated how well the provider ensured that they understood their explanations and asked questions related to their medical problem.
To determine if patients’ levels of uncertainty changed, on the pre- and post-consultation surveys the patients ranked how certain or uncertain they felt about six aspects of their pain – including its cause, diagnosis, prognosis, the available treatment options and the risks and benefits of those. The patients also rated themselves on catastrophising – their tendency to worry that they would always be in pain and never find relief.
Patients’ feelings of distress were reduced when they and their physician mutually agreed that the other person was effective at seeking and providing medical information, and when the patients felt emotionally supported by their doctors, the team found.
“Patients’ ratings of their providers’ communication competency significantly predicted reductions in their pain-related uncertainty and in their appraisals of fear and anxiety, as well as increases in their positive uncertainty and pain self-efficacy,” Thompson said. “Providers’ reports of patients’ communication competency were likewise associated with decreases in patients’ pain-related uncertainty and marginally significant improvements in their positive appraisals of uncertainty.”
In a related study, the U. of I.-led team found that, for a subset of spinal pain patients, satisfaction, trust in and agreement with their doctor were strongly associated with the doctors exceeding patients’ expectations for shared decision-making and the quality of the provider’s history-taking and people skills. U. of I. graduate student Junhyung Han was a co-author of that paper, which was published in the journal Patient Education and Counseling.
The team wrote that providers and patients need to discuss their mutual expectations for testing, medication and treatment, such as which options are worth pursuing and their potential to meet patients’ expectations for pain relief.
Thompson said that while these studies’ findings highlight the effects that providers’ overall communication skills have on chronic pain patients’ emotions, expectations and attitudes about their condition, the patients’ communication skills matter, too.
“I wanted to challenge the notion that pain patients are frustrated or ‘difficult’ because they have unrealistic standards,” Thompson said. “No matter how high their expectations are, what seems to matter most to conversation outcomes is the extent to which patients’ expectations are met or exceeded.
“Consultations mark what may be a long, challenging diagnostic and treatment journey for these patients, and they could benefit from learning about therapies and strategies to help them manage their pain and uncertainties,” Thompson said. “Giving them the tools and language to communicate their symptoms and concerns to providers could make their interactions more productive. Learning about the uncertain nature of pain may validate their fears and anxieties, while awareness and education about the various treatment options and therapies such as cognitive behavioural therapy could enhance their coping and dispel feelings of helplessness and fear.”
Over 30% of older adults take five or more medications daily, which is termed polypharmacy. It is associated with poor health outcomes like falls, medication interactions, hospitalisations and even death. Multiple chronic conditions in older adults increases the risk of polypharmacy. While polypharmacy is more common in older adults with Alzheimer’s disease and related dementias, there is little research examining the impact on symptoms, health outcomes and physical function.
Researchers from Drexel University’s College of Nursing and Health Professions recently published a study in Biological Research For Nursing examining symptoms, health outcomes and physical function over time in older adults with and without Alzheimer’s disease and related dementias and polypharmacy.
Led by Martha Coates, PhD, the research team found that individuals who are experiencing polypharmacy and have Alzheimer’s disease and related dementias experience more symptoms, falls, hospitalisations, mortality and had lower physical function – indicating that polypharmacy can also negatively impact quality of life for older adults with Alzheimer’s disease and related dementias.
“The cut-off of point of five or more medications daily has been associated with adverse health outcomes in previous research, and as the number of medications increase the risk of adverse drug events and harm increases,” said Coates.
The research team used a publicly available dataset from the National Health and Aging Trends Study – a nationally representative sample of Medicare beneficiaries in the United States from Johns Hopkins University. Since 2011, data is collected yearly to examine social, physical, technological and functional domains that are important in aging.
For this study, the research team used data from 2016 through 2019 to compare changes in symptoms, health outcomes and physical function among four groups: 1) those with Alzheimer’s disease and related dementias and polypharmacy; 2) those with Alzheimer’s disease and related dementias only; 3) those with polypharmacy only; and 4) those without either Alzheimer’s disease and related dementias or polypharmacy.
Coates explained that the researchers used analytic weights to analyse the data, which generates national estimates, making the sample of 2052 individuals representative of 12 million Medicare beneficiaries in the US, increasing the generalisability of the findings.
“We found that older adults with Alzheimer’s disease and related dementias and polypharmacy experienced more unpleasant symptoms, increased odds of falling, being hospitalised and mortality compared to those without Alzheimer’s disease and related dementias and polypharmacy,” said Coates. “They also experienced more functional decline, required more assistance with activities of daily living like eating, bathing and dressing, and were more likely to need an assistive device like a cane or walker.”
Coates noted that there are tools available to help health care providers review and manage medication regimens for older adults experiencing polypharmacy and possibly taking medications that are potentially inappropriate or no longer provide benefit. However, currently there are no specific tools like that for older adults with Alzheimer’s disease and related dementias.
The findings from this research shed light on the negative impact polypharmacy can have on older adults with Alzheimer’s disease and related dementias. But Coates added that further research is needed to develop strategies to reduce the occurrence of polypharmacy in people with Alzheimer’s disease and related dementias.
The research team anticipates this study will help guide future analysis of the impact of specific medications on health outcomes in individuals with Alzheimer’s disease and related dementias and that it provides a foundation to support intervention development for medication optimisation in older adults with Alzheimer’s disease and related dementias and polypharmacy.
A heart attack can trigger a desire to get more sleep, allowing the heart to heal and reduce inflammation as a result of the heart’s special signals to the brain, according to a new Mount Sinai study. This is the first study showing how the heart and brain communicate via the immune system to promote sleep and recovery after a major cardiovascular event.
The novel findings, published in Nature, highlight the importance of increased sleep after a heart attack, and suggest that sufficient sleep should be a focus of post-heart-attack clinical management and care, including in intensive care, where sleep is frequently disrupted, along with cardiac rehabilitation.
“This study is the first to demonstrate that the heart regulates sleep during cardiovascular injury by using the immune system to signal to the brain. Our data show that after a myocardial infarction (heart attack) the brain undergoes profound changes that augment sleep, and that in the weeks following a myocardial infarction, sleep abundance and drive is increased,” says senior author Cameron McAlpine, PhD, Assistant Professor of Medicine (Cardiology), and Neuroscience, at the Icahn School of Medicine at Mount Sinai. “We found that neuro-inflammation and the recruitment of immune cells called monocytes to the brain after a myocardial infarction is a beneficial and adaptive response that increases sleep to enable heart healing and the reduction of damaging cardiac inflammation.”
The researchers from the Cardiovascular Research Institute at Icahn Mount Sinai first used mouse models to discover this phenomenon. They induced heart attacks in half of the mice and performed high-resolution imaging and cell analysis, and used implantable wireless electroencephalogram devices to record electrical signals from their brains and analyse sleep patterns. After the heart attack, they found a three-fold increase in slow-wave sleep, a deep stage of sleep characterized by slow brain waves and reduced muscle activity. This increase in sleep occurred quickly after the heart attack and lasted one week.
When the researchers studied the brains of the mice with heart attacks, they found that immune cells called monocytes were recruited from the blood to the brain and used a protein called tumour necrosis factor (TNF) to activate neurons in an area of the brain called the thalamus, which caused the increase in sleep. This happened within hours after the cardiac event, and none of this occurred in the mice that did not have heart attacks.
The researchers then used sophisticated approaches to manipulate neuron TNF signaling in the thalamus and uncovered that the sleeping brain uses the nervous system to send signals back to the heart to reduce heart stress, promote healing, and decrease heart inflammation after a heart attack. To further identify the function of increased sleep after a heart attack, the researchers also interrupted the sleep of some of the mice. The mice with sleep disruption after a heart attack had an increase in heart sympathetic stress responses and inflammation, leading to slower recovery and healing when compared to mice with undisrupted sleep.
The research team also performed several human studies. The first studied the brains of patients 1–2 days after a heart attack and found an increase in monocytes compared to people without a heart attack or other CVD, mirroring the mice findings. The next analysed the sleep of more than 80 heart attack patients during the four weeks post-event and followed them for two years. The patients were divided into good sleepers and poor sleepers based on the quality of their sleep during the four weeks post-heart attack. The poor sleepers had a worse prognosis; their risk of having another cardiovascular event was twice as high as good sleepers. Additionally, the good sleepers had a significant improvement in heart function while poor sleepers had no or little improvement.
In another human study, the researchers analysed the impact of five weeks of restricted sleep in 20 healthy adults. Sleep was monitored using electronic devices and the participants kept a sleep diary. During the five-week study period, half the participants slept for the recommended seven to eight hours a night uninterrupted, while the other half restricted their sleep by 1.5 hours each night – either delaying bedtime or waking up early. After the study period, researchers analysed blood monocytes and found similar sympathetic stress signaling and inflammatory responses in the sleep-restricted group as those that were identified in mice.
