Some people living in tropical regions are already living under conditions of heat stress that are approaching the upper limits of human survivability, a study has found.
In this study published in iScience, researchers noted that climate models used to predict heat conditions around the world are generally based on data from weather stations in relatively populated areas. Such data, they note, excludes conditions for people living in what they describe as informal settlements. To find out more about the conditions for people living in areas expected to be hit by the worst global warming effects, the researchers placed heat sensors in and around 100 houses in Makassar, Indonesia, a settlement in a tropical part of the country. The observed conditions are likely representative of many such settlements in the tropics, the researchers suggested.
Analysing the data, the researchers discovered that, during the rainy season, 80% of the sensors recorded temperatures in excess of established health thresholds. At such temperatures and humidity levels, adverse health impacts are said to be felt by people living there. In a few instances, they found that the sensors recorded temperatures that are believed to represent the upper limit of human survivability.
These findings are alarming for several reasons, they noted. For one, millions of people living in many parts of the world are already living under heat conditions that are harmful to their health. Another is the fact that many such people engage in physical labour for their livelihoods, and doing so in extreme heat can be fatal. Perhaps most alarming is the near certainty that conditions in such places are going to get worse as the planet continues to warm from fossil fuel burning and climate change. An analysis of the agreements reached at the COP26 summit found that the Earth was on course for a 2.4°C increase in temperature, well above the 1.5°C increase suggested by scientists to avoid the worst effects of climate change. For most such places, there are no relocation plans, and little chance that heat-mitigating technology such as air-conditioning will be installed. This suggests that a disaster of massive proportions is on the way.
The use of tranexamic acid (TXA) reduced blood loss during myomectomies in women with large uterine fibroids, a retrospective cohort study has found.
Patients who underwent a myomectomy to remove uterine fibroids with a total weight greater than 173 g had lower estimated blood loss after receiving TXA compared with those who did not (205.6 mL vs 405.4 mL), reported Rachel Cullifer, MD, at the virtual American Association of Gynecologic Laparoscopists (AAGL) annual meeting. Furthermore, patients whose largest fibroid was greater than 73 mm had lower levels of blood loss with TXA (229.2 mL vs 408.3 mL).
“TXA is a highly safe hemostatic agent that gynecologic surgeons can utilize during myomectomies,” Cullifer said. “There is a role for TXA in myomectomies performed with a minimally invasive approach,” she added, noting that the treatment should be strongly considered for patients suspected of having a large fibroid burden.
When looking at all myomectomies not stratified by fibroid characteristics, there was not no significant difference in estimated blood loss between patients who received TXA and those who did not (184 mL vs 266 mL). Fibroids are the primary indication for hysterectomy in the US, Dr Cullifer noted, but myomectomy provides a safe alternative for those who want to preserve their fertility.
“Despite advances in laparoscopic techniques, blood loss and blood transfusions still remain higher in myomectomies when compared with hysterectomy,” Dr Cullifer pointed out, adding that elevated plasmin levels during surgery can result in prolonged bleeding. TXA lowers plasmin function and productivity, reducing blood loss, she stated.
Dr Cullifer and colleagues focused on fibroid characteristics to find out which patients might benefit most from TXA.
The researchers analysed patients who had a myomectomy from 2015 to 2020, compared myomectomy cases treated with TXA versus those that were not, and measured estimated blood loss, blood transfusion administration, and operative time. Of the 71 patients who had a myomectomy, 26 received TXA and 45 did not. The average estimated blood loss was 236 mL, and almost all patients underwent minimally invasive procedures, with 53% undergoing laparoscopic surgery and 40% undergoing robot-assisted procedures.
Save for age, all demographic characteristics were similar between the two groups. Patients who received TXA were an average of two and a half years younger than those who did not. Fibroid characteristics were also similar between the two groups. Additionally, adverse events were similar between the two groups. There was one case of thromboembolism in the cohort who did not receive TXA.
In a study published in the Annals of Internal Medicine, scientists have reported the identification of a second HIV patient who appears to have completely eliminated HIV from their systems in a ‘sterilising cure’.
During infection, HIV creates a viral reservoir by inserting copies of its genome into a cell’s DNA. This allows the virus to escape from anti-HIV drugs and the body’s immune response. In most people, new viral particles are constantly made from this reservoir. Antiretroviral therapy (ART) can prevent new viruses from being made but cannot eliminate the reservoir, necessitating daily treatment to suppress the virus.
Some, known as ‘elite controllers’, have immune systems that are able to suppress HIV without the need for medication. Though they still have viral reservoirs that can produce more HIV virus, a type of immune cell called a killer T cell keeps the virus suppressed without the need for medication.
Xu Yu, MD, a physician investigator at Massachusetts General Hospital, led a research group that identified one patient with no intact HIV viral sequence in her genome, indicating that her immune system may have eliminated the HIV reservoir: a sterilising cure. When they sequenced billions of cells from this patient, known as the San Francisco Patient, searching for any HIV sequence that could be used to create new virus, they found no sign. This extraordinary finding, the first known incidence of a sterilising cure without a stem cell transplant, was reported in Nature in 2020.
Now, Dr Yu’s group reports a second untreated HIV-infected patient, known as the Esperanza Patient who also has no intact HIV genomes found in more than 1.19 billion blood cells and 500 million tissue cells sequenced. This may represent a second instance of a sterilising cure.
“These findings, especially with the identification of a second case, indicate there may be an actionable path to a sterilizing cure for people who are not able to do this on their own,” said Dr Yu.
She further explains that these findings may suggest a specific killer T cell response common to both patients driving this response, with the possibility that other people with HIV have also achieved a sterilising cure. If researchers can figure out the immune mechanisms behind this response, they could develop treatments that teach others’ immune systems to mimic these responses in cases of HIV infection.
Yu adds: “We are now looking toward the possibility of inducing this kind of immunity in persons on ART through vaccination, with the goal of educating their immune systems to be able to control the virus without ART.”
Plant-based burgers often promise an amount of protein comparable to their animal-based counterparts, but not all sources of proteins are equal. Rather the body depends on essential amino acids, the concentration and digestibility of which differ among protein sources.
To account for these differences, a new standard for protein quality, the digestible indispensable amino acid score (DIAAS), was developed by the U.N.’s Food and Agriculture Organization (FAO), which specifically focusses on the digestibility of essential amino acids.
A new study, published in the European Journal of Nutrition, used the DIAAS system to compare protein quality in meat-based and plant-based burgers.
The researchers fed the pigs (the recommended test animal) with patties alone for pork burgers, 80% and 93% lean beef burgers, the soy-based Impossible Burger, and pea-based Beyond Burger. They then measured digestibility of individual essential amino acids, computing DIAAS values from those scores.
Both beef and pork burgers scored as “excellent” sources of protein (DIAAS scores 100+, for people of all ages). The Impossible Burger also scored as an excellent protein source for ages 3 and up, but not under 3. Beyond Burger scored 83, a “good” source of protein for ages 3 and up.
“We have previously observed that animal proteins have greater DIAAS values than plant-based proteins and that is also what we observed in this experiment,” says Hans H. Stein, professor in the Department of Animal Sciences and the Division of Nutritional Sciences at Illinois and co-author on the European Journal of Nutrition study.
Since burger patties are usually eaten with a bun, the researchers looked at the impact of adding the low-protein bun and as expected, it reduced DIAAS values.
Consuming the Impossible Burger together with a bun reduced the DIAAS value to “good” for ages 3 and up. But when pork or 80% lean beef patties were consumed together with buns, DIAAS values were still at or above 100 for the over-3 age group, demonstrating that the needs for all essential amino acids were met by these combinations.
“There was a greater DIAAS value of mixing either the pork or beef burger with the bun – values of 107 and 105 respectively, for the over-3 age group—than there was for the Impossible Burger, which had a DIAAS value of 86 if consumed with the bun. That means you need to eat 15% more of the Impossible Burger-bun combination to get the same amount of digestible amino acids as if you eat the pork-based or the beef-based burgers. And if you have to eat more, that means you also get more calories,” said co-author Mahesh Narayanan Nair, professor at Colorado State University.
Stein said, “It’s particularly children, teenagers, lactating women, and older people who are at risk of not getting enough amino acids. Results of this experiment, along with previous data, demonstrate the importance of getting animal-based proteins into diets to provide sufficient quantities of digestible essential amino acids to these populations.”
During the early days of the COVID pandemic, an automated text messaging system saved two lives a week, and, overall, the patients who enrolled in that system had a 68% lower mortality rate than those not on it.
These insights about Penn Medicine’s COVID Watch – a system designed to monitor COVID outpatients using automated texts and then escalate those with concerning conditions to a small team of health care providers – were published in the Annals of Internal Medicine.
“At the beginning of the pandemic, we instinctually thought patients needed extra support at home, even if they weren’t sick enough or ill yet. And if they were to get very sick, we wanted to help them get to the emergency department earlier, so COVID Watch was our solution,” said a co-primary investigator of the study, Krisda Chaiyachati, MD, the medical director of Penn Medicine OnDemand and an assistant professor of Medicine. “Our evaluation found that a small team of five or six nurses staffing the program during some of the most hectic days of the pandemic directly saved a life every three to four days.”
COVID Watch was rapidly developed and designed to help patients with the virus recover safely at home and keep hospital capacity available. The system uses algorithmically guided text message conversations with patients to assess their conditions. It sent out twice-daily routine questions to patients, such as “How are you feeling compared to 12 hours ago?” and “Is it harder than usual for you to breathe?” If a patient indicated a worsening condition, follow-up questions were asked and they were elevated to the human members of a centralised team – headed by co-author Nancy Mannion, DNP, COVID Watch’s nurse manager – who would call to check in and recommend hospitalisation, if needed.
Since the start of COVID Watch, nearly 20 000 patients have been enrolled in it.
“We did an early analysis of the system and determined that we could safely monitor more than 1,000 patients simultaneously, 24/7, with a small, well-trained team of registered nurses,” said Anna Morgan, MD, COVID Watch’s medical director and an assistant professor of Internal Medicine. “On top of that, those same nurses could often also take care of other COVID-related tasks such as helping patients arrange COVID testing and discussing their results, which is important during surges.”
To further assess COVID Watch’s effect on patients, researchers analysed data from every adult who received outpatient care from Penn Medicine, starting the day COVID Watch launched until Nov. 30, 2020. Only three out of 3448 patients in COVID Watch died within 30 days of their enrollment, compared to 12 of the 4337 otherwise equivalent patients outside of the program: a three times higher mortality rate. At 60 days after enrollment, five people within COVID Watch died compared to 16 not using the system.
This amounted to a 68 percent reduction mortality risk with COVID Watch. Additionally, COVID Watch was credited with saving 1.8 lives per 1000 patients at 30 days, and 2.5 per 1000 at 60 days.
The study’s lead author and co-primary investigator, M. Kit Delgado, MD, an assistant professor of Emergency Medicine and Epidemiology, believes that the benefits seen by COVID Watch patients could be explained by: Increased access to and use of telemedicine, and more frequent and earlier trips to the hospital – an average of two days earlier for COVID Watch patients – when symptoms worsened.
Importantly, the study found that COVID Watch was equally accessible and effective for everyone.
“We saw a higher proportion of higher-risk patients and also low-income and Black patients enrolled in COVID Watch, but the fact that we measured a significant benefit associated with enrollment in the program is a good indicator that there truly is a treatment benefit for everyone,” Prof Delgado said. “It’s crucial that we found all major racial and ethnic groups benefited because non-white and low-income communities have had disproportionately higher infection rates, lower access to care, and higher death rates. This implies that this model of care could have reduced disparities in COVID outcomes if it was scaled up more broadly to these communities.”
The COVID Watch team plans to see if the approach, which had originally been built off a system for keeping tabs on chronic obstructive pulmonary disease (COPD) patients, can be applied to helping people with other conditions manage their health at home. They see the system as a lasting technology that will play an important part in future care.
A miscarriage during the first 6 months of pregnancy should be recognised as a bereavement, rather than illness in UK law, argues psychiatrist Nathan Hodson in correspondence published online in the journal BMJ Sexual & Reproductive Health.
Some MPs in the UK government have called for following in the steps of New Zealand’s policy of giving bereavement leave at any stage of pregnancy loss, though this has been met with opposition.
The Parental Bereavement (Leave and Pay) Act 2020 allows for two weeks’ statutory bereavement leave for a stillbirth after 24 weeks and for the loss of a child up to the age of 18 in the UK. In South Africa, the 2002Basic Conditions of Employment Act allows for six weeks’ maternity leave for pregnancy loss after 28 weeks.
Dr Hodson pointed out that parents in these circumstances are also entitled to take maternity or shared parental leave planned before the stillbirth, giving them weeks or months to recover from their loss.
But those who miscarry before 24 weeks in the UK have no such rights, added to which the miscarriage is regarded as an illness, with entitlement to sick leave. And if this lasts longer than 7 days, a formal sick note from a doctor is required.
“This policy creates an arbitrary cliff edge at 24 weeks,” with few women who miscarry being aware of their employment rights, Dr Hodson insisted.
Presently it is not known how many miscarriages occur in the UK annually nor how much sick leave is taken for them. He acknowledges this could open up private companies to unknown costs for employee miscarriage at any stage.
A single week of statutory bereavement leave when miscarriage occurs after the 12 week scan could reduce these costs. “Miscarriage risk after 12 weeks is less than 1% so this policy would be highly targeted with a less uncertain price tag,” he explained.
And within 2 or 3 years there should be sufficient data from New Zealand to estimate the impact of the policy, which was introduced in March this year. This allows women and partners 3 days of paid leave, irrespective of how long the woman had been pregnant, but excluding abortions.
But in any case, “miscarriage should as far as possible be recognised as bereavement, not sickness, and many parents will need time off work afterwards,” wrote Dr Hodson.
“Leave following first-trimester miscarriage should be prioritised when New Zealand has published data. But whatever approach is taken with regard to early miscarriages, the cliff edge at 24 weeks is a stark injustice demanding remedy.”
