Women with prolonged mental health problems up to three years after childbirth may be suffering from irregular immune system responses, suggests new research published in the American Journal of Reproductive Immunology.
“We found that women who had clinically elevated symptoms of depression, anxiety, and/or post-traumatic stress disorder (PTSD) two to three years after delivery had genetic evidence of a higher prevalence of immune system defence mechanism activation,” said Eynav Accortt, PhD, principal investigator of the study and director of the Reproductive Psychology Program at Cedars-Sinai.
“These women also appeared to have a reduction in the activity of genes related to antiviral immune responses that can offer the body protection from pathogens,” said Accortt, a clinical psychologist.
Roughly 1 in 8 women experience significant symptoms of perinatal mood and anxiety disorders that can interfere with health and quality of life. Much of the research into maternal mental health to date has focused on the perinatal period and the first year after childbirth.
Cedars-Sinai investigators surveyed 33 women about their mental health over a longer period, two to three years after giving birth. Study participants also provided a blood sample, and scientists performed bioinformatic analyses of differential gene expression.
“Delayed or persistent postpartum anxiety, depression and PTSD is an area that is woefully understudied,” said study co-author Sarah Kilpatrick, MD, PhD, chair of the Department of Obstetrics and Gynecology at Cedars-Sinai.
“In this preliminary research, we have identified genetic differences related to inflammation when comparing women experiencing prolonged symptoms of mood and anxiety disorders to those who did not report poor mental health. Additional studies will be needed for a deeper dive into the role inflammation may play in postpartum mental illness,” said Kilpatrick.
One of the research aims is to design a blood test to identify those at high risk for serious and prolonged postpartum mood disorders, according to Accortt.
“A blood test could help us develop early interventions that provide medical and mental health treatments and support. We want to figure out why some women are at greater risk for depression, anxiety and PTSD. No one should have to suffer for years after childbirth,” said Accortt.
Drugs that block the cancer-promoting activity of oestrogen are known to reduce the risk of developing new breast cancers. A new computer modelling study in the Journal of Clinical Oncology has shown that these treatments could also reduce the risk of dying from the disease in women who are at high risk.
“Recent studies have shown that women diagnosed with oestrogen receptor (ER) positive tumours continue to experience breast cancer recurrence and death for as long as 30 years after their primary diagnosis,” says Claudine Issacs, MD, of the Georgetown Lombardi Comprehensive Cancer Center, one of the study’s two senior authors.
She says this new evidence prompted researchers to revisit the lifetime benefits and harms of risk-reducing medications developed for the primary prevention of breast cancer to see if the drugs could reduce the rate of death from the disease in the long term.
“Based on the available data, recommendations for preventing ER-positive breast cancer with tamoxifen or aromatase inhibitors presumed that women at elevated risk who took the drugs simply reduced their chances of developing the disease, but our modelling study found that, over the long run, there could also be a significant impact on mortality” Isaacs says. “Giving an oestrogen blocker to a woman in her 30s who is at high risk could potentially forestall death due to breast cancer for 20 years or more, which would be significant.”
Over the past several decades, a number of large, federally-funded randomised clinical trials have shown that risk-reducing antioestrogen medications such as tamoxifen and aromatase inhibitors could decrease the incidence of ER-positive breast cancer by 30 to 50% in women who are at high-risk of developing the disease. Despite evidence from these trials, the drugs have remained underutilised, perhaps due to the risk, albeit low, of endometrial cancer conferred by the drugs as well as other factors.
“What has been missing from our conversation until now is our ability to say to women that these drugs can not only prevent them from getting breast cancer but they can ultimately prevent them from dying of the disease,” Isaacs says.
Studies have shown that chemoprevention drugs are most effective if taken for five years and not longer. This latest study shows that the impact on mortality could confer a lasting benefit for a decade or more.
The study used computer models developed by the Cancer Intervention and Surveillance Modeling Network (CISNET), a National Cancer Institute sponsored consortium, to determine the lifetime benefits and harms of oestrogen blockers for women with a five-year risk of developing breast cancer equal to or greater than three percent. The researchers evaluated the effects of oestrogen blockers, along with annual screening with mammograms and MRI if necessary, to calculate the risk of invasive breast cancer, breast cancer death, side-effects, false positives and chances of overdiagnosis.
Tamoxifen, and the use of annual screening, reduced the risk of developing new invasive breast cancers by 40% and reduced the risk of breast cancer deaths by 57%. This translates to 95 fewer invasive breast cancers and 42 fewer breast cancer deaths per 1000 women compared to women who didn’t get screening or risk-reducing drugs. Tamoxifen was not without downsides, potentially increasing new endometrial cancers by up to 11 per 1000. Furthermore, a randomised clinical trial would be too large and take too long to generate results, Isaacs noted.
Both health minister Dr Joe Phaahla and health authorities in the Free State last week denied claims from activists that there are shortages of antiretroviral medicines at health facilities in the province. Authorities did however confirm that some people living with HIV are only given a two-week supply of medicines at a time.
“I can confidently say that there are no stockouts or shortages of ARVs in the Free State,” Phaahla told Spotlight at the World AIDS Day commemoration event in Mangaung.
This was reiterated by spokesperson for the Free State Department of Health, Mondli Mvambi saying, “We do not have shortages of HIV medicines in the province.”
He says allegations of patients not receiving their medication are very serious and cannot be taken lightly. He says should the department hear from patients who are not receiving their HIV medicine, they will investigate.
But Makhosazana Mkhatshwa, a research officer at the Treatment Action Campaign (TAC), says in the past three months, nine clinics in the province indicated that patients have left their facility without the medicine that they needed and of these nine clinics, three of them had sent people home because there was a stockout of HIV medication. She says impacted clinics include Poly Clinic and MUCPP in Mangaung, and Namahadi Clinic in Thabo Mofutsanyana District.
According to community-led monitoring group Ritshidze’s latest report on clinic services in the Free State, there were 40 patient reports this year of shortages of HIV medication compared to 13 patient reports last year. The report states that the most commonly reported medicine shortages by public healthcare users were contraceptives, HIV, and TB medicines. The report was based on monitoring at 28 clinics. TAC is a Ritshidze partner organisation.
Only 7 or 14-day supply for some
One woman Spotlight spoke to at the World AIDS Day commemoration event held in Mangaung last week says she is a patient at Pule Sefatsa Clinic in Botshabelo, Mangaung. “I am forced to go to clinic every week because they only give me a supply for eight days. This is an inconvenience for me because I have to skip work every week just to get my medication.”
Another public healthcare user from Bloemfontein tells Spotlight that for two weeks in October he was stranded without ARVs. He says that he is usually given a 14-day supply at a time. When he requested a full month’s supply to last him through a work-related trip to Cape Town he says his request was declined at the Poly Clinic at Pelenomi Hospital. He says he ended up going without medication.
Aron Malete, District Health Manager for Mangaung, told Spotlight there are no ARV shortages in the district, but asked for details of the above cases so that he could investigate.
The problem is not stockouts per se, but a shortage of medication, says Sello Mokhalipi, Secretary General of Positive Action Campaign. “You will find that there is a shortage of ARVs for seven days, then the next week it will be available,” he says.
Mokhalipi, like other activists Spotlight spoke to, is opposed to giving people only a seven or 14-day supply of medication at a time. He says people should be given enough for three to six months.
When Spotlight put the concerns and calls for multi-month dispensing to Mvambi he says, “We have identified people who are clinic hoppers who steal medicine. They get three months and thereafter run to another clinic to get another three months’ supply. To curb this practice,” Mvambi says, “we keep people on seven and 14 days’ supply The idea is to give them a few days because they claim to have forgotten their clinic cards.”
According to him, people get three months’ supply when they have their clinic card because clinic staff can verify who they are and what medicine they have been receiving.
Doing ‘exceptionally well’ but there are concerns
According to Phaahla who delivered a speech at the World AIDS Day commemoration event, the province has done “exceptionally well in terms of testing, having already surpassed the 94 percent threshold”. Phaahla said 94 percent of people who are living with HIV in the province know their status, 86 percent of those who know their status are on antiretroviral treatment, and 92 percent of those who are on treatment are virally suppressed.
He, however, singled out some districts such as Xhariep and Lejweleputswa where he says the “number of people with HIV and on treatment fare poorly on the target of being virally suppressed”. “This,” Phaahla says, “is very concerning and we must urgently intervene to create a balance among the targets in order to achieve zero new infections by 2030. This includes ensuring that services are brought closer to the people and that our health facilities are adequately resourced with medicine and related necessities.”
“Results for each of the sub-populations vary with adult females at 95 – 91 – 93, adult males at 93 – 77 – 93, and children at 82 – 65 – 68,” says Mvambi. “To achieve the 95 – 95 -95 targets the Free State must increase the number of adult men on ART by 25 745, adult women on ART by 9 744, and children on ART by 5 138.”
“As you can see,” says Mvambi, “the women are more likely to get tested, be initiated on ART, and have their viral load suppressed than their counterparts.”
According to the Free State Department of Health’s latest annual report for the financial year 2021/2022, the number of patients initiated on ARV treatment dropped from 36 776 in 2019/2020 to 26 364 in 2021/2022. In the report, the department states that it failed to meet its target for retaining adults on ART in care. The ART adult remain-in-care rate in 2019/20 was 68%. In 2020/21, it dropped to 52.8% and picked up in 2020/21 at 67.3%. Among the reasons the department cites are the high number of loss to follow-up of clients and “poor tracing by community healthcare workers due to poor supervision”.
NOTE: An employee of the TAC is quoted in this article. Spotlight is published by SECTION27 and the TAC, but is editorially independent – an independence that the editors guard jealously. Spotlight is a member of the South African Press Council.
Public transport is used by more than 10 million commuters in South Africa every day. It’s how people get to work, how they get to the grocery store, how they get their children to school. It’s quite simply a way of life.
For many of these commuters, there is no alternative to minibus taxis. They are an indisputably dominant pillar of the informal public transport system, but they are also notoriously unsafe. The constant threat of an accident is a real concern for commuters, especially those who cannot afford private medical aid.
“We live in a country where 73% of the population doesn’t have access to private medical aid. Couple this with the high number of road accidents in South Africa, and what recourse do the vast majority of commuters have if they are involved in a road accident?” asks Rikus Scheepers, managing director at AcciCare Medical Service Providers.
AcciCare is a medical funding company that assists people who do not have medical aid, to get access to private hospital care when they are involved in a motor vehicle accident. Scheepers started AcciCare in 2017, with the intention of making private medical care accessible to all commuters.
“We started AcciCare in a few hospitals and had limited capital to work with but soon realised the extensive need for this type of service. As a start-up without a long trading history, it became impossible to grow the business to meet the demand. We needed a business partner who shared our vision to supply this essential service throughout the country, and so we approached Standard Bank,” says Scheepers.
“AcciCare is a unique concept not offered in South Africa,” says Jocelyn Hamilton at Standard Bank. “When they approached us for finance we had to apply some out-the-box thinking in order to provide a working capital solution that would enable the business to grow and expand into more provinces in the country.”
In the event a person is injured in a motor vehicle accident, AcciCare will assist treating doctors and hospitals to collect and complete the correct documentation in order for medical costs to be claimed back from the Road Accident Fund (RAF). AcciCare provides financial assistance to these service providers, so they don’t carry the costs while waiting for the RAF to settle accounts.
“We firmly believe that all commuters should have access to private medical care when they need it the most. Through our partnership with Standard Bank we are expanding our footprint and we have exciting initiatives in place for 2023, to educate more people about the reliable private care that is available to them,” says Scheepers. “Together with Standard Bank, AcciCare has saved countless lives and has significantly improved the quality of life of those who have unfortunately been involved in a motor vehicle accident.”
“Our business banking model is centred on partnering with clients to grow their businesses in the communities in which they exist. While we came in as a working capital solution that would see AcciCare achieve their vision, in return we indirectly partnered in improving the long-term quality of life for those unfortunate enough to be in need of medical care at critical times. We hope to continue with this partnership, as they take their business to new heights,” says Hamilton.
Young people with Type 1 diabetes (T1D) who took bromocriptine, a medication used to treat Parkinson’s disease and Type 2 diabetes, had lower blood pressure and less stiff arteries after one month of treatment compared to taking placebo, according to a small study published today in Hypertension.
Hypertension and stiff arteries contribute to the development of heart disease, for which those with T1D are at higher risk. Those diagnosed with T1D as children have even higher risks for heart disease than people diagnosed in adulthood. Therefore, researchers are interested in ways to slow down the onset of vascular disease in children with T1D.
“We know that abnormalities in the large vessels around the heart, the aorta and its primary branches, begin to develop in early childhood in people with Type 1 diabetes,” said lead study author Michal Schäfer, PhD, a researcher and fourth-year medical student at the University of Colorado School of Medicine. “We found that bromocriptine has the potential to slow down the development of those abnormalities and decrease the risk for cardiovascular disease in this population.”
The multidisciplinary team conducted this study to examine the impact of bromocriptine on blood pressure and aortic stiffness compared with a placebo in adolescents with Type 1 diabetes. Bromocriptine is in a class of medications called dopamine receptor agonists. It increases levels of dopamine, a chemical in the brain, which leads to an increase in the body’s responsiveness to insulin, called insulin sensitivity. Bromocriptine has been FDA-approved since 2009 to treat adults with Type 2 diabetes due to its effect on insulin sensitivity.
The study included 34 participants (13 male, 21 female) aged 12 to 21 years who had been diagnosed with Type 1 diabetes for at least a year, and their HbA1c was 12% or less. An HbA1c level of 6.5% or higher indicates diabetes. They were randomly divided into two groups of 17, with one group receiving bromocriptine quick-release therapy and the other receiving a placebo once daily. The study was conducted in two phases. Participants took the first treatment or placebo for 4 weeks in phase 1, then had no treatment for a 4-week “wash-out” period, followed by phase 2 with 4 weeks on the opposite treatment. In this “crossover” design, each participant served as their own control for comparison.
Blood pressure and aortic stiffness were measured at the start of the study and at the end of each phase. Aortic stiffness was determined by assessing the large arteries with cardiovascular magnetic resonance imaging (MRI) and a measurement of the velocity of the blood pressure pulse called pulse wave velocity.
The study found:
Compared to placebo, blood pressure was significantly decreased with bromocriptine. On average, bromocriptine therapy resulted in a systolic blood pressure decrease of 5 mm Hg and a diastolic blood pressure decrease of 2 mm Hg at the end of 4 weeks of treatment.
Aortic stiffness was also reduced with bromocriptine therapy. The improvement in aortic stiffness was most pronounced in the ascending aorta with a lowered pulse wave velocity of about 0.4 meters/second, and an increase in distensibility, or elasticity, of 8%. In the thoraco-abdominal aorta, bromocriptine was associated with a lowered pulse wave velocity of about 0.2 meters/second, with a 5% increase in distensibility.
“A stiff aorta predisposes a patient to other health issues, such as organ dysfunction or atherosclerosis and higher stress or strain on cardiac muscle,” Schäfer said. “We were able to take it a notch further and show, using more sophisticated metrics, that these central large arteries are impaired, and impairment among adolescents and young adults with Type 1 diabetes may be decelerated with this drug.”
The study’s small size is a limitation. However, the researchers note that further research into bromocriptine’s impact on vascular health in a greater number of people with Type 1 diabetes is warranted; they are planning larger trials.
