Tag: 9/2/23

Categories : Hospitals Lab Tests and ImagingTags : Leave a comment

Patients ‘Don’t Need to be Checked for Everything’, Recommendation Says

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Blood samples
Photo by National Cancer Institute on Unsplash

Commonly ordered tests can provide early warning of underlying disease, but could also create unnecessary risks of false positive results, provoking anxiety in the patient, wasted time and money and risks of invasive testing.

Therefore, to combat commonly ordered – but not always necessary – procedures and tests, the Society of General Internal Medicine (SGIM) on Tuesday released its revised list of recommendations on five primary care procedures and tests that patients and physicians should question.

Northwestern University’s Dr Jeffrey A. Linder and David Liss, who have previously published research on the benefits of primary care checkups, helped revise the list.

For instance, the age-old idea of getting an annual physical exam with “routine blood tests” from a primary care doctor is a misconception because a person’s age and other risk factors should influence how frequently they should see their doctor, Linder said.

“We often have patients come in asking us to ‘check me for everything,’ but this is a potentially anxiety-provoking, dangerous thing for patients because the more testing we do, the more stuff we find, and the more we need to follow up,” said Linder, chief of the division of general internal medicine at Northwestern University Feinberg School of Medicine and a Northwestern Medicine physician. “In someone who is asymptomatic, an ‘abnormality’ is much more likely to be a false positive or of no clinical significance than for us to catch early disease.

“False positives can expose patients to all of the anxiety, costs, hassle and time commitment, and danger from sometimes invasive testing, with a very low likelihood that it is going to improve their health.”

This isn’t to say nobody should get a checkup every year. For instance, patients who have overdue preventive services, rarely see their primary care physician, have low self-rated health and/or are aged 65 or older should get an annual checkup, the scientists said.

The newly revised list is part of SGIM’s Choosing Wisely campaign, which is an initiative of the American Board of Internal Medicine Foundation. SGIM members originally selected the topics in 2013 and later updated the list in 2017.

The list generated controversy when it was first developed in 2013, recalls Linder.

“The list was widely misinterpreted as ‘specialty society says you don’t need to see your doctor,’ but that was not what it said,” Linder said.

Time and downstream financial costs also are issues of these commonly ordered but oftentimes unnecessary tests and procedures, Liss said.

“Patients and care teams often spend valuable time on low-value checkups that could have been devoted to high-need patients,” said Liss, research associate professor of general internal medicine at Feinberg. “There also is the overall increase in costs to the health system. And even if annual checkups are covered by most insurance, patients often have copays for services like blood draws and other diagnostic tests.”

The revised list was developed after months of careful consideration and review, using the most current evidence about management and treatment options. Linder and Liss served as ad hoc members of the SGIM’s Choosing Wisely Working Group.

Here are the five recommendations, based on a review of the most recent studies in the field:

  1. Don’t recommend daily home glucose monitoring in patients with Type 2 diabetes mellitus not using insulin.
  2. Don’t perform routine annual checkups unless patients are likely to benefit; the frequency of checkups should be based on individual risk factors and preferences. During checkups, don’t conduct comprehensive physical exams or routine lab testing.
  3. Don’t perform routine pre-operative testing before low-risk surgical procedures.
  4. Don’t recommend cancer screening in adults with life expectancy of less than 10 years.
  5. Don’t place, or leave in place, peripherally inserted central catheters for patient or provider convenience.

Source: Northwestern University

Categories : Cardiovascular Disease Obstetrics & GynaecologyTags : Leave a comment

Pre-eclampsia Causes Coronary Artery Changes Normally Seen in Older Women

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A large new study led by researchers from Lund University in Sweden shows that narrowing and calcification of the blood vessels of the heart are more common in women previously affected by pregnancy complications, and in some cases can result in coronary artery changes similar to those in women 10 years older who had no pregnancy complications.

Despite complications in pregnancy having increasingly been acknowledged as a new type of risk factor for heart disease, it is yet to be determined how this information can best be used within healthcare.

“Our results suggest that the correlation exists even among women with a low expected risk of cardiovascular disease. The study is an important piece of the puzzle in understanding how women with pregnancy complications should be followed-up by their healthcare provider after pregnancy,” says lead researcher Simon Timpka, associate professor of clinical epidemiology at Lund University.

Researchers included 10 528 women from the National Medical Birth Register* who have subsequently gone on to participate in the large population study SCAPIS at age 50-65 years. All the women underwent coronary CT angiography in order to detect calcification of blood vessels, narrowing and other signs of heart disease. The researchers investigated signs of heart disease by history of five common complications in pregnancy: pre-eclampsia, gestational hypertension, preterm delivery, gestational diabetes and infants born small for gestational age.

Four per cent more of the women with pregnancy complications had visible atherosclerosis of the coronary arteries, compared to the group who had not had complications in pregnancy (32% as opposed to 28%).

Pre-eclampsia and gestational hypertension were the most strongly linked: among women who had not experienced any pregnancy complications, 2% had narrowing in coronary arteries while the corresponding number among women who previously suffered from pre-eclampsia or pregnancy-induced hypertension was 5%.

“To reduce the risk of these women developing coronary heart disease in the future, it is important that they check risk factors such as blood pressure, blood sugar and cholesterol regularly,” says co-author Sofia Sederholm Lawesson, consultant cardiologist at the University Hospital in Linköping.

“In this study, we have investigated many different associations between complications in pregnancy and heart disease all at once, so it is possible that chance might explain individual results,” says Timpka. “Yet the pattern is relatively consistent, which makes it easier to draw conclusions including that women with prior pre-eclampsia have changes in the coronary arteries that are equivalent to the changes seen in women who have not experienced complications in pregnancy but are five to ten years older.”

According to Timpka, CT scans of the coronary arteries are increasingly used in patients presenting with symptoms, but there is still a lack of large studies into the significance over time of some of the studied changes among women without current symptoms.

“Even if our study provides new knowledge on the development of coronary heart disease among middle-aged women who have previously suffered complications in pregnancy, there is a need for long-term studies in order to understand the true meaning that our discoveries have for symptomatic disease,” concludes Timpka.

Source: Lund University

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In Anorexia, Brain Scans Show that Mindfulness Exercises Reduce Anxiety

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A team of researchers at Kyoto University’s Graduate School of Medicine has now found that mindfulness meditation does reduce anxieties associated with anorexia nervosa. Results from the study, published in BHPsych Open, show changes in the activity of brain regions involved in anxiety.

Anorexia nervosa (AN) is a severe psychiatric illness associated with intense anxieties concerning weight, shape, and self-esteem. AN is characterised by food restriction, voluntary vomiting, and extreme emaciation. Mindfulness meditation has already become a globally recognised method for addressing AN but its effectiveness in clinically treating neurogenic emaciation has not been studied yet.

The team’s mindfulness meditation program has seen a significant decrease in obsessive thoughts about test subject’s self-image and brain activity associated with related emotions.

“Our results suggest that the participants in the study became better at accepting their anxiety as it is,” says lead author Tomomi Noda.

Mindfulness and meditation work hand-in-hand. The former teaches practitioners to hone their awareness of their present experience and their ability to not judge and rather accept their circumstances. The latter is the medium by which mindfulness can be approached.

“We focused on the possibility that patients with AN try to avoid their crippling anxiety about weight gain and self-image by restricting food or vomiting,” adds co-author Masanori Isobe.

A 4-week mindfulness intervention program examined neural changes using tasks designed to induce weight-related anxiety. The researchers then regulated this anxiety by helping patients accept their current situations and experiences at face value, instead of avoiding them.

The researchers used functional magnetic resonance imaging (fMRI) to analyse attention regulation in relation to eating disorders. The study’s results support the subjective experiences of the researchers, although it was unexpected to them that several global events, such as the COVID pandemic and the Russo-Ukrainian war, were significant factors in patients’ anxieties.

“We anticipate practical implications of our results in clinical psychiatry and psychology and broader research into mitigating suffering through mindfulness, using the strategy of self-acceptance to regulate attention,” concludes group leader Toshiya Murai.

Source: Kyoto University

Categories : NeurologyTags : Leave a comment

MRI Reveals How a Dip in Cold Water Boosts Mood

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Photo by Yaroslav Shuraev

Observations of the brain when the body is immersed in cold water reveal changes in connectivity between areas which process emotion, which could explain why people often feel more upbeat and alert after swimming outside or taking cold baths.

During a research trial, published in the journal Biology, 33 healthy volunteers were given a functional MRI (fMRI) scan immediately after bathing in cold water. The team included imaging experts from Bournemouth University and University Hospitals Dorset (UHD), and extreme environments researcher, Dr Heather Massey, from the University of Portsmouth. 

Dr Massey, from the School of Sport, Health and Exercise Science, said: “It has been a really pleasing experience to work with this interdisciplinary team to develop a method and publish this piece of research that could only be completed by a group with such a diverse skill set.

“With the growing popularity of outdoor swimming and cold water immersion, which many now use to support improved mood, it is long overdue that we study how it may affect us. We know so much about the impact cold water immersion can have on the body, but the brain has had little focus, primarily as it has been more challenging to study. It is only now that technology is developing, can we start to get some insight.”

Dr Ala Yankouskaya, Senior Lecturer in Psychology at Bournemouth University, led the study. She said: “The benefits of cold-water immersion are widely known from previous studies where participants were questioned on how they feel afterwards, but we wanted to see how the shock of going into the cold water actually affects the brain.” 

Each participant was given an initial fMRI scan and then immersed in a pool of water at 20°C for five minutes whilst an ECG and respiratory equipment measured their bodies’ physiological responses. After being quickly dried they were given a second fMRI scan so the team could look for any changes in their brains’ activity.

“All tiny parts of the brain are connected to each other in a certain pattern when we carry out activities in our day-to-day lives, so the brain works as a whole.” said Dr Yankouskaya. “After our participants went in the cold water, we saw the physiological effects – such as shivering and heavy breathing. The MRI scans then showed us how the brain rewires its connectivity to help the person cope with the shock.”  

Comparing the scans showed that changes had occurred in the connectivity between specific parts of the brain, in particular, the medial prefrontal cortex and the parietal cortex.

“These are the parts of the brain that control our emotions, and help us stay attentive and make decisions,” Dr Yankouskaya said. “So when the participants told us that they felt more alert, excited and generally better after their cold bath, we expected to see changes to the connectivity between those parts. And that is exactly what we found.”

The team are now planning to use their findings to understand more about the wiring and interactions between parts of the brain for people with mental health conditions. 

“The medial prefrontal cortex and parietal cortex have different wiring when people have conditions such as depression and anxiety,” Dr Yankouskaya explained.

“Learning how cold water can rewire these parts of the brain could help us understand why the connectivity is so different for people with these conditions, and hopefully, in the long-term, lead to alternative treatments,” she concluded.

Source: University of Portsmouth

Categories : CancerTags : Leave a comment

Why Lung Cancer Doesn’t Respond Well to Immunotherapy

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A new MIT study explains why dendritic cells (green) in lymph nodes that drain from the lungs fail to stimulate killer T cells (white) to attack lung tumours.
Credits: MIT/ Courtesy of the researchers

Immunotherapy works well against some types of cancer, but it has shown mixed success against lung cancer. A new study from MIT helps to shed light on why the immune system mounts such a lacklustre response to lung cancer, even after treatment with immunotherapy drugs. In a study of mice, the researchers found that bacteria naturally found in the lungs help to create an environment that suppresses T-cell activation in the lymph nodes near the lungs.

The researchers did not find that kind of immune-suppressive environment in lymph nodes near tumours growing near the skin of mice. They hope that their findings could help lead to the development of new ways to rev up the immune response to lung tumours.

“There is a functional difference between the T-cell responses that are mounted in the different lymph nodes. We’re hoping to identify a way to counteract that suppressive response, so that we can reactivate the lung-tumour-targeting T cells,” says Stefani Spranger, the Howard S. and Linda B. Stern Career Development Assistant Professor of Biology, a member of MIT’s Koch Institute for Integrative Cancer Research, and the senior author of the new study.

MIT graduate student Maria Zagorulya is the lead author of the paper, which appears today in the journal Immunity.

Failure to attack

For many years, scientists have known that cancer cells can send out immunosuppressive signals, which leads to a phenomenon known as T cell exhaustion. The goal of cancer immunotherapy is to rejuvenate those T cells so they can begin attacking tumours again.

One type of drug commonly used for immunotherapy involves checkpoint inhibitors, which remove the brakes on exhausted T cells and help reactivate them. This approach has worked well with cancers such as melanoma, but not as well with lung cancer.

Spranger’s recent work has offered one possible explanation for this: She found that some T cells stop working even before they reach a tumour, because of a failure to become activated early in their development. In a 2021 paper, she identified populations of dysfunctional T cells that can be distinguished from normal T cells by a pattern of gene expression that prevents them from attacking cancer cells when they enter a tumour.

“Despite the fact that these T cells are proliferating, and they’re infiltrating the tumour, they were never licensed to kill,” Spranger says.

In the new study, her team delved further into this activation failure, which occurs in the lymph nodes, which filter fluids that drain from nearby tissues. The lymph nodes are where ‘killer T cells’ encounter dendritic cells, which present antigens (tumour proteins) and help to activate the T cells.

To explore why some killer T cells fail to be properly activated, Spranger’s team studied mice that had tumours implanted either in the lungs or in the flank. All of the tumours were genetically identical.

The researchers found that T cells in lymph nodes that drain from the lung tumours did encounter dendritic cells and recognise the tumour antigens displayed by those cells. However, these T cells failed to become fully activated, as a result of inhibition by another population of T cells called regulatory T cells.

These regulatory T cells became strongly activated in lymph nodes that drain from the lungs, but not in lymph nodes near tumours located in the flank, the researchers found. Regulatory T cells are normally responsible for making sure that the immune system doesn’t attack the body’s own cells. However, the researchers found that these T cells also interfere with dendritic cells’ ability to activate killer T cells that target lung tumours.

The researchers also discovered how these regulatory T cells suppress dendritic cells: by removing stimulatory proteins from the surface of dendritic cells, which prevents them from being able to turn on killer T cell activity.

Microbial influence

Further studies revealed that the activation of regulatory T cells is driven by high levels of interferon gamma in the lymph nodes that drain from the lungs. This signalling molecule is produced in response to the presence of commensal bacterial – bacteria that normally live in the lungs without causing infection.

The researchers have not yet identified the types of bacteria that induce this response or the cells that produce the interferon gamma, but they showed that when they treated mice with an antibody that blocks interferon gamma, they could restore killer T cells’ activity.

Interferon gamma has a variety of effects on immune signalling, and blocking it can dampen the overall immune response against a tumour, so using it to stimulate killer T cells would not be a good strategy to use in patients, Spranger says. Her lab is now exploring other ways to help stimulate the killer T cell response, such as inhibiting the regulatory T cells that suppress the killer T cell response or blocking the signals from the commensal bacteria, once the researchers identify them.

Reprinted with permission of MIT News