Category: Medicine

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Planning Pregnancy 6 Months After Radioactive Iodine Therapy Has Good Outcomes

 Receipt of radioactive-iodine treatment (RAIT) after thyroidectomy for thyroid cancer does not appear to be associated with adverse pregnancy outcomes when conception occurs six months or more after treatment, researchers from South Korea report.

 “Women are concerned about the risks associated with pregnancy after radioactive iodine treatment,” Dr. Hye Ok Kim from Health Insurance Review and Assessment (HIRA) Service and Ewha Womans University, in Seoul, told Reuters Health by email. “Therefore, accurate information about the recommended interval between radioactive iodine treatment and conception is critical for childbearing-age women and their treating physicians.”

 RAIT is commonly associated with oligomenorrhea and is a risk factor for congenital malformations. The American Thyroid Association and the European Association of Nuclear Medicine Therapy Committee recommend avoiding pregnancy for at least six months after RAIT, albeit based on relatively low quality of supporting evidence.

 Dr. Kim’s team used data from South Korea’s HIRA database to investigate whether RAIT was associated with an increase in adverse pregnancy outcomes among more than 10,000 women who became pregnant after thyroidectomy for thyroid cancer; 55% had surgery alone, while the rest had surgery plus RAIT.

 Conception rates in the RAIT group were significantly lower than in the surgery-only group in both the 0-to-5- and 6-to-11-month intervals after treatment but did not differ between the groups in the 12-to-23 months after treatment.

 Overall, there were no significant differences between the surgery-only and surgery-plus-RAIT groups in rates of abortion (spontaneous and induced), preterm deliveries or congenital malformations, the researchers report in JAMA Internal Medicine, online October 21.

 Among women who received RAIT, congenital malformation rates were higher, though not significantly so, for those whose interval between treatment and conception was 0 to 5 months (13.3%) versus 6 to 11 months (7.9%), 12 to 23 months (8.3%), or 24 months or more (9.6%).

 After adjusting for age at conception and cumulative radioactive iodine dose, the odds of congenital malformation were 74% higher (P=0.04) for early conception (0 to 5 months after RAIT) versus late conception (12 to 23 months after RAIT).

 The cumulative dose of radioactive iodine, however, was not associated with the risk of congenital malformations.

 The odds of abortion were also significantly higher (OR, 4.08) among women who received RAIT less than six months before conception versus those who conceived later.

 “These large-scale real-world data suggest that radioactive-iodine treatment after thyroidectomy is not associated with an increase in adverse pregnancy outcomes when conception occurs after a 6-month waiting period,” Dr. Kim said.

 “This study is the first large-scale, nationwide cohort study to examine the associations between radioactive-iodine treatment and pregnancy outcomes,” she said. “We believe that this data would be informative to women who attempt pregnancy during the early period after radioactive iodine treatment and their treating physicians.”

 Dr. James Wu of UCLA Section of Endocrine Surgery, in Los Angeles, who earlier reported delayed childbearing among women treated with radioactive-iodine ablation for well-differentiated thyroid cancer, told Reuters Health by email, “These findings provide more evidence that radioactive-iodine therapy does not impact birth outcomes long-term, but prolongs the time to conception. It reassures younger women with thyroid cancer that radioactive-iodine therapy will not adversely affect their offspring.”

 “On the other hand, the average time from radioiodine treatment to conception was a little over two years – a significant amount of time to women diagnosed in their thirties who desire children,” he said. “Women near advanced maternal age (35) who desire future pregnancy should communicate that clearly to their endocrinologists, as it may influence the decision to treat with radioactive iodine or not after thyroid surgery.”

 Dr. Wu added, “In general, radioactive iodine is an effective therapy for thyroid cancer with minimal side effects. However, it has only been proven to benefit high-risk cases of thyroid cancer and it is likely overused in cases in lower risk patients. All patients, especially those desiring future children, should have a thoughtful discussion with their endocrinologist about the risks and benefits of radioactive-iodine therapy.”

Courtesy : Medscape

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Weight Cutoffs for Elective Surgeries: Bias or Economics?

 Is access to elective surgeries a human right? For patients with severe obesity, this isn’t simply an interesting philosophical question. Rather, the answer is one that could change the trajectory of their lives. From breast reductions to knee replacements, fertility treatments, and more, weight as an exclusion criterion is a regular reality. But is it good medicine?

 Defenders of weight-based denial of care will often point to increased surgical risks or complications as the rationale for a BMI cutoff. But increased risks can be covered by obtaining informed consent, as is done with other conditions and circumstances that increase risks but—unlike obesity—don’t preclude consultation, let alone surgery.

 Some studies actively refute the presumptive risks. Multiple publications have suggested that weight-based restrictions for breast reductions should be abandoned, and others have found that the degree of pain relief after knee replacements is greater in those with obesity, while functional improvements are comparable. And finally, at least here in Canada, national recommendations have called for an end to BMI-based cutoffs for fertility treatments.

 Recently, this question led to a legal challenge in the Canadian province of Nova Scotia. Melody Harding was seeking a breast reduction but was told that because her BMI was above 27, she was ineligible for provincial coverage. Frustrated, she wrote to the Nova Scotia Human Rights Commission, and 2 years later, their intervention led to the removal of Nova Scotia’s BMI cutoff for reduction mammoplasty. Whether other cases and similar outcomes in other provinces will follow remains to be seen, but given the evidence and the precedent, I suspect they are inevitable.

Surgical Economics

 But what drives the cutoffs? If it’s not surgical outcomes, is it old-fashioned weight bias and paternalism, with doctors thinking that these cutoffs will motivate people to lose weight? Or worse, that people with obesity should not receive care because they have brought their miseries onto themselves by not moving more and eating less? That might be true for some, but a conversation I had with a plastic surgeon has me thinking that there are far more mundane considerations afoot. 

 We chatted about human rights, obesity, and elective surgeries. When I suggested that weight bias might be behind the cutoffs, he very quickly dismissed that as unlikely. More likely, according to him, are the boring realities of operating on patients with severe obesity: The surgeries take longer; may be more technically difficult or demanding; may require specialized equipment, training, or knowledge; and though not life-threatening, may also involve the surgeon spending more time dealing with complications or medical management postoperatively. He argued that weight-based cutoffs are about simple, dispassionate, surgical economics. And at least in regard to increased operative time and postoperative superficial skin infections, the medical literature is in agreement.

No Clear Answers

 When it comes to strategies for improvement, there are some obvious considerations, including reevaluating the evidence for and validity of existing weight-based cutoffs; ensuring surgical remuneration is commensurate for longer, more technically difficult cases and follow-up courses; improving clinical training to ensure that surgeons are comfortable dealing with common comorbidities associated with these more medically complicated patients; and recognizing weight bias as a subject worthy of careful attention in medical education.

 Without robust medical evidence to the contrary, obesity alone should never preclude a patient from the consideration of surgery, and informed consent is the tool with which to handle risk increases that are comparable to those of other conditions that don’t themselves preclude conversation. Anything less is weight-based discrimination.

 But if the basis of that discrimination is logistical, can surgeons be required to take on more complicated or lengthy cases, or to buy equipment specifically to work with patients with obesity? Is there a precedent for that in any other area of medicine? I don’t know the answers to these questions and would love to hear your thoughts in the comments.

Courtesy : Medscape

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Modern Gadgets Supposedly Accelerates Your Ageing

 Imagining a day without taking a look at your phones or laptop seems impossible today but being in front of screens for a long time has been found to affect our aging process!

 Continued and prolonged exposure to blue light, which emanates from your phone, computer, and household fixtures, might affect the longevity or accelerate the aging process, even when the screen isn’t directly shining in your eyes.

 This study, published in the journal – Aging and Mechanisms of Disease – suggests that the blue wavelengths produced by light-emitting diodes damage cells in the brain as well as retinas.

  It involved a widely used organism, Drosophila melanogaster, the common fruit fly, an important model organism because of the cellular and developmental mechanisms, it shares with other animals and humans.

 Researchers examined how flies responded to daily 12-hour exposure to blue LED light — similar to the prevalent blue wavelength in devices like phones and tablets — and found that the light accelerated aging.

 The flies exposed to blue light showed damage to their retinal cells and brain neurons and had impaired locomotion — the flies’ ability to climb the walls of their enclosures, a common behaviour, was diminished.

 Some of the flies in the experiment were mutants that do not develop eyes, and even those eyeless flies displayed brain damage and locomotion impairments, suggesting flies didn’t have to see the light to be harmed by it.

 “The fact that the light was accelerating aging in the flies was very surprising to us at first. We’d measured the expression of some genes in old flies, and found that stress-response, protective genes were expressed if flies were kept in the light. We hypothesised that light was regulating those genes. Then we started asking, what is it in the light that is harmful to them, and we looked at the spectrum of light,” said lead researcher Jaga Giebultowicz, a professor of integrative biology.

 “It was very clear cut that although light without blue slightly shortened their lifespan, just blue light alone shortened their lifespan very dramatically,” added Giebultowicz.

 Natural light is crucial for the body’s circadian rhythm — the 24-hour cycle of physiological processes such as brain wave activity, hormone production and cell regeneration that are important factors in feeding and sleeping patterns, Giebultowicz noted.

 “But there is evidence suggesting that increased exposure to artificial light is a risk factor for sleep and circadian disorders,” she added.

 The researcher went on to explain that with the prevalent use of LED lighting and device displays, humans are subjected to increasing amounts of light in the blue spectrum since commonly used LEDs emit a high fraction of blue light.

 In the meantime, there are a few things people can do to help themselves that don’t involve sitting for hours in darkness, the researchers say. Eyeglasses with amber lenses will filter out the blue light and protect your retinas. And phones, laptops and other devices can be set to block blue emissions.

 “In the future, there may be phones that auto-adjust their display based on the length of usage the phone perceives,” said lead author Trevor Nash, a 2019 OSU Honors College graduate, who was a first-year undergraduate when the research began.

Courtesy : Hindustan Times

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EMA Gives Thumbs Up For Ebola Vaccine

  European Medicines Agency (EMA) Committee for Medicinal Products for Human Use (CHMP) has recommended approval of the V920 Ebola Zaire vaccine (Ervebo, Merck ), the first vaccine to protect against the Ebola virus disease caused by Zaire Ebola virus in at-risk adults aged 18 years or older.

 “This is an important step towards relieving the burden of this deadly disease. The CHMP’s recommendation is the result of many years of collaborative global efforts to find and develop new medicines and vaccines against Ebola,” Guido Rasi, EMA’s executive director, said in a news release.

 The CHMP’s decision is a “triumph for public health, and a testimony to the unprecedented collaboration between scores of experts worldwide,” Tedros Adhanom Ghebreyesus, PhD, director-general of the World Health Organization (WHO), said in a news release.

 He offered his “deepest gratitude is to the studies’ volunteers, researchers, health workers in Guinea, other countries and the Democratic Republic of the Congo who have put themselves at risk to ensure people are protected with this vaccine.”

 The mortality rate in Ebola patients has varied from 25% to 90% in past outbreaks. The largest Ebola outbreak to date occurred in West Africa in 2014-2016, with more than 11,000 deaths.

 The current outbreak in the Democratic Republic of Congo (DRC), which is caused by Ebola Zaire, has a case fatality rate of roughly 67%. More than 3000 people have been infected with Ebola during the ongoing outbreak, which the WHO declared a public health emergency of international concern in July.

 Ghebreyesus said that in the current Ebola outbreak in the DRC more than 236,000 people have been vaccinated with Ervebo donated by Merck to the WHO, including more than 60,000 health and frontline workers in the DRC and in Uganda, South Sudan, Rwanda, and Burundi. “This vaccine has already saved many lives in the current Ebola outbreak, and the decision by European regulator will help it to eventually save many more,” Ghebreyesus said.

 Ervebo is a genetically engineered, replication-competent, attenuated live vaccine. Data from clinical trials and compassionate use programs have shown that a single dose of Ervebo protects against Ebola virus disease.

 The CHMP’s recommendation, completed under accelerated assessment, will now be considered by the European Commission, which will issue a final decision. 

 Ervebo is currently under review by the US Food and Drug Administration (FDA), which granted it breakthrough therapy designation.

 Last week, as reported by Medscape Medical News, the FDA approved OraQuick Ebola Rapid Antigen Test (OraSure Technologies), the first rapid diagnostic test to identify Ebola virus antigens, or proteins, in certain body fluids from living and deceased individuals.

Courtesy : Medscape

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Antibiotic Resistance In Race

   Resistance to commonly-used antibiotic clarithromycin is rising among Indian patients and that too at quite a fast pace, health experts have warned.

  Clarithromycin is used to treat a wide variety of bacterial infections. This medication can also be used in combination with anti-ulcer medications to treat certain types of stomach ulcers.

   According to the World Health Organization (WHO), antibiotic resistance is one of the biggest threats to global health, food security and development today.

   Sunil Sofat, Additional Director, Department of Interventional Cardiology (Adult) at Jaypee Hospital in Noida, said that every antibiotic medicine has its own mechanism to treat diseases.

   “Yes, this is true that the resistance to clarithromycin is rising among the Indian patients and that too at quite a fast pace. There are multiple factors for the same but one of the major reasons behind it is self-medication,” Sofat told IANS.

   “In India, a huge population prefers to consume over-the-counter (OTC) drugs without even consulting a doctor. In the long run, this may make them resistant to most of the antibiotics including clarithromycin,” Sofat added.

   In a recent study presented at United European Gastroenterology (UEG) Week Barcelona 2019, researchers have found that resistance to clarithromycin, one of the most established antimicrobials used to eradicate Helicobacter pylori (H. pylori), had increased from 9.9 percent in 1998 to 21.6 percent last year, with increases in resistance also seen for levofloxacin and metronidazole.

   The study, which analysed 1,232 patients from 18 countries across Europe, investigated resistance to antibiotics regularly taken for Helicobacter pylori infection, a harmful bacterium associated with gastric ulcers, lymphoma and gastric cancer.

   According to Gaurav Jain, Senior Consultant, Internal Medicine at Dharamshila Narayana Superspeciality Hospital, New Delhi, antibiotic resistance is a major concern.

   “In India the consumption of antibiotics without consulting a qualified physician is quite common which is leading to its resistance,” Jain told IANS.

   “There is increase in resistance to antibiotics including clarithromycin which is undoubtedly a worrisome situation in the country,” Jain said.

   However, Deepak Verma of Internal Medicine at Columbia Asia Hospital, Ghaziabad said: “Most of the cases that we see in India are connected to gram-negative bacteria such as e.coli that causes urinary tract infection (UTI).”

   He added that the main causes for antibiotic resistance in India are its rampant misuse where people indulge in self-doctoring as well as taking medicines prescribed by unregistered medical practitioners, including quacks who suggest antibiotics quite indiscriminately.

   “They primarily use antibiotics symptomatically which is not a correct method for all ailments — without blood and urine culture. Antibiotics can force the pathogen to develop resistance,” Verma explained.

   “Since the clinical culture in India is different from that of the western countries, the lack of awareness of the right process to prescribe antibiotics increases the chances of people using antibiotics without questioning,” he stressed.

Courtesy : India Today

 

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Which is the best time for excercise to loose weight ?

   The research was performed on 30 men and extended over a period of one and a half months. The men were classified as obese or overweight and compared results from two intervention groups (who ate breakfast before/after exercise) and a control group (who made no lifestyle changes), found that people who performed exercise before breakfast burned double the amount of fat than the group who exercised after breakfast.

   The study established that increased fat use is mainly due to lower insulin levels during exercise when people have fasted overnight, which means that they can use more of the fat from their fat tissue and the fat within their muscles as a fuel.

   While this did not show any significant weight loss, it has a very positive impact on their health because their bodies were better able to respond to insulin, keeping blood sugar levels under control and potentially lowering the risk of diabetes and heart disease. The researches also wanted to focus on the impact on the fat stores in muscles for individuals who either worked out before or after eating and the effect this had on insulin response to feeding.

   In the trial that extended over a period of a month and a half, the research team found that the muscles from the group who exercised before breakfast were more responsive to insulin compared to the group who exercised after breakfast, in spite of identical training sessions and matched food intake.

   The muscles from those who exercised before breakfast also showed greater increases in key proteins, specifically those involved in transporting glucose from the bloodstream to the muscles. For the insulin response to feeding after the six-week study, remarkably, the group who exercised after breakfast were in fact no better than the control group, the study said.

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Knee, Hip Steroid Injections May Speed Joint Damage in Some

   Steroid injections are frequently used to relieve pain associated with osteoarthritis of the knee and hip, but new evidence suggests the treatment may do more harm than good for some people. Experts now stress the need for better informed consent about potential risks and benefits of injections.

   Data from more than 450 patients who received intra-articular corticosteroid injections for osteoarthritis at Boston University show that the treatment may speed the pace of osteoarthritis and contribute to joint destruction.

   The article was published online October 15 in the journal Radiology.

   “We are now seeing [that] these injections can be very harmful to the joints, with serious complications such as osteonecrosis, subchondral insufficiency fracture, and rapid progressive osteoarthritis,” senior author Ali Guermazi, MD, PhD, said in a press release. Guermazi is chief of radiology at the Veterans Affairs Boston Healthcare System and professor of radiology at Boston University School of Medicine.  

   Some patients may be more prone than others to poor outcomes from the treatment, but it’s not yet known how to identify these people. The researchers stress the importance of informed consent, and urge radiologists to take x-rays before administering steroid injections, in order to identify underlying problems that may contribute to adverse events.  

   “Intra-articular corticosteroid injection should be seriously discussed for pros and cons. Critical considerations about the complications should be part of the patient consent, which is currently not the case right now,” Guermazi added.

Long-term Data Has Been Lacking

   The first-line treatment for osteoarthritis, which most commonly affects the hip and knee, is conservative pain control, but many patients eventually need joint replacement. Yet people with osteoarthritis are often older and have multiple medical problems that make them ineligible for surgery or long-term treatment with acetaminophen or nonsteroidal anti-inflammatory (NSAIDs) medication.

   Steroid joint injections have been widely used for decades to treat patients like these, and others with inadequate pain control. While short-term complications are rare, most studies on the long-term effects are of low quality. Some evidence from animal and human laboratory studies suggests steroid joint injections may contribute to progression of osteoarthritis. Professional societies differ on whether or not to recommend steroid joint injections for osteoarthritis.

   Therefore, Andrew Kompel, MD, also from Boston University School of Medicine, and colleagues reviewed the records of 459 individuals who received at least one corticosteroid injection in the hip or knee joint in 2018 at an inner city hospital in Boston.

   Overall, 8% (n = 36) of patients experienced an adverse joint event after receiving a steroid joint injection. These individuals ranged in age from 37 to 79 years (mean age, 57 years) and most (72%) showed moderate osteoarthritis at baseline. They received an average of 1.4 injections and developed joint complications anywhere between 2 to 15 months after injection, with an average of 7 months.

   The authors identified four main adverse joint events after steroid joint injections. The most common was accelerated progression of osteoarthritis, found in 6% of individuals (n = 26).  

   The second most common adverse joint event was subchondral insufficiency fracture, found in 0.9% (n = 4) of individuals. Subchondral insufficiency fracture has traditionally been thought to occur in older individuals with weak bones, but recent evidence suggests it may be more common and affect younger patients.

   The condition is potentially underdiagnosed due to lack of awareness. Delayed diagnosis can lead to joint damage and eventual joint replacement.  Diagnosis is important before giving steroid joint injections, which can impair healing in these kinds of fractures, according to the authors.  

   In addition, osteonecrosis and rapid joint destruction each affected 0.7% (n = 3) of patients, respectively.

   Osteonecrosis refers to decreased blood flow to the bone that can cause breakdown of the bone, eventual fracture, and need for joint replacement. Patients with osteonecrosis but without fracture sometimes receive steroid joint injections. The authors emphasize the need to inform such patients that steroid joint injections could potentially worsen their condition.

   They also note that rapid joint destruction and accelerated bone loss may occur after the first steroid injection and in patients without evidence of underlying disease on x-ray. In these patients, they suggest closely reviewing the need for injection and repeating x-rays before giving further injections.

   The authors conclude: “The radiology community should actively engage in high-quality research to further understand these adverse joint findings and how they possibly relate to [intra-articular corticosteroid] injections to prevent or minimize complications.”

   In an accompanying editorial, Richard Kijowski, MD, of the University of Wisconsin School of Medicine and Public Health, notes several limitations of the study, including the small number of patients and lack of standardized methods.

   “The report is neither a prospective clinical trial nor a retrospective observational study…The objective is to educate radiologists that the intra-articular corticosteroid injection they routinely perform with little, if any, thought about long-term safety may cause more harm than benefit,” he writes.

   He agreed with the authors about the importance of informed consent.

   “Patients might be more than willing to take the small risk of an adverse joint event requiring eventual joint replacement for the possibility of at least some degree of pain relief after intra-articular corticosteroid injection,” he concludes. “However, patients have the right to make this decision for themselves, and this requires radiologists to discuss all potential risks and benefits with the patient when obtaining written informed consent.”

   The study authors acknowledge that they could not determine whether these adverse joint events were already present when patients had their steroid joint injections, or if the injections caused these problems.

Courtesy : Medscape