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First African American Face Transplant Done

 In July, Robert Chelsea became the first African American patient to have a full face transplant, Boston’s Brigham and Women’s Hospital announced. The procedure took 16 hours and involved a team of over 45 medical professionals.

 Chelsea, 68, is also the oldest face transplant patient. He’s one of just 15 recipients in the United States, out of around 40 worldwide done since 2005.

 “May God bless the donor and his family who chose to donate this precious gift and give me a second chance,” Chelsea said in a statement. “Words cannot describe how I feel. I am overwhelmed with gratitude and feel very blessed to receive such an amazing gift.”

 A drunken driver slammed into his car in 2013, leaving Chelsea with third-degree burns covering half his body, according to Time. After having more than 30 surgeries, he was put on the transplant list in March 2018. Just 2 months later, a face became available, but the skin tone was much lighter than Chelsea’s. He turned it down, then waited more than a year for another opportunity.

 According to the hospital, Chelsea “is likely to achieve near normal sensation and about 60 percent restoration of facial motor function within a year, including the ability to eat, smile and speak normally.” His was the ninth face transplant procedure done at Brigham and Women’s Hospital.

 “The face symbolically is such an important part of our bodies, to some people it’s almost who we are,” says Jerry McCauley, MD, chief of nephrology at Thomas Jefferson University Hospital and former chairman of minority affairs at the United Network of Organ Sharing (UNOS). “African Americans have a wide variety of skin colors, so there could be a major difference. When you’re doing cosmetic transplants you want to match as closely as you can: What will my lips look like, my nose? Will I resemble people in my family?”

 Until recently, African Americans were less likely than white people to receive transplants of any kind. At one point, they waited almost three times as long, McCauley says. In 2015, UNOS rolled out a new allocation system that removed much of the systemic bias. Today, the wait time for kidneys is approximately the same for both races, though there’s still a disparity among heart and lung recipients.

 “That may have to do with some of the diseases that African Americans have, compared to whites. Also, the number of people even being evaluated for heart and lung transplants is lower in the African American population than in the white population,” says McCauley. UNOS is working on the allocation system for those organs, aiming to achieve equal sharing among races. “With UNOS, it’s a good story/bad story. The bad is, it took so long to fix it, and the good is they’re all in now,” he says.

 According to Organdonor.gov, African Americans make up nearly 30% of the wait list for transplants, compared to almost 41% for white people — yet African Americans only receive about 21% of transplants, while white people get more than 55%. Black people make up around 13% of the U.S. population.

 “That may have to do with physician selection, socioeconomics, even where you’re being evaluated,” says McCauley. “And the final issue may be the discrimination factor that nobody likes to talk about.”

 For many years, there was also a substantial racial disparity in the number of donors. Distrust of the medical system, certain religious beliefs, and other concerns kept many black people from donating. In 1988, for example, there were only 359 African American deceased donors. Because of a joint effort to increase donations, by 2018, that number had surpassed 7,000. The percentage of donors who are black now reflects their percentage in the population, even though allocation of organs remains uneven.

 When it comes to organs and non-cosmetic transplants, race isn’t a factor — we’re all the same beneath the skin. But body parts like the face, hands, and reproductive organs require composite tissue transplants. Those take multiple tissue types, including skin, bones, nerves, and blood vessels, and when skin is involved, appearances count. Thanks to the increased rate of donation among African Americans, the larger pool of skin tone matches may have helped bring about Chelsea’s transplant, McCauley says.

 “It’s going to be exciting,” says McCauley. “Other African Americans will see this gentleman and know this is for them, too. You don’t have to worry about getting a transplant with a white face. You can have a face that makes sense for you.”

Courtesy : Medscape

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Cardiac Biomarkers Maybe Helpful In Identification Of High-Risk Kidney Disease Patients

 Scientists have found that two biomarkers — high-sensitivity troponin (hs-TnT and N-terminal prohormone BNP (NT-proBNP) — are linked to increased risk for poor cardiovascular outcomes in patients with chronic kidney disease (CKD).

 The study was published in Mayo Clinic Proceedings by Shravya Vinnakota,  MBBS, of the Department of Internal Medicine at the Mayo Clinic, Rochester, and colleagues.

 NT-proBNP, a precursor to brain natriuretic peptide (BNP), and hs-troponin are both cleared by the kidneys. Clinicians have therefore been hesitant to use them to predict cardiovascular outcomes in people with CKD because of concerns that they may be falsely elevated in these patients.

 But, “In this study we demonstrated that NT-proBNP and hs-TnT have  prognostic value regardless of kidney function,” senior author Horng H. Chen, MB, BCh, told Medscape Medical News by email.

 “Hence, these two biomarkers can be used to help clinicians…identify patients with kidney disease who are at highest risk for adverse cardiac events and [who] would be candidates for aggressive risk factor modification to prevent adverse outcomes,” added Chen, a cardiologist who specializes in heart failure at the Mayo Clinic.

Does Impaired Kidney Function Alone Up Risk of CVD?

 Cardiovascular disease (CVD) claims more lives in people with CKD than complications of kidney disease. This can be explained in part by shared common risk factors including hypertension, diabetes, hyperlipidemia, smoking, and obesity.

 However, there is growing evidence that impaired kidney function and raised albuminuria levels are risk factors for CVD independent of traditional factors such as hypertension and diabetes.

 In addition, there are pathologic mechanisms that are unique to CKD that promote vascular disease, thus contributing to the increased burden of CVD, Vinnakota and colleagues explain.

 However, there is a paucity of studies stratifying cardiovascular risk in patients with CKD, they add.

Heart Attack Risk Almost Doubled in Those With Significant CKD

 The researchers therefore set out to classify participants by renal function, characterize trends of cardiac biomarker activation and left ventricular function, and report cardiovascular outcomes over a 10-year follow-up period using data from a retrospective study, including 1981 participants from the Olmsted County Heart Function Study.

 Participants were aged 45 years and older between January 1997 and  December 2000, and had had a clinical evaluation, medical record review, lab tests, and echocardiogram. Follow-up was a median 10.2 years. Results were adjusted for age and sex.

 The prevalence of stage 3 CKD (eGFR < 60 mL/min/1.73m2) was 6.4% (126/1981). In the remainder of the group, 52.3% (1036/1981) had mild renal insufficiency (eGFR 60-89 mL/min/1.73m2) and 41.3% (819/1981) had normal kidney function.

 Compared to participants with normal kidney function, those with stage 3 CKD had a 38% increased risk of the primary outcome, a composite of myocardial infarction (MI), congestive heart failure (CHF), stroke, and all-cause mortality (HR, 1.38; P = .02).  

 Similarly, those with stage 3 CKD had almost double the MI risk (HR, 1.95; P = .006), and were also at higher risk for stroke, CHF, and death individually, compared with those with normal kidney function, although the latter three results were not statistically significant.

 Furthermore, people with NT-proBNP and hs-TnT levels in the highest tertile were at greater risk for adverse cardiovascular outcomes including CHF, MI, stroke, and all-cause mortality, compared to those with lower levels of the biomarkers.

 And the degree of kidney impairment, as estimated by eGFR, did not significantly affect the results, suggesting renal impairment was not the only reason for elevation of the biomarkers

 The authors note some study limitations, however.

 Because most participants were white, the results may not apply to more diverse groups. The study also lacked information about duration and severity of coexisting medical conditions and cardiac medications, which could have affected outcomes. And cardiac biomarkers were only measured at the start of the study, so whether they changed over time is unknown.

Lower Thresholds of Biomarkers for Prediction of Poor Outcomes

 Further analysis suggested an optimal cut-point for the overall study group of 97.1 pg/mL for NT-proBNP and 3.8 ng/L for hs-TnT; these values were similar to the third tertile for both biomarkers, say the researchers.

 “In comparison with prior studies, these data suggest lower thresholds of both biomarkers for prediction of poor outcomes,” they note.

 “Our findings validate the importance of monitoring these levels in patients with CKD and propose an additional tool to identify those at highest risk for adverse cardiovascular events,” the authors state.

 Nevertheless, more work is needed to confirm the results and whether “these cardiac biomarkers could identify high-risk CKD patients for aggressive management of cardiovascular risk factors,” they conclude.

Courtesy : Medscape

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Trans Fats Has Increased Dementia Risk

 Higher serum trans-fat levels have been associated with a significantly elevated risk of dementia, including Alzheimer’s disease (AD), results of a large, longitudinal study show.

 Participants with the highest concentrations of serum elaidic acid, a major trans-fatty acid formed in the partial hydrogenation of vegetable oils, had a 53% increased risk of dementia. This group also had a 43% higher likelihood for developing AD compared with those with the lowest levels.

 “We found that higher serum elaidic acid levels were associated with greater risk of developing all-cause dementia and Alzheimer’s disease, after adjustment for traditional risk factors as well as dietary saturated and polyunsaturated fatty acids intake,” principal investigator Toshiharu Ninomiya, MD, PhD, told Medscape Medical News.

 “In addition, the self-reported intake of breads, margarine and confectioneries were correlated with serum elaidic acid levels, although the magnitude of the correlation was not strong,” added Ninomiya, a professor in the Departments of Epidemiology and Public Health and the Center for Cohort Studies, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.

 The study was published online October 23 in Neurology.

US Ban

  Previousresearch has linked excessive consumption of trans fats to the development of coronary artery disease, diabetes, and other conditions.

 Given these health concerns, the FDA banned artificial trans fats from grocery store and restaurant foods in June 2018. The agency permits foods with less than 0.5 grams of trans fats to be labeled as containing zero grams of trans  fats, so some foods still contain partially hydrogenated oils.

 “These results give us even more reason to avoid trans fats,” Ninomiya said in a news release. “In the United States, the small amounts still allowed in foods can really add up if people eat multiple servings of these foods, and trans fats are still allowed in many other countries.”

 The World Health Organization also is taking action with an initiative to eliminate industrial trans fat from the global food supply by 2023.

 However, less is known about any potential association between trans fat and dementia. The few studies in the literature have yielded inconsistent results, the researchers note.

 In search of a more definitive answer, the investigators assessed data from 1628 participants in the ongoing, prospective Hisayama Study. The 925 women and 703 men completed questionnaires and provided blood samples in 2002 to 2003. All were 60 years or older at baseline.

 The researchers also classified serum levels of elaidic acid into quartiles, and then followed participants prospectively for a median of 10.3 years.

10-Year Follow-up

 Participants completed the Diet History Questionnaire, reporting intake of 150 food items in 23 categories. The researchers focused on seven of these food groups known to contain trans fats, including cereals, confectioneries, animal and plant fat, sugar and sweeteners, seasonings, meat, and dairy products.

 Participants self-reported educational status, smoking, alcohol intake, regular exercise, and any treatments for hypertension or diabetes.

 Over more than a decade of follow-up, 377 participants developed all-cause dementia, including 247 who developed AD and 102 who developed vascular dementia.

 Using the lowest quartile of serum elaidic age concentration group as a reference, the likelihood for developing all-cause dementia significantly increased with higher serum trans-fat groups. For example, the second quartile cohort had a hazard ratio (HR) of 1.24 (95% confidence interval [CI], 0.92 – 1.68; P = .16).

 Findings for the third quartile (HR, 1.63; 95% CI, 1.21 – 2.18; P = .001) and the fourth and highest serum quartile (HR, 1.53; 95% CI, 1.14 – 2.04; P = .004) also were noteworthy.

 “Although significant linear trends were observed, the risk of developing dementia and AD appeared to increase at the level of the third quartile,” the researchers note.

 Again, using the lowest serum trans-fat cohort as reference, the risk for developing AD increased with increasing concentrations of elaidic acid. The hazard ratios were 1.22, 1.79, and 1.43 for the second, third, and fourth quartiles, respectively.

Pastries, Margarine, Candy

 The association between serum elaidic acid and risk of all-cause dementia and AD remained in a multivariable model that adjusted for age, sex, education, hypertension, diabetes, total cholesterol, BMI, history of stroke, and other traditional risk factors. This model also adjusted for total energy intake, as well as intake of saturated and polyunsaturated fatty acids.

 Investigators found no significant association between higher elaidic acid levels and risk of vascular dementia.

 “Since serum elaidic acid levels are likely to reflect industrially produced trans-fat intake, our findings raise the possibility that avoiding the intake of foods high in trans fat may reduce the risk of future onset of dementia,” Ninomiya said.

 Sweet pastries were the strongest predictor of higher serum elaidic levels, followed by margarine and sugar confections such as candy, caramels, and chewing gum. Croissants, nondairy creamers, ice cream, and rice crackers were also associated with higher trans-fat levels in the study.

 “Public health policy to augment food industry efforts to reduce trans-fatty acids in the food supply and to educate the public about healthy food choices may additively contribute to the primary prevention of dementia,” the researchers note.

 The mechanisms underlying the link between serum elaidic acid levels and dementia are still unknown, Ninomiya said. More research is necessary to confirm these findings, she added.

 A potential limitation is that all participants were from the same town in Japan and levels of trans fats in the diet vary by country, region, and time period. Therefore, the results may not apply to other populations, the researchers note.

A “Good News Story”

 The study is “definitely interesting. There is a growing body of evidence between diet and risk of dementia. And it’s probably about people not getting enough green leafy vegetables, nutrients, or vitamin B, for example,” Keith Fargo, PhD, director of scientific programs and outreach at the Alzheimer’s Association in Chicago, told Medscape Medical News.

 “The risk could also be related to environmental toxins, where people are exposed via food or environmental pollution,” he added.

 Caution is warranted but the study is about associations and not causation, Fargo noted. “The authors did a good job of controlling for other factors, but it is impossible to control for everything,” he said.

 “I would consider this a good news story. In the US, we have largely banned trans fats, and this could be good news for future dementia levels,” Fargo said. “This is another piece of evidence to support the FDA’s actions.”

Courtesy : Medscape

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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