Diagnosing Food Allergies

What Is the Main Idea?

This blog post is about the reliable diagnosis of food allergies, which is currently mainly done through the use of oral food challenges. In addition, it refers to the paper “Diagnostic Performance of IgE Anti-Der p 10 to Identify Patients with Shrimp Allergy”, published in the journal International Archives of Allergy and Immunology, which describes one of many studies trying to find new and reliable ways of diagnosing food allergies.

What Else Can You Learn?

The blog post also goes into the differences between food allergies and food intolerances: an important distinction that is often misunderstood.

What Is the Difference between a Food Allergy and a Food Intolerance?

Food allergies are extremely dangerous. If someone has one, it means there is a protein in a foodstuff that causes an anaphylactic reaction from their immune system. This reaction can be life-threatening: Although it may be restricted to skin reactions or a sudden drop in blood pressure, it can also cause the airways to constrict, making it difficult or impossible to breathe. Other effects include nausea and dizziness. Anaphylaxis requires rapid medical intervention.

People with food allergies should carry an EpiPen, which allows them to inject epinephrine into a large muscle, usually the thigh. This medication relaxes the muscles in the airways, stomach, intestines, and bladder; and can increase blood pressure to a safer level. After using an EpiPen, people are still advised to seek medical attention as they may need prescription antihistamines or other support.

Food intolerances are unpleasant, but not necessarily dangerous. If someone has one, it means they have difficulty digesting a certain food, a group of foods, or even a range of different foods. They may suffer bloating, indigestion, cramps, diarrhea, and so on. Skin reactions are also possible. The reaction generally occurs within hours of eating the food.

Medical attention might be necessary as there can be significant impact (e.g., malnutrition due to a lack of proper digestion of food, dehydration from longer-lasting or regular diarrhea, poor quality of life). Note that medical intervention is always advised when a child has a food intolerance, as they can interfere with development.

How Are Food Allergies Diagnosed?

Since the allergic reaction to a food protein can be so serious, it is obviously very important to have a reliable method for diagnosing food allergies. Currently, the commonly used method is an oral food challenge, which works by actually causing an allergic reaction.

Oral food challenges involve giving a patient the food (or the protein from that food) that is suspected to cause an allergy, initially in miniscule quantities that may not cause any reaction. The administrating physician observes the patient for a set period to see if there is any reaction, then gives a slightly larger amount of the food (or protein), and so on. Because the amounts are so small, a severe reaction is not expected. Instead, a mild rash, flushed skin, or hives might develop. If this occurs, the test is concluded and ruled positive (i.e., the patient is allergic to a protein in that foodstuff). Naturally, the patient will then receive something to alleviate the reaction — even a mild allergic reaction can be uncomfortable!

National medical authorities require that oral food challenges only be given by trained medical professionals because there is a small risk of a severe anaphylactic reaction. If this happens, treatment must be administered immediately.

Is This the Only Method for Diagnosing Food Allergies?

Oral food challenges are the only method that is 100% reliable, but there are other methods. Blood tests can also work: A blood sample is taken and tested against various proteins to see if there is a measurable change in the level of the allergy-related antibody immunoglobin E (IgE). However, we do not yet know what the most reliable IgE antibodies are for every food allergy.

A skin prick test can also support diagnosis: Similar to a skin prick test for airborne allergens, a solution containing the protein is placed on the skin, which is then pricked with a needle to allow a small amount under the top layer of the skin. However, a positive reaction from the skin does not always indicate an allergy.

Do Oral Food Challenges Work for Diagnosing Food Intolerances?

The described type of oral food challenge does not work for diagnosing food intolerances because these are digestive reactions, not allergic reactions. Giving someone a miniscule amount of the food will not provoke a digestive reaction; and even giving someone a larger amount will not provoke a quick reaction. Similarly, since a food intolerance is not an allergic reaction, testing for antibody responses or skin responses will not show anything. The best way to diagnose a food intolerance is through elimination diets and food records.

What Is the Paper about?

The paper “Diagnostic Performance of IgE Anti-Der p 10 to Identify Patients with Shrimp Allergy” describes a study done to see if the IgE named anti-Der p 10 would be useful for diagnosing shrimp allergies. This type of study is done to try to find reliable replacements for oral food challenges.

In this case, anti-Der p 10 was found to be a reliable biomarker for predicting a shrimp allergy: Every single patient who was positive for a shrimp allergy in an oral food challenge was also positive for anti-Der p 10.

More studies of this type will be important to identify more IgE antibodies that give similarly reliable results.

A Note about Celiac Disease

Although the symptoms of celiac disease are related to the gut, it is not the same as a gluten intolerance. It is also not a food allergy, although the immune system is involved. Celiac disease is an autoimmune disorder where reactions are triggered by gluten, a protein found in wheat. Therefore, the information in this blog post and in the paper are not relevant for the diagnosis of celiac disease.

In some cases, oral food challenges are given to people who already have a known food allergy. For example, an allergist may order the test to find out if a patient has outgrown the allergy. In clinical trials, oral food challenges help researchers learn how well participants are responding to the treatment under study.

Note: This post is based on an article that is not open-access; i.e., only the abstract is freely available.

An Introduction to Cochlear Implants and Auditory Brainstem Implants

What Is the Main Idea?

This post focuses on cochlear implants and auditory brainstem implants, which are two similar medical devices that can make it possible for some people with hearing loss to hear some sounds. The post describes the differences between them, and lists the benefits and risks. It also lays out some advice for people considering such implants, especially parents of children with hearing loss. In addition, it refers to the paper “Children with Auditory Brainstem Implant: How Do They Perform in Motor and Language Skills?”, published in the journal Audiology and Neurotology, which describes a study that would be interesting to parents of children up for such an implant and for physicians working in this area.

What Else Can You Learn?

The blog post also goes into some of the objections to childhood cochlear implants, which could also apply to auditory brainstem implants. These objections are raised by members of the Deaf community, including many who received such implants as children or infants.

Hearing Aids Aren’t Suitable for Every Type of Hearing Loss

Hearing aids can help people who are hard of hearing to hear sounds by amplifying sounds they have difficulty picking up. They essentially consist of a microphone, a processor programmed to amplify specific sounds, and an in-ear speaker. However, not everyone with hearing loss can benefit from hearing aids: If the hearing loss is due to damage to the ear structure, an implant may be an option.

What Is the Difference between a Cochlear Implant and an Auditory Brainstem Implant?

A cochlear implant is an electronic medical device that can make it possible for some people with hearing loss to hear some sounds. It consists of an external microphone and processor that pick up sounds and transmit them to an implanted wire ending in small electrodes in the cochlea, which is part of the inner ear. The signals transmitted to these electrodes can then be transmitted via the cochlear nerve to the brain.

An auditory brainstem implant can provide some level of hearing to some people who would not be helped by a cochlear implant. For example, if the auditory nerve is missing, the inner ear is scarred after an infection or injury, or the inner ear has an atypical structure, a cochlear implant may not work. Auditory brainstem implants bypass any damage to the inner ear or auditory nerve because the internal wire and electrode array are implanted directly in the brainstem. The external part is similar to a cochlear implant: a microphone and processor.

Cochlear implant surgery is more common and less invasive than auditory brainstem implant surgery, because the latter requires an expertise in complex brainstem work.

After either surgery, the recipient of the implant must work with a specialist to learn how to interpret the signals, as they are not the same as the signals that the ear would generate on its own. It is possible that the recipient of either type will not benefit from the implant at all.

Currently available cochlear implants are more likely than auditory brainstem implants to provide word recognition. Both can require lip reading to gain much benefit in conversation.

Why Are These Implants Seen as Controversial?

Activists in the Deaf community have raised objections to the way these implants are seen as a way to “fix” infants and children who have limited or no ability to hear sounds. They point out that neither surgery is guaranteed to work; that neither provides the ability to hear sounds in the way people commonly understand hearing; and that the aural rehabilitation after surgery can be arduous and upsetting for infants and younger children.

What Do Deaf Adults with Childhood Cochlear Implants Say?

I’ll focus here on cochlear implants because there is more written about them and they are more spoken about within the Deaf community.1

Not all adults who received cochlear implants as infants are happy with the decision having been taken for them. This attitude is especially common if the aim was to “fix” them and put them into mainstream education, with no attempt on the part of the family to learn the national sign language, engage with the Deaf community, and look at broader education possibilities. Even with a cochlear implant, there can be issues with engaging with mainstream education, particularly if the implant is not fully successful and there is no attempt to compensate for any failings with other support (e.g., in-class assistance). Such a child can feel cut off from the Deaf community, which could otherwise provide valuable support.

Other adults who received cochlear implants as infants are happy with them because they had positive experiences. This can include feeling comfortable operating in speech- and sound-centric environments, and finding their way in mainstream education without further support. Some feel the lack of other Deaf people in their lives; some have connected with the Deaf community.

What Does This Mean for Parents?

It’s important for parents considering cochlear or auditory brainstem implants for an infant or child to engage with such information. These personal experiences of Deaf and hard-of-hearing adults can help them make a fully informed decision as well as prompting questions for the surgeons and other physicians.

Ultimately, any implant has more complicated considerations than hearing aids, glasses, mobility aids, and other external devices. It may not be possible to remove implants later and they cannot be “swapped for a better model”. Ensuring that one understands the lifelong implications of an implant is critical.

What about the Videos of Babies Who’ve Received Implants?

Beyond these experiences, objections are raised over the commonly shared videos with titles like “Baby hears for the first time”. The videos rarely show the full truth of the experience, which can involve a whole range of reactions, including infants’ fear and confusion at suddenly receiving signals that their brains don’t know how to interpret. The videos focus instead on the “inspirational” quality of the moment(s).

Within the Deaf community and the broader disabled community, there is a general skepticism about the motivation of non-Deaf and non-disabled people’s attempts to create inspirational content from our1 experiences, challenges, medical procedures, and successes.

Does This Mean That the Implants Are not Appropriate for Teenagers and Adults with Hearing Loss?

Teenagers and adults can advocate for themselves and give informed consent. As such, they can discuss the potential risks and benefits of the implants with their physicians and gain a better understanding of the post-surgical rehabilitation. This is a very different situation. It is especially important for a teenager or adult to engage with how rigorous the post-surgical rehabilitation can be.

What Are the Risks of Cochlear and Auditory Brainstem Implants?

Surgery always carries risks such as bleeding, swelling, and infection. Cochlear implants are generally well tolerated, but there are rare cases of post-surgical tinnitus (ringing in the ears), vertigo, nerve injury causing movement problems in the face, and meningitis. The same risks are associated with auditory brainstem implants, but since they are less commonly used, there is less data on their tolerance in the broader population.

What Is the Paper about?

The authors of “Children with Auditory Brainstem Implant: How Do They Perform in Motor and Language Skills?” focus on how congenital hearing loss or loss of the aural vestibule (the part of the ear between the semi-circular canals and the cochlea) can impair not only the acquisition of language, but also the development of motor skills. The described study involved ten children between the ages of 4 and 17 who had been fitted with an auditory brainstem implant on one side. The children were evaluated on their fine motor control, balance, manual dexterity, language, and sound perception using standardized tests.

The results showed a strong correlation between poor manual and balance skills and poor speech perception and language skills in the children. The group is too small to draw a broad conclusion, but it indicates the need to assess children before and after the implant surgery to establish the baseline manual, balance, and speech perception skills; and to give greater support to children after the implant surgery to ensure the best outcome.

What Does the Paper’s Conclusion Mean for the Parent(s) of a Potential Recipient of an Auditory Brainstem Implant?

The paper focuses on support. It states that an infant or child patient’s parent(s) and physician(s) should ensure the child is going to get the best support and post-surgical rehabilitation, to ensure that the benefits are the best possible. It also shows how important it is to ask for pre- and post-surgical evaluations.

Note: This post is based on an article that is not open-access; i.e., only the abstract is freely available.

1Victor Kelly has adult-onset hearing loss and uses hearing aids, lip reading, Irish sign language, and Danish sign language to communicate. They are also a wheelchair user. Victor considers themself an activist and engages regularly with various disabled communities, including the Deaf community.

How Do Patient Expectations Impact Dermatological Treatments?

What Is the Main Idea?

Patient expectations can affect their treatment experiences, even having an impact on efficacy and tolerability. The open access review paper “Effects of Patients’ Expectation in Dermatology: Evidence from Experimental and Clinical Placebo Studies and Implications for Dermatologic Practice and Research”, published in the journal Dermatology, discusses some of these effects as they relate to dermatological treatments. This post summarizes the main points from that article.

What Else Can You Learn?

The post also gives fundamental information about placebo and nocebo effects and the importance of countering them with information.

The Placebo Effect

I’m sure you’re familiar with the term “placebo effect”. It’s mainly assumed to describe the situation when someone feels better after a drug or treatment that is fake (not designed to have a pharmacological or physiological effect, pharmacologically or medically inactive). Impacts can be apparent improvements in physical or mental health, actual alleviation of some symptoms (e.g., pain relief), or an upswing in energy.

Do Placebos Affect the Body?

Research has shown that placebos do have an effect on the brain: For example, there can be a reduction in activity in the parts of the brain related to pain experiences when a patient receives a placebo and is told it will reduce pain. This reduction in activity can even be mapped in neuroimaging studies. There is also evidence that the body’s own pain management systems (e.g., endogenous opioids like enkephalins and endorphins) can be involved in placebo-related pain management.

Studies into the impact of placebos on other physiological systems and organs are still ongoing, but participants in placebo groups have displayed or reported improvements in their heart rates and blood pressure as well as reduction in anxiety and other psychiatric symptoms.

What Is the Nocebo Effect?

The placebo effect can also be used to describe the negative impact of a treatment: Placebo group participants have reported increased pain, heart murmurs, increased blood pressure, rise in anxiety, and other undesirable effects when given a placebo and told it might have certain side effects. However, this is more accurately referred to as a nocebo effect.

Can Placebo and Nocebo Effects Occur with “Real Medicine”?

It’s important to realise that the placebo effect doesn’t only apply to “fake medicine” or happen in control groups in clinical trials. Medical treatments that are designed to have pharmacological and physiological impacts can also have placebo and nocebo effects. Placebo effects of “real medicine” can include a perceived improvement of symptoms prior to the drug having taken effect and a reduction in illness-related anxiety in the early stages of taking the drug. Nocebo effects of pharmaceutical and medical treatments include patients reporting very rare side effects that they have read or heard about but that cannot be substantiated by a medical examination; perceived negative side effects before it is pharmacologically possible for the drug to have caused them; and patients showing physical symptoms of anxiety around a treatment that should not have such an effect.

What Is the Paper About?

As reported in “Effects of Patients’ Expectation in Dermatology: Evidence from Experimental and Clinical Placebo Studies and Implications for Dermatologic Practice and Research”, there is a large body of evidence that patients’ expectations from an active or “real” treatment can influence the perception of symptoms as well as the efficacy and tolerability of the treatment. The purpose of the paper is to collect the evidence related to patient expectations and medical impacts from dermatological placebo and actual treatments; and to propose some takeaway messages for clinical dermatological practice.

The paper reviews some of the neurobiological mechanisms related to placebo and nocebo effects to “fake” and “real” medical treatments. It also goes into some of the person-to-person differences in responses. An interesting point is that there is no reliable profile of a “responder”: a person who will respond well to placebo treatments or have an additional positive response to actual medical treatments based on good expectations. This means that medical practitioners cannot currently identify whether a patient will gain more from a treatment if they’re told what to expect or indeed experience additional perceived or real side effects if they hear a lot of negative things about treatments.

What Are the Implications for Dermatological Practice?

The article points out that every communication with a patient has the potential to induce positive or negative expectations that can have a knock-on effect on treatment efficacy. The first recommendation is to establish a sense of the patient’s expectations so that they can be discussed in a scientifically grounded way. Positive communication on the treatment’s potential benefits are important, with clear indications of the expectable level of improvement (e.g., “an improvement of 90%”). Patients can also benefit from hearing other people’s successful experiences.

At the same time, the physician is obliged to talk about possible side effects. This is essential in terms of informed consent, but is also critical because a patient must be able to identify whether a side effect requires medical attention. However, these can be framed in terms of how rare or mild they are, how the potential benefits outweigh the side effects, how side effects can be a sign that the drug is working, and so on. The article does state that further study is needed in this area.

An important observation relates to a strategy called partial reinforcement. This is described in the paper in relation to the chronic inflammatory skin disorder called psoriasis. Research has found that mild and moderate psoriasis can be treated with a full-dose of topical corticosteroids for a period of time, followed by using a topical placebo used some of the time and a topical corticosteroid some of the time. The patients were aware that they were using a placebo, but the treatment was still effective. This minimized any side effects from corticosteroids and reduced treatment costs. A placebo that the patient knows about is called an open-label placebo.

What Does This Mean for Me as a Patient?

Consider talking to your dermatologist about this study, especially in terms of how the discussion of drug benefits and side effects can go. Positive framing still works, even when people know that communication techniques are being employed to try to induce a placebo effect. Improving the quality of communication about expectations, effects, and so on is valuable, and worth trying.

Note: Some of the authors of the paper declared that they have relationships with companies that produce or sell dermatological treatments relevant for described medical conditions. It is normal for authors to declare this in case it might be perceived as a conflict of interest. More detail can be found in the Conflict of Interest statement by visiting the original article page.

What’s the Best Method of Monitoring Hair Loss and Related Treatments?

What Is the Main Idea?

Hair loss can be hereditary or a normal symptom of aging, but it can also be a sign of illness. The recent paper “Efficiency of Hair Detection in Hair-to-Hair Matched Trichoscopy”, published in the journal Skin Appendage Disorders, describes the trichoscopic techniques used to monitor the progression of hair loss and support treatment efforts. This post summarizes the authors’ findings.

What Else Can You Learn?

What is the impact of hair loss? And what are some of the causes, besides hereditary and aging? This post summarizes the answers.

What Is the Impact of Hair Loss?

Hair loss may seem trivial at first: It’s commonly associated with male aging and as yet, there are no non-invasive interventions that reliably slow or prevent so-called male pattern baldness. However, hair loss shouldn’t be seen as trivial. Hair has considerable personal and social importance in many cultures and its loss can be very troubling.

Anyone, regardless of gender, can experience hair loss, but it is most common in cisgender men. Male hair loss is associated with aging, lack of virility, loss of attraction, and other markers of social status. In cisgender and transgender men, its impact includes lowered self-esteem, decreased confidence, and depression.

Female hair loss is associated with illness, depression, and lack of self-care. In cisgender women, its impact includes depression, lowered self-esteem, avoidance of social situations, and altered self-image. Transgender women experience hair loss similarly, but it is also linked with increased gender dysphoria. There have been no studies focused on hair loss in non-binary presenting individuals.

What Causes Hair Loss?

Hair loss has multiple potential causes, including genetic predisposition, hormone levels, aging, autoimmune diseases, skin conditions (including psoriasis and certain types of dermatitis), thyroid disorders, anemia, and extreme weight loss (including eating disorder-related weight loss). Hair loss can occur during pregnancy and due to polycystic ovary syndrome. It can also occur during chemotherapy and radiation therapy.

Because of this range of possible causes, some of which have treatment options, some of which do not, it is important for dermatologists to have accurate diagnostic methods. That’s where trichoscopy comes in.

What Is Trichoscopy?

Trichoscopy is another name for scalp dermoscopy: a non-invasive technique for examining the hair and skin of the scalp. It uses magnifications from 10× (usually done with a manual dermoscope) to 1,000× (requiring a videodermoscope). It is generally used for diagnosing hair and scalp diseases. As you may know, dermatological diagnoses are complicated by the superficial similarities in presentation between various dermatological conditions. The close magnification of dermoscopy reveals differentiating details.

Trichoscopy has another use beyond the diagnosis of diseases of the hair and scalp: monitoring how hair loss is progressing and the effects of any treatment. The authors of “Efficiency of Hair Detection in Hair-to-Hair Matched Trichoscopy” compared the various examination and assessment techniques.

Microscopic hair images can be processed statistically using a few different methods. In the referenced study, these were compared. The average errors in determining the change in the hair count were calculated and the authors concluded that the best approach is to combine manually corrected image processing with follicular mapping and hair-to-hair matching. Manual correction of auto-processed results is almost twice as accurate as auto-processing on its own. However, adding follicular mapping and hair-to-hair matching overcomes limitations that manual correction alone cannot — for example, when hair shafts are sticking together in tight follicular units.

Is This Applied Commonly?

Unfortunately, the described combination procedure remains time-consuming, so it’s not possible for every dermatologist to apply it. However, there is ongoing development, and it may become available for regular use in the future. For now, it’s important to know that in challenging diagnostic cases where treatment may be possible, there are advanced techniques that could provide answers.

Note: Some of the authors of the paper declared that they have relationships with companies that may provide treatment or diagnostic equipment relevant for described medical conditions. It is normal for authors to declare this in case it might be perceived as a conflict of interest. More detail can be found in the Conflict of Interest Statement by visiting the original article page.

Does Platelet-Rich Plasma Improve the Outcome of Plastic Surgery?

What Is the Main Idea?

“Platelet-Rich Plasma in Plastic Surgery: A Systematic Review” is a systematic literature review published in the journal Transfusion Medicine and Hemotherapy. The authors (S.K. Hasiba-Pappas and co-workers) reviewed 50 studies that looked at the use of platelet-rich plasma as an aid to healing in various types of plastic surgery and summarized their findings. This post looks at those findings along with other information about platelet-rich plasma.

What Else Can You Learn?

This blog post describes what platelet-rich plasma is, how it is used, and what it can be used for, along with some of the side effects and controversies around its use.

What Is Platelet-Rich Plasma?

Platelet-rich plasma (PRP) is blood taken from a patient and centrifuged (spun very rapidly), which separates the components of the blood and concentrates the platelets within the plasma. This plasma is then re-injected into the patient. This concentrated sample is intended to accelerate healing, particularly of muscles, tendons, ligaments, and joints. The theory is that the higher concentrations of growth factors, cytokines, etc. will stimulate tissue regeneration. There is also some evidence that it could be used in osteoarthritis as a means to reduce inflammation and in bone grafting and lipofilling procedures to increase graft survival. Theoretically, it could be used for treating chronic wounds, burn injuries, and even scars.

Why Is It Important to Have a Literature Review of PRP Use in Plastic Surgery?

The authors of “Platelet-Rich Plasma in Plastic Surgery: A Systematic Review” aimed to collect all the information about PRP use in plastic surgery in one place. This will help advance research into treatments based on this approach. The papers they reviewed included procedures for reconstruction or wound treatment; cosmetic treatment; hand surgery; burn injuries; craniofacial disorders; and fat grafting.

Why Is Platelet-Rich Plasma Use Controversial?

This approach has gained considerable attention in clinical settings because of the potential for accelerating tissue regeneration. However, there is a lack of consistent data on the results of procedures using PRP and the Food and Drug Administration (FDA) and the European Medicines Agency (EMA) have not yet approved it fully. For example, the FDA allows it as an “off-label” treatment for certain muscular and skeletal conditions as well as some plastic surgery.

Part of the issue with PRP is the lack of a standardized protocol for its preparation. One of the aims of the authors of “Platelet-Rich Plasma in Plastic Surgery: A Systematic Review” was to look at the differences in preparation methods. They noted that some studies used double-spin centrifugation while others used a single-spin protocol. Some activated the platelets in the PRP, some didn’t. The number of treatments varied as well. This type of variation will always cause controversy when something is considered for medical applications.

Does Platelet-Rich Plasma Treatment Have Side Effects?

The main side effect (or adverse effect) of PRP treatment is pain. Patients report pain at the site of injection and in the joint, muscle, or general area that is injured or damaged. This pain is to be expected though: Platelet-related healing involves an inflammatory response. Platelets release chemicals in the injured area to ensure that other healing factors move to and activate in that area. In addition, as noted in “Platelet-Rich Plasma in Plastic Surgery: A Systematic Review”, hematomas can occur. These are localized bleeding outside of the blood vessels, similar to a bruise. However, hematomas need more careful observation as they can lead to a critical drop in blood pressure. Yet, most patients did not experience any adverse effects and all the authors of the studies reviewed by S.K. Hasiba-Pappas and co-workers concluded that PRP is safe for therapeutic use.

What Were the Results for Plastic Surgery?

Based on the papers reviewed, PRP use showed:

  • Significantly better results in skin grafting, including for skin grafts on burns, and wound treatment
  • Inconclusive results in scar treatment, breast reconstruction, managing hair loss, and face lifts
  • Promising results in hand surgery
  • Varied results in fat grafting

The authors conclude that PRP is becoming increasingly widely used in plastic surgery, with a good number of trials on the benefits in reconstructive and aesthetic surgery. Several beneficial effects have been identified, but the variations in preparation methods, treatment protocols, and outcomes are still holding this method back from widespread use. Unfortunately, further prospective randomized controlled studies are needed, and standardized protocols will be essential.

Should You Ask Your Plastic Surgeon about PRP?

If you are having plastic surgery, particularly skin grafts and wound treatment, but also hand surgery, there’s certainly enough evidence to support talking to your plastic surgeon about the possibility of using PRP to accelerate or improve healing. However, it may be counterindicated by other factors (e.g., the presence of metastatic diseases, active infections, or low platelet counts) or your plastic surgeon may not have the equipment for it. In the future, it’s very likely to become a more common procedure, based on current evidence.

What Are COVID Toes and Can the Vaccines Cause Them?

What Is the Main Idea?

Inspired by the recent report “Vaccine Toes Are the New COVID Toes” published in the journal Skin Appendage Disorders, this post looks at perniosis, more commonly known as chilblains. What causes perniosis? Can COVID-19 cause perniosis and how common are these media-dubbed COVID toes?

What Else Can You Learn?

The post also looks at the case reported in “Vaccine Toes Are the New COVID Toes”. It dealt with a patient who developed pernio-like lesions after vaccination. Importantly, the report and the blog post both discuss why this should not cause concern about the vaccine.

What Is Perniosis?

You might know perniosis by its more common name: chilblains. Although it generally appears as lesions on the skin, it is actually a type of vasculitis (an inflammation of the small blood vessels). It happens when skin is repeatedly exposed to humid air at temperatures between 0 °C and 16 °C, especially when this exposure is followed by rewarming.

This is an abnormal bodily reaction to temperature changes and its underlying cause is unknown. Risk factors include autoimmune disorders, particularly lupus; circulatory disorders, such as Raynaud’s disease; being underweight; and wearing unsuitable clothing for the weather conditions (no gloves, unsuitable shoes, tight clothing).

Perniosis has the appearance of lesions in the form of itchy or burning bluish-red patches and swelling. It is most commonly seen on the hands, toes, ears, nose, and cheeks, but can appear on calves, thighs, buttocks, and other areas. It doesn’t appear immediately after exposure to cold, damp air, but generally hours to a day after the return to warmer temperatures.

Is Perniosis Reversible?

While freezing air can cause permanent damage, perniosis is generally reversible provided there is no blistering or infection. In most people, the lesions will improve after one or two weeks of avoiding exposure to cold-and-rewarming cycles. Some patients benefit from hydrocortisone for the itching or burning sensation, and of course if an infection sets in, that will need to be dealt with.

If there are signs that they’re not healing, seek medical support. Note that diabetes and poor circulation can complicate the healing process. If you know you have either of these conditions, seek medical support after the lesions appear.

What Does Perniosis Have to Do with COVID-19?

Perniosis is not a symptom of COVID-19. However, during the pandemic, some patients have presented with pernio-like lesions on their toes. Deemed COVID toes in the popular press, the lesions are bluish-red and associated with swelling. It has been seen on people of any age but is particularly common in younger patients with no or mild other symptoms.

As with perniosis, COVID toes are generally not dangerous, but they have been seen to last months, worsen with blisters forming, and have the potential for infection. More commonly, they last up to two weeks.

But Are the Lesions Definitely Connected with COVID-19?

A recent study of 21 people with COVID toes suggested that there was no direct relationship between the SARS-CoV-2 virus and these pernio-like lesions, even going as far as to suggest that these were simply perniosis. The cohort wasn’t large enough to say those results are statistically significant, but it is interesting to note that there are divided opinions on COVID toes. Other studies are ongoing, some concluding that there is a direct relationship.

One interesting report is “Vaccine Toes Are the New COVID Toes”. It deals with a case of a person in their 60s who developed pernio-like lesions on their toes around a week after receiving their second dose of the Pfizer-BioNTech COVID-19 mRNA vaccine. The lesions cleared up within 6 weeks. The report also refers to 9 other vaccine-associated pernio-like lesions mentioned in the literature and posits that the lesions have a relationship to the immune system response to the vaccine.

How Common Are “Vaccine Toes”?

As “Vaccine Toes Are the New COVID Toes” points out, there have not been many cases of pernio-like lesions occurring after vaccination. Therefore, it should not be considered a common vaccine response and people should not be reluctant to take the vaccine because of them. Media outlets may be interested in reporting the story, because it relates to COVID-19, and physicians should be aware that patients may express concerns over “vaccine toes” and assuage their fears.

Note: This post is based on an article that is not open access, i.e., only the abstract is freely available.

Understanding and Screening for Prostate Cancer

What Is the Main Idea?

The open access case report “Genetic Analysis of a Family with Multiple Incidences of Prostate Cancer”, published in the journal Case Reports in Oncology, deals with the genomic screening of three brothers, of whom two had prostate cancer. This case includes examples of how genomic screening can be beneficial in making treatment decisions.

What Else Can You Learn?

This post contains information about the prostate and its function, the equivalent organ in cisgender women and trans men, the warning signs of prostate cancer, and the screening and diagnostic process for prostate cancer.

What Is the Prostate and What Is Prostate Cancer?

The prostate is a small gland located just below the bladder and close to the rectum. It has two functions: generating the thick white fluid that mixes with sperm to form semen; and generating the protein (prostate-specific antigen (PSA)) that ensures that semen is liquid. The gland is found in the bodies of cisgender men, trans women, and nonbinary individuals assigned male at birth, as well as in the bodies of some intersex people.

As with any cancer, prostate cancer is due to abnormal cell growth. It can be a slow or rapid growth and metastases (where the cancer spreads to other parts of the body) can occur. It is one of the most common cancers in cisgender men worldwide. Its risk is significantly lower in trans women who use hormone treatments during their transition.

The warning signs of prostate cancer are pain while urinating or difficulty urinating; erectile dysfunction; and blood in the urine. Pain in the bones and a feeling of compression in the lumbar spine are also reported by patients. The issues with urination are caused by the tumor compressing the urethra, which runs through the gland.

Early or localized prostate cancer is diagnosed when the cancer has not spread to other tissues or organs. Locally spread prostate cancer means that the abnormal cell growth has spread to tissues like the seminal vesicles, local lymph nodes, rectum, or the bladder. Metastases mean that the cancer has spread to other parts of the body. Metastatic prostate cancer most commonly affects the lymph nodes, bones, liver, or lungs.

Does Prostate Stimulation Reduce the Risk of Prostate Cancer?

Stimulation of the prostate gland during sexual intercourse can be pleasurable. Although some non-peer-reviewed reports suggest that massaging or stimulating the prostate can reduce the risk of prostate cancer, there is no firm evidence to support this hypothesis. Such massages can be helpful with non-cancerous inflammation of the prostate, which can reduce the risk of cancer. In addition, there is some evidence that massaging the prostate before some screening methods can improve the test sensitivity.

Do Cisgender Women or Trans Men Have Prostate Glands?

There is no prostate gland in the bodies of cisgender women, trans men, or nonbinary individuals assigned female at birth. Rather, they have Skene’s glands, which are sometimes referred to as “the female prostate gland”, despite having a very different structure. Skene’s glands produce the same protein as the prostate gland, PSA, but are otherwise different. Cancer of the Skene’s glands is believed to be extremely rare.

How Can Physicians Screen for Prostate Cancer?

Screening for prostate cancer is common, especially after patients turn 50. A digital rectal exam, where the doctor inserts a finger into the rectum to examine the texture, shape, and size of the prostate, is the most well-known test, mainly due to its use in comedy that plays on outdated and homophobic ideas regarding anal examinations. It is unfortunate that this trope persists as it may prevent some people getting screened regularly or early.

Another regular screening test is the prostate-specific antigen test. A blood sample is analyzed for the protein. Higher than expected levels for a person of that age may indicate prostate inflammation, infection, or cancer.

Diagnostic tests would use an ultrasound, magnetic resonance imaging, or a prostate biopsy (where a sample of cells from the prostate is taken for analysis). If prostate cancer is determined, these are followed by determination of the aggressiveness and potential metastasis of the cancer. Genomic testing may be done at this stage.

Why Is Genomic Testing Helpful?

Genomic testing results support treatment decisions by providing information on the genetic mutations that are present. Some mutations indicate a treatment approach that may be more effective than another. There are several common gene mutations associated with a predisposition to prostate cancer and research is progressing on the implications of the various patterns of mutation.

The case report “Genetic Analysis of a Family with Multiple Incidences of Prostate Cancer” reports on a single-family genomic test performed in China. Such a case does not provide statistically significant information that can be broadly applied, but it does contribute to the store of knowledge on the topic of mutations and prostate cancer. In the case, three brothers in a family were diagnosed with prostate cancer, and BRCA1 G275D appeared to have a high impact on the progress of the cancer. Since prostate cancer with mutations in DNA damage repair genes like BRCA1 and BRCA2 respond favorably to the drugs olaparib and rucaparib, this information would be valuable to the clinical team.

Should I Discuss My Risk of Prostate Cancer with My Primary Care Physician?

It is always advisable to talk about the risk of prostate cancer if you have a prostate and there is any cancer in your family, and especially if there is prostate cancer in your family. Discuss whether early genomic screening, regular physical examination or annual prostate-specific antigen tests might be helpful. Any change in your urination pattern, especially blood in the urine, demands a consultation with a doctor.

Understanding Ectopic Pregnancy

What Is the Main Idea?

This post summarizes the state of knowledge on ectopic pregnancy, a rare but life-threatening complication of pregnancy. Although it only occurs in 1.2 to 1.4% of all reported pregnancies, it is important to have ready access to information on it.

What Else Can You Learn?

The open access case report “Advanced Abdominal Ectopic Pregnancy with Subsequent Fetal and Placental Extraction”, published in the journal Biomedicine Hub, deals with a rare but important case where a fetus from an abdominal ectopic pregnancy was delivered alive. This report shows how a multidisciplinary team performed surgical intervention to save both the fetus and the mother.

What Is Ectopic Pregnancy?

Ectopic pregnancy is the term for any situation when a fertilized egg implants outside of the uterus. It is a complication that occurs in 1.2–1.4% of all reported pregnancies worldwide. While this may not seem like a large number, this can be a life-threatening condition if not identified early. Furthermore, people who experience ectopic pregnancy can go through considerable emotional trauma as the pregnancy must almost always be terminated. Therefore, access to information about this condition is important.

Around 90% of ectopic pregnancies occur when the egg implants in the fallopian tube on its way to the uterus and another 4% in the interstitial region where the fallopian tube enters the uterus. Tubal implantation might be due to inflammation of the tube (for example due to a sexually transmitted infection (STI)), a hormonal imbalance, or an irregularity in the tube shape (either congenital or due to tubal surgery). There is a correlation between smoking and tubal ectopic pregnancies.

Other ectopic pregnancy locations are in scars from previous cesarean sections; in the intramural tissue or myometrium surrounding the uterus; in the cervix; in the ovary; or in the abdominal cavity around the reproductive organs. These implantations are less well understood because they are so rare, but again, inflammation due to STIs or other infections, hormonal imbalance, or irregularities due to scarring are believed to be the cause.

The Medical Response to Ectopic Pregnancies

A tubal or interstitial ectopic pregnancy can cause life-threatening damage to the fallopian tube. Similarly, ectopic pregnancies within cesarean scars, intramural tissue, or the myometrium can cause life-threatening damage to the uterus. Ovarian ectopic pregnancies can self-abort but there may still be damage to the ovary. Cervical ectopic pregnancies can result in significant bleeding and damage to the whole reproductive system. Medical intervention is essential.

Unfortunately, despite efforts from medical teams, it has not been possible to transplant an ectopically implanted egg into the uterus. Damage may already have occurred within the reproductive system. The removal of the egg from the site of implantation is likely to cause further shock. The development of the egg is sometimes abnormal due to the location. Furthermore, these types of ectopic pregnancy must be ended early, long before there is a viable fetus that can survive in an incubator.

Therefore, to prevent life-threatening complications, the pregnancy must be terminated. If it is diagnosed early enough and there is no serious bleeding, this may be done with a medication. However, it may require surgery: either laparoscopic surgery, which involves very small incisions in the abdomen and small surgical tools, or laparotomic surgery, which involves opening the abdomen. The surgery type depends on the degree of damage and bleeding caused by the ectopic pregnancy. Removal of an ovary, fallopian tube, or even a full hysterectomy can be required. It is important to get the clearest possible diagnosis, to know the extent of any bleeding, and to discuss the surgery with full consent to the interventions.

The Aftermath of Ending an Ectopic Pregnancy

All the major medical bodies acknowledge that ending an ectopic pregnancy can emotionally impact the parent(s) in the same way as the loss of a pregnancy at any other stage. Even if the pregnancy is not known about for very long, in many cases, the potential for stress, trauma, depression, and even self-blame is high. The advice is that the parent(s) should seek therapeutic support in the aftermath of the ectopic pregnancy.

Furthermore, there may be an emotional impact from the loss of the ovary, fallopian tube, or whole reproductive system. These are also circumstances where emotional support is highly recommended. There is also considerable anxiety related to future pregnancies. Although many people who have an ectopic pregnancy go on to have a healthy pregnancy later, this fear can remain. It’s always important to acknowledge the emotional impact of such medical interventions and seek support.

What about Abdominal Ectopic Pregnancies?

Abdominal ectopic pregnancies are the only type of ectopic pregnancy that can reach full-term gestation with a viable fetus. This is extremely rare, but it can occur. Between 2008 and 2013, 38 abdominal ectopic pregnancies resulted in a live birth. However, it can result in death of both the fetus and the pregnant person, so medical monitoring and intervention are essential.

The open access case report “Advanced Abdominal Ectopic Pregnancy with Subsequent Fetal and Placental Extraction” deals with a successful live birth. A cisgender woman who was pregnant for the first time aged 38 presented to the hospital, aware that she had been pregnant for at least three months, based on home testing. She was diagnosed with an ectopic pregnancy based on an ultrasound revealing an empty uterus. She refused treatment at that time because she did not want to terminate the pregnancy and feared that the doctors would insist on this. A month later, she returned and was admitted for further evaluation, but refused to remain in the facility for treatment. She did, however, make further visits to the facility and, eventually, in what was believed to be the 35th gestational week, she underwent surgery to deliver the fetus, which had developed normally.

The surgery was performed by a multidisciplinary team and is described in detail in the paper. Not only was the fetus delivered alive and the placenta removed without complications for the mother, but the newborn had no limb defects, facial or cranial asymmetry, joint abnormalities, or central nervous system malformations.

Why Is This Case Report Important?

This is a very unusual case. However, the details of the operation and the experience of the multidisciplinary team that performed it give important insight into how such a case might be handled successfully. Of course, there are many factors that can be different in various abdominal ectopic pregnancies; and it cannot be denied that the woman in this case took a large risk in refusing admission to the hospital.

What Can an Individual Do about Abdominal Ectopic Pregnancy?

The last thing that expectant parents need is more stress. However, it is essential to quickly seek medical help if you suspect or know that you are pregnant (e.g., have missed a period and/or tested positive with a home pregnancy test) and notice:

  • Light, medium or heavy vaginal bleeding.
  • Unexpected urges to have a bowel movement, especially early in pregnancy, or pain when defecating or urinating.
  • Unexpected back, abdominal or pelvic pain, especially early in pregnancy.
  • Extreme light-headedness, with or without fainting.
  • Shoulder pain on one side of the body, particularly if located at the tip of the shoulder where it joins the arm.
  • Feeling very full when lying down despite not having overeaten.

Furthermore, if you are not aware that you are pregnant, but you notice lower stomach pain on one side of the body and/or vaginal bleeding that is different than your normal period (darker, more watery, heavier, more prolonged, or much lighter), then you should seek medical help immediately.

Treating Onychomycosis: A Fungal or Yeast Infection of the Nails

What Is the Main Idea?

Onychomycosis is a relatively common infection of the fingernails and toenails. The currently available oral antifungals are not without risk. In the review article “Complementary and Alternative Therapies for Onychomycosis: A Systematic Review of the Clinical Evidence”, published in the journal Skin Appendage Disorders, alternative treatments were considered.

What Else Can You Learn?

Learn about the causes of onychomycosis and some of the ways you can approach your nail health to prevent it.

What Is Onychomycosis?

Onychomycosis is a fungal infection of the fingernails and toenails. It’s a common infection, occurring in around 10% of the population overall. It’s more common in older people, with around 50% of those over 70 years of age experiencing it. It’s also more common in people with immune disorders, including HIV; auto-immune disorders, including psoriasis; and diabetes. It’s more likely to occur in toenails than fingernails because the damp and dark are more conducive to fungal growth.

There are three main classes of fungus that cause onychomycosis:

  • Dermatophytes are by far the most common. These are fungi that grow on keratin, the protein found in hair, nails, and skin.
  • Non-dermatophyte molds are the least common cause in the general population, but the dominant cause in patients with HIV. They can only infect keratinized tissues if the keratin is damaged by some other infection or physical trauma.
  • Yeasts of the genus Candida are a slightly more common cause than non-dermatophyte molds. Candida is more common in fingernail onychomycosis than in toenail onychomycosis.

How Can Nails Be Protected?

Hand and foot hygiene should go beyond washing the skin and using a nail brush to clean under the nails. It’s also important to consider what environment and condition the nails are in. Continually wearing shoes and socks is not good for the toenails, as it keeps them in the dark and prevents them from drying properly. Wearing nail polish and nail varnish continually means the tissues of the nail bed don’t “breathe” properly. Damaging the nails during gardening exposes them to bacteria and fungus. Leaving dermatophyte infections untreated can allow non-dermatophyte infections to take hold. It’s important to treat your nails as well as you treat your skin, considering them not just as “dead keratin”, but as part of your hands that need good conditions to stay healthy.

How Is Onychomycosis Treated?

As explained in the review article “Complementary and Alternative Therapies for Onychomycosis: A Systematic Review of the Clinical Evidence”, onychomycosis is very difficult to treat. The nails are made of keratin and are not permeable to many topical agents. What’s more, while oral antifungals can be effective against onychomycosis, this type of drug cannot be used in every patient population due to the risk of system-wide effects.

Are Alternative Treatment Strategies Effective?

The authors of the review looked at every paper that mentioned complementary or alternative therapies for the treatment of onychomycosis. They found 17 articles with alternatives, including:

  • Tea tree oil, which seems successful against Candida infections and has shown some potential against dermatophytes.
  • An extract from Ageratina pichinchensis, a plant used in traditional Mexican medicine, which exhibited some therapeutic effectiveness against onychomycosis in pilot clinical trials.
  • An extract from Arthrospira maxima, also called spirulina, which also showed promise in a pilot clinical trial.
  • Vicks VapoRub®, a commercially available topical ointment used to ease breathing, which showed promising results with cure or partial clearance of the fungus in the majority of patients in a non-clinical trial.

Does This Mean These Treatments Can Be Used?

As pointed out in the review article “Complementary and Alternative Therapies for Onychomycosis: A Systematic Review of the Clinical Evidence”, all the results with alternative or complementary therapies for onychomycosis are preliminary. There have not been any large-scale, randomized, placebo-controlled trials. Therefore, while these treatments are promising, they could not be endorsed as official therapies.

However, you could certainly discuss this paper and these treatments with your physician if you had onychomycosis and wanted to try something other than antifungals to deal with it.

Note: This post is based on an article that is not open access, i.e., only the abstract is freely available.

Understanding Penicillin Allergies

What Is the Main Idea?

If a patient has an allergy to penicillin, it can complicate the treatment of common bacterial infections, such as tetanus, meningitis, strep throat, pneumonia, food poisoning, and chlamydia. But are penicillin allergies as common as people believe? And do they cause greater mortality in hospital settings? This post refers to the research article “Impact of Penicillin Allergy Label on Length of Stay and Mortality in Hospitalized Patients through a Clinical Administrative National Dataset” published in the journal International Archives of Allergy and Immunology.

What Else Can You Learn?

This post also briefly explains the common classification of bacteria as Gram-positive or Gram-negative and explains why penicillin cannot be used to treat the latter.

A Very Common Antibiotic

Discovered almost 100 years ago, penicillin has been used to treat infections since 1930. It functions by deactivating the enzymes responsible for forming the cell walls of certain bacteria, called Gram-positive bacteria (see below). Penicillin is not effective against all bacteria, but there are derivatives like amoxicillin and ampicillin, which are commonly prescribed against Gram-negative bacteria (see below).

What Are Gram-Positive and Gram-Negative Bacteria?

The Danish scientist Hans Christian Gram developed a method of staining bacteria to aid in their identification. His method divides them into two large groups: Gram-positive bacteria, which stain violet; or Gram-negative bacteria, which stain pink or red. There are some bacteria that stain with a mixture of pink and violet cells, referred to as Gram-intermediate bacteria.

Gram-Positive Bacteria

Common genera of Gram-positive bacteria include Clostridium, Listeria, Staphylococcus, and Streptococcus, which respectively include species causing botulism and tetanus; listeriosis manifesting as sepsis or meningitis; staph-related food poisoning; and strep throat, meningitis, pneumonia, and pink eye. Gram-positive bacteria have a cytoplasmic cell membrane surrounded by a thick peptidoglycan cell wall. They are susceptible to antibacterial agents that target this cell wall, including penicillin.

Gram-Negative Bacteria

Common genera of Gram-negative bacteria include Chlamydia, Escherichia, Pseudomonas, and Salmonella, which respectively include species causing chlamydia; Escherichia coli food poisoning; ventilator-associated pneumonia and sepsis; and salmonella food poisoning. Gram-negative bacteria have a cytoplasmic cell membrane surrounded by a thin peptidoglycan cell wall surrounded by an outer membrane. This outer membrane protects them from a range of antibacterial agents, including penicillin. They also have other protective measures that are different to those of Gram-positive bacteria.

Allergy to Penicillin

If you are allergic to penicillin, you’ve probably encountered issues with getting treatment for some common bacterial infections. Penicillin allergies can manifest as minor to major skin reactions (hives, rashes, or itching); watery eyes and a runny nose; shortness of breath or wheezing; fever; tissue swelling; or in extreme cases, life-threatening anaphylaxis. There are also delayed reactions that can result from penicillin allergies, although these are rare. These can include inflammation of the kidneys, severe blistering and peeling of the skin, and drug-induced anemia.

Around 10% of the U.S. population report having allergies to penicillin, but several studies have found evidence that this number is too high. Some suggest that just 1 or 2% of the population have allergies. One suggests that as few as 0.03% have serious allergies. Nevertheless, since anaphylaxis is possible and potentially fatal, if a patient reports a penicillin allergy, physicians will avoid prescribing it or any of its derivatives. They may also avoid cephalosporins, a group of antibiotics that have a similar structure to penicillins.

In some cases, this can leave very few options for treatment, as alternative antibiotics may be too expensive for the hospital, clinic, or patient to afford. This could mean a longer hospital stay, which is the topic of the research article “Impact of Penicillin Allergy Label on Length of Stay and Mortality in Hospitalized Patients through a Clinical Administrative National Dataset”.

What Does the Paper Describe?

This study of adult patients in the hospital system in Spain compared the lengths of hospital stay and in-hospital mortalities of patients with and without a penicillin allergy. Note that the patients were not admitted because of the allergy: The study focused on whether having an allergy that might complicate the management of disease had a significant effect on hospitalization.

Over a 10-year period, almost a million patients who were admitted to hospital had a penicillin allergy on record. This was just 2.63% of all hospital admissions. The comparison group was a random sample of equivalent size. The study found:

  • If a patient has a penicillin allergy, they are more likely to have a longer stay in hospital.
  • Penicillin allergies are not associated with higher mortality rates in hospital.

What Does that Mean for You?

If you or a family member have a penicillin allergy, you are probably already familiar with the complications that can arise in the treatment of bacterial infections. It may be important to discuss the results of this study with your physician(s) if a hospital stay is coming up. What will happen if you need an antibiotic while in hospital? And do you need to prepare for a potentially longer stay?

Should Physicians Test for Penicillin Allergies?

A few papers published in recent years have suggested testing for penicillin allergies to see if the patient could in fact tolerate the antibiotic. This approach has not entered common practice, but it might also be worth discussing with your physician if there is a suspected allergy. It would be better to know for sure than to have a more difficult experience because of a false assumption.

Note: This post is based on an article that is not open access, i.e., only the abstract is freely available.

Long-Term Surgical Mask Use and Skin Conditions

What Is the Main Idea?

We’re all accustomed to wearing masks in public now due to the COVID-19 pandemic. However, there are some issues that can occur if masks are worn too much or for too long. The open access report “Demodicosis Associated with Wearing a Face Mask: A Case Report”, published in Case Reports in Dermatology, deals with a case where a naturally occurring ectoparasite became a problem due to a patient’s excessive mask use.

What Else Can You Learn?

Learn more about the life of the common ectoparasite, Demodex, and how infestations can occur.

What Is a Demodex Mite?

Demodex is a genus of common mite that lives on the skin surface, feeding on sebum that is excreted from the hair follicles and sebaceous glands. The two species that are commonly found on humans are Demodex folliculorum and Demodex brevis. Both are referred to as eyelash mites or face mites, but they can be found anywhere on the body. One further species that is found less commonly on humans is Demodex canis, the Demodex mite of the domestic dog. It tends to only be found on humans with immunosuppressive conditions. The feline equivalent, Demodex cati, has not been reported from humans.

Demodex mites are tiny: less than half a millimeter long. They generally don’t cause any problems, but as with a lot of symbiotes and ectoparasites (parasites that live on the outside of the body), if their population builds up, then health issues can occur. Blepharitis (inflammation, scaling and reddening of the eyelids) and demodicosis (a rosacea-like skin condition associated with inflammation of the hair follicles) are two examples of skin conditions directly related to Demodex infestation.

When Do Infestations Occur?

Infestations are most likely to occur if people have suppressed or challenged immune systems, for example due to HIV, cancer, liver disease, or corticosteroid use. However, they can occur in other circumstances, as described in “Demodicosis Associated with Wearing a Face Mask: A Case Report”.

How Can Infestations Be Treated?

Treatment includes topical insecticides or the oral anti-parasitic drug ivermectin. If an infestation is diagnosed early, it may be possible to deal with it using specialized facial wipes for Demodex or even gentle surfactants like baby shampoo. Changes in behavior can also be needed: avoiding oily skin products and cosmetics, for example.

Can Surgical Masks Cause Imbalances in Demodex Populations and Other Skin Problems?

The case described in “Demodicosis Associated with Wearing a Face Mask: A Case Report” deals with a case where behavior rather than immunosuppression led to a Demodex infestation. It’s a behavior that we have all experienced in the past few years: wearing a surgical face mask.

Wearing a face mask for over one hour can cause an increase in skin temperature and sebum excretion in some people. It can also cause the skin to become drier. It would be rare to see any significant issues in an individual with healthy skin after one or two hours. However, wearing a mask for longer continuous periods has been associated with issues in many people, with 5 or 6 hours often cited as the problem point. Skin conditions associated with face mask use include atopic dermatitis, acne, and rosacea.

How Often Should You Change Your Mask?

Public health advice in many countries is that you should change your mask once every four hours, preferably cleaning the face during the change, and not re-use masks over multiple days. It doesn’t matter whether it’s a cloth mask or a surgical mask, the result can be the same from excessive use.

What Is the Report About?

The report is from the first case of demodicosis associated with wearing a face mask. The patient in this case was wearing a surgical mask (at first) and a cloth mask (after suspecting an allergy to something in the surgical mask) for over 8 hours per day for three weeks. The patient was helped by treatment with ivermectin and behavioral changes (avoiding wearing the same mask continuously, using a new mask every day). This quickly cleared up the issue.

The author recommends that demodicosis be included in the differential diagnosis for facial rashes associated with face masks during the COVID-19 pandemic. And we can all take care to change our masks after 4 hours and keep our faces clean using gentle surfactants during the ongoing health measures for COVID-19.

Why Should We Care about Circulating Tumor Cells?

What Is the Main Idea?

Circulating tumor cells (CTCs) are showing promise in cancer diagnostics, with new studies looking at their potential. For example, the study detailed in “Preliminary Clinical Validation of a Filtration-Based CTC Assay for Tumor Burden and HER2 Status Monitoring in Metastatic Breast Cancer”, published in the journal Oncology Research and Treatment, shows how CTCs can be used to determine whether a breast tumor expresses the protein HER2 (human epidermal growth factor receptor 2), which can influence treatment decisions.

What Else Can You Learn?

This post includes fundamental information about CTCs, metastasis, tumor stages and grades, and mutational differences between tumors.

What Is a Circulating Tumor Cell?

Sometimes, a solid primary tumor can shed cells into the blood and lymph vessels. These cells are then carried around the body. They are individually referred to as circulating tumor cells (CTCs) but they can also exist as clusters (CTC clusters).

CTCs can be seeds for additional tumors to grow in other parts of the body. These tumors are called metastases. After metastasis, cancer is much more difficult to treat because all the tumors must be located, and the effect of chemotherapy, radiotherapy, and surgery on multiple organs must be considered.

Note that not every CTC becomes a seed for an additional tumor and the presence of CTCs does not automatically mean that metastasis has occurred. CTCs are not currently considered within definitions of the stages or grades of cancer. In fact, there are indications that CTCs can be shed during all stages of cancer.

What Are the Stages and Grades of Cancer?

As you may know, part of the diagnostic process for cancer involves defining the stage and/or grade. This information helps in informing the treatment regime. Staging defines how advanced the cancer is; grading defines the cell behavior. Information on the size and number of tumors can also be used to determine the tumor load or tumor burden.

One staging system involves defining stages 0 through IV:

  • Stage 0 and stage I cancer, respectively, mean a very small or small tumor located on only one organ. Stage 0 tumors may not require immediate treatment, just monitoring.
  • Stage II and stage III mean that the tumor is growing and may push into or spread to surrounding tissues and lymph nodes. With most cancers, stage II does not involve any actual spread to the surrounding tissues or lymph nodes, but note that the definition of stage II can vary depending on the tumor type, creating some overlap between these categories.
  • Stage IV cancer is when the cancer has spread to other organs. The new tumors (metastases) are distant from the primary tumor and, due to differences in the organ where they arose, can have different characters.

Another staging system is the TNM system:

  • T1–4 to indicate the size of the primary tumor;
  • N0–3 to indicate the number of lymph nodes affected; and
  • M0 or M1 to indicate the absence or presence of metastases.

The grading system in common use defines cancer cells as grade 1, 2, or 3. Those that resemble normal cells and have a normal growth rate are grade 1. When the appearance and growth rate change, the grade increases, with grade 3 indicating abnormal appearance and aggressive spreading due to a high growth rate.

What about Genetic Information?

Other information is of course essential to make informed treatment decisions. We know that there can be significant genetic differences between tumors of the same organs in different people. This relates to the possibility to investigate the tumor mutational burden: the number of non-inherited mutations in the cells of a tumor. It is also important for looking at what receptors the tumor cells are expressing, which influences treatment decisions.

For example, when considering the breast cancer called ductal carcinoma, physicians want to know if the tumor is estrogen receptor-positive (ER+), progesterone receptor-positive (PR+), human epidermal growth factor receptor 2-positive (HER2+), or triple-negative. This information is normally obtained by taking a biopsy directly from the tumor, which can be an invasive and painful process.

What Is the Value of CTCs?

CTCs come from the tumor and therefore carry genetic information about it. They can therefore be used for a process called a liquid biopsy, which is a less invasive way to gather information about a cancer. Rather than taking a solid biopsy directly from the tumor, blood can be drawn and analyzed for CTCs.

However, CTCs are rare. Are there enough to guarantee accurate diagnostic information?

This Study on CTCs Yielded Promising Results

The study detailed in “Preliminary Clinical Validation of a Filtration-Based CTC Assay for Tumor Burden and HER2 Status Monitoring in Metastatic Breast Cancer” is just one of many currently looking at clinically valuable information from CTCs. In this study, blood samples from 47 patients with metastatic breast cancer were analyzed for tumor burden and HER2 status using a new method. The preliminary results indicate that tumor burden and HER2 status can be successfully determined from CTCs. The assay requires further clinical validation, but this is very promising.

Such studies are common, especially since emerging technologies are making it easier to detect and analyze CTCs. If CTC assays can help to determine tumor burden, tumor mutational burden, or even define the grade of a cancer, then liquid biopsies could become a commonplace diagnostic technique.

Crucially, there are studies looking into the possibility of CTCs being used for early diagnosis of cancer, since they can even be shed by stage I solid tumors. Suggestions of using a routine blood test to check for the presence of common cancers have been made. We may be on the verge of an important new phase in cancer diagnosis and treatment.

Note: This post is based on an article that is not open-access; i.e., only the abstract is freely available. Please also note that one of the authors of the paper declared that they are a full-time employee of a biotech company. It is normal for authors to declare this in case it might be perceived as a conflict of interest.

Do Antibiotics Help in Controlling Acute Exacerbation of Asthma?

What Is the Main Idea?

Antibiotics are frequently prescribed to children experiencing acute worsening of their asthma, but are they always needed? Published in the International Archives of Allergy and Immunology, the research article “Antibiotic Treatments Prolong the Wheezing Period in Acute Exacerbation of Childhood Bronchial Asthma” focuses on this question and shows that antibiotics might even make it harder to recover from an asthma attack.

What Else Can You Learn?

The post describes the symptoms of asthma, why attacks occur, and gives some advice on what to do if you’re having an asthma attack.

What Is Bronchial Asthma?

Bronchial asthma is commonly known as asthma. It is an incurable condition that affects the airways (i.e., the trachea, bronchi, and bronchioles). During an episode of asthma, referred to as an asthma attack, the airways swell, narrow, and may produce extra mucus.

Symptoms of an asthma attack include trouble breathing, a tightness across the chest, a cough, and wheezing. The attack can be mild, moderate, or severe, with the differentiation based on the person’s ability to speak, lie down, or sit, and the presence of retractions (where the ribs pull in during a breath). A diagnostic device called a peak flow meter can be used to precisely differentiate the three states. While asthma doesn’t directly cause fevers, there is an association between bronchial asthma and bronchitis that can lead to a fever co-occurring with prolonged or frequent asthma attacks.

Wheezing is a required symptom for a diagnosis of asthma. Described as a high-pitched whistling or purring noise that is particularly noticeable on exhale, wheezing must occur during multiple instances of difficulty breathing.

Asthma can flare up due to allergens in the air (e.g., pollen, dust mite droppings, dander from animals), allergens in the body (e.g., an insect sting, medication, food proteins), irritants in the air (e.g., chemical fumes, sawdust, cigarette smoke), environmental changes (e.g., moving into colder air), or physical exertion.

What Should You Do If You Have an Asthma Attack?

If you have already had a diagnosis of asthma, you probably have an action plan from your physician. You may have an inhaler or other medication. That is certainly enough for a mild asthma attack and may be enough for a moderate attack. Because severe asthma attacks can be life-threatening, there are circumstances when calling an ambulance or seeking emergency care is vital.

For example, if an asthma attack comes on after exposure to allergens, the patient is struggling for every breath, the patient passes out or their lips turn blue, there is a co-occurring fever around 40 °C (104 °F), emergency care is absolutely essential. Attacks lasting longer than 24 hours, milder fevers lasting multiple days, and disruptions to sleep are also given as reasons to seek advice from healthcare professionals.

Antibiotics and Asthma

Managing asthma in children is naturally challenging, particularly when one considers the emotional distress that both child and parent or guardian experience during an asthma attack. This can prompt the desire to go further with attempts to treat the condition than are advisable or necessary.

The research article “Antibiotic Treatments Prolong the Wheezing Period in Acute Exacerbation of Childhood Bronchial Asthma” focuses on an effort to help that may actually do more harm. Medical guidelines in many countries state that antibiotics should not be routinely prescribed to children with worsening asthma symptoms. Nevertheless, children with acute exacerbation of asthma are prescribed antibiotics more frequently, even when they don’t have any signs of a bacterial infection.

The only reason to prescribe antibiotics to someone with asthmatic wheezing is if they have a bacterial infection in their respiratory system or are at a very high risk of developing one (for example, if a family member already has one). Prescribing an antibiotic when there is no presence or risk of bacterial infection is entirely unnecessary.

In the study described in “Antibiotic Treatments Prolong the Wheezing Period in Acute Exacerbation of Childhood Bronchial Asthma”, the researchers examined pharyngeal samples and took clinical information from over 100 children with acute exacerbation of asthma. The period of time when wheezing occurred was of particular interest. They found that over half the children had been given antibiotics and that the period of wheezing was longer in those patients than in the ones who didn’t receive antibiotics. Even in those patients with a bacterial infection (Streptococcus pneumoniae, which can cause pneumonia), the period of wheezing was longer when antibiotics were prescribed.

What Does This Mean for Me?

If you or your child has asthma and a physician suggests an antibiotic during a period when your asthma is worse, ask if it’s absolutely necessary. Although this study needs to be repeated with a larger cohort of patients, it is still a significant indication that antibiotics might hinder the calming of the asthma symptoms. Check if the antibiotic is needed, discuss the pros and cons, share the link to the article with your physician. It’s still possible that the antibiotic is needed: Unchecked pneumonia is dangerous! But this information may be helpful in making a decision that leads to the asthma coming under control sooner.

Note: This post is based on an article that is not open-access; i.e., only the abstract is freely available.

Is COVID-19 Affecting Infants’ Microbiota?

What Is the Main Idea?

COVID-19 is having an impact on infants’ microbiota, and this may affect them in their later lives. Published in the International Archives of Allergy and Immunology, the open access review “The Effect of COVID-19 Pandemic on the Infants’ Microbiota and the Probability of Development of Allergic and Autoimmune Diseases” gives details about the increased risk of allergic and autoimmune diseases in children born during the pandemic.

What Else Can You Learn?

This post includes a reminder of the impact of COVID-19 on the individual as a disease and on our behaviors and lifestyles as a pandemic. This context is important to understand the impact on infant microbiota. The post also gives a brief explanation of the composition and importance of microbiota.

COVID-19 Affects Humans in Various Ways

“How will COVID-19 affect my child?” It’s only natural that a parent would ask this about their child, especially if that child is too young for vaccination. COVID-19 is still a global concern and is likely to remain one for some time, with the potential for more variants, reinfection, and further surges not ruled out.

SARS-CoV-2, the virus that causes COVID-19, is primarily transmitted via respiratory routes. Its highest levels are detected in the lungs and upper respiratory system, but it can spread to other organs, including the heart, kidneys, liver, and brain. Gastrointestinal symptoms are also common and can be persistent.

Although the risk of severe illness from COVID-19 seems to be low in children (unless they have underlying health conditions), given the possibility of SARS-CoV-2 spreading to other organs, it’s important for doctors and parents to have an awareness of how the virus might affect children’s development.

However, it’s also important to consider the effect of the pandemic itself on humans — and again, parents and doctors should be especially concerned when it comes to children. The pandemic has changed the way we live our daily lives, and researchers have studied how this has impacted our psychology, physical health, and development.

The open access review “The Effect of COVID-19 Pandemic on the Infants’ Microbiota and the Probability of Development of Allergic and Autoimmune Diseases” focuses on the impact of the COVID-19 pandemic on the composition of the body’s microbiota.

What Is the Microbiota and How Does COVID-19 Affect It?

The human microbiota consists of trillions of symbiotic microbes (bacteria, fungi, viruses, protists, and archaea) living in and on the human body. The majority are found in the gut, where they play a role in protecting the intestine against colonization by other microorganisms. The gut microbiota is proven to play an essential role in shaping the development of immunity, and it is critical that its development begins in early childhood. Exposure to environmental microbial species and nonharmful symbiotic and commensal organisms should occur during pregnancy, childbirth, and infancy. Factors that are relevant include the levels of social interactions, use of detergents and disinfectants in the child’s environment, exposure to pets, and use of antibiotics.

As the review points out, the lifestyle changes caused by the COVID-19 pandemic have included decreased social interactions; an increased use of detergents, disinfectants, and antibiotics; changes in exposure to pets; and changes in infant feeding patterns. All these behavioral changes have an impact on the infant’s microbiota, and this has a knock-on effect on the immune system.

What Is the Significance of the Impact of COVID-19 on Breastfeeding?

One example of this pertains to breastfeeding patterns. Based on the available evidence, SARS-CoV-2 cannot be transmitted through breast milk. It is recommended that breastfeeding continues, even when the mother has tested positive for COVID-19. Understandably, many choose to be more cautious and stop feeding for the weeks after the positive test. This can affect the microbiota of the child. Even if the COVID-19-positive mother continues breastfeeding, medical advice is that they should use a mask, disinfect their hands, and limit the time holding the baby. This also has an impact, as the child has a change in exposure levels during this critical developmental period.

Breastfeeding and exposure to the mother during breastfeeding reduces the risks of: diseases caused by immune system deficiencies; type 1 diabetes; later-life type 2 diabetes; rheumatoid arthritis; multiple sclerosis; and celiac disease.

What Else Does the Review Cover?

This is just one example of how a change in behaviors during the pandemic can affect the development of a child’s microbiota. The review “The Effect of COVID-19 Pandemic on the Infants’ Microbiota and the Probability of Development of Allergic and Autoimmune Diseases” also gives information on how the mode of delivery of the baby (vaginal birth or cesarean section), use of detergents, antibiotic treatment, and contact with pets have potentially affected the microbiota of infants.

What Is the Conclusion?

It is essential for doctors and parents to be aware of the potential impact of altered microbiota formation. It can provide a greater awareness in the future when children have symptoms of autoimmune diseases and other conditions. This can accelerate diagnostics and ensure that the child gets the support they need sooner. It could also inform current practices regarding exposure to animals, breastfeeding, and exposure to environmental bacterial. Finally, it is a reminder to get older children and family members vaccinated against COVID-19 as soon as possible so that the whole family can return to behaviors that ensure exposure to the necessary environmental microbes.

Atopic Eczema Is Associated with Depression and Anxiety

What Is the Main Idea?

Our mental health can be influenced by long-term conditions, including dermatological ones such as eczema. This post was inspired by the open access research article “Depression, Anxiety, and Suicidal Ideation in Patients with Atopic Eczema in a Prospective Study in Leipzig, Germany”, published in the journal International Archives of Allergy and Immunology. It describes the state of knowledge on the link between atopic eczema, depression, and anxiety, particularly in the light of a recent study.

What Else Can You Learn?

This post also describes some of the ways atopic eczema can be triggered and managed.

Content Warning

This blog post mentions suicidal ideation. There are no descriptions of suicidal ideations or suicide attempts.

What Is Atopic Eczema?

Atopic eczema, which is also called atopic dermatitis, is a chronic skin condition that causes dry, itchy, and cracked skin. It often presents as red, brown, brownish-gray, or purple patches of skin, raised bumps, or scaly patches. It can become swollen or infected if patients scratch it. This type of eczema can be localized or widespread, its manifestation can vary in severity over time, and patients often report considerable associated pain. The symptoms most commonly start in early childhood, but there is also adult-onset eczema.

An association between atopic eczema and allergies has been identified, with some eczema patients showing allergies to certain detergents, foods, or airborne particles like pollen. However, these allergies trigger more severe symptoms rather than being the underlying cause of eczema. Stress and other environmental factors are also known to trigger an increase in symptoms. The actual cause is probably genetic.

Can Atopic Eczema Be Cured?

There is no cure for atopic eczema, but it can be managed. Topical steroids (an artificial version of an adrenal gland hormone) are often prescribed when the symptoms are severe. However, most of the management falls on the patient, with recommendations including:

  • Regular moisturizing of the skin.
  • Identifying and avoiding the triggers of more severe symptoms, which may include soy, wheat, milk, or eggs; soaps, detergents, and other surfactants; or dust and pollen.
  • Reducing the frequency of showers and baths and using only gentle soaps, to prevent drying the skin.
  • Avoiding scratching or rubbing the skin, which includes being gentler when toweling off after a shower or bath.
  • Reducing activities that cause you to sweat or ensuring that sweat does not stay on the body for long.
  • Losing weight if recommended by a dermatologist, as people with eczema and obesity often show more severe symptoms.

What Is the Relationship between Atopic Eczema and Mental Health Conditions?

A significant percentage of patients with atopic eczema present with depression and anxiety. In the study reported in the paper “Depression, Anxiety, and Suicidal Ideation in Patients with Atopic Eczema in a Prospective Study in Leipzig, Germany”, the researchers worked with atopic eczema patients and control subjects to investigate any correlation between the severity of eczema and psychosocial conditions.

Participants in the study had their atopic eczema scored for severity by a trained dermatologist, who used objective indexes. They were also assessed for sleeping problems. They filled out a set of five standardized questionnaires to assess depression, anxiety, social network size, and quality of life. They also did a questionnaire about suicidal ideations, which was designed by the researchers.

The results showed that patients with atopic eczema:

  • Show more signs of anxiety and depression than control subjects.
  • Show more severe anxiety and depression if their eczema is more severe.
  • Are more likely to have suicidal ideation if their eczema is severe.
  • Are not at a higher risk for social isolation.

They also showed that sleep disturbance, which can be associated with atopic eczema, is linked to an increased risk of suicidal ideation.

The findings still require further validation with a larger group of subjects, but considered alongside the results of other studies on eczema and mental health, they show a clear signal about psychological conditions and skin health.

What Do the Results of the Study Mean for Patients?

If you or someone in your life has atopic eczema, it’s important to be aware of the link with anxiety, depression, and suicidal ideation. It’s also important to talk openly with your dermatologist and primary care physician about these findings, and about your own mental well-being. Mental health should never be ignored within the larger treatment plan.

Note: The authors of this paper make a declaration about grants received from pharmaceutical companies and memberships on the boards of such companies. It is normal for authors to declare this in case it might be perceived as a conflict of interest. For more detail, see the Conflict of Interest Statement at the end of the paper.

Melanoma Diagnosis: How a New Technology Could Help

What Is the Main Idea?

This post was inspired by the open access research article “The Additive Value of 3D Total Body Imaging for Sequential Monitoring of Skin Lesions: A Case Series” published in the journal Dermatology. The article focuses on the benefits of a recently introduced dermatological technique called 3D total body photography. This blog post describes the conclusions of the article in the context of diagnosing melanoma.

What Else Can You Learn?

This post also gives the risk factors for melanoma and discusses why timely diagnosis is essential but can be challenging. It recommends being actively involved in monitoring your skin health.

What Is Melanoma?

Melanoma is a type of skin cancer that develops in the melanocytes, which are the cells that produce the skin pigment melanin. They are located in the bottom layer of the skin’s epidermis (the outermost layer of the skin). The melanin they produce plays a role in protecting the hypodermis (also known as the subcutaneous tissue) from the damaging effects of ultraviolet radiation. Melanocytes are also part of the immune system.

The risk factors for melanoma are:

  • Excessive exposure to ultraviolet radiation, including from sunlight and tanning beds.
  • A family history of melanoma.
  • Having a large number of moles, unusually shaped moles, fair skin, or a tendency to sunburn.
  • Being immunocompromised.

Although the greatest risk of melanoma is related to the damage from ultraviolet radiation, it can develop on any part of the skin, including those that don’t get much sun. Melanoma has also been found on the eyes, nose, and throat, although these are very rare cases.

The Challenge of Timely Diagnosis of Melanoma

Melanoma is the second most common cancer in adults aged 25 to 49 and its incidence in people under 40 is increasing. It is considered the most serious form of skin cancer. Early treatment is essential to control its spread. If it is detected and treated early, it is usually curable, with a five-year survival rate in the US of 99%. However, if it metastasizes to other parts of the skin or deeper into the body, this survival rate drops significantly.

Regular skin monitoring is the key to detecting any malignancies of the skin, including melanoma. Short-term digital dermoscopy at regular intervals (e.g., once every three months) is the current method applied to moles and other lesions that arouse suspicion. In the longer term, dermoscopy is performed every 6 to 12 months, with the goal of identifying certain changes that might indicate the onset of melanoma. These techniques are successful in detecting melanoma and in avoiding unnecessary surgical intervention (e.g., the removal of benign moles).

However, there is a certain flaw in these approaches. Dermoscopy is time-consuming and is thus generally only applied to known potential issues — moles, lesions and so on. This ignores the rest of the skin, and melanoma can develop from skin with no existing issues. It is essential to have techniques that cover the whole body but are not as time-intensive as traditional dermoscopy or even 2D total body imaging combines with digital dermoscopy.

How 3D Total Body Photography Helps Overcome These Limitations

With 3D total body photography, 92 images of the patient’s body are captured simultaneously and assembled digitally to give a picture of almost the entire surface of the skin. This recently introduced technique is better at imaging curved surfaces. It also makes it much easier to compare images of any part of the body over time, as the images can be compared side-by-side onscreen. Software has been designed to support clinicians working with the images, for example facilitating the linking of an area of the whole-body image to a dermoscopy image of a lesion.

In the research article “The Additive Value of 3D Total Body Imaging for Sequential Monitoring of Skin Lesions: A Case Series”, the authors looked at three case studies to highlight the benefits of using 3D total body photography alongside traditional methods. They identify how helpful it is in the surveillance of skin lesions, particularly when patients have multiple lesions or moles of concern. They also point out the value in identifying issues in areas of skin that were not previously areas of concern.

The cases selected for the paper were chosen by the authors as they have educational value and illustrate the value of longitudinal 3D total body photography alongside other techniques. Based on their experience with the technique, they also suggest that further development of the technology may come in the form of better resolution in the photographs and software-aided analyses of the images.

Should I Ask My Doctor about 3D Total Body Photography?

If you are worried about melanoma, you should regularly see a dermatologist and/or talk to your general practitioner about your concerns. As mentioned, melanoma is dangerous and must be diagnosed and treated early. If you have any of the risk factors listed above, this is all the more reason to have a professional assessment of your skin on a regular basis.

Since it has been shown that 3D total body photography supports the diagnosis of melanoma and other skin malignancies, it’s worth mentioning the technique to your dermatologist and general practitioner. They may be interested in the paper and they may also have experience with the technique or know of a clinic or hospital that practices it. Taking an active role in monitoring your skin health is in your best interest.

Note: One of the authors of the paper declared that they are a shareholder and consultant for two dermatological companies, a consultant for a third, and an advisor for a fourth. It is normal for authors to declare this in case it might be perceived as a conflict of interest. For more detail, see the Conflict of Interest Statement at the end of the paper.

The Interesting Case of Raynaud’s Phenomenon Occurring after a COVID-19 Vaccine

What Is the Main Idea?

This post looks at a single case of Raynaud’s phenomenon (a disruption of the blood flow in the fingers and toes) in a patient who had received the AstraZeneca COVID-19 vaccine two weeks prior. It is important to realize that the case does not prove causation, but the correlation is interesting for healthcare professionals and medical researchers. The full details are in the open access case report “Raynaud’s Phenomenon after COVID-19 Vaccination: Causative Association, Temporal Connection, or Mere Bystander?”, published in the journal Case Reports in Dermatology.

What Else Can You Learn?

The post describes Raynaud’s phenomenon: the appearance, risk factors, and treatment. It also describes how to understand case reports like this.

What Is a Raynaud’s Phenomenon?

Raynaud’s phenomenon affects the small muscular arteries of the fingers and toes, and more rarely, the nose, ears, knees, or nipples. When a patient has an episode of Raynaud’s phenomenon, the blood vessels in the affected areas spasm, causing decreased blood flow.

In response to this decrease in blood flow, the pallor of the skin changes, usually becoming much paler. The area becomes numb and cold, often with notable temperature differences between affected digits and unaffected digits. The hands can become swollen and even painful if the patient tries to warm them up. In serious cases, the disruption to the vascular system can lead to sores, pitting, ulceration, or even gangrene. However, for most patients, it is a manageable inconvenience rather than a serious problem.

It affects approximately 5% of the population and is more common in cisgender women than in cisgender men. The cause is unknown, but there are theories that it has something to do with the blood thickness or the blood vessel diameter. Risk factors include smoking, certain medications, exposure to some chemicals, some autoimmune and connective tissue disorders, and injury, including some manual repetitive strain injuries.

Can Raynaud’s Phenomenon Be Treated?

There is no cure. Most of the treatments are behavioral: quitting smoking, avoiding exposure to cold, and avoiding the sources of repetitive strain injuries to the hands. Blood pressure medications can help.

What Happened in the Case?

The case is described in “Raynaud’s Phenomenon after COVID-19 Vaccination: Causative Association, Temporal Connection, or Mere Bystander?”. A 31-year-old white cisgender woman received her first dose of the AstraZeneca COVID-19 vaccine (Vaxzevria). Two weeks later, she developed Raynaud’s phenomenon on three fingers in the form of well-defined, pale, cold, numb areas. She had none of the risk factors associated with Raynaud’s phenomenon and there was no family history of the condition.

After a thorough set of blood tests, the patient was advised to avoid known triggers of Raynaud’s phenomenon, including exposure to cold. The patient showed no symptoms at follow-up appointments (1, 2 and 3 months later). This might be due to the warmer spring weather at the time, so the consulting physician has advised further evaluation in the coming winter.

Is Raynaud’s Phenomenon a Common Response to Vaccination?

It’s rare for people to develop Raynaud’s phenomenon after vaccination. It has been reported to occur after the administration of diphtheria–tetanus, hepatitis B and human papillomavirus vaccines. However, there is no clear association between the vaccines and the condition. More study would be needed to confirm such a relationship.

Why Is This Reported as a Side Effect of the COVID-19 Vaccination?

Healthcare professionals and medical researchers have an obligation to report on all the side effects of drugs that are in circulation, even if the effects only appear in one person. Even if they are not sure that the effect is related to the drug, they must report it. In this case, because the condition appeared in an otherwise healthy person within two weeks of receiving the AstraZeneca COVID-19 vaccine, it is possible that the onset of Raynaud’s phenomenon is related to the vaccine.

The report is important for the medical community. It makes healthcare practitioners aware to ask about the date of COVID-19 vaccination if they have patients presenting with Raynaud’s phenomenon, whether it is a new onset or a recurrence. If more such reports are published, Raynaud’s phenomenon might be added to the list of side effects for the vaccine or a broader study might be undertaken.

The Potential for Adverse Effects from Finasteride

What is the Main Idea?

This post looks at finasteride, explaining what it is, what it is prescribed for, and what adverse effects it can have. It mainly focuses on the psychological adverse effects, including depression and suicidality.

What Else Can You Learn?

The post also looks at the conclusions of the editorial “Suicidality and Psychological Adverse Events in Patients Treated with Finasteride”, published in the journal Skin Appendage Disorders, including a recommendation to physicians considering prescribing the medication.

Content Warning

This blog post discusses suicidality in a clinical manner. There are no descriptions of suicidal ideation or suicide attempts.

What Is Finasteride?

Finasteride is an oral medication used to treat hair loss and noncancerous prostate enlargement in cisgender men and excessive hair growth in cisgender women. It can also be used in hormone therapy for transgender women.

It is an antiandrogen, which means it functions by stopping androgens from having an effect in the body. Finasteride specifically reduces the production of dihydrotestosterone, which is produced in several locations in the body, including in the prostate gland, scalp, and brain.

Does Finasteride Have Adverse Effects?

Although they are rare, adverse effects are known for finasteride. Some of these are reversible, which means they stop after patients stop taking the drug. However, others can persist. In both cases, these effects are rare enough that the medication is still very commonly prescribed.

The adverse effects include disruptions to sex drive and erectile dysfunction; changes in the production of steroids related to the neurological system; loss of muscular strength; breast enlargement in cisgender men; and psychological effects, including depression and increased suicidality (see the next section for a definition of this term).

Post-finasteride syndrome is sometimes used to refer to the collection of serious adverse effects that are seen in patients that take finasteride and persist after they discontinue it. Note that despite there being some literature available on post-finasteride syndrome, it is a contentious term. As pointed out in the editorial “Suicidality and Psychological Adverse Events in Patients Treated with Finasteride”, it is not recognized by the research community as a valid classification. There is even a paper that suggested that post-finasteride syndrome has only been documented in low-quality studies.

What Is Suicidality?

Suicidality is a term that covers all the aspects of suicide: ideation, which means having serious thoughts about suicide; planning; and attempts. In psychological and psychiatric research and practice, suicidality is sometimes discussed in terms of the balance between the will to live and the wish to die, with subjects ranked as nonsuicidal, or having low, moderate or high suicidality.

Note that suicidal ideation does not always imply or lead to planning or attempts. It is a difficult topic to study, because there is no universal definition of suicidal ideation. This makes it difficult to compare results from different research papers. Furthermore, healthcare records often document suicidal ideation as present or absent rather than considering the nuances of it.

Increases in suicidality of any kind in response to medication are considered an adverse effect. If researchers look at a population (a group of people with common demographic characteristics) and see that the suicidality is significantly higher in those taking a medication than in those not taking it, this is called a significant disproportionality signal for increased suicidality.

What Is the Editorial About?

The editorial “Suicidality and Psychological Adverse Events in Patients Treated with Finasteride” looks at the disproportionality signal for suicidality, depression, and other psychological adverse effects related to finasteride. The authors briefly review what is known about this important topic.

The authors have over 20 years’ experience in dermatological practice and prescribe oral finasteride for androgenetic alopecia (male hormone-related baldness). They suggest that prior to prescribing finasteride, it may be important to obtain a personal history or screen for preexisting personality disorders, since there is a significant but rare indication that finasteride could trigger or exacerbate such issues.

What Is the Takeaway Message for Patients?

Finasteride is an important medication with a range of applications, but it shouldn’t be taken lightly. Even if adverse effects are rare, they do occur. Always discuss the adverse effects with your doctor prior to taking a new medication.

How Accurate Is Trichoscopy in Diagnosing Inflammatory Scalp Diseases?

What Is the Main Idea?

This post is based on the free access article “Diagnostic Accuracy of Trichoscopy in Inflammatory Scalp Diseases: A Systematic Review” published in the journal Dermatology, which looks at how a noninvasive diagnostic technique called trichoscopy can be used to differentiate between dermatological conditions with very similar symptoms. If you have a skin condition that’s affecting your scalp and the diagnosis is proving difficult, this article might be of interest to you and your dermatologist.

What Else Can You Learn?

Read this post to gain some insight into the various diseases that can cause inflammatory reactions on the scalp, including the trichoscopic features that differentiate them.

Why Are Inflammatory Scalp Diseases Difficult to Diagnose?

There are multiple diseases that can cause inflammation and lesions on the scalp. Differentiating between them is not simple, as the lesions and other signs can look similar.

For example, psoriasis, seborrheic dermatitis, contact dermatitis, lichen planopilaris, tinea capitis, discoid lupus erythematosus, pemphigus foliaceus, pemphigus vulgaris, dermatomyositis, and syphilis all cause erythematous patches and scaling.

Erythematous patches are red or purple rashes, often raised or circular, sometimes with small blisters in them. They occur due to injured or inflamed blood capillaries. Scaling means that the outer layers of the skin are coming off in large, scale-like flakes. Scaling often has a dry appearance and can be white or red.

Since the macroscopic appearance is so similar between many diseases, differential diagnosis can be very challenging. There are plenty of methods that help, but many involve taking biopsies or performing other tests that may be uncomfortable for the patient.

What Is Trichoscopy?

Trichoscopy is a noninvasive diagnostic method that can be done by a dermatologist in their office. It is based on dermatoscopy, which involves an instrument that shines a special light on the skin and has a magnifying lens. In trichoscopy, hair and scalp structures may be visualized at many-fold magnification. The trichoscopic instruments can give 10- to 70-fold magnification of hair and scalp structures.

It is widely used for diagnosing the reasons for hair loss but recently, there has been a lot of interest in using it to diagnose inflammatory scalp diseases. In particular, medical researchers hope that it can be used to differentiate between conditions with very similar presentations.

How Does Trichoscopy Help?

Because trichoscopy looks at close magnification of the skin, it can reveal subtle features that are not visible to the naked eye. For example, the scaling might appear continuous but on closer examination, it might be patchy. There might be a pattern to the redness on the skin. When these features appear consistently for a particular disease and are different for other diseases, then they can be considered suitable for differential diagnosis.

What Does the Article Say?

As its name suggests, the article “Diagnostic Accuracy of Trichoscopy in Inflammatory Scalp Diseases: A Systematic Review” is based on a systematic review. That means the authors searched for studies describing the frequency of trichoscopic features related to inflammatory scalp conditions and analyzed the accuracy of using these features in differential diagnosis. They found 58 studies that they could include in a qualitative analysis; of those, 57 were suitable for quantitative analysis.

The qualitative analysis involved reading the descriptions of the trichoscopic features in the papers and case reports to find common and differentiating ones across the diseases. The quantitative analysis involved calculating some diagnostic parameters based on the frequency of the feature appearing for that disease.

The authors’ systematic review indicates that trichoscopy can be used as an accessory tool in the differential diagnosis of inflammatory scalp diseases. They list the trichoscopic features that have the highest specificity for each disease. These are described below along with some information about each disease.

What Is Psoriasis?

Psoriasis is an autoimmune disease that causes abnormal, excessive, and rapid growth of the epidermal (outermost) layer of the skin. This usually causes red patches with white scales on top, but there are forms of psoriasis that cause blisters and changes to the nail pits and nail color. There are many treatment options that focus on managing the symptoms, but there is no cure. The most specific trichoscopic features for scalp psoriasis are diffuse and patchy scaling and simple red loops.

What Is Seborrheic Dermatitis?

Seborrheic dermatitis is also a long-term skin condition that causes red, scaly, and inflamed skin. The areas of the skin with a lot of oil-producing glands are most commonly affected, especially the scalp, but it can also occur on the face, chest, and upper back. Its cause is unknown but there are a number of medications that are able to reduce the symptoms. The most specific trichoscopic features for seborrheic dermatitis are comma vessels (slightly curved blood vessels like a comma) and perifollicular pigmentation (skin color changes around the follicles).

What Is Contact Dermatitis?

Contact dermatitis is an inflammation of the skin that is usually due to the skin being exposed to chemical, physical, allergenic, or other irritants. For example, exposure to turpentine, alcohol, kerosine or drain cleaners can cause chemical irritant contact dermatitis. Poison ivy, poison sumac and poison oak cause allergic contact dermatitis. Nickel in jewelry can also cause allergic contact dermatitis. Treatment depends on the cause. Again, the appearance can be dry skin, red rashes, bumps, blisters and swelling, so it is very similar to the other diseases on this list. The most specific trichoscopic features for contact dermatitis are twisted red loops.

What Is Lichen Planopilaris?

Lichen planopilaris, or lichen planus, is a chronic inflammatory disease with a relationship to the immune system. There are many different forms, including ones that affect the mucous membranes, but the types that commonly affect the scalp have similar red or purple patches with a fine, white scaling over the top. Treatments are rarely effective and there is no cure. The most specific trichoscopic features for lichen planopilaris are milky red areas and fibrotic patches (excessive scarring).

What Is Discoid Lupus Erythematosus?

Discoid lupus erythematosus is an autoimmune disorder that presents as scaling or crusty disc-shaped patches of inflamed skin that are often red. They can cause scarring because they can last a long time, especially if they are not treated. If a patient has discoid lupus erythematosus, they should avoid exposure to sunlight as it brings on the lesions. Steroids can be used to treat existing lesions and a special sunscreen can protect against new ones. The most specific trichoscopic features for discoid lupus erythematosus are follicular plugs (oil from the sebaceous glands trapped around the follicles) and erythema (red rashes) encircling follicles.

What Is Pemphigus Foliaceus?

Pemphigus foliaceus is a generally benign autoimmune skin disorder that presents as blisters, particularly ones that appear when the skin is rubbed. It can be managed quite well but there is no cure. The most specific trichoscopic features for pemphigus foliaceus are scaling in the form of white polygonal structures and serpentine vessels (blood vessels that look like snakes).

What Is Pemphigus Vulgaris?

Pemphigus vulgaris is also an autoimmune disorder that presents as blistering of the skin. It differs from pemphigus foliaceus because it also affects the mucous membranes and can erode the skin to a greater degree. It is rare and more serious, potentially life-threatening. As with most of these conditions, there is no cure but steroids and immunosuppressants can keep it under control. The most specific trichoscopic features for pemphigus vulgaris are red dots with whitish haloes and lace-like vessels (blood vessels that look like lace).

What Is Dermatomyositis?

Dermatomyositis causes skin rashes and muscle inflammation. It is considered a muscle disease and it can be life-threatening. It might be an autoimmune disorder, although this has not been established. The skin symptoms are not the most important aspect of the disease. It cannot be cured, but comprehensive treatment involving steroids, immunosuppressants, heat therapy, physiotherapy and rest is essential. The most specific trichoscopic features for dermatomyositis are lake-like vascular structures, which look like dark blue patches on the skin.

What Is Syphilis?

Syphilis is a sexually transmitted bacterial infection, although it can also be spread by contact with an infected sore on the skin or by sharing intimate items like a razor or a toothbrush with an infected person. It is cured with antibiotics. However, if it causes damage to the body during its course, this might be permanent. If it runs past its primary phase, it can cause a patchy or diffuse set of lesions on the scalp. The article doesn’t define a clear differential diagnostic feature for syphilis that can be found with trichoscopy.

Why Would Your Dermatologist Be Interested in This Article?

Naturally, any dermatologist would be interested in techniques that allow them to perform differential diagnoses without invasive biopsies. Even though the article states trichoscopy can be used as an accessory tool rather than a primary tool, it’s still of great importance that such techniques are developed further.

How Does Type 1 Diabetes Affect Brain Development in Young Children?

What Is the Main Idea?

This post looks at the impact of type 1 diabetes on the development of children’s brains. Type 1 diabetes is known to affect multiple organs, but how does it affect the brain’s structure and function? It references the open access review “The Impact of Hypo- and Hyperglycemia on Cognition and Brain Development in Young Children with Type 1 Diabetes” in the journal Hormone Research in Paediatrics, which delves into the details of this important area of impact. If your child has been diagnosed with type 1 diabetes, your physician may be interested in this review, which summarizes everything known about the condition.

What Else Can You Learn?

Read this post to gain a better understanding of type 1 diabetes, the role of insulin, and the role of artificial insulin in treating type 1 diabetes. The post also references the improvements in diabetes management thanks to new technologies. Please also note that World Diabetes Day is on November 14.

What Is Type 1 Diabetes?

Type 1 diabetes is usually a genetic condition, although there are some viruses and environmental factors that may contribute to it. If someone is diagnosed with type 1 diabetes, it means their pancreas is not producing any insulin or only producing very small amounts because their body’s immune system or external factors have destroyed the insulin-producing cells. This means their body cannot work with the glucose from their diet: Glucose doesn’t enter their cells and thus cannot be used to generate energy.

The normal cycle of insulin is straightforward. We eat food. Glucose enters our bloodstream. The increased glucose in the bloodstream causes a signal to be sent to the pancreas, which starts producing and secreting insulin. The insulin facilitates the entry of glucose to the cells. As the level of glucose in the bloodstream (which you may have heard of as the blood sugar level) decreases, insulin secretion stops.

With type 1 diabetes, glucose builds up in the bloodstream. Complications can affect most of the major organs and become life-threatening or cause disabilities.

Does Type 1 Diabetes Only Affect Children?

The condition used to be referred to as juvenile diabetes because its onset is generally during childhood or early adolescence. However, it can also develop in adults. The symptoms of its onset include extreme hunger and unintended weight loss; increased thirst as well as frequent urination, which may include nighttime incontinence; mood changes; fatigue; and blurred vision. Healthcare practitioners urge anyone observing such symptoms in themselves or their child to consult their doctor.

How Is Type 1 Diabetes Treated?

There is no prevention or cure for type 1 diabetes. However, it’s possible for people with the condition to live long and healthy lives. Their health depends on their management of their blood sugar levels, which means being able to manage their food, insulin, and activity levels. This is especially difficult for children, meaning their parents or guardians, other family members, and teachers must support them continuously.

Artificial insulin is a crucial tool in treating type 1 diabetes. It is generally available as an injection although there are also pump-based solutions. The technologies for monitoring blood sugar, warning the patient, and administering the insulin are continuously improving. The best options should be investigated based on the patient and their lifestyle.

What Does the Paper Say about Brain Development?

The open access review “The Impact of Hypo- and Hyperglycemia on Cognition and Brain Development in Young Children with Type 1 Diabetes” focuses on how type 1 diabetes can affect children’s brain structure and function. This is obviously an area of considerable concern to parents or guardians whose children are diagnosed at a young age with the condition. It is a frightening time for everyone concerned with a lot of new information to process.

Two important terms are hypoglycemia (too little sugar in the blood) and hyperglycemia (too much sugar in the blood). The paper refers to the impact of each on the child’s developing brain. Hypoglycemia is well known to have a serious impact on children’s health and development, but an understanding about the impact of hyperglycemia has come more recently. This makes the paper an important one for healthcare practitioners as there may be new information that they are unaware of. Consider sending them the link to the review if you have a child with type 1 diabetes.

It is essential to understand that hypo- and hyperglycemia can both affect the brain structure, causing injury that directly impacts cognitive function (e.g., thinking, listening, learning, reasoning, and focusing); executive function (e.g., adapting, planning, self-monitoring, remembering, and managing time); and even mental health. The focus of the review is mainly the physical changes and cognitive function.

What Does the Future Hold?

As mentioned, new and improved technologies for blood sugar monitoring and insulin delivery are enhancing the flexibility and impact of daily treatment. The aim is to give all type 1 diabetes patients, including children, as “normal” an experience and development as possible. It’s important for parents, teachers and other adults in a child’s life to be as educated as possible about what hypo- and hyperglycemia could mean for the child, and help them to adapt to the challenges and limit any damage caused by type 1 diabetes.

Can Advanced Gastric Cancer Be Treated?

What Is the Main Idea?

This post looks at gastric cancer. What is it, how does it happen, and what are the treatment options? Based on the open access paper “Advanced Gastric Cancer: Current Treatment Landscape and a Future Outlook for Sequential and Personalized Guide” in the journal Oncology Research and Treatment, the post references some of the treatments that are in clinical trials. Your physician may be interested in this new research.

What Else Can You Learn?

Read this post to learn more about the importance of taking gastric symptoms seriously.

What Is Gastric Cancer?

Gastric cancer refers to cancers that arise in the cells of the mucosa, which line the stomach. Risk factors include Helicobacter pylori infections, chronic gastritis, Epstein-Barr virus infections, salty diets, diets that don’t include plant fiber, and smoking cigarettes. The cancer generally begins in the mucosa, but it can spread through the other layers of the stomach lining as well as metastasizing (spreading to other organs).

Early symptoms of gastric cancer are difficult for patients to identify as very serious, as they can have multiple causes and patients often assume they are caused by diet. They include heartburn, loss of appetite and indigestion. That’s why it’s so important to consult your physician if such “mild” symptoms persist. At more advanced stages, gastric cancer causes noticeable issues, including vomiting, jaundice, difficulty swallowing, and sudden weight loss. Advanced stage metastasis causes other symptoms as other organs are affected.

Gastric cancer is the third leading cause of cancer-related death. Unfortunately, partially due to the ambiguous early symptoms, it is often diagnosed when it is at an advanced stage, which precludes surgery as an option. Advanced gastric cancer has a poor prognosis with a very low five-year survival rate.

What Are the Treatment Options?

Most first-line chemotherapy options for gastric cancer combine fluoropyrimidine and platinum, although there are several EMA(European Medicines Agency)- and Swissmedic-approved options. However, newer options are emerging. Adding monoclonal antibodies substantially improves the clinical outcome of treatment. Immuno-oncology is evolving as a strong option, with immunochemotherapy showing significant survival benefits in advanced gastric cancer patients.

The open access paper “Advanced Gastric Cancer: Current Treatment Landscape and a Future Outlook for Sequential and Personalized Guide” states that molecular profiling is recommended for all patients prior to systemic treatment. At a minimum, such profiling should check for the expression of HER-2 (a gene that plays a role in the development of multiple cancers, including breast cancer), Epstein-Barr virus, and programmed death ligand-1 (a molecule with immunoregulatory functions). It’s also recommended to check for predisposition to mutation, which is assessed by looking at the stability of certain short, repeated sequences of DNA called microsatellites. The reason for this recommendation is that the results can influence the treatment regime. If certain targets are identified, immune checkpoint inhibitors can be used. These are drugs that block the protein–protein binding that prevents T cells from killing tumor cells. In other cases, antibodies can be added to the treatment to boost immune responses.

The paper goes on to detail everything that is known about the possible targets for treatment that could improve outcomes in this serious disease. If your physician hasn’t read it, they may be interested in the trials and treatment options mentioned.

What Can I Do?

Gastric health should never be taken lightly. If you have heartburn, nausea, indigestion, or loss of appetite lasting more than a few days, see your doctor. If you have a sudden and unexplained weight loss, see your doctor. If you see blood in your stool or vomit, if you’re vomiting frequently, if you’re bloated or retaining water, see your doctor.

Too often, people accept gastric symptoms as normal or blame them on their last meal. We should all be more conscious of our stomachs: what we put into them and how they feel.

 

Note: Some of the authors declared that they have scientific consultancy roles with pharmaceutical companies. It is normal for authors to declare this in case it might be perceived as a conflict of interest. For more detail, see the Conflict of Interest Statement at the end of the paper.

What Is Personalized Nutrition?

What Is the Main Idea?

Based on the open access paper “Interactions of Carbohydrate Intake and Physical Activity with Regulatory Genes Affecting Glycaemia: A Food4Me Study Analysis” published in the journal Lifestyle Genomics, this post looks at the concept of personalized nutrition. What is it, why should we care about it, and what is the research currently finding?

What Else Can You Learn?

Read this post to learn more about the factors that should be considered when designing a dietary plan. These are things you could discuss with your dietician or healthcare professional to ensure they are getting the full picture.

Food and Exercise Don’t Affect Everyone in the Same Way

We all know that what we eat and how much we exercise can affect our appearance and health. However, obviously not everyone who eats the same food and does the same exercise ends up with the same body type. Other factors, including genetics, have an influence. This makes it difficult for physicians and dieticians to help: There is no universally effective plan for nutrition and exercise. Personalized nutrition might be the answer.

What Is Personalized Nutrition?

Personalized nutrition involves considering a broad range of information about a patient when designing a dietary plan. As with personalized medicine, this approach can integrate data about the patient’s phenotype (their physical and observable body), genotype (their genetic makeup), lifestyle, and clinical history, including biochemical parameters. Personalized nutrition planning may also consider individual food preferences, although this has not always been the case.

The result should be a dietary plan that helps the patient to achieve a goal: for example, reduce their body weight, maintain a lower body weight, manage metabolic conditions like diabetes, or manage food intolerances.

What Is the Food4Me Project?

Food4Me is a special clinical trial focused on the effectiveness of personalized nutrition. There are multiple studies within the project. It describes its mission as understanding the relationship between food and gene expression with the aim of designing a better, healthier, and more individual diet.

The paper “Interactions of Carbohydrate Intake and Physical Activity with Regulatory Genes Affecting Glycaemia: A Food4Me Study Analysis” reports on one Food4Me study that looked at glucose homeostasis: the balance between insulin and glucagon that maintains healthy blood glucose levels. The researchers wanted to know how genetic background, physical activity, and carbohydrate intake interact to influence this important balance.

What Did the Study Involve?

The 1,271 participants in this particular study each completed online questionnaires about their diet, lifestyle, and body type. They also provided blood samples to measure glucose, cholesterol, and other important parameters, and buccal cell samples for genetic analyses. The researchers looked for the expression of 15 genes known to be involved in carbohydrate metabolism or in energy-related processes that affect glucose metabolism. Their expression was used to calculate the participants’ genetic risk scores (GRS), referring to the likelihood of issues with carbohydrate and/or glucose metabolism.

What Is the Significance of the Study?

The expected trends were found. There is a clear impact of carbohydrate intake and physical activity on the concentration of glucose circulating in the blood, and this is influenced by a person’s individual genetic makeup. This means, for example, that while increased physical activity is related to a lower blood glucose concentration, more exercise cannot be the only thing that a healthcare professional or patient considers in glucose level management.

Results like these are the first step towards more effective personalized nutrition. As researchers gain a better understanding of this interplay and other similar food–exercise–genetics relationships, they can start to find the patterns that will support more people in achieving their goals related to the nutrition that’s healthy for them. The Food4Me project has already shown benefits in terms of providing advice to patients and understanding glycemia.

In the meantime, we all need to be aware that the same approach to goals like weight loss and blood glucose management won’t work for everyone. We have to be prepared to try different approaches or even look into what genes our body might be expressing to see if there are any complications.

 

Note: Two of the authors declared that they have a relationship with Vitas Ltd., which performs the dried blood spot analyses for the study. It is normal for authors to declare this in case it might be perceived as a conflict of interest. For more detail, see the Conflict of Interest Statement at the end of the paper.

Tattoos and Delayed Allergic Reactions

What Is the Main Idea?

Delayed allergic reactions, also known as delayed hypersensitive reactions, occur days, weeks or even months after exposure. This post deals with delayed reactions to tattoo ink, based on the case report “Delayed-Type Hypersensitivity Reaction to Red Tattoo Ink Triggered by Ledipasvir/Sofosbuvir for Hepatitis C” and published in the journal Case Reports in Dermatology. Discover why these reactions occur, why they’re difficult to predict and why it’s important to know about them.

What Else Can You Learn?

Learn the difference between an allergy to tattoo ink, keloids and short-term changes in your tattoo. You can also find out what components of different tattoo inks are responsible for allergies.

Tattoos and Allergic Reactions

Did you know that it’s possible to have an allergic reaction to tattoo ink? An allergic reaction is defined as your immune system overreacting to something harmless or relatively harmless. Skin-related allergic reactions can include rashes, itching, flaky or scaly skin, small blisters, and swelling. A common allergic reaction to a tattoo is a red, bumpy, persistent rash that can be very itchy. Interestingly, it can occur in the first days after you get the tattoo or months or years later. To the best of my knowledge, there are no reports of anaphylaxis (the most serious and life-threatening allergic reaction) in response to a permanent tattoo.

There are also times that parts of your tattoo may feel raised for a short time. This can be due to internal and external factors, such as dehydration, tension, or even extreme heat or cold. Remember that a tattoo becomes part of the structure of your skin, which reacts dynamically to your physical state and environment. That means the tattoo will also react.

Are Keloids an Allergic Response?

Note that allergic rashes or slightly raised tattoos are not the same as the formation of keloids. These are enlarged, raised scars that can form anywhere that you have trauma to your skin. They can take months to form and will look like thickened skin. Anyone can get keloids, but not everyone does. If you know that you’re prone to them and you’re getting a tattoo, consider talking to a dermatologist about how you might prevent them occurring.

What Triggers the Allergic Response?

Getting back to allergic reactions: Red tattoo pigments are the most common triggers of this response. This used to be due to the presence of the mercury-derived pigment cinnabar in red inks. Even though this component has been replaced by cadmium red, sienna, sandalwood and other substances, reactions to red ink persist. Because there are multiple ingredients, it is difficult to isolate the component that’s causing the problem.

Other tattoo pigments can also trigger allergic reactions due to metallic components such as nickel, chrome and cobalt, and preservatives like formaldehyde. The carbon-based pigments in black tattoos can cause issues on their own or break down over time to cause issues. Yellow tattoos have particular sensitivity to sunlight, with photoreactive decay potentially leading to allergens being created. The mineral components of blue ink can also be an issue.

What Is a Delayed Hypersensitive Reaction?

The phenomenon of an allergic reaction occurring days, weeks or months after exposure is known as a delayed hypersensitive reaction. Normally, delayed hypersensitive reactions are expected two to three days after exposure, but as mentioned, the time limit is different with tattoos.

This post was inspired by the case of a 51-year old cisgender man, described in the case report “Delayed-Type Hypersensitivity Reaction to Red Tattoo Ink Triggered by Ledipasvir/Sofosbuvir for Hepatitis C”. For four months, the man had had itchy lesions on the red areas of a multi-colored tattoo on his back. They had appeared one week after he started taking ledipasvir/sofosbuvir for a hepatitis C infection. The examination of the lesions showed that he had a delayed hypersensitive reaction to red tattoo ink. Treatment produced a mild improvement.

Can You Test for the Risk of Delayed Hypersensitive Reactions?

Interestingly, when researchers used patch tests on patients with red tattoo reactions, the results were inconsistent, suggesting that this technique is not useful for diagnosing a risk of delayed hypersensitive reactions.

The reason for the reaction — and the reason for the difficulty in diagnosing it — may be a phenomenon related to the metabolism of the tattoo pigments over time. The impact of exposure to the sun, which may cause photochemical breakdown of tattoo pigments, has also been suggested as a cause. The idea is that the pigment might not be an allergen at the time that the tattoo is created, but its breakdown products might cause the reaction.

Immune reconstitution and its related inflammatory syndrome are also mentioned in the paper as reasons for the delayed response. Immune reconstitution is the process of the immune system rebuilding itself after a period of suppression due to disease or medical treatment. Immune reconstitution inflammatory syndrome occurs when the rebuilding immune system overreacts to previously acquired infections or to allergens in the body.

How Common Are Allergic Reactions to Tattoos?

Reports of immune or allergic reactions to tattoos are quite rare. In quite a few cases, the reports of delayed hypersensitive responses involve patients receiving treatments for hepatitis C or HIV and then developing the allergy. These therapies include ledipasvir/sofosbuvir and antiretrovirals, which can lead to immune reconstitution.

Reports of this type will hopefully lead to research into how this occurs as well as increasing the awareness of such phenomena among healthcare workers. It is also worth knowing that drugs and other changes can lead to an immune reaction or tattoo allergy. If it happens, you will know to talk to a specialist right away, rather than waiting to see if it disappears.

 

Note: Two of the authors of the paper declared that they receive personal fees and/or nonfinancial support from pharmaceutical companies. It is normal for authors to declare this in case it might be perceived as a conflict of interest. For more detail, see the Conflict of Interest Statement at the end of the paper.

Can Fecal Microbiota Transplantation Help with Irritable Bowel Syndrome?

What Is the Main Idea?

This blog post is about irritable bowel syndrome (IBS). It is inspired by the recent open access paper “Improvement in Food Intolerance Symptoms after Pretreatment with Antibiotics Followed by Faecal Microbiota Transplantation: A Case Report” in the journal Case Reports in Clinical Nutrition, which looks at a technique called fecal microbiota transplantation that has considerable potential in the treatment of IBS.

What Else Can You Learn?

Learn about the differences between food allergies, which involve immune system reactions and can be life-threatening, and food intolerances, which have major impact on quality of life, but do not provoke anaphylactic reactions.

What Is Irritable Bowel Syndrome?

Irritable bowel syndrome (IBS) affects around 12% of the world’s population. It is a lifelong condition with symptoms including abdominal pain, cramping, constipation, diarrhea, and bloating. Patients may have periods with no symptoms followed by days, weeks or even months of symptoms that impact quality of life.

Despite considerable research, the cause of IBS is unknown and there is still no cure. Evidence suggests that multiple factors may contribute to IBS, with current thinking focused on interactions between the gut microbiome (i.e., the microorganisms that live in the gut), the gut endocrine cells (which produce and secrete hormones), the central nervous system, and the diet. Food certainly plays a part, and anyone with IBS will have identified various foods they believe to trigger reactions. However, the biological mechanisms underlying these food reactions require more research.

Because the cause is unknown, treatments for IBS can only focus on the symptoms. Patients are often asked to keep diaries of what they eat to see what might trigger problems, with fatty and spicy foods, excessive amounts of fruit, and alcohol being commonly identified culprits. Probiotics are often prescribed. Regular meals, relaxation and exercise are also recommended. However, since stress is a trigger and food triggers can be unpredictable, management of IBS proves difficult for many patients.

What’s the Difference between a Food Allergy and a Food Intolerance?

A food allergy is an adverse food reaction that involves the immune system: for example, peanut allergies and shellfish allergies. They can affect multiple organs, usually have a rapid onset, within seconds or minutes, and may include skin reactions (rashes, hives, itching); swelling of facial and throat tissues that can result in difficulty swallowing or breathing; or digestive responses such as vomiting, cramps or diarrhea. They are triggered by even the smallest amounts of the food.

Anaphylaxis is the most severe type of allergic reaction, and it can be caused by a food allergy. The immune system releases a high amount of chemicals that can send the body into life-threatening shock, with symptoms including a sudden drop in blood pressure, changes in heart rate, narrowing of airways and vomiting. An immediate medical response is essential: an epinephrine injection (e.g., an EpiPen) followed by an emergency room visit.

Celiac disease has many features of food allergies: The immune system is involved, and it affects multiple organs, with responses including gastrointestinal issues, headaches, and joint pain. However, anaphylaxis is not a feature of celiac disease. Some sources classify it as a food allergy, others as a food intolerance.

A food intolerance is also called a non-immune mediated food reaction. The immune system is not involved, the impact is not always immediate, and it may even be possible for the sufferer to eat small amounts of the food. The reactions can be caused by the lack of an enzyme that is needed to digest the food (e.g., lactose intolerance is due to a lack of lactase); sensitivity to particular chemicals in food, such as sulfites, fermentable carbohydrates, or biogenic amines; and even psychological responses, such as recurring stress related to particular foods. Food intolerances affect around 20% of the general population and are commonly seen in patients with IBS.

What Is Fecal Microbiota Transplantation?

Fecal microbiota transplantation (FMT) is emerging as a potentially effective treatment for IBS. The patient receives an infusion of a homogenized and filtered stool from a healthy donor who has gone through an intensive screening process. This transplantation of healthy gut bacteria can help with a number of diseases, such as Clostridioides difficile infection, ulcerative colitis, and Crohn’s disease.

The case study “Improvement in Food Intolerance Symptoms after Pretreatment with Antibiotics Followed by Faecal Microbiota Transplantation: A Case Report” describes how a 35-year old cisgender female patient with IBS was helped by FMT and indicates that the gut microbiome plays a role in the pathogenesis of food intolerances.

What Does the Case Involve?

The patient had been suffering from nausea, abdominal pain, and alternating loose stools or constipation for 18 months. She had identified severe food intolerances to dairy, gluten, egg and soy, and moderate intolerances to onion, garlic, raw vegetables and high-fructose fruit.

After an intensive examination to rule out other pathologies, the diagnosis of IBS with suspected gut microbiota dysbiosis (a medically significant reduction in microbial diversity) was given. She was treated with antibiotics followed by FMT enemas over a 12-month period.

Twelve weeks after the start of the FMT treatment, the patient reported an 80–90% improvement in her symptoms, with less pain and nausea, better bowel movements, and improved energy levels. After the year, she was able to include gluten and dairy in her diet with no symptoms.

What Does This Case Mean?

As mentioned, the linked paper is a case study, so its conclusions are preliminary and cannot be considered thoroughly clinically tested. In addition, it is unknown how long the improvements will last. However, it certainly shows that FMT has promise and could be the way forward for treating some people’s IBS and food intolerances.

Should I Go Gluten-Free If I Have IBS?

As mentioned in Dr. George Marx’s post “How Useful Is a Gluten-Free Diet?”, a gluten-free diet is not harmful provided your nutrition is balanced. Unfortunately, it can be difficult to create a balanced gluten-free diet, so you should always seek support from a doctor or dietician before taking such a decision.

 

Note: One of the authors of the paper declared that they have a pecuniary interest in the Centre for Digestive Diseases, is a medical advisor to Finch therapeutics, and holds patents for FMT treatment. It is normal for authors to declare this in case it might be perceived as a conflict of interest. For more detail, see the Conflict of Interest Statement at the end of the paper.

Cancer and Sleepless Nights

What Is the Main Idea?

Sleep disorders are reported in 30–50% of cancer patients, but the specific causes are unknown. A detailed series of questionnaires was given to 107 patients with various types of cancer to establish what the reasons might be. The open access paper written about the study and published in the journal Oncology Research and Treatment is titled “Why Do Our Cancer Patients Sleep So Badly? Sleep Disorders in Cancer Patients: A Frequent Symptom with Multiple Causes”. It discusses the importance of considering the causes of poor sleep when planning treatment.

What Else Can You Learn?

Learn about the stages of sleep and what constitutes a good sleep. Find out what you could talk to your physician about if you’re a cancer patient suffering from a sleep disorder, pain, depression, or anxiety.

What Is a Good Sleep?

Getting a good sleep is essential for our physical and mental well-being. We should try to get a good sleep every day. But what does “good” mean in this context?

A good sleep is one where our body and brain can recover from the day’s events. For this recovery to be effective, we need to give our body time to cycle through the four stages of sleep, ideally a few times.

  • Stage 1 of sleep is when your eyes are closed but you’re still a little bit aware of your surroundings. You might wake up or your leg or arm might twitch. It would be easy for someone to wake you. If you’re getting good sleep, this stage is short — maybe 10 minutes.
  • Stage 2 is the light sleep when your heart rate slows down and your core temperature declines. You could still be woken quite easily but you’re not aware of your surroundings. This stage can last up to 25 minutes.
  • Stage 3 is the period of sleep when your muscles are fully relaxed, your body is producing melatonin at a higher rate, and your core temperature has stabilized. It would be difficult to wake you. Your body and brain can start recovering from the day’s events during stage 3. It’s the first stage of regenerative sleep. It can last up to an hour.
  • REM sleep is the second stage of regenerative sleep. REM sleep is a period of more intense brain activity, faster breathing and an elevated heart rate. Dreams occur during this stage. The length of REM depends on what cycle of sleep you’re in. During the first cycle, REM might only be 10 minutes. If you get a full sleep, the final stage of REM can be an hour.

Cancer Patients Have Disrupted Sleep

Cancer is a source of considerable anxiety, stress and fear. What’s more, cancer may cause pain or other obvious physical symptoms. If you’ve ever lain awake at night because you’re anxious, stressed, depressed or afraid about something or because you have backache, a headache or other discomfort, the statement that cancer patients have difficulty getting a good night’s sleep may seem obvious. Even cancer patients themselves seem to think bad sleep is normal for them and they under-report it to doctors unless they are specifically asked about it.

As discussed in “Why Do Our Cancer Patients Sleep So Badly? Sleep Disorders in Cancer Patients: A Frequent Symptom with Multiple Causes”, there is a lot more to the story of why so many cancer patients sleep poorly — and importantly, a lot more that could be done to support them.

What Percentage of Cancer Patients Sleep Poorly?

In the medical literature, sleep disorders are reported in 30–50% of cancer patients. In this paper, 68% of patients reported a sleep disorder, with 44.9% reporting insomnia.

What Role Do Cancer Drugs Play?

Interestingly, medication was not found to have a significant impact on sleep in this study.

What Role Does Pain Play?

Pain is a major cause of sleep disorders. In this study, a markedly increased level of pain was found in the group of patients with sleep disorders. However, only 35.5% of them were taking a medication to alleviate the pain. The authors recommend that physicians should interview patients about pain and try to address it, focusing on optimizing pain therapy before prescribing sleeping pills.

The authors also note that when you can’t sleep, there is a knock-on effect on the intensity and frequency of pain. This vicious circle needs to be broken to give patients the regenerative rest they need.

What Role Do Depression and Anxiety Play?

In the study, 49.5% of the patients had mild or moderate depressive symptoms and most of these showed markedly more disrupted sleep. The authors recommend that if a patient says they’re not sleeping, physicians should ask about depression. Also, if a patient mentions depression but doesn’t mention not sleeping, the physician should check on their sleep quality.

As mentioned, anxiety is another source of disruption in sleep. In the study, this also proved true. Around 50% of the participants had moderate or extreme feelings of anxiety and almost all of them had a sleep disorder. What’s more, patients with a sleep disorder rated their anxiety as double that of patients without a sleep disorder. This again indicates that physicians should talk to their cancer patients about both anxiety and sleep.

Related to mental and emotional health were material concerns. Cancer patients who had lost their job or were afraid of losing their job reported sleep disturbances, as did the majority of those with financial stress.

What You Can Do

All the authors’ recommendations to physicians to talk about sleep-related issues can translate into topics for you to bring up first.

Therefore, if you are a cancer patient, be prepared to talk to your doctor clearly about pain, sleep, depression, anxiety and even personal worries. Give your doctor a clear picture of what you’re going through and how you’re sleeping. Make it clear you’d like to address pain before trying sleeping pills. Ask for support with mental health. If you aren’t sure why you can’t sleep, get your doctor to discuss it with you — they might have the answer.

Above all: Get the help you need to eliminate the barriers to that all-important regenerative sleep.

Could MP-AzeFlu Be the Right Treatment for Allergic Rhinitis?

What Is the Main Idea?

Allergic rhinitis is an unpleasant condition that can significantly impact people’s quality of life. There is no cure, but perhaps there is a treatment option that can quickly and effectively alleviate the symptoms. This post is based on a recent open access review titled “MP-AzeFlu in Moderate-to-Severe Allergic Rhinitis: A Literature Review” and published in the journal International Archives of Allergy and Immunology, which looks at a combination antihistamine/corticosteroid treatment named MP-AzeFlu.

What Else Can You Learn?

This post also includes information on other treatments for allergic rhinitis.

What Is Allergic Rhinitis?

If you get a runny or blocked nose, itchy or watery eyes, and/or sneeze a lot every time there’s pollen or dust in the air, then you probably have allergic rhinitis. This is an allergic reaction — and quite an unpleasant one! I have allergic rhinitis myself, triggered by dust mites and mold spores, so I definitely empathize with you if you have it too. Allergic rhinitis is often accompanied by other issues: asthma, sinus problems, conjunctivitis and other issues related to irritation of the eye, sleep disturbance and even dermatitis.

As discussed in the article “MP-AzeFlu in Moderate-to-Severe Allergic Rhinitis: A Literature Review”, allergic rhinitis is commonly moderate to severe, and it can have a significant impact on quality of life. A range of treatments are available, but most patients are not satisfied with their current treatment.

How Is Allergic Rhinitis Treated?

Allergic reactions are the immune system overreacting to an allergen, which is often a harmless particle or protein. The body releases histamine, which is normally only released in response to something harmful, such as an infection. It mediates bodily reactions intended to stop the harm from spreading, such as swelling, blood vessel expansion and mucous production.

There is no cure for an allergy. Any treatment aims to control the symptoms and/or suppress the immune system overreaction.

Allergic rhinitis is the overreaction to airborne allergens. Treatment options include:

  • Corticosteroid nasal sprays that reduce inflammation by inhibiting inflammatory protein synthesis
  • Decongestant nasal sprays that cause blood vessels to contract, reducing swelling and making breathing easier
  • Non-steroidal, non-decongestant nasal sprays that can relieve itchiness
  • Prophylactic or on-demand antihistamines that block the effects of histamine in your body
  • Immunotherapy, which involves controlled exposure to increasing concentrations of the allergen to try to retrain the immune system
  • Lifestyle changes that are intended to reduce the amount of an allergen present in your environment

Doctors will often prescribe more than one treatment in cases of moderate and severe allergic rhinitis. However, even with this approach, satisfactory results can be difficult to achieve. Not every medication works well for every patient. Some of the medications are not suitable for long-term use, e.g., decongestants and itch-relieving nasal sprays. In addition, some patients do not follow the treatment regimen precisely, resulting in changes in the daily intake.

What Is MP-AzeFlu?

MP-AzeFlu is a combination product with an antihistamine (azelastine hydrochloride, AZE) and a corticosteroid (fluticasone propionate, FP). AZE and FP have shown synergistic effects in allergic rhinitis treatment. AZE is the inhibitor and FP is the anti-inflammatory. MP-AzeFlu delivers both medications in a nasal spray.

The article “MP-AzeFlu in Moderate-to-Severe Allergic Rhinitis: A Literature Review” focuses on whether MP-AzeFlu might be more effective than other treatment options.

What’s the Conclusion?

The authors analyzed the results of 16 studies on the efficacy of MP-AzeFlu against allergic rhinitis and established that:

  • Long-term use of MP-AzeFlu is safe, with benefits in children and adults, including people over 65 years old.
  • Other treatment options do not provide the same rapid and sustained relief from allergic rhinitis. This includes AZE or FP on their own or a combination of intranasal corticosteroids and an oral antihistamine.
  • MP-AzeFlu improves patient quality of life.
  • MP-AzeFlu has the potential to be a first-line therapy for allergic rhinitis.
  • Using a single medication like this may improve patient adherence to treatment.

Note: Some of the authors of the paper declared that they have received grants and consultancy work from pharmaceutical companies. It is normal for authors to declare this in case it might be perceived as a conflict of interest. More detail can be found in the Conflict of Interest statement at the end of the referenced paper.

The Impact of COVID-19 on the Heart and Kidneys

What Is the Main Idea?

This post is based on a recent open access review titled “Cardio-Pulmonary-Renal Consequences of Severe COVID-19”, published in the journal Cardiorenal Medicine. It looks at the effect of COVID-19 on the heart, lungs, and kidneys. The post includes suggestions on what to talk to your doctors about if you have concerns about your heart and kidney health in terms of COVID-19 infection.

What Else Can You Learn?

Learn why SARS-CoV-2 is able to infect cells in different organs and how this relates to symptoms of COVID-19. This post also briefly touches on long COVID, also called post-COVID-19 syndrome.

COVID-19 Affects More than Just the Lungs

Thanks to the work of researchers and physicians, we now know that SARS-CoV-2 can attack more than just the respiratory system. Like the previous two coronaviruses that caused pandemics, SARS-CoV-2 can directly and indirectly cause cardiovascular and renal complications. That’s the focus of the open access review titled “Cardio-Pulmonary-Renal Consequences of Severe COVID-19”. This post looks at some of the authors’ findings.

How Does the SARS-CoV-2 Virus Affect Other Organs?

First, it’s important to understand how SARS-CoV-2 enters cells and causes damage. The virus uses its spike protein to bind to an enzyme (ACE-2) found on the surfaces of certain cells. Another enzyme (a protease called TMPRSS2) cleaves the spike protein, making the virus release peptides that allow the virus to fuse to the membrane and enter the cells. Cells with a high amount of ACE-2 and TMPRSS are thus more susceptible to SARS-CoV-2 infection.

The heart, lungs, kidneys, and intestines all express high amounts of these two enzymes, so these organs are all at risk. That’s among the reasons why there is a range of symptoms for COVID-19: Not every patient has SARS-CoV-2 infecting the same organs to the same degree. For example, if the virus was more abundant in the kidneys and lungs of one patient, they might have acute kidney injury along with difficulty breathing. If another patient had a high intestinal presence of COVID-19, diarrhea might result.

What Effects Does SARS-CoV-2 Have on the Lungs, Heart and Kidneys?

When SARS-CoV-2 infects cells in the lungs, it can directly injure them. For example, it can damage the alveoli (the “bunches of grapes” where carbon dioxide and oxygen exchange occurs); cause congestion of the capillaries that line the alveoli; kill off the lining of air spaces in the lungs; and lead to fluid filling air spaces in the lungs. Even in asymptomatic COVID-19-positive people, scarring and inflammation in the lungs is found. Indirect injury can come from a range of sources, including mechanical ventilation, problems arising from inflammation and dysfunction in the vascular system, and hypertension.

Cardiac injury is common in critically ill COVID-19 patients. This can be direct damage from SARS-CoV-2 infection of cardiac cells and the blood vessels surrounding the heart. It can also be indirect, for example due to drugs being used to treat other symptoms; inflammation and dysfunction in the vascular system; or from sepsis.

COVID-19 can also injure the kidneys directly or indirectly. SARS-CoV-2 has been shown to invade renal cells, causing symptoms ranging from increased levels of protein in the urine (proteinuria) to acute kidney injury. Around 20% of patients with severe COVID-19 even require long-term dialysis or a kidney transplant. Indirect kidney injury can come from a range of sources too, including septic shock, drug-induced nephropathy, and, again, inflammation and dysfunction in the vascular system.

This repeated mention of the impact of problems in the vascular system illustrates a topic that the authors emphasize in the paper: The heart, lungs and kidneys have a strong interaction to the point where injury to one can influence the others. In particular, they discuss cardiorenal syndrome: when an acute or chronic dysfunction in the heart negatively affects the kidneys and vice versa. Cardiorenal syndrome may play an important role in severe COVID-19.

What Is Long COVID?

Although the paper “Cardio-Pulmonary-Renal Consequences of Severe COVID-19” does not deal with long COVID (or post-COVID-19 syndrome), it is certainly relevant to mention. The British National Health Service (NHS) and the World Health Organization (WHO) defines long COVID as disabling symptoms that last weeks or months after the infection has gone. The WHO also states that it may include disabilities that are likely to be very long lasting. Both organizations point out that the symptoms during infection do not need to be severe for long COVID to occur.

Symptoms include fatigue, insomnia, difficulty concentrating, breathing problems, heart palpitations, pain, digestive issues, changes to the sense of smell or taste, and even skin conditions. Long COVID is something that still requires research.

What Can I Do to Protect Myself?

Following public health guidelines is still important: The pandemic is not over. At the time of writing, just 15.5% of the global population is fully vaccinated. In so-called high-, upper middle-, lower middle- and low-income countries, respectively roughly 56, 39, 19 and 1.1% of the populations have been vaccinated. Epidemiological research indicates that it’s still likely that variants will arise and spread. Masking, social distancing, hand sanitizing and continuing global vaccination programs are all essential.

Beyond that, having a full awareness of your cardiovascular and kidney health is critical. If you’re concerned, talk to your doctors about ways that you can improve the health of your heart, circulation, and kidneys.

Finally, be aware of the conditions and behaviors associated with higher risk of severe COVID-19, which include cardiovascular disease, chronic kidney disease, hypertension, diabetes, obesity, asthma, and smoking. If you test positive for COVID-19 and have concerning conditions or behaviors, talk to your doctors about proactive hemodynamic management of COVID-19, as detailed in the fourth and fifth sections of “Cardio-Pulmonary-Renal Consequences of Severe COVID-19”. Proactively monitoring the heart and other important parameters in the emergency department and outside of intensive care could ensure that problems are detected early, possibly preventing hospitalizations and the development of complications in the heart, lungs, and kidneys.

Want to know more about kidney health and COVID-19? I’ve written another post focusing on acute kidney injury and how it can worsen the impact of other conditions, including COVID-19.

Can Obesity Complicate Kidney Transplants?

What’s the Main Idea?

Learn more about kidney transplants and how obesity can affect their chances of success. This post is based on a recent free access review titled “Obesity in Renal Transplantation” in the journal Nephron.

What Else Can You Learn?

This post also discusses body mass index (BMI): How is it calculated, what are the issues with it, and why is it still used in research and medicine?

What Qualifies Someone for a Kidney Transplant?

Kidney transplants happen when someone’s kidneys have failed or are about to fail. That means that the kidneys are not able to filter waste and excess fluid from the blood. The commonest reason is end-stage kidney disease, also called end-stage renal disease, which is the final stage of chronic kidney disease.

The only alternative to a kidney transplant is dialysis. However, it’s important to note that kidney transplants tend to be the better option. They can restore quality and even longevity of life in a way that dialysis cannot.

Perhaps this is because kidney transplants have become a routine operation. The first attempt was in the 1930s. Success was achieved in the 1950s. The surgical and aftercare procedures are well supported by extensive research and are considered safe, particularly if the patient is healthy and aftercare instructions can be followed. Interestingly, if the kidney comes from a living donor, the transplant tends to last longer.

What Disqualifies Someone from a Kidney Transplant?

There are a number of medical conditions that can disqualify a patient from a kidney transplant. They can be short-term, such as active infections, or long-term, such as certain serious cardiovascular diseases. Lifestyle can also be an issue: Smoking, excessive alcohol consumption and narcotic substance abuse can prevent someone from being a candidate.

The factor we’re interested in today is obesity; specifically, could obesity prevent someone from getting a kidney transplant?

There isn’t a straightforward answer. Obesity can complicate surgery and recovery. It’s a cardiovascular risk factor (CVRF) that is associated with other CVRFs and with metabolic disorders. Over 75% of kidney transplant recipients present at least one CVRF and around 17% die from cardiovascular disease. Obesity can also complicate the graft survival (the survival of the new kidney).

Most kidney transplant centers covered in the free access review “Obesity in Renal Transplantation” recommend that patients on kidney transplant waiting lists lose wait if their body mass index (BMI) is over 35. International guidelines recommend getting the BMI to under 30. However, there isn’t a definitive cutoff point where surgery is not an option. Some centers consider a BMI over 40 to be the point where surgery doesn’t make sense, others say 35, others 30 – each for reasons I’ll go into shortly. First, let’s take a look at why BMI is used and ask whether that’s a fair measurement to use.

What’s the Problem with BMI?

BMI is calculated by dividing a subject’s weight in kilograms by the square of their height in meters. Thus, my BMI would be 22 — that’s 78 kg divided by (1.88 m)2, equaling 22.06 kg/m2. According to the World Health Organization and the United States National Institute of Health, overweight means a BMI over 25 and obese means a BMI over 30.

However, there are some things to consider. The United States National Institute of Health describes how BMI may overestimate body fat in people with a muscular build, such as athletes, and underestimate it in older people, among others. The European Medicines Agency and the World Health Organization have made similar points, as have many individuals with reference to their own experiences with the metric.

The waist circumference or waist-to-hip ratio and the percentage of body fat in combination with BMI could give a better picture of the state of someone’s body. Unfortunately, there isn’t a standardized method to measure the former and there isn’t a reliable and inexpensive way to measure the latter!

Furthermore, it’s very important to consider lifestyle, diet, and risk factors for diseases before making any bold statements about someone’s health based solely on their weight or size.

Despite the problems, BMI is still used as a measurement in research and medicine because it is correct roughly 80% of the time. In research, this is sufficient to make some general statements and recommendations. In medicine, it can be a starting point for further discussions.

Can a Kidney Transplant Work for Someone with a High BMI?

As mentioned, there isn’t a definitive universal cutoff BMI for kidney transplants. However, there are some things that can be considered, as summarized in “Obesity in Renal Transplantation”.

Patients with a BMI up to 40 show better survival rates after a kidney transplant than with long-term dialysis. However, patients with a BMI over 30 are more likely to have complications during surgery and complications with the graft starting to function. What’s more, in the long term, the transplanted kidney is less likely to survive if the patient’s BMI is over 30.

All that said, it is essential to look at each individual as more than just BMI: Weight distribution, body shape, muscle mass and fluid accumulation (which is common with kidney failure) all need to be considered.

Does Weight Loss Help?

There isn’t enough evidence to say that weight loss is beneficial. Clinical trials on the benefits of pre-transplant weight loss would be needed to make clear recommendations. However, many centers still recommend weight loss because of the potential to reduce surgical complications, prevent delays in graft function, and improve long-term graft survival. In general, self-care, moderate exercise and a healthy diet are important for people with chronic kidney disease.

If your doctor recommends that you lose weight, you might be interested in my post “Increasing the Success of Behavioral Approaches to Weight Loss”. It talks about some of the things you might consider when trying to lose weight, such as emotional support or compensating for changes in your body’s structure and energy demands.

Why Some Chemotherapy Patients Keep Their Hair

What Is the Main Idea?

Hair loss due to chemotherapy is well known, but is it well understood? This post is based on an editorial titled “Why Do Not All Chemotherapy Patients Lose Their Hair? Answering an Intriguing Question” in the journal Skin Appendage Disorders. Here, we attempt to summarize what the authors found when they looked into why some chemotherapy patients keep their hair.

What Else Can You Learn?

What are the phases of hair growth and how do they relate to chemotherapy? What are the two types of chemotherapy and what are their general effects? This post also provides answers to these questions.

Chemotherapy and Hair Loss

Chemotherapy has various side effects, but hair loss (alopecia) is probably the most visible. If a character in a television show or film undergoes chemotherapy, they go bald. It’s a visual shorthand that directors can’t seem to resist. However, not every patient has hair loss. Even when two patients have the same chemotherapy regimen for the same cancer type, there’s no certainty that they’ll both experience the same effects.

In their editorial, Rebora and Guarrera of the University of Genoa’s Department of Dermatology reference a study where only 44% of patients had alopecia despite taking the same dosage of two drugs at the same intervals. They also cite a study where 31.3% of patients kept their hair and point out the lack of understanding of alopecia in beard, eyebrow, and body hair.

Why Should We Talk about Hair?

Hair loss might seem like a trivial topic, but hair has a great deal of cultural importance. When you consider that up to 14% of women refuse chemotherapy due to a fear of hair loss, it makes it clearer why it’s important to study and explain this topic.

In an effort to demystify this process, Rebora and Guarrera considered some of the factors that have not been extensively studied, focusing not on chemotherapy drugs but on the hair follicle and how hair grows.

What Are the Phases of Hair Growth?

To understand why chemotherapy affects hair, it’s helpful to look at the growth cycle of hair, which has four phases: anagen, catagen, telogen and exogen. A simple explanation of these phases is: growth, transition, resting and shedding.

  1. In the anagen phase, the hair grows due to the active division of keratinocytes (cells that produce keratin) in the hair matrix (part of the hair follicle). This phase can last between 2 and 8 years for scalp hair.
  2. In the catagen phase, the structures of the hair follicle transition into their resting phase.
  3. In the telogen phase, the follicle is dormant for a few months, but the hair is still anchored in place.
  4. In the exogen phase, the hair base breaks free from the root and the hair is naturally shed.

About 85 to 90% of the average person’s scalp hair is in the anagen phase, less than 1% is in catagen phase and 10 to 15% is in telogen phase at any given time. As for exogen phase: We lose between 50 and 100 hairs from our whole body per day.

What Is the Mitotic Rate of Cells?

Cancer tissues often show a high mitotic rate. This is the measure of the number of cells that are dividing in a given amount of cancer tissue. In general, patients whose cancers show very high mitotic rates have lower chances of survival because the cells are dividing rapidly, meaning the tumor can grow and metastasize faster.

How Does Chemotherapy Work?

Cytotoxic chemotherapy drugs function by damaging DNA or microtubules. They have been proven to preferentially kill cells with a high mitotic rate (although they have also been found to affect some solid tumors with low mitotic rates — a topic for another time!). Cytotoxic drugs can be highly effective so, despite their side effects, they remain an important tool in oncology.

Targeted chemotherapy drugs work by disrupting cancer-specific cellular pathways. They have a lower toxicity, which is of course highly desirable. However, their development requires an understanding of the specific pathways of a given cancer. Therefore, we don’t have targeted chemotherapy drugs for many cancers. They are often used together with cytotoxic drugs for greater efficacy.

Why Do Cytotoxic Chemotherapy Drugs Affect Hair?

As mentioned, cytotoxic chemotherapy drugs preferentially kill cells with a high mitotic rate. Keratinocytes were once believed to divide at a speed close to the maximum for human cells. This very high mitotic rate is perfect for quick hair growth. Unfortunately, it puts hair loss high on the list of chemotherapy’s side effects.

How Do Some Hairs Escape the Effects of Chemotherapy?

Chemotherapeutic drugs interrupt the anagen phase of the hair cycle by stopping keratinocyte mitosis in the hair matrix. Based on the earlier statement that 85 to 90% of the scalp hair is in anagen phase, that would suggest 85 to 90% of the hair would be damaged at the root. However, this is not always the case. Even within the anagen phase, the keratinocytes may be in a short resting subphase (mitotically silent). The active growth phase isn’t a constant growth phase!

Therefore, the effect of a cytotoxic chemotherapy drug on a cell is usually considered in terms of how strong the drug is and how long it is in the body. With hair, we also have to consider whether the keratinocytes are resting (mitotically silent despite being in the anagen phase or because they’re in the catagen, telogen or exogen phase).

I’ve only talked about scalp hair so far, but of course we also have eyebrows, eyelashes and other facial hair, and body hair of various types. In the European population, beard hair grows at a similar rate to scalp hair. In the Japanese population, scalp hair grows faster than in the European population. Beard hair grows faster in the summer months than in the winter. Eyebrows grow at roughly half the speed of scalp hair. These differences are significant when we’re talking about hair loss due to chemotherapy.

Differences in the timing of hair loss and the impact of the patient’s gender also need further exploration. Some patients lose hair quickly within days or weeks of the first treatment, others experience gradual hair loss months later in a manner that they might not even associate with their chemotherapy.

What Does This Mean for a Patient?

All patients who are given a cytotoxic chemotherapy drug have a chance of losing scalp hair (and beard hair if they have it). Other hair, even eyebrows and eyelashes, may be affected. However, there is no certainty about hair loss: It might not happen. If it does, in the vast majority of cases, it is temporary. Within days of the chemotherapeutic drug leaving the system, the body is capable of repairing the DNA and restoring the structures of the hair bulb. Within months, new hair can grow.

Ultimately, the side effects of chemotherapy must be weighed against its potential to arrest cancer cell division and shrink or destroy the tumor. Have an honest and open conversation with your oncologist and other physicians about your fears, drug options and prognosis. I won’t tell you that hair loss isn’t important, but you might not lose it. You might not even be taking something cytotoxic. Knowledge can reassure us, so make sure you know what your treatment involves.

Best Practices for Chronic Lymphocytic Leukemia

What Is the Main Idea?

Chronic lymphocytic leukemia compromises the immune system, making patients more susceptible to infections. It’s important for patients and physicians to know the latest best practices for dealing with this cancer. This post details some of the evidence-based best practices described in the open access article “Immune Dysfunction in Patients with Chronic Lymphocytic Leukemia and Challenges during COVID-19 Pandemic” in the journal Acta Haematologica.

What Else Can You Learn?

Read this post to find out more about the demographics and prognosis of chronic lymphocytic leukemia, the way that it affects the immune system, and some things that you can discuss with your doctor if you or a family member is diagnosed with this cancer.

What Is Chronic Lymphocytic Leukemia?

Chronic lymphocytic leukemia (CLL) is the most common form of leukemia. It is a slow cancer that affects lymphocytes, which are a type of white blood cell. Lymphocytes include B cells, T cells and natural killer cells, all of which have very important immune functions. Because CLL disrupts their function, it has a major impact on the immune system.

CLL patients tend to be middle-aged and older: Around 75% are over 65 when they are diagnosed. It is rare in children. The progress of CLL is slow. It can even be asymptomatic in its early phase. Most patients live 5 to 10 years after diagnosis: The five-year survival rate is around 83%. However, if the patient is older at diagnosis, this survival metric is lower.

CLL Disrupts the Immune System

As mentioned, a key feature of CLL is dysregulation of both the innate and adaptive immune responses. The innate immune system delivers the first response to invading pathogens. This response is not specific to a particular pathogen. The system recognizes pathogens as “non-self” (i.e., not part of the body) and directs certain cells and proteins against them.

Adaptive immunity fights pathogens more directly and accurately. As our immune system encounters pathogens, it learns about their structure and protein signature, remembering this in case of future encounters. Vaccination works by training the adaptive immune response.

Due to this disruption of immune responses, infections are the main cause of death in CLL patients. Additional supportive care is essential to compensate for their compromised immune systems.

What Supportive Care Is Suitable for CLL Patients?

Vaccination against seasonal influenza and Streptococcus pneumoniae is recommended, with the sequence of vaccines for the pneumonia-causing pathogen being PCV13 followed by PPSV23. Early vaccination is important to give the most benefit.

Immunoglobin substitution using IVIG is also suggested. There is evidence that it can decrease bacterial infection rates in CLL patients who have a condition called severe hypogammaglobulinemia. The European Medicines Agency (EMA) has specific criteria to qualify CLL patients for immunoglobin substitution. Your physician should be aware of these. They are described in the article.

In addition, all the standard lifestyle practices for immunocompromised individuals are important. CLL patients should maintain a clean environment, personal hygiene, and a healthy diet. Furthermore, if the patients need care, their carers should be informed of the importance of cleanliness and the risk of infection.

Finally, extra care should be taken during outbreaks, epidemics, and pandemics. We are all well informed on what taking care during a pandemic means! Wearing masks, using hand sanitizer, keeping a certain distance from people in public, and staying home when possible have become normal all over the world during the COVID-19 pandemic. Immunocompromised individuals are encouraged to apply such practices during seasonal influenza outbreaks and epidemics as well as during any other type of infectious disease crisis.

The article also mentions that physicians should consider reducing the number of in-person consultations with CLL patients and replacing them with phone calls to reduce the risk of SARS-CoV-2 infection. While there is very little data on SARS-CoV-2 and CLL, patients with this cancer are in a high-risk group.

What Direct Treatment Is Used for CLL?

Because the initial course of CLL is slow, immediate treatment is not required. The strategy that is employed is called “watch and wait”: careful and regular observation of the impact of CLL on the immune system, with a response being initiated when the patient becomes immunocompromised.

When treatment does become necessary, it is rare to use chemotherapy-based regimens. Chemoimmunotherapy, which combines antibody and drug treatment, has shown some success in a limited group of patients. Opportunistic infections are a danger with both chemotherapy and chemoimmunotherapy, so their use should be weighed carefully.

Inhibitors of pathways associated with CLL proliferation have also been trialed. Called BCR inhibitors, these drugs are well tolerated and have positive impact in the short term, but longer-term data shows severe opportunistic infections associated with their use. More recent evidence shows that BCL-2 inhibitors are promising. They increase the apoptosis (cell death) of CLL cells. They are both effective and well tolerated provided the drug regimen is carefully planned to avoid certain side effects.

What Should I Talk to My Doctor About?

If you or a member of your family are diagnosed with CLL, ensure that you talk to the doctors about the longer-term strategy. What tests will they do during the “watch and wait” phase? What results should you record? How can you improve your home environment, diet and so on to reduce infection risk? What CLL treatments might be available to you after the CLL starts to strongly affect your immune system, based on your medical history, age, existing medication and so on?

You should also talk to your doctor about your annual vaccination plan, which may now also include a COVID-19 vaccine alongside the seasonal influenza and S. pneumoniae ones.

Note: The article “Immune Dysfunction in Patients with Chronic Lymphocytic Leukemia and Challenges during COVID-19 Pandemic” was written and accepted for publication before the approval of a COVID-19 vaccine. Therefore, some of the information on COVID-19 infection and treatment is out of date.

The Value of Patient-Reported Outcomes

What Is the Main Idea?

Patient-reported outcomes are a valuable aspect of clinical trials. Regulatory authorities and research groups are encouraging the inclusion of these insights earlier in the clinical trial process, even as early as phase I. An interesting open access clinical study titled “The Use of Patient-Reported Outcome Measures in Phase I Clinical Trials”, published in the journal Oncology, goes into detail on the importance of this type of information as well as studying how often such information is used. This blog post summarizes the main points.

What Else Can You Learn?

Get a straightforward explanation of the phases of a clinical trial so you can better understand what is meant when a drug is being trialed, approved, and released. You can also see some suggestions for how you can share your experiences with a drug or treatment.

Refresh Your Memory on Clinical Trials

In 2020, we were all strongly invested in the clinical trials of the COVID-19 vaccines. These expedited trials were frequently in the news, and many people became familiar with the phases of clinical trials and the questions researchers try to answer in each one.

Nevertheless, it’s always handy to collect information in one place, so here’s a quick refresher. Clinical trials are studies focused on testing if a drug, medical device, treatment, or diagnostic will function in the broader population.

What Are the Phases of a Clinical Trial?

If preclinical studies suggest that a drug should be safe and might be effective, an application is made to a regulatory body (e.g., the European Medicines Agency (EMA) or the Food and Drug Administration (FDA)) to approve the clinical trial. Then it can begin.

  • Phase I looks to establish whether the drug is safe. They try to establish the highest safe dose by giving subjects increasing doses and closely observing any effects and side effects. They involve small numbers of participants.
  • Phase II asks whether the drug works. A larger group of people receive the highest safe dose from phase I. The drug is given until the goal of the treatment is achieved (improved quality of life, reduced pain, tumor shrinkage, etc.).
  • Phase III asks whether the drug is better than existing ones. For drugs, this involves giving several hundred patients an existing drug or the new drug and comparing the effects.
  • After phase III, the drug may be approved. However, it is generally still subject to an ongoing phase IV trial, which looks at its behavior over a longer period of time in the general population. This helps to establish more safety, efficacy, and treatment information. An example of something found in this way is the extremely rare blood clots seen with the Pfizer–BioNTech COVID-19 vaccine.

What’s Changing about Phase I Trials?

As described above, phase I clinical trials traditionally focused on quantifiable parameters such as the maximum tolerated dose (the highest dose a patient can tolerate safely). However, in recent years, regulatory and research bodies have begun to request or even require the inclusion of certain qualitative measures even in these very early phases.

What Are Patient-Reported Outcomes?

One such qualitative measure is the patient-reported outcome, which is defined by the FDA as “any report of the status of a patient’s health condition that comes directly from the patient, without interpretation of the patient’s response by a clinician or anyone else.” Examples of patient-reported outcomes are pain level, fatigue, changes in mood, and changes in concentration.

Asking for information of this type during a phase I clinical trial means that the pros and cons of a treatment are visible right from the start. It could mean that changes are made to phase II and III or a revised phase I is designed. This increase in the adaptiveness of trial design might mean effective treatments are made available sooner.

Including patient-reported outcomes is important because it puts the patients’ experiences in greater focus, reflecting a commitment to improved patient care and quality of life. If healthcare workers and patients are more aware of the qualitative impact of a drug, they can make better-informed decisions.

Are Patient-Reported Outcomes in Common Use?

Even though the value of this information is increasingly widely recognized, adoption of this approach is low. There is an expectation that they will be included more frequently in the future. There is also hope that patient-reported outcomes will start to be included on pharmaceutical product labels, providing patients with direct access to these insights.

The article discusses some of the barriers to the inclusion of patient-reported outcomes in phase I clinical trials, on product labels, and in other stages of drug development. You may be interested in diving deeper into this information, which is towards the end of the discussion.

Is There a Place for My Experiences?

If you’re ever involved in a clinical trial, consider asking if patient-reported outcomes are being incorporated and during which phase. Also, if your doctor is prescribing you a new medication, ask them what the clinical trial patients reported. They may be able to retrieve this information for you. Finally, if you know a drug is new, you can share your experiences with your doctor or directly with the pharmaceutical company as part of a phase IV trial that may be ongoing.

It’s important that we share our experiences with drugs and other treatments to further the understanding of their impact and improve patient-centric medical care.

Connecting Psoriasis and Celiac Disease

What Is the Main Idea?

If you have psoriasis, you have a higher probability of developing other autoimmune disorders, including celiac disease. The authors of the recent case study “Development of Dermatitis Herpetiformis in Chronic Plaque Psoriasis” in the journal Case Reports in Dermatology recommend that doctors should consider all patients with psoriasis for celiac disease. If a patient tests positive for markers of celiac disease, trialing a gluten-free diet is also advised.

What Else Can You Learn?

Read this post to learn more about chronic plaque psoriasis, celiac disease and autoimmunity in general. You might also be interested in Dr. George Marx’s post “How Useful Is a Gluten-Free Diet?”, which looks at the difference between celiac disease and gluten intolerance, as well as giving advice on gluten-free diets for people who do not have celiac disease. Please also note that May is Celiac Disease Awareness Month.

What Is an Autoimmune Disorder?

Autoimmune disorders are medical conditions where the immune system attacks your cells and tissues. Some affect particular organs or cell types while others affect the whole body. You might be familiar with some of them: multiple sclerosis, rheumatoid arthritis, lupus, Crohn’s disease, type 1 diabetes, psoriasis and celiac disease are among the most common. In this post, I’m focusing on two of these conditions: psoriasis and celiac disease.

What Is Psoriasis?

Psoriasis is an autoimmune disorder that causes the skin to grow or regenerate more quickly. Its most common presentation is called chronic plaque psoriasis: small or large thickened areas of red skin, often covered with silvery flaking scales. These areas are most often found on the elbows, knees and back, but they can also appear on other parts of the body.

The pain associated with the plaques can be an uncomfortable itch, ache or burning sensation. Chronic plaque psoriasis tends to go through cycles, flaring up and fading for a time, although psoriasis patches can also be very persistent.

If you have psoriasis or you know someone who has it, you’re probably very familiar with these physical manifestations. You might also be aware of the emotional distress it can cause. It is associated with low self-esteem and depression, which is at least partially due to social focus on image.

It’s also important to realize that people with psoriasis are known to have a greater risk of developing other autoimmune conditions, including celiac disease.

What Is Celiac Disease?

Celiac disease is a serious autoimmune condition that is believed to affect around 1% of the population, although it often goes undiagnosed for much of people’s lives. If someone has celiac disease and they eat anything containing certain proteins, their immune system attacks their own tissues, particularly the lining of the intestine. Damage to this tissue affects the ability to absorb nutrients from food.

The proteins that cause the autoimmune reaction are gliadins and glutenins, which are also referred to as gluten proteins. We associate them with wheat, but similar proteins are found in wheat subspecies like durum and spelt, and in other crops, including barley, rye and even oats.

Celiac disease has a wide range of gastrointestinal symptoms, but patients can also exhibit various systemic symptoms. The initial symptoms can appear weeks to years after the initial consumption of gluten proteins, but as the disease progresses, the reaction time becomes much shorter and can be far more intense. The treatment is diet free of any of the proteins that cause the reaction.

What Connects Psoriasis and Celiac Disease?

Evidence from multiple studies supports an association between psoriasis and celiac disease. One analysis of the literature showed that psoriasis patients are over two times more likely to be diagnosed with celiac disease; and celiac disease patients are almost two times more likely to have psoriasis.

Furthermore, psoriasis and celiac disease are both related to a particular immune cell type called T helper (Th) cells. Th1 and Th17 are involved in both conditions. Also, over 16% of patients with psoriasis have higher than average levels of antibodies associated with celiac disease, such as anti-gliadin IgA, anti-gliadin IgG and anti-tissue transglutaminase IgA.

What Is the Case Study about?

The case study “Development of Dermatitis Herpetiformis in Chronic Plaque Psoriasis” reports on a white, cisgender man with a 40-year history of chronic plaque psoriasis that was getting worse, and a 3-month history of another autoimmune skin condition, dermatitis herpetiformis. He did not have a diagnosis of celiac disease The patient’s serological screen for celiac disease showed higher than average levels of anti-gliadin IgA, anti-gliadin IgG and anti-tissue transglutaminase IgA. A subsequent endoscopy confirmed a diagnosis of celiac disease.

Part of the patient’s treatment involved a gluten-free diet, although surgical and pharmacological interventions were also needed due to the severity of the conditions. The gluten-free diet was confirmed to have a significant positive impact on both the dermatitis herpetiformis and psoriasis, although the patient had difficulty sustaining the diet in the long term.

What Does This Mean in Practice?

As the paper mentioned above is a case study, its conclusions cannot be considered thoroughly clinically tested, but the connection between psoriasis and celiac disease relies on evidence from several other studies.

Thus, since there is evidence of a significant association between the two autoimmune disorders, it is logical to consider serologically screening psoriasis patients for markers of celiac disease, especially if they present with gastrointestinal problems. If a patient with psoriasis tests positive, then a balanced gluten-free diet should at least be trialed. It might improve the patient’s skin condition and protect them from any autoimmune reactions to the gluten proteins.

Should I “Go Gluten-Free” If I Have Psoriasis?

As mentioned in Dr. George Marx’s post “How Useful Is a Gluten-Free Diet?”, a gluten-free diet is not harmful provided your nutrition is balanced. Unfortunately, it can be difficult to create a balanced gluten-free diet, so you should always seek support from a doctor or dietician before taking such a decision.

Increasing the Success of Behavioral Approaches to Weight Loss

What Is the Main Idea?

If you are losing weight for personal or medical reasons, it could be important to talk to your primary care physician about your approach. They might be able to help you define different behaviors for weight loss and weight loss maintenance as well as showing you how to more objectively monitor your progress. They might be interested in “The H2020 ‘NoHoW Project’: A Position Statement on Behavioural Approaches to Longer-Term Weight Management” published in the journal Obesity Facts. It explains the current understanding of this complex area.

What Else Can You Learn?

Consider looking for emotional or therapeutic support if you’re losing weight. There is considerable emotional cost in weight loss, especially if goals are not reached. It’s also important to understand that as you lose weight, your body’s structure and energy needs may change. You’ll need to compensate for such changes in your behavior.

The Emotional Cost of Weight Loss

Weight loss is a sensitive subject. Despite the increased visibility of body positivity movements and a better understanding of the range of healthy body shapes, being heavier than average is still stigmatized in most parts of the world. There is considerable societal and personal pressure on “larger” people to slim down by changing their diet and lifestyle or even by seeking medical intervention.

This pressure has a huge impact. People who feel that they have “the wrong” body shape are more likely to develop low self-esteem, depression and anxiety. They may make frequent attempts to diet. If they don’t succeed — or they succeed and then regain some weight — this results in further emotional cost. Emotional or therapeutic support is advisable, especially if you have plans for major changes.

Is Regaining Weight Inevitable?

Studies have shown that some degree of weight regain generally happens in the long term, regardless of whether behavioral, surgical or pharmaceutical approaches were applied. Even when people have medical reasons for slimming down, maintaining the target weight proves challenging.

Weight loss maintenance depends on changing behaviors in the long term. Although many techniques exist to help people change their behavior, it’s still unclear which of these techniques would work best for maintaining the desired weight. Furthermore, physiological, psychological and environmental factors influence our behaviors: These are powerful influences that can overwhelm our efforts.

 What Is the NoHoW Consortium?

Discovering how to help people with weight loss maintenance is the goal of the NoHoW Consortium. This inter-institutional research group aims to create evidence-based approaches to help people reach their desired weight and maintain it. You can learn more about their work here.

What Has the NoHoW Consortium Found?

This open access paper details six position statements that were discussed in a workshop at the 2019 European Congress on Obesity. The hope is that these concepts can form the foundation for better long-term weight maintenance practice.

The position statements can be summed up as follows:

  • Behavioral approaches must take into account that we have different motivations and methods for losing weight than those for maintaining the desired weight. Similarly, the factors that disrupt weight loss are different from those that disrupt weight loss maintenance.
  • Weight management interventions need to dynamically align behavior (diet, lifestyle, exercise) with changes in the body’s energy balance. Weight loss has an impact on body structure, which affects energy requirements. More sophisticated methods of measuring energy intake and energy expenditure would help to understand what’s happening so behaviors could be adjusted over time.
  • Objectively tracking how the energy balance changes over time could help personalize approaches to weight management. There is considerable evidence that weight loss maintenance would respond well to such personalization.
  • More long-term, structured studies are needed to better understand the relationship between behavioral changes and the factors that disrupt weight loss maintenance.
  • Weight loss attempts carry the risk of disappointment and other negative emotions, which can make longer-term weight management more difficult. It’s essential to develop a more comprehensive understanding of the factors that promote and disrupt weight loss maintenance, including personal experiences.
  • Evidence-based, standardized, longitudinal studies are essential for a better understanding of how to compensate for the physiological and emotional factors that undermine weight loss maintenance. They will also give a better sense of who is likely to succeed in their longer-term weight goals.

Can I Apply These Ideas in My Weight Loss Journey?

You could certainly start to consider weight loss and weight maintenance as two separate phases of your journey. Thinking of them separately might help you find different approaches for each. You should also bear in mind that as you lose weight, your body will undergo some changes. Consider talking to a professional about what this means. Finally, finding objective ways to measure your energy intake and energy expenditure would be valuable.

And most importantly of all, if you’re trying to lose weight for personal or medical reasons, ensure that you’re not pushing your body too hard. Talk to your primary care physician before you take any major steps.

Nutrition in a Difficult Pregnancy

What Is the Main Idea?

How impactful can a healthy diet be? In the case study “Quality or Quantity of Proteins in the Diet for CKD Patients: Does ‘Junk Food’ Make a Difference? Lessons from a High-Risk Pregnancy” published in the journal Kidney and Blood Pressure Research, the authors show how switching a pregnant woman with chronic kidney disease to a healthier diet meant she could avoid dialysis during pregnancy. They suggest that plant-based fresh food diets with appropriate supplements are important for pregnant individuals with compromised kidneys.

What Else Can You Learn?

It’s important for pregnant individuals to understand their kidney health and talk to their obstetrician about it. It’s also essential to understand that health issues occurring during pregnancy can have longer-term impact.

How Does Kidney Disease Affect Pregnant Individuals?

Health issues occurring during pregnancy are obviously stressful for the patient. They can also have implications for the post-natal health of the pregnant individual and their child. For example, if hypertensive disorders (heart and circulatory problems related to high blood pressure) are present during pregnancy, that indicates a higher risk of future cardiovascular diseases.

Chronic kidney disease can increase the risk of hypertensive disorders during pregnancy, although the exact mechanisms are not fully understood. It’s challenging to manage severe kidney issues in pregnant individuals.

How Can Nutrition Help?

Interestingly, nutrition can play a role in managing kidney disease in pregnancy. Although there are no comprehensive reviews on the topic, there are cases that show that plant-based diets largely consisting of fresh foods have benefits. Conversely, patients with compromised kidneys seem particularly prone to adverse reactions to high amounts of dietary additives. Furthermore, unintentional contaminants (e.g., from packaging or polluted agricultural food chains) also present challenges for the kidneys.

Going from a Healthy Diet to a Risky One

In the case discussed in the above-mentioned open access paper, a 39-year old cisgender woman presented with chronic kidney disease during her second pregnancy. Dialysis was not an option, so the doctors chose a nutritional approach.

The woman’s first child had been delivered by caesarean section due to preeclampsia, which is a hypertensive disorder of pregnancy. Written records from the first pregnancy were not available, but it is likely that kidney disease had been detected because she was told to have periodic blood tests to monitor the organs’ function and to eat less meat. Reducing the animal protein in the diet is associated with better kidney health.

When she became pregnant again, she moved from her home (over 6 hours from the hospital) to her mother-in-law’s house (2 hours from the hospital). Her diet changed drastically. At home, she ate a largely fresh plant-based diet. At her mother-in-law’s, she had “a high-calorie diet, consisting mainly of sodas and processed, canned, and preserved food.” Her health worsened and she was admitted to hospital, where her kidneys were found to be in a chronic diseased state, although the fetus was normal for its gestational age.

Returning to a Healthy Diet

Because the fetus appeared healthy and dialysis was both expensive and logistically challenging, the doctors attempted to help with a nutritional approach, switching the woman back to a plant-based diet with vitamin and mineral supplements. One week later, her laboratory results had already improved.

The progress of the pregnancy was not entirely smooth. Logistical and economic challenges meant she was “overall adhering to a plant-based diet [but] had resumed a diet rich in packaged and junk food.” She was hospitalized for the remainder of the pregnancy. Caesarean section was performed after 37 weeks and 17 days later, both the mother and the baby were in stable condition.

What Is the Conclusion?

Although it’s not possible to generalize based on a single case, studies like this one are still valuable. They can indicate a direction for research or provide some guidance in challenging cases.

This case study suggests that dietary approaches to kidney disease should look at the macronutrient composition, the sources of those macronutrients, and the quality of the food. The ideal would be fresh food offering a balance of macronutrients with the majority of the protein coming from plants — and this is all the more important during difficult pregnancies.

Acute Kidney Injury and COVID-19

What Is the Main Idea?

Learn more about acute kidney injury and its impact on the body. Discover how this condition can worsen the impact of other conditions, including COVID-19. This post references a study on co-occurrence of COVID-19 and acute kidney injury, which is described in the free access research paper ‘Community- and Hospital-Acquired Acute Kidney Injury in COVID-19: Different Phenotypes and Dismal Prognosis’ published in the journal Blood Purification.

What Else Can You Learn?

See why it’s important to be proactive about your kidney health and discuss your risk factors with your primary care physician. Recognizing acute kidney injury early does improve outcomes, but mitigating the risk of developing it is advisable.

Why Should You Talk about Your Kidney Health?

Kidney problems can worsen the impact of other conditions, including COVID-19. That means if you have any kidney problems, you should make your current doctors aware of them, both to ensure you’re in the right priority group for COVID-19 vaccination and so they can take appropriate steps if you do contract the virus.

This free access research article might be of interest to your doctor. It deals with acute kidney injury and COVID-19.

What Is Acute Kidney Injury?

Acute kidney injury is also sometimes called acute renal failure. It’s the diagnosis given when kidney function is disrupted suddenly, going from healthy to damaged or non-functional within a few days or even a few hours. Waste products then build up in the blood because the kidneys are not filtering it properly. Symptoms can include swelling in the legs, ankles and around the eyes, fatigue, shortness of breath and chest pain, and even confusion or seizures. It always requires a hospital stay as part of the treatment. Not everyone requires dialysis, but it can be necessary.

The condition can be caused by decreased blood flow to the kidneys. This could be related to injury, overuse of pain medication, the failure of other organs or major surgery. It can also be caused by direct damage to the kidneys from diseases like multiple myeloma, sepsis or scleroderma. Another cause is blockages of the urinary tract, for example due to kidney stones or bladder, prostate or cervical cancer. There is also some evidence that long-term use of diuretics can lead to acute kidney injury.

It is common in hospitalized patients, especially when they are in intensive care units. This is referred to as hospital-acquired acute kidney injury. It is distinct from community-acquired acute kidney injury.

The Long-Term Effects of Acute Kidney Injury

After recovery, you still have a higher chance of other health problems: heart disease, stroke, additional episodes of acute kidney failure, chronic kidney failure and kidney disease. It’s essential that sufferers of this condition work with their healthcare providers to monitor their kidney recovery and behavior — and, as mentioned above, to consider the increase in risk from other conditions.

The Impact of Acute Kidney Injury on COVID-19 Prognosis

In the study, researchers looked at 1,170 hospitalized COVID-19 patients to see how many also had acute kidney injury. All the patients included in the study presented with severe COVID-19 pneumonia and required supplementary oxygen, but none of them had prior kidney transplantation or end-stage kidney disease.

They found that both the hospital-acquired and community-acquired forms were common: 11% of patients had the former and 19% had the latter. Sadly, around 50% of patients presenting both COVID-19 and acute kidney injury passed away. This was a much higher mortality rate than in patients who did not have acute kidney injury.

Other relationships between COVID-19 and acute kidney injury include longer periods on ventilation and longer hospital stays. It is also noted that even the patients that recover from COVID-19 can have a greater risk of developing chronic kidney injury.

Talk to Your Physician about Kidney Health!

Studies like this one can cause a lot of worry. People might ask themselves if they’re at risk of acute kidney injury and worry more about their COVID-19 risk. That’s why it’s so important to be proactive about kidney health. Talk to your primary care physician about your kidney health. Understand your risk factors and then try to mitigate them. Early and appropriate management of acute kidney injury seems to improve short-term outcomes and research is ongoing into how to achieve even better outcomes.

Let’s Talk about Asthma and Fungal Spores

What Is the Main Idea?

If you have asthma, you need to know what you’re allergic to. When your doctor is doing a skin prick test for airway allergies, they should include the fungi Aspergillus, Alternaria, and Cladosporium, and possibly Penicillium. These fungi are relevant for asthma and very common in our environment. The open access article “Sensitization against Fungi in Patients with Airway Allergies over 20 Years in Germany” in the journal International Archives of Allergy and Immunology explains the science behind this blog post.

What Else Can You Learn?

If you have asthma and you test positive for allergies to fungal spores, your doctor may be able to help with targeted allergen immunotherapy, which is also known as desensitisation or hypo-sensitisation. You can also take steps to avoid coming into contact with large quantities of fungal spores.

How Do Triggers Inform Therapy?

If you have asthma, it’s important to know what triggers an attack. When your doctor knows your triggers, they can give you more effective treatment. In fact, if the plan is to use allergen immunotherapy, it’s essential that they know exactly what you’re allergic to.

You might already have heard of allergen immunotherapy, which is also known as desensitisation or hypo-sensitisation. It helps with environmental allergies: dust, pollen, fungal spores, animal dander and even insect bites. It involves exposure to increasingly large amounts of the allergen, and it can be very effective against asthma and allergic rhinitis, which is often called hay fever.

What’s Important During Diagnosis?

Fungal spores are highly associated with several severe forms of asthma. If you have asthma and you don’t yet know why, you should definitely ask your doctor to do a skin prick test for fungal spore allergies (or ‘mould allergies’) as well as for pollen, dust mite and animal dander allergies. In particular, the fungi Aspergillus, Alternaria, and Cladosporium should be included. There’s also evidence for including Penicillium in the tests.

There are of course more steps in diagnosing a fungal airway allergy. For example, a detailed patient history is essential and follow-up blood tests for serological analyses of recombinant allergens can be very useful. But including these three fungi in skin prick tests is a great starting point.

If your doctor would like to know more about the research supporting testing for fungal spores, you can send them the link to the above-mentioned research paper. It concludes that fungi are relevant allergens for asthma and explains why the four named fungi are important. It also states that it’s not a good idea to use just one fungus as a representative (or proxy) for fungal allergies in general.

What Should You Know about Fungal Spores?

When you know what you’re allergic to, you should get an appropriate treatment, such as immunotherapy, but it’s also good to know how to avoid contact with the allergen. Fungal spores are present everywhere. It might sound like they’re impossible to get away from, but you can certainly minimise your risk of inhaling large quantities of them.

  • Aspergillus is mainly found in soil and dust. When you disturb these, especially during garden work, construction, renovation or demolition, you might cause the fungus to release large quantities of spores. If you’re allergic to Aspergillus, consider wearing a mask if you’re doing such work and keep your home environment low on dust.
  • Alternaria is a plant pathogen, so your main chance of encountering it in high quantities is in the garden or on agricultural properties. Again, wearing a mask is advisable if you’ve tested positive for an allergy.
  • Cladosporium is very common indoors and outdoors. If you see greenish, brown or black mould, that’s probably Cladosporium. You’ll most likely see it in bathrooms, attics or cellars — anywhere with a moderate to high moisture level. It’s important to have good ventilation that keeps humidity down in your house, especially in those spaces. A humidity of 50–55% is considered healthy for humans. Also, wear a mask if you’re going to be working in the attic or cellar for a longer period.
  • Penicillium is very important in the natural environment. You’ve probably seen it on mouldy bread or cake. It can also grow on fruit and vegetables or even on wood surfaces and carpets. Again, good ventilation and the appropriate humidity are important, but you should also make sure spoiling food is thrown out as soon as possible if you have an allergy.

Stay Safe!

Hopefully this has helped you get a better sense of what to do if you have asthma. If you don’t know what you’re allergic to, get tested! And if you do, make sure you take the appropriate treatment and precautions.

Victor Kelly

Victor Kelly (pronouns: they/them) is an experienced science writer and science communications educator based in Ireland. Combining a background in biology and linguistics with a talent for storytelling, their focus is helping people in academia and industry to get their message across. They take considerable pride in ensuring that an author’s message is clear and accessible to the audience and appropriate to the medium. They are also passionate about anti-prejudice activity. Based on their own experiences as a queer and disabled person, they have developed a workshop on the experiences of people with intersecting marginalized identities in academic and corporate environments. In addition to their professional work, they enjoy role-playing games and working with clay.

Photo: Victor Kelly

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