Use of Vagus Nerve Stimulation for Stroke Recovery

What Is the Main Idea?

Stroke is a medical condition where the blood flow to the brain is interrupted, causing nerve cells to die. This can lead to the impairment of various functions of the body. Depending on how quickly the patient is treated and the post-recovery rehabilitation, the patient could potentially get back to leading an independent life. In this blog post based on the open-access review paper “Efficacy and Safety of Vagus Nerve Stimulation in Stroke Rehabilitation: A Systematic Review and Meta-Analysis”, published in the journal Cerebrovascular Diseases, we discuss vagus nerve stimulation as an adjunct therapy along with standard rehabilitation for stroke recovery.

What Else Can You Learn?

This blog post also briefly describes what happens during a stroke, what the symptoms are and how it can be treated. The standard recovery and rehabilitation process is also explained.

What Is Stroke and What Are the Symptoms?

Stroke is a disease condition that affects the blood flow in the brain. This causes a lack of oxygen to the brain cells (neurons) in the affected area and ultimately death of those cells. This, in turn, causes impairment to the body’s function that is normally stimulated by the neurons that died. The flow of blood to the brain through the arteries is affected either by a clot in a blood vessel (ischemic stroke) or a blood vessel bursting (hemorrhagic stroke).

The symptoms that a person having a stroke displays could be a slur of speech, paralysis or numbness of parts of the face and body, headache, trouble walking or eyesight issues. Usually, in the case of a stroke, one side of the body will be affected more than the other, such as one arm falling when both are lifted up or one side of the face drooping. If this is observed, it should be treated as an emergency.

The cause behind the stroke or specifically a blocked or burst blood vessel is varied. People above 55 years have a higher chance of stroke. Medical issues like high blood pressure, high cholesterol, cardiovascular diseases, sleep apnea, or diabetes can cause a stroke. Additionally, lifestyle conditions like lack of physical activity, smoking, and drinking can also be factors leading to stroke.

How Is It Treated?

Stroke is a medical emergency because, without oxygen, the brain cells can start dying within minutes. Early treatment can reduce the damage to the brain and avoid further complications. As soon as the patient is brought in to the hospital, certain tests might be done including imaging to confirm stroke and rule out other conditions. Treatment involves therapy with drugs that can break a clot if it is an ischemic stroke. In the case of hemorrhagic stroke, the focus is on controlling the bleeding and reducing pressure in the brain due to excess fluid.

What Is the Recovery Process and What Does Stroke Rehabilitation Involve?

The extent of disability and the required recovery and rehabilitation process depends on the severity of the stroke and the time lapsed till the treatment was administered. The patient might lose independence after a stroke and require help for daily living. In many cases, the patient will need rehabilitation to regain any lost function of the body or to learn to perform tasks with a disability or both.

An important point to note is that soon after a stroke, the healthy neurons in the brain are capable of being rewired (known as plasticity) to perform the tasks that the damaged neurons were doing earlier. Using this window of time and augmenting the patient’s recovery with rehabilitation is important.

Therefore, the rehabilitation usually starts immediately after recovery within 48 hours with the goal to help the patient regain independence through rewiring the brain. These are mainly done through education and task-specific training. A team of people is involved in rehabilitation and can include neurologists and psychiatrists, therapists for physical, speech, occupational, and neurological therapy, nurses for care, nutritionists, and others.

What Is Vagus Nerve Stimulation and How Does It Help in Stroke Rehabilitation?

Vagus nerves are the nerves running on the left and right side of the body from the brain stem to the large intestine while also connecting with the neck, heart, and lungs. They play an important role in involuntary body functions like digestion, maintaining heart rate, respiration, mucus and saliva production, speech, taste, and more.

Vagus nerve stimulation is the process of using electrical impulses to stimulate the brain through the left vagus nerve. Mild, painless electric signals are sent to the brain; this is known to calm down irregular electric activity in the brain. It is mainly used as an alternative treatment for epilepsy and depression. Vagus nerve stimulation involves a small device surgically implanted under the skin in the chest and a wire that is connected to the left vagus nerve. In more recent times, a non-invasive version of the device has been developed where the electric pulses pass through the skin, usually to stimulate the branch of the vagus nerve reaching the left ear.

In stroke rehabilitation, vagus nerve stimulation is believed to cause the production of neuromodulators like norepinephrine, serotonin, and acetylcholine. The molecules help with creating, rewiring, and strengthening neural connections.

Learnings about Vagus Nerve Stimulation from a Review

According to the recent review which analyzed results from several published trials, vagus nerve stimulation therapy helped stroke patients with better upper limb function, health-related quality of life, and levels of independence. The timing of when the vagus nerve stimulation therapy is administered in relation to task-specific therapy has yet to be well studied. However, one research showed that brief vagus nerve stimulations given in parallel to the task-specific therapy tripled the neural connections to the task-specific muscles.

However, by combining results from various trials as done in this review, it was not clear what optimal number of vagus nerve stimulation therapy sessions or session duration is required for effective therapy. This review could also not differentiate whether using the invasive method of stimulation or the non-invasive method was better. In testing negative effects of this therapy, there was no clinically significant effect on the heart rate, blood pressure, or respiration. There were a few adverse effects reported which were resolved by ceasing the vagus nerve stimulation. Hence, this therapy has to be closely monitored when being administered, especially for the first time.

In short, along with the standard medical and therapy treatment, in the post-recovery rehabilitation of stroke patients, using vagus nerve stimulation as an adjunct therapy should be discussed with the physician and therapist.

Breast Cancer Genes and Hereditary Breast and Ovarian Cancer

What Is the Main Idea?

Hereditary Breast and Ovarian Cancer (HBOC) syndrome is cancer due to inherited mutated breast cancer (BRCA) genes or some other genes. Awareness about this syndrome and family history is necessary for a patient and doctor to help with the prevention and early detection of cancer. Based on the case study “Detection of BRCA1 Pathogenic Variant in a 24-Year-Old Endometrial Cancer Patient: Risks of Several Hereditary Tumor Syndromes Assessed Using Germline Multigene Panel Testing”, published in the journal Case Reports in Oncology, the syndrome is discussed in the context of an endometrial cancer patient in this article.

What Else Can You Learn?

This blog post discusses the function of breast cancer (BRCA) genes, the chances of developing cancer if a person has mutated genes, and the screening and diagnosis of hereditary breast and ovarian cancer.

What Is Hereditary Breast and Ovarian Cancer?

Cancer is a disease where cells in a specific part of the body grow uncontrollably, thereby destroying the healthy tissues surrounding it. There are many factors for cancer to develop and one of them is the hereditary disposition of the patient to it. Cancer itself cannot pass from parent to child. A parent can have genetic changes (mutations) in certain genes that increase the risk of developing cancer. This mutation can potentially be passed on to the child if present in the egg or sperm. This passing of a potentially cancer-causing mutated gene is termed hereditary cancer syndrome.

Hereditary breast and ovarian cancer (HBOC) is one such syndrome where the person has a higher chance of developing breast, ovarian and other types of cancers including pancreatic or prostate cancer. This hereditary cancer is often associated with mutations to the BReast CAncer 1 (BRCA1) or BReast CAncer 2 (BRCA2) gene. It must be noted that there could also be other genes that can cause this type of cancer when mutated.

What Do These Breast Cancer Genes Do?

When cells replicate, so does the DNA. At times, there might be an error in the DNA that is replicated. Breast cancer genes BRCA1 and BRCA2 are caretaker tumor-suppressor genes which means that they help repair the error and avoid any changes occurring in the gene, hence promoting genetic stability.

These breast cancer genes are also known to help in multiple other cellular processes like chromosome segregation and cytokinesis which are part of the cell division process. Hence, mutations in these genes can disrupt the regular cell division process which can result in the cells turning cancerous.

What Are the Chances of Developing Cancer with the Mutation?

If there is a cancer-causing mutation in the breast cancer genes, then there is a 65% chance of developing breast cancer by the age of 70 and a 39% chance of developing ovarian cancer. There are also higher chances of developing other cancers including pancreatic, prostate and endometrial cancer. It has been seen that hereditary breast and ovarian cancer syndrome can cause a 2- to 3-fold increase of the risk of endometrial cancer.

While the mutation has been associated with breast cancer, not all those who have breast cancer have this mutation. It must be noted that only 3% of breast cancers and 10% of ovarian cancers are due to the breast cancer (BRCA) genes.

Screening, Diagnosis, and Precautions for Hereditary Breast and Ovarian Cancer Syndrome

When there is a family history of cancer and in this case specifically, breast, ovarian or related cancers, then it is important to talk to the doctor regarding it. The doctor might suggest consulting with a genetic counselor who in turn might suggest doing a genetic test. The test will check for mutations to the breast cancer genes and other genes that have been associated with hereditary breast and ovarian cancer.

If it is determined that there is a mutated gene that could lead to cancer, then the patient should undergo more frequent cancer screenings and discuss preventive methods like medication or in some cases even surgery to remove the breasts, ovaries, and fallopian tubes.

Case Study of an Endometrial Cancer Patient with the Breast Cancer 1 (BRCA1) Gene Mutation

In a recently published case study, a 23-year-old woman with a menstrual history was diagnosed to have endometrial cancer. The doctors, assuming it to be a high-risk case, surgically removed her uterus, cervix, ovaries, fallopian tubes, and lymph nodes in the pelvic region. After the surgery, it was determined that surgery alone was sufficient for the patient’s health.

To determine the cause of this endometrial cancer, the doctors considered genetic origins since the patient had a family history of cancer on both sides of her family, including breast cancer, ovarian cancer, and colorectal cancer. Different genetic tests including multi-gene panel testing were conducted to determine if there was a genetic basis for the cancer. Interestingly, the doctors found that instead of Lynch Syndrome which is the most common genetic cause of endometrial cancer, the patient was detected to have a mutation in the breast cancer 1 gene. Hence, she was determined to have hereditary breast and ovarian cancer syndrome. Subsequently, the patient’s mother was also found to have the same mutation, and thus, both the mother and daughter were asked to undergo frequent screening to help in the early detection of cancer if it occurs in the future.

Conclusion

Discovering and understanding the genes causing hereditary breast and ovarian cancer has helped improve screening and treatment steps for it.

At an individual level, it is important to be aware of the family history of cancer in the family. If there is any history of cancer especially related to the breast, ovaries, fallopian tubes or prostrate, or pancreas, then the person must discuss the possibility of hereditary breast and ovarian cancer with their doctor. If there is a family member who has or who had cancer, then it might be recommended to test them first. Based on the genetic test, preventative steps for developing cancer can be taken from early on.

Acute Kidney Injury during Pregnancy

What Is the Main Idea?

Acute kidney injury is a sudden reduction in kidney function which usually occurs in conjunction with other health issues. In the case of pregnancy, acute kidney injury can occur due to different reasons. Based on the open access mini-review “Pregnancy-Related Acute Kidney Injury: Do We Know What to Do?”, published in the journal Nephron, this blog post describes the prevalence of pregnancy-related acute kidney injury, the causes behind it occurring in different stages of pregnancy and potential treatments that can be administered.

What Else Can You Learn?

The blog post also explains in general what acute kidney injury is, the reason it occurs, the different symptoms, how to identify it, and some potential treatment strategies.

What Is Acute Kidney Injury?

Acute kidney injury (AKI) is a condition caused by a sudden decrease in kidney function within a matter of a few hours to a few days. It can be any structural damage to the kidney or impairment in function. This condition was earlier referred to as acute renal failure (ARF). This differs from chronic kidney disease in that in the chronic condition, the kidney gradually loses function over a longer timescale.

Acute kidney injury occurs mostly along with other health issues, especially in patients who are already hospitalized or in intensive care units. It makes this condition hard to identify early. Acute kidney injury causes waste products to build up in the blood, further affecting the kidneys and water balance in the body. This can also start affecting other organs, such as the brain, heart, and lungs. Hence, acute kidney injury is often seen as part of a multi-organ dysfunction.

What Causes Acute Kidney Injury?

The reason for acute kidney injury can be multifold depending on the condition of the patient. It can occur because of decreased blood flow due to low blood pressure, organ failure, etc., or direct damage to the kidneys caused by conditions like sepsis and cancer or due to blockage of the urinary tract. While previously mostly the severe cases of acute kidney injury were given importance and immediate treatment, meanwhile even a mild case of acute kidney injury has been identified to lead to severe clinical consequences. Therefore, identifying and treating mild cases has become equally important.

Depending on the trigger of acute kidney injury, the symptoms can vary, such as low urine output, swelling in the legs, shortness of breath, fatigue, nausea, diarrhea, confusion, chest pain, and others.

How Is Acute Kidney Injury Identified and Treated?

While in the short term, acute kidney injury may affect kidney and other organ functions temporarily, in the long term, it can lead to further incidences of acute kidney disease or conditions like chronic kidney disease and heart disease. Therefore, it is vital to identify the issue early and treat it. Urinary tests, blood tests to check creatine levels (a chemical waste product from the muscles), glomerular filtration rate (to test kidney function), ultrasound imaging of the kidney, and kidney biopsies are a few tests the doctors may recommend for acute kidney injury if they suspect it. The poorer the kidney function, the higher the creatine levels in the blood will be. This is one of the standards used in testing for the condition.

The cure primarily involves treating the primary cause of acute kidney injury. For example, if a blocked urinary tract is causing the condition, then the tract is cleared. If the condition occurs due to dehydration, appropriate fluids need to be given. Depending on the comorbidities, the treatment can vary and the patient may be able to fully recover from the acute kidney injury. In severe cases, dialysis might be required until the function of the kidney is restored.

If the patient is known to be at risk for acute kidney injury, then regular blood tests must be done to check for creatine levels along with being watchful of urine output and other parameters as recommended by the doctor.

Acute Kidney Injury in Pregnancy

The incidence of an acute kidney injury occurring in pregnancy was around 0.12% in the USA in 2015 and has been shown to have increased over time. The increase is partially due to better detection but also due to other factors like older age, other health complications like diabetes or history of preeclampsia, and even ethnicity.

Acute kidney injury in pregnancy is associated with a 14-fold higher chance of mortality. With two lives involved, this becomes a serious condition that needs to be better understood. There is a risk of adverse fetal outcomes including pre-term birth, low baby weight, and fetal mortality. Diagnosing acute kidney injury in pregnant women is similar to what has been mentioned earlier about non-pregnant patients. The serum creatinine level is the main test, and depending on the symptoms and suspected cause, other tests can be done. Kidney biopsies are also safe to do in the first and second trimesters. In the third trimester, depending on the fetal viability and patient’s condition, the doctor may decide to do the biopsy postpartum.

What Are the Reasons for Pregnancy-Related Acute Kidney Injury and How Can It Be Treated?

In the first trimester, acute kidney injury can be caused due to dehydration caused by pregnancy-related nausea and vomiting or due to an abortion complicated with an infection. In the former case, hydration is the treatment while in the latter case, antibiotics are used to treat the patient.

In the second trimester, there are multiple ways acute kidney injury could occur. In the case of urinary tract infections, antibiotics are administered before it leads to further complications. Acute kidney injury can also occur due to conditions like preeclampsia, which is a pregnancy complication involving high blood pressure, or Hemolysis, Elevated Liver enzymes, and Low Platelets (HELLP) syndrome. In these cases, premature delivery of the baby is the main option of treatment considered.

Thrombotic thrombocytopenic purpura, a condition of blood clots forming in small blood vessels, can lead to acute kidney injury, too. Plasma exchange or certain medications are given to treat this condition. For glomerulonephritis, a condition involving damage of the filters in the kidney, steroids and immunosuppressants are administered depending on the condition of the patient and fetus.

How Can Incidences and Complications due to Pregnancy-Related Acute Kidney Injury Be Reduced?

It is essential to create awareness among physicians of the many different causes of pregnancy-related acute kidney injury. The treatment needs to involve a multidisciplinary approach including a nephrologist, gynecologist, and neonatologist. Early diagnosis can also be improved by screening pregnant women for kidney function at the beginning of pregnancy and during any pregnancy-related hospitalization. By improving the diagnosis, treatment, and care of pregnant women, the rate of women developing or dying from acute kidney injury can be reduced.

Continuous Glucose Monitoring in Dialysis Patients

What Is the Main Idea?

Glucose monitoring in diabetic patients is essential to provide an appropriate treatment plan. Patients with chronic kidney disease who undergo dialysis are susceptible to developing diabetes but have complications in measuring glucose levels. There are different methods of measuring glucose. In this blog post, based on the open access mini-review “Can the Use of Continuous Glucose Monitoring Improve Glycemic Control in Patients with Type 1 and 2 Diabetes Receiving Dialysis?”, published in the journal Nephron, continuous glucose monitoring as a preferred choice of tracking glucose in dialysis patients is discussed.

What Else Can You Learn?

Diabetes as a condition, the reason for monitoring glucose, and the different methods to do it are explained. Further, it is briefly discussed what has been recommended for patients with chronic kidney disease undergoing dialysis.

Glucose Levels and Diabetes

Diabetes is a health condition where the conversion of food into energy is compromised. The food that enters the body gets broken down into glucose and enters the bloodstream. The glucose is then transported to the cells with the help of a hormone called insulin, to provide energy for cellular functions.

However, it can happen that either insulin production is affected in the body or there is a malfunction in the use of the insulin by the body which results in excessive glucose left in the bloodstream. This is termed diabetes. Diabetes can have symptoms like thirst, frequent urination, fatigue, blurry vision, and more. It can also lead to long-term complications of cardiovascular issues, chronic kidney disease, issues with vision, and nerve damage. On the other hand, conditions like chronic kidney disease could lead to diabetes, too.

Measuring Glucose from Blood

An important step in treating diabetes is monitoring glucose levels. The most common and widely used technique is measuring the amount of glucose in the blood periodically. In the blood, glucose can attach to a protein called hemoglobin which is part of the red blood cells. It is termed as glycated hemoglobin or HbA1c. The red blood cells have an average lifetime of 2 to 3 months. Hence, the glucose levels measured using this method are an average value of glucose over time which gives a bigger picture of glucose levels and changes.

For those who are already diabetic, at-home glucose monitors are available that involve a skin-prick blood test. This gives an instantaneous value of the glucose level in the blood and can depend on the food eaten or activity done before taking the measurement. Logging these measurements over time is more useful and will give a better understanding of the changes in glucose levels.

Measuring Glucose using a Continuous Glucose Monitoring Device

Continuous glucose monitoring is a wearable technology that helps keep track of glucose level changes over time, from minutes to days or months. The device contains a sensor that is placed under the skin in the belly or arm. This sensor measures the glucose content of the fluid under the skin (and not from the blood) every 5 to 15 minutes. Depending on the model of the sensor, it will have to be replaced periodically, starting from 1 to 2 weeks or in some cases in 3 months. The glucose measurements can be accessed and tracked using an app or computer.

In different smaller studies, the continuous glucose monitoring system has been shown to better manage diabetes compared to using a skin-prick test alone. The way to know if the monitoring system is working properly is to check the number of events of the patient having a lower glucose value than normal between different cases. This is because if the number of incidences of below-normal glucose levels is higher than on average, it can seem like it has helped manage glucose levels better. In these studies, the low glucose incidences did not increase with the use of the continuous measuring system. While there are indications that this continuous monitoring can also help against developing long-term complications of diabetes, further research and large-scale studies are required to understand the relationship better and confirm all these results.

Advantages and Disadvantages of the Different Monitoring Systems

The main difference between the testing methods is detecting glucose from the blood (HbA1C and skin-prick blood testing) or from the fluid between the body’s cells under the skin (continuous glucose monitoring). The glucose digested first enters the blood before reaching the space between the cells. Therefore, the blood tests show more accurate levels of momentary glucose reading compared to the continuous monitoring device. So, it is highly recommended to use the at-home glucose monitor (skin-prick test) to confirm abnormal readings obtained from the continuous monitoring device before treating it.

In contrast, in some patients, identifying the trends of direction and speed of glucose change is more important to provide a proper treatment plan. In this case, the continuous monitoring device provides better information than the blood test method.

At a practical level, the continuous monitoring system does not require pricking or drawing blood for each measurement and can also take more measurements over time. However, inserting the sensor and replacing it requires going to a professional, and the system is more expensive.

What Are the Issues with Glucose Monitoring in Dialysis Patients?

Chronic kidney disease patients at the latter stages require dialysis. These patients are also highly susceptible to developing comorbidities, especially diabetes. This is because insulin secretion, sensitivity, clearance, and glucose metabolism are highly affected. Therefore, monitoring glucose levels in chronic kidney disease is essential. The process of dialysis in chronic kidney disease patients reduces the lifespan of the red blood cells. Additionally, the use of agents to stimulate the production of red blood cells causes there to be more time periods with less glycated hemoglobin. So, using blood for measuring glucose levels can be inaccurate in dialysis patients. Therefore, Kidney Disease: Improving Global Outcomes (KDIGO) has recommended the use of continuous glucose monitoring instead of measuring glycated hemoglobin to track glucose levels in patients undergoing dialysis.

This report has provided guidelines for time ranges of specific glucose values that a patient with chronic kidney disease should aim to achieve. The ideal situation is to have the following glucose levels:

  • Greater than 12 hours per day in the target range of 3.9 to 10.0 mmol/L.
  • Less than 15 min per day below 3.9 mmol/L.
  • Less than 12 hours per day at 10.0 mmol/L.
  • Less than 2 hours and 24 mins per day above 13.9 mmol/L.

Continuous Glucose Monitoring in Dialysis Patients

Preliminary studies indicate that controlling glucose levels based on data from continuous glucose monitoring is correlated with lower mean glucose levels at the end of the study. Larger-scale studies of these need to be conducted to confirm these results.

It must be noted that none of the continuous glucose sensing monitors are approved for dialysis patients because they have not been tested for this particular use. It is important to talk to the doctor and associated medical team to determine the best monitor to use and all the practical implications involved in using a continuous glucose monitoring system in chronic kidney disease patients undergoing dialysis.

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.

Nail Lichen Planus: An Inflammatory Health Condition

What Is the Main Idea?

Lichen planus is an inflammatory condition that can affect different parts of the body including the nails. It is not dangerous and may also go away on its own without treatment when mild. However, when it is moderately severe or severe, treatment is important to avoid any permanent issues. This blog post is based on the open access article “Successful Treatment of Nail Lichen Planus with a Lacquer Containing Urea, Keratinase, and a Retinoid Molecule: Report of 10 Cases”, published in the journal Case Reports in Dermatology. It discusses lichen planus as a condition and a possible new line of treatment using a medicated nail lacquer.

What Else Can You Learn?

In this blog post, the general condition of lichen planus and possible causes are discussed. The different symptoms, especially for nail lichen planus, and the current treatment procedures are explained in detail.

What Is Lichen Planus?

Lichen planus is an inflammatory health condition that can affect the skin, hair, mucous membranes, and nail. It is a benign and non-contagious condition which means it cannot be passed on by direct or indirect contact. This disease is seen in men and women equally and is rare in the old and very young populations.

On the skin, it is often seen as small, itchy purple rashes or bumps. It mostly occurs on the wrist, arm, back, and ankle. In mucosal membranes of the mouth and genital organs, vagina and penis, it can appear as white patches with painful sores. It may affect the nails, too, causing them to disfigure.

The reason behind lichen planus is not always known. However, a few reasons why it appears include autoimmune issues, hepatitis C infection, reaction to some pigment or metal, and reaction to certain medications like those used to treat high blood pressure, heart disease, malaria, and diabetes.

How Does It Manifest in the Nails?

Nail lichen planus is observed in 10 to 15% of cases of those with lichen planus. In some cases, it could be the only symptom of lichen planus. If not treated, it is one of the few conditions that could lead to permanent nail loss.

The nails can show different abnormalities in morphology. There could be issues of attachment of nail plate, nail plate thinning, changes in nail surface or color, raised vertical lines on the nail, splitting of nail along the length, or excessive skin tissue between nail plate on top and the nail bed (the part of the nail below the nail plate). In advanced stages, it can lead to a condition called dorsal pterygium which causes the skin from the lower end of the nail to grow and fuse with the matrix underneath it and ultimately the nail bed. Nail lichen planus must be treated immediately after diagnosis to avoid permanent disfiguration.

How Is Nail Lichen Planus Diagnosed?

In general, lichen planus is diagnosed by examining the patient for the symptoms. It can be hard to diagnose nail lichen planus because it must be differentiated from other diseases that cause similar symptoms. An additional step to diagnosing this specific condition is to take a sample of tissue (biopsy) from the affected area of the nail and to examine it carefully.

Nail anatomy

Treating Nail Lichen Planus

Lichen planus does not have a specific treatment procedure. The treatment mainly caters to symptomatic relief. Therefore, in patients without symptoms but having been diagnosed with lichen planus, no treatment is given. In the case where the trigger of the condition is identified, for example, a side-effect of medication, then the medication is immediately stopped. However, it might still take 2 to 3 months for symptoms to disappear.

The treatment for lichen planus, in general, could include antihistamines, topical or oral steroids, ointments used for eczema, ultraviolet light treatment, and retinoic acid. For nail lichen planus, specifically, the first line of treatment is topical steroids that are anti-inflammatory. This may be accompanied by topical tacrolimus which are immune suppressors. This is helpful in case the condition has an autoimmune origin. These medications may or may not help reduce the symptoms. Oral medication of steroids is also used in more severe conditions. However, this treatment may also lead to mild to moderate improvement, and there might be side-effects. Oral retinoids, compounds similar to vitamin A, have been shown to be effective against nail lichen planus.

Latest Treatment Option: Medical Nail Lacquer

Since more effective treatments for nail lichen planus are required, a nail lacquer that has a combination of urea, keratinase, and retinoid was tested in a small study. This lacquer was already shown to be effective against other nail conditions which have similar symptoms to nail lichen planus. In the small pilot study, 10 participants were treated with this nail lacquer for 12 weeks with one daily application. Patients with pterygium where nail lichen planus is in the latter stages were not included in the study.

In the 10 patients, 7 different nail symptoms, as discussed earlier, were assessed and scored before and after the treatment. Overall, the symptom score was reduced by 80% in all cases together. The significance could be seen visually, too. Hence, this treatment seems to be promising for mild to moderately severe nail lichen planus. However, the study needs to be improved with the number of patients, a more thorough examination of the condition (with tissue examination), and using a control group to understand whether the condition improved naturally or due to the lacquer.

Visiting the Doctor

It is important for patients having issues with the nail or skin to seek medical help from the doctor, or specifically a dermatologist, immediately. While lichen planus itself is not a dangerous disease, when left unattended, in some cases it may lead to more serious issues like permanent changes in the body.

Lichen planus and when the condition affects the nail can take time to diagnose because of other conditions like it. When visiting the health care practitioner, it will be helpful to talk about all the triggers discussed above, such as medications that you are taking or the possibility of an autoimmune condition. Also, while going over the treatment plan, this new line of treatment with this specific nail lacquer containing urea, keratinase, and retinoid can be discussed with the health care practitioner.

Note: One of the authors of the paper declared that they have relationships with the company 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.

Mediterranean Diet and the Gut Microbiome

What Is the Main Idea?

The Mediterranean diet is a plant-based diet that has multiple benefits for healthy living. Based on the review article “Influence of Mediterranean Diet on Human Gut Microbiota”, published in the journal Kompass Nutrition & Dietetics, this blog post describes how through its interaction with the microorganisms in the intestine, the diet helps in reducing cardiovascular risks and other inflammatory diseases.

What Else Can You Learn?

The composition of the Mediterranean diet compared to the Western diet is described. Further, details of how the diet and microorganisms influence the health of the individual are explained.

How Was the Importance of the Mediterranean Diet Identified?

The Mediterranean diet was conceptualized by the American physiologist Ancel Keys. In the Seven Countries Study, led by him, the authors compared the local diet and correlated it to the health of people in 7 countries including the USA, Finland, Netherlands, Italy, Yugoslavia, Japan and Greece (Crete). The results showed that the Cretan diet was the least associated with cardiovascular diseases. This is despite the diet containing high fat, primarily olive oil.

Similarly, in another study called the Lyon Diet Heart Study, 605 patients who had previously had a heart attack were split into 2 groups. One group consumed the diet recommended for their heart condition (low in fat and cholesterol) and the other group followed the Mediterranean diet which included omega-3 fats. Surprisingly, the group following the Mediterranean diet had 70% less chance of mortality.

Finally, the Mediterranean diet was tested in the largest prevention trial called PREDIMED involving more than 7,000 participants. Those following the diet showed a reduction in cardiovascular issues, in type 2 diabetes, and in the development of Alzheimer’s disease, as well as an increase in life expectancy.

What Is the Mediterranean Diet and How Does It Differ from the Western Diet?

The Mediterranean diet is essentially based on the traditional food cooked along the Mediterranean Sea. To make it easier to understand how to consume the diet, a food pyramid has been envisioned. The bottom of the pyramid consists of exercise followed by the consumption of whole grain cereals, legumes, nuts, and seeds. Along with fresh fruits, vegetables, and fats, specifically extra virgin olive oil, these are the food groups that need to be consumed every day. Followed by this, consuming seafood like fish is recommended a few times per week, dairy, eggs, and poultry in small portions are recommended once a week and red meat and sweets should be limited to occasional consumption. A moderate amount of red wine consumption is allowed. Therefore, the diet heavily focuses on plant-based components. It is made flavorful with the use of herbs and spices, which also provides additional health benefits.

In contrast, the Western diet contains saturated fat, refined carbohydrates, and salt. It typically consists of a high amount of red meat, high-fat dairy products, high-sugar foods, and processed and packaged food.

Characteristics of Mediterranean diet (Merra G, Noce A, Marrone G, Cintoni M, Tarsitano MG, Capacci A, De Lorenzo A. Influence of Mediterranean Diet on Human Gut Microbiota. Nutrients. 2020;13(1):7 (DOI: 10.3390/nu13010007) © 2020 by the authors (reprint, publisher’s note removed) licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/deed)).

How Do These Differences in Diet Affect the Gut Microbiome?

The gut microbiome is composed of microorganisms that reside in the digestive tract of humans and animals. The present organisms and the diet correlate with each other. Based on the diet and the fiber consumed, the concentration of certain species of organisms thrives by feeding on this fiber. In turn, based on the composition of the organisms present, certain by-products of their metabolism are released that may or may not be beneficial for the health.

With a primarily plant-based Mediterranean diet, the percentage of fiber-degrading bacteria and short-chain fatty acids (SCFA) increases. Short-chain fatty acids are a by-product of gut bacteria metabolism. They help the gut in multiple ways, including maintaining the intestinal barrier and mucus production as well as protecting against inflammation. These help with regulating immunity, lipid metabolism, blood pressure, and glucose. Primarily, with this diet, there is an increase in Bifidobacteriaceae, Bacteroidaceae, Lactobacillaceae, and Prevotellaceae families of bacteria.

On the other hand, if the Mediterranean diet is poorly adhered to or if a Western diet is followed, then there is a higher concentration of bacteria that create a by-product of bacteria metabolism called trimethylamine N-oxide in the urine. The higher concentration of this has been associated with cardiovascular events with alteration of cholesterol and activation of inflammatory pathways.

Gut Dysbiosis and Diseases

Dysbiosis occurs when there is a structural or functional change in the gut microbial composition. This causes adverse health issues like triggering inflammation and diseases. Dysbiosis can occur due to stress, infections, and bad eating habits. In chronic kidney disease, the gut microbiome is altered with bacteria that cause dysbiosis. With an Italian Organic Mediterranean Diet, the authors of the above paper could show that various parameters of chronic kidney disease patients improved.

Dysbiosis is also directly correlated to colorectal cancer. There is an increase in bacterial species that promote tumor cells to multiply and induce an inflammatory state. With a Mediterranean diet and higher amounts of short-chain fatty acid production, there is shown to be a reduced risk of colorectal cancer.

To rectify dysbiosis, a short-term modification of 6 months was not enough to change the microbiome composition. However, in a study where the participants had a Mediterranean diet for 2 years, there were an increase in healthy bacteria and possible anti-cancer effects.

Benefits of Extra Virgin Olive Oil, Polyunsaturated Fats, and Fiber in the Mediterranean Diet

Extra Virgin Olive Oil

The main components of extra virgin olive oil are oleic acid and polyphenols. These are antioxidants and anti-inflammatory compounds that work against oxidative stress. Oxidative stress is associated with heart diseases, cancer, and inflammatory diseases.

In a study with cells, it was shown that polyphenols present in olive oil were able to mix with gastric juices and survive the acidic condition. They also had a bactericidal effect on 8 strains of Helicobacter pylori, which are bacteria that can cause ulcers and lead to stomach cancers. In another study with patients with high cholesterol, adding olive oil to the diet was able to stimulate the immune system. While these are preliminary results, they are promising and need to be further tested.

Polyunsaturated Fats

Fish and other marine-based diets as recommended in the Mediterranean diet contain high quantities of polyunsaturated fatty acids, especially omega-3. As described in a previous blog post, omega-3 has been shown to help in cardiovascular health and reduce inflammation which is the basis of diseases like cancer, diabetes, renal failure, and more. One of the mechanisms of the anti-inflammatory effect is found to be through reducing the unhealthy bacteria in the gut and improving the intestinal barrier.

Fiber

Dietary fibers are prebiotics which are compounds required for the growth of healthy bacteria in the intestines. The bacteria feed on these fibers and release the short-chain fatty acids. With higher dietary fibers, healthier bacteria occupy the gut and also help reduce the level of cholesterol and insulin. Whereas, with low dietary fibers, the bacteria use mucoglycoproteins from the intestinal lining of the host which can lead to damage to the intestinal barrier, allowing disease-causing bacteria to pass through and resulting in colitis (inflammation of the intestine). The Mediterranean diet provides 14 g of dietary fiber per 1,000 kcal of food. This is double the amount of fiber compared to that provided by the Western diet. Hence, it has a direct effect on the prebiotic composition and in supporting healthy gut bacteria.

In Short

The Mediterranean diet has huge health benefits, especially by increasing the antioxidants, anti-inflammatory compounds, dietary fiber, and healthy fats. These help with promoting the good bacteria in the gut which in turn release short-chain fatty acids which have multiple benefits. It also helps avoid dysbiosis of the gut which can be a cause of chronic diseases. A healthy Mediterranean diet consists of daily consumption of a healthy dose of whole grain cereals, legumes, nuts, fruits, vegetables, and olive oil, with fish and dairy products consumed on a weekly basis. Red meat and sweets are meant to be consumed only occasionally.

Monitoring Nutrition in Premature Infants

What Is the Main Idea?

Babies born before 37 weeks of gestation require special care and potentially external help in their growth and development. Nutrition, in the form of milk and additional supplements, plays a vital role in weight gain and appropriate overall growth. Lack of proper growth can lead to various health issues. It becomes essential that these premature babies are screened regularly for their growth. Based on the open access research article “The Development and Evaluation of the Nutritional Risk Screening Tool for Preterm Infants from Birth to Corrected Age Four Months Old: A Pilot Study” published in Annals of Nutrition and Metabolism, in this blog post, the parameters that need to be monitored in premature babies and a screening tool to help identify any nutritional issues that can progress to a health risk are described.

What Else Can You Learn?

The reason for monitoring the nutrition in premature infants and the different ways nutrients are fed are explained. Additionally, the kind of nutrition the infant needs is described.

Premature Infants and Why Nutrition Is a Concern

Babies are considered premature when they are born before the 37th week of pregnancy. Some of the issues that a premature infant can have include difficulty breathing since the lungs are not fully developed, maintaining body temperature, slow weight gain, and difficulties with feeding. Long-term issues for those born prematurely can be developmental delays, issues related to neurology as well as cardiovascular, metabolic, or bone health of the person.

For healthy growth, proper nutrition becomes vital in premature babies. Apart from physical growth, being premature affects their metabolism and immune function. It can also lead to problems related to psychomotor and mental skills. Additionally, premature babies are susceptible to nutrition-related problems like malnutrition in protein and energy and iron deficiency.

Things to Know regarding Providing Nutrition for Premature Infants

The main goal regarding nutrition for premature infants is to achieve growth similar to what the baby would have if it was still in the uterus. However, depending on the level of prematurity, feeding the infant can be associated with different issues. Based on how early the infant was born, the infant might have feeding issues because of breathing troubles, oxygen levels, and circulation problems.

There are 2 modes of providing nutrition called enteral and parenteral. With enteral feeding, the food passes through the digestive tract through a tube that starts from the nose or the mouth. In parenteral feeding, the nutrients are given directly into the blood through intravenous (IV) therapy. The main issue with food going through the digestive tract in premature babies is that they can develop a condition called necrotizing enterocolitis (NEC). This condition causes inflammation of the tract and consequently, cells in the tract start dying. In most cases, this issue is addressable. For example, feeding breast milk and slowing the rate of feeding are supposed to help avoid this condition.

Without enteral feeding, if IV therapy alone is used for feeding, it can affect the gut development as the gut will not be active and hence will not produce the required hormones or enable gut mobility.

So, what kind of nutrition is best for the infant? The expressed mother’s milk is considered ideal followed by pasteurized donor’s milk. However, there are some nutrients for growth that are not present sufficiently in mother’s milk to enable the premature infant to grow at the right rate. Therefore, the mother’s milk needs to be supplemented through fortification. The milk can be fortified with extra protein, energy, minerals, and vitamins.

Babies that are born closer to full term could potentially feed directly from the breast or from a bottle. In the case where the infant struggles to form a proper suction at the breast and is not able to control the feed from a bottle, the infant can be given milk through the tube.

Parameters that Help Monitor the Growth of a Premature Infant

To be able to assess whether the premature infant is getting enough nutrition and growing steadily, there are various parameters that can be monitored. While weight gain is of primary importance, the measurements of the body length from crown to heel, head circumference, mid-upper arm circumference, and weight to body length value are measurements that are equally important. These measurements are termed anthropometric measurements. These values will help give a better understanding of how the body composition is changing.

Biochemical markers that indicate the amount of iron, proteins, metabolic and electrolyte composition, and bone status also provide useful information about the growth of premature babies.

To assess if the baby’s growth is progressing well, all these measurements have to be analyzed in conjunction with each other by an expert.

Latest Research on Developing a Nutritional Risk Screening Tool for Premature Infants

As described in the beginning, premature babies have the risk of developing health issues from early on till adulthood. To identify issues early and to provide the appropriate intervention, it becomes vital to be screening the newborns for any risk. However, while there are screening tools that have been developed, there are no standardized methods to do the test yet.

In a recently published article mentioned above, the authors developed a new screening tool to assess for any issues in babies from the time of birth till 4 months corrected age (the age from the time of birth minus the number of weeks or months the infant was born prematurely). The newborns’ medical history, the feeding practices like milk intake, formula use or any fortification, nutrition supplements like vitamin D, and anthropometric measurements were monitored. Through their work, the authors were able to make correlations and predict factors like growth retardation and intellectual development issues to a large extent. However, their models could not predict microencephaly to a similar extent. The research needs more work in developing the predictor model better.

Take-Home Message regarding Premature Nutrition

Parents of premature infants should ensure that the infant is receiving the right nutrition and supplements and in appropriate quantities. One way of ensuring this is by talking to the doctor and doing a nutritional risk assessment. Early intervention can make a big difference in an infant’s development all the way to adulthood.

Skin Prick Test: How Does Reading Time Influence the Detection of Allergies in Infants?

What Is the Main Idea?

Allergies are a body’s adverse reaction to a relatively harmless substance. The methods to test allergies have been well established for the general population. However, for infants less than 2 years old, the result interpretation has to be done differently and carefully. Based on the open access research article “Evaluation of Skin Prick Test Reading Time at 10 versus 15 min in Young Infants”, published in the journal International Archives of Allergy and Immunology, skin prick testing is described and discussed in the context of infants in this blog post.

What Else Can You Learn?

This blog post explains allergy in general and in children. Further, the basics of how a skin prick test is done and how the results are interpreted are explained.

Allergies in Children and Infants

Allergies occur when the body’s immune system reacts to foreign substances called allergens which are generally considered harmless. People who have allergies usually have developed antibodies against the allergen. Subsequently, when they encounter the allergen, their bodies react by releasing histamine which is visible in the form of inflammation of the digestive system, airways, sinuses, or skin.

Allergy in children can come in all the different forms. It can be an allergy due to food or airborne particles, asthma, skin-related (eczema, dermatitis), or allergic rhinitis (which affects the upper respiratory tract). Around 30–35% of children are affected by allergies because of various types of allergens, irritants, and infections. Some common allergens are eggs, milk, nuts, wheat, soy, pollen, dust and pet dander.

Infants are less prone to seasonal allergy but can develop food allergy or eczema. When they are less than 6 months old and are purely breastfed, chances of food allergies are also less. However, they can still have reactions to other allergens or some components in the breast milk which come from the mother’s diet. These can be identified by testing.

What Is a Skin Prick Test?

To figure out what is causing the allergic reaction, different tests can be done such as blood tests, skin tests or elimination diet tests (by eliminating one food at a time in the diet). In the skin prick test, through a needle prick, a little bit of the allergen is introduced just under the skin. If the person has antibodies (specifically the type called immunoglobulin E (IgE)) against the specific allergen, their body will react to this by releasing histamines and other factors. This will cause the pricked area to be raised, which is called the wheal, and a surrounding red area called the flare. The wheal and the flare are usually measured by their mean diameter. Multiple allergens can be tested at different locations at the same time. Additionally, a solution without any allergen is also tested as a negative control which should ideally show no reaction. Histamine, by itself, is tested as a positive control to ensure the test is done properly and to check that the body does react. It is important to note that no anti-histamines should be taken before the test so that the body is allowed to react.

Results from a Skin Prick Test

In the general population, the reaction of wheal and flare is measured around the 15- to 20-min time point for allergens and the 10- to 15-min time point for histamine. After this time point, the reaction slowly subsides and will also go away. Ideally, the negative control should have no wheal but there can be a small reaction in some cases. On the other hand, the positive control should show a significant wheal size of around 6 mm. When the allergen prick responds with a wheal diameter of larger than 3 mm compared to the negative control, the person is considered allergic to that specific allergen. The larger the wheal diameter, the more allergic the person is to the allergen.

Skin Prick Test in Infants

Skin prick tests in babies are harder for a few reasons:

  • Firstly, the reaction is diminished with the wheal diameter being smaller than for adults but the red flare can be larger.
  • Secondly, the time of reaction and reading the results need to be done appropriately.
  • Finally, there are higher chances in infants below 6 months of a generalized allergic reaction to some fresh food allergens which will require immediate care.

Due to these reasons, it is important that skin prick testing in children below 2 years is done by specialists.

Interpretation of Skin Prick Test Results in Infants

As mentioned earlier, the results of skin prick testing in infants must be interpreted carefully. The infant is said to have an allergy if the wheal diameter is above 2 mm as opposed to 3 mm for older children and adults. Regarding the time of read-out, a study comparing the skin prick test reaction for children above and below 2 years concluded that below 2 years, results should be read after 10 min and not 15 min. To understand these results better in younger infants, a recently published article analyzed allergic reaction results at 10 min and 15 min from skin prick tests done on 1,431 6-month-old infants. The allergens tested were egg, cow’s milk, peanut, wheat, soy, birch, timothy grass, dog and cat. The infant was considered to be allergic if the wheal diameter was at least 2 mm larger than the control. The authors found that both 10-min and 15-min time points were equally good at identifying allergies. Including both time points increased the number of infants identified to have an allergy compared to using only one time point. Interestingly, the wheal diameter on average was greater at the 10-min time point compared to the one at 15 min. Therefore, the authors’ recommendation is to consider both time points when interpreting skin prick test results for infants.

What to Do as Parents?

While it is hard to differentiate some symptoms of allergy from other illnesses, parents should watch out for triggers that potentially cause the reaction they are observing. The symptoms themselves can be varied, for example rashes, runny nose, swelling of face, legs or arms, breathing trouble, cough, diarrhea, vomiting, and many more. To identify the allergen and next course of action, the parents can discuss doing the skin prick test with their pediatrician. They should ensure that the test is performed by a specialist for children below 2 years of age. Further, discussing this article and asking the specialist to read results at both 10 min and 15 min can potentially lead to a better diagnosis.

Prediabetes, Proteinuria and Kidney Health

What Is the Main Idea?

Type 2 diabetes is a known factor which can lead to poor kidney health. An indication for kidney damage is the increase in protein levels in the urine, termed as proteinuria. However, at what levels of glucose increase is there a significant effect on proteinuria and kidney health? This is the question we address in this blog post based on the open access article “Impact of Glucose Tolerance and Its Change on Incident Proteinuria: Analysis of a Nationwide Population-Based Dataset”, published in the American Journal of Nephrology.

What Else Can You Learn?

In this blog post, we discuss the symptoms and causes of proteinuria. The measurement of glucose levels and the connection between diabetes and kidney health are also explained here.

What Is Proteinuria?

Proteins are large biomolecules that are essential for a lot of functions in the body, including growth and repair of cells. These proteins need to remain in the blood to reach the required parts of the body and carry out its function. On the other hand, the kidneys are involved in filtering the blood to remove waste and excess water through urine. When the kidneys start malfunctioning, they may allow proteins to pass through to the urine. Increased levels of protein in the urine is called proteinuria.

While small levels of protein in the urine do not lead to symptoms, higher levels of protein can cause foamy or bubbly urine, swelling of hands and feet, increased frequency of urine, vomiting and muscle cramps.

Protein in the blood is detected by a urine test. The ratio between levels of albumin (a small protein) and creatinine (a waste product) is measured and if above a certain threshold, it indicates presence of proteinuria.

What Causes Proteinuria?

In many cases, a person might have short-term proteinuria due to issues like dehydration, stress, cold temperatures, fever, high intensity of physical activity or kidney stones. In these mild and temporary cases, treatment might not be required, or specific treatment related to the cause will be administered.

If proteinuria is present over a long period of time, it could be an early indication of chronic kidney disease. The two major causes of chronic kidney diseases are high blood pressure and diabetes. Here, we will further discuss diabetes and glucose tolerance related to proteinuria.

As a side note, apart from chronic kidney disease, proteinuria may also occur in other serious health conditions including immune disorders, cancer, cardiovascular diseases and preeclampsia in pregnant woman.

Diabetes and Kidney Diseases

Type 2 diabetes is a condition where insulin, a hormone that regulates the sugar in the blood, does not function effectively. If not regulated, increased levels of sugar or glucose in the blood can damage various organs in the body including the kidneys.

The damage can occur in multiple ways. The increased sugar in the blood can cause blood vessels in the kidneys to constrict (endothelial dysfunction) which can damage the filtering function of the kidney. With diabetes, there can be damage to the nerve function as well which can disrupt the communication between brain and bladder. If the bladder does not get the message to pass urine in time, it can put pressure on the kidneys and damage its function.

Independent of diabetes causing kidney damage, type 2 diabetes and proteinuria have similar clinical features. In both cases, there is increase in inflammation and dysfunction of blood vessels (endothelial dysfunction) in the body.

Prediabetes and Proteinuria Levels

Since it is well known that diabetes can cause kidney damage, most diabetic patients are regularly checked for this health condition. However, before becoming diabetic, patients may be identified at a stage where glucose levels are higher than normal but are not considered diabetic. They are known to be prediabetic.

To find out if someone is prediabetic, a blood test can be done to measure the levels of glucose attached to the hemoglobin (called HbA1C). This gives the average glucose levels present over 2 to 3 months. When the level of HbA1C is less than 5.6, it is considered normal. From 5.7 to 6.4, it is considered prediabetic, and when higher than 6.5, it is considered diabetic.

Because about 33% of newly detected diabetic patients have some extent of kidney-related issues, the question arises whether prediabetic patients might already have an increased risk of proteinuria and kidney disease. While the research in this area has not yielded definitive results, a recent open access article addressed this question by analyzing the health history from 1.8 million patients. These patients were specifically selected for not having taken any glucose-lowering medication at the start of when their data was studied.

Some trends that were observed were that the proportion of men increased when the glucose category level increased. Also, the number of people who were overweight, smoked cigarettes or had hypertension increased with higher levels of glucose. The main observation was that the proteinuria levels in the blood increased with increasing glucose levels. Additionally, when the yearly glucose levels (HbA1C) increased by 0.5% or more, there was a greater risk for proteinuria, especially in those patients having prediabetes. This risk was observed even if people with hypertension were excluded or in subgroups divided based on age and sex. More interestingly, the authors found that if the glucose levels could be brought back to normal, the increase in proteinuria could be prevented.

Take-Home Message

Apart from diabetic patients, patients having prediabetes are already at a risk of having increased proteinuria, potentially leading to chronic kidney disease. However, detecting this early by routine tests and consultations with the doctor can help prevent the kidney from further damage.

Learn about Delay in Kidney Function after Transplantation

What Is the Main Idea?

With improvement in science, kidney transplants have been quite successful in recent days. However, under certain conditions, there are chances that the transplanted kidney does not function properly, requiring dialysis in the first week of the transplant. This is called delayed graft function. In the open-access research article “Predictors of Delayed Graft Function in Renal Transplantation”, published in the journal Urologia Internationalis, the authors analyze and discuss the potential factors that could lead to this medical issue.

What Else Can You Learn?

In this blog post, kidney transplants in general and factors that are assessed before performing the transplant are discussed. Details of the factors affecting delay in kidney graft function are also explained.

Kidney or Renal Transplantation

Kidneys have the important function of removing toxins from the body by filtering the blood. Due to different reasons, this function can get disrupted and lead to chronic kidney disease. As described in a previous blog post, depending on the stage, the patient is treated through lifestyle modifications and dialysis, and might finally end up needing a new kidney. Dialysis is the procedure of removing toxins and excess fluid from the body which often involves passing the blood through an external machine. Kidney transplantation, on the other hand, involves placing a healthy kidney from a deceased or living person in a patient whose kidneys do not function anymore. Kidney transplantation is mostly the recommended treatment procedure for patients in the last stage of chronic kidney disease called end-stage renal disease.

Before doing a kidney transplant, the patient and the donor are examined for many criteria like their age and health status, and are thoroughly examined for their physical condition through routine laboratory tests and specialized tests. Most importantly, the blood compatibility between patient and donor has to be matched to proceed with the transplantation. With all these checks in place, kidney transplants have been quite successful. The Scientific Registry of Transplant Recipients (SRTR) reported the 1-year national (USA) survival rate as 98.11% success rate for a living donor transplant and 94.88% for a deceased donor transplant.

Delayed Function of Transplanted Kidney

Despite the general overall statistics of successful kidney transplants, there is a chance of temporary kidney function failure immediately post the transplant. This acute kidney failure condition is termed “delayed graft function”. It is defined specifically as the requirement of dialysis within 7 days of transplantation. The rate of having a delayed graft function is about 25–35% when the kidney is donated from a deceased patient. With a living donor transplant, this rate is lower but can still occur.

While, as indicated by the term, the kidneys start functioning after the delay, there are other consequences due to the delay. In delayed graft function transplants, long-term outcomes are worse, and there is an increased incidence of poor graft function and in some cases complete rejection of the graft within one year of transplant.

Moreover, there is no known treatment for delayed graft function or the longer-term consequences. Therefore, the onus lies in understanding the factors that can cause it and trying the best to avoid them.

Current Understanding of Delayed Graft Function

The major problem with this health issue is that the exact biological reason for a delayed graft function is not completely understood yet. However, one of the most probable causes could be the injury caused when kidneys that have been devoid of oxygen (ischemia) during the transplantation procedure are suddenly flooded by oxygen (reperfusion) after the transplantation is complete. This injury is accompanied by the release and activity of inflammatory molecules which can be hindering to achieve proper kidney function.

Associated Factors of Delayed Graft Function

While treatments for the condition are being researched, it can potentially be avoided by understanding associated factors that might cause delayed graft function. In a recently published open-access research article, the authors conduct a comprehensive analysis of factors associated with delay in graft function. They revisited the medical history of 531 transplant patients collected over 11 years.

Firstly, it was seen that the age of the patient and donor affected the graft function. The older they were, the higher were the chances of delay in function. The main reason could be general medical conditions including comorbidities.

Secondly, the cold ischemia time, defined as the time between when the kidney graft is outside in cold preservation solution and finally grafted and connected to the recipient’s blood supply, significantly affects the outcome of the transplant. In this report, the authors found that when the cold ischemia time was over 15 hours, the delay in graft function increased substantially. This is also one of the reasons why the chance of delayed graft function was higher when the transplant was from a deceased donor compared to that from a living donor.

The matching of donor-recipient blood types was another important factor. Human leukocyte antigens (HLA) are proteins on the cell surface of human cells which help in regulating the immune system. These are the proteins that are matched between donors and recipients, and a significant mismatch can lead to poor outcomes. Usually, immunosuppressants are administered to combat this problem after transplantation. In the study mentioned, the researchers further found that a specific type of antigen mismatch (HLA-DR) specifically correlated with the delayed graft function. Therefore, administering immunosuppressants for this specific factor is also important.

One finding of the study was also that when patients had delayed graft function, the long-term renal function was poorer than those transplants that immediately functioned.

Take-Home Message for Patients

All the factors discussed above regarding chances of a delayed graft function have been consistent with other studies. Therefore, there is a need to be aware of these predictors. As research continues to find solutions to reduce the chances of delayed graft function, here are some factors that the patient can discuss and work on with the medical system: ensure reduced ischemia time (time the kidney is outside of the body without blood supply) and carefully choose the immunosuppressants by anticipating the chance of delayed graft function based on age, comorbidities and blood compatibility between donor and recipient.

Stem Cell Transplant for Refractory Acute Myeloid Leukemia

What Is the Main Idea?

Acute myeloid leukemia is a type of blood cancer that can occur and flare up suddenly. The treatment needs to start immediately. However, with the first line of treatment, in many cases, cancer does not go into remission, or it relapses. Therefore, based on already available data, the authors of the open access article “Chemotherapy or Allogeneic Stem Cell Transplantation as Salvage Therapy for Patients with Refractory Acute Myeloid Leukemia: A Multicenter Analysis”, published in the journal Acta Haematologica, study which strategy, i.e. salvage chemotherapy or stem cell transplant, and in which order resulted in better treatment outcomes.

What Else Can You Learn?

This blog post describes what acute myeloid leukemia is and its symptoms. Further, the different types of treatment outcomes and procedures are explained.

What Happens in Acute Myeloid Leukemia?

Acute myeloid leukemia (AML) is an aggressive form of cancer that affects the precursor of many types of blood cells including cells that transport oxygen (red blood cells), fight infection (neutrophils), and help the blood clot and heal wounds (platelets). Since the precursor cells multiply a lot or, in other words, become cancerous and occupy the bone marrow, the production of these important blood cells is affected. Consequently, the symptoms of acute myeloid leukemia are tiredness due to anemia, risk of bleeding, and increased risk of infections.

Being an acute type of cancer, acute myeloid leukemia requires immediate treatment. Chemotherapy is the main first line of treatment method. Drugs, radiotherapy, and bone marrow transplant are recommended based on the condition. These therapies are often combined with blood transfusion since blood count will be low as well as antibiotics to reduce the risk of infections.

Refractory Acute Myeloid Leukemia

For acute myeloid leukemia, generally, 1 to 2 cycles of primary induction chemotherapy are administered to patients to start observing remission. However, being a complex disease, even after the standard treatment methods, some patients do not reach complete remission where all the signs and symptoms of the disease go away. The disease is now called refractory acute myeloid leukemia. In other cases, there can be a recurrence of cancer after the remission which is termed relapsed cancer.

These conditions, especially refractory acute myeloid leukemia, require assessing and modulating further treatment steps and are called salvage therapy. The options are limited for salvage therapy with the main method being intensive chemotherapy with modified regimens. A curative technique considered is stem cell transplant using cells derived from healthy donors. This technique is called allogeneic hematopoietic stem cell transplantation.

The new stem cells introduced from a healthy donor through the stem cell transplant can help in replacing diseases and damaged marrow and potentially even fight the cancer cells. The main disadvantage of using donor cells, even after careful matching to the recipient, is that there is always a risk of immune response and rejection of the foreign cells. Hence, in most cases, the bone marrow transplant is not considered when not in remission.

Stem Cell Transplantation and Salvage Chemotherapy

For both refractory and relapsed leukemia, the question that arises is which is the best treatment option? While the mainstay is salvage chemotherapy, the latest study, “Chemotherapy or Allogeneic Stem Cell Transplantation as Salvage Therapy for Patients with Refractory Acute Myeloid Leukemia: A Multicenter Analysis”, asks the question whether stem cell transplant without salvage chemotherapy can be considered.

The group looked at treatment information and outcome of 220 patients who had refractory or relapsed acute myeloid leukemia. Of these patients, 191 were given salvage chemotherapy treatment and only 42% achieved complete remission. Among the remaining 29 patients who were directly given stem cell transplants without any salvage chemotherapy, around 90% reached complete remission. When those given stem cell transplants were further monitored, the survival rate of these patients over 4 years (called 4-year survival rate) was close to 52%. This showed that stem cell transplant can be effective.

Even among those patients who were first given salvage chemotherapy, when it was followed by stem cell transplant their 4-year survival rate was 36–46% compared to a rate of 3–11% without transplant treatment. In short, if the first line of treatment for these patients was salvage chemotherapy, then following it with a stem cell transplant increased their chances of 4-year survival considerably.

The main caveat of the study was the number of patients, especially those who underwent direct stem cell transplants. Secondly, the fact that the study was done in retrospect means that it will be hard to make a direct comparison of different conditions and procedures. It is important to do these in larger-scale studies to conclusively change treatment recommendations for now.

Take-Home Message

Acute myeloid leukemia is a difficult disease to treat. There are some standard lines of chemotherapy and stem cell transplant treatments, along with new lines of treatment being developed. However, through different studies, the order and administration of these treatments to attain better outcomes have to be considered. For now, based on the study described above, it can be said that stem cell transplantation without salvage chemotherapy is an option that clinicians should consider when treating patients with refractory or relapsed acute myeloid leukemia.

Bacterial Vaccination for Recurrent Urinary Tract Infections

What Is the Main Idea?

Urinary tract infections belong to the most common bacterial infections. They do commonly recur and affect primarily women. Antibiotics have been the main treatment procedure, but repeated use of antibiotics can lead to bacteria becoming resistant to them and is not cost-effective. Bacterial vaccines have been developed and have been shown to be effective in reducing the need for antibiotic treatment. In the open-access article “Cost-Effectiveness of a Sublingual Bacterial Vaccine for the Prophylaxis of Recurrent Urinary Tract Infections” recently published in the journal Urologia Internationalis, the authors go a step further to study the economic benefits of using a specific bacterial vaccine that has shown to be highly effective already.

What Else Can You Learn?

The blog post describes urinary tract infections, the symptoms, and the current treatment. Further, the reason why these infections occur repeatedly in women and ways to prevent them are also explained.

Urinary Tract Infections

Urinary tract infections (UTIs) refer to infections by bacteria of any part of the urinary tract, which includes the urethra, bladder, ureters, and kidneys. When there is no structural abnormality of the urinary tract or if the patient does not have any other disease, the infection is classified as an uncomplicated UTI. The main symptoms of UTI are increased frequency or urgency of urination, burning or pain during urination, pain in the pelvic region, and blood in the urine. Uncomplicated UTI usually affects the urethra and bladder and may not show symptoms of fever, nausea, or vomiting.

Why Do Urinary Tract Infections Recur and Why Do They Affect Women More?

Annually about 150 million people suffer from UTIs. Women are estimated to have a 30 times higher chance of having a UTI compared to men, especially during their sexually active age. About 40–60% of women are expected to get the infection at least once in their lifetime. UTI is considered recurrent if there are more than 2 episodes in 6 months or 3 episodes in 12 months.

Recurrent UTIs are more common in women because they have shorter urethras than men. Hence, bacteria can more easily climb up the organ and cause infection. Also, the vaginal and rectum openings are in proximity to the urethral opening. So, if the vulvar region is not cleaned correctly, “bad” bacteria can pass from other openings to the urinary tract. In postmenopause, the lower estrogen levels cause lower levels of “good” bacteria and vaginal dryness. These, in turn, increase the chance of developing an infection.

Current Treatments and Need for Alternatives

The good news is that in about 20% of cases, the infection goes away on its own, especially with increased hydration. However, if it is persistent, and to avoid the infection from climbing up to the kidneys, the patient will be required to take an antibiotic course. This is the mainline treatment for UTIs. If there are recurrent infections, a low-dose, long-term course of antibiotics, or single courses after sexual activity (if sexual activity is the known cause) may be prescribed.

The problem with the use of antibiotics is that it does not stop infections from recurring. Moreover, for such a prevalent type of infection requiring repeated courses of antibiotics, there is the possibility of the bacteria becoming resistant to these medications. Additionally, with recurring infections, there is a huge burden of cost to the individual and the medical system in treating them.

Vaccine for Urinary Tract Infections

Vaccines are preventive treatments where the body develops the ability to fight the disease without requiring any further treatments in most cases. There are a few bacterial vaccines against UTIs that are being developed and are in various stages of development and trials. In this blog post, we are discussing Uromune®, which is a bacterial vaccine in phase III trial and which has been mainly tested for its ability to reduce recurrent uncomplicated UTIs, especially in women. The vaccine has inactivated whole bacteria of 4 common strains of infection of urinary tracts. This helps cover most infections. The vaccine is not administered as an injection but instead as a flavored spray in the mouth over a period of 3 months.

Multiple studies have been conducted in different countries to test the effectiveness of the vaccine. Based on these studies, the vaccine has been shown to be between 35 and 90% effective in preventing recurrent UTIs which were followed up for 1–2 years. These results are from studies that included only women or some that included also men, children, and old people with other comorbidities. In contrast, there is almost no chance of preventing UTIs with the use of antibiotics as the treatment procedure. The vaccine has also shown to be highly safe with mostly only minor side effects being reported. Most importantly, adherence rates to the continuous use of the spray for 3 months were high.

Economic Advantages of Using Bacterial Vaccines

Considering UTIs are mostly not fatal and can be treated with antibiotics, the recent open-access article “Cost-Effectiveness of a Sublingual Bacterial Vaccine for the Prophylaxis of Recurrent Urinary Tract Infections” studied whether the use of vaccination for them has economic benefits. According to the study, prior to administering the bacterial vaccination, the annual cost per patient suffering from recurrent UTIs was approximately 1,000 EUR. However, after administering the vaccination, the annual cost was reduced to approximately 500 EUR (excluding the one-time vaccination cost of around 172 EUR/treatment). The study included costs from routine laboratory tests, ultrasounds, doctor’s visits, emergency room admissions, and hospitalizations. Therefore, even including the cost of the vaccination, there is a considerable saving to healthcare costs when using the vaccine.

What Can Patients with Recurrent Urinary Tract Infection Do?

Firstly, in many cases, the infection can be prevented by hydration, emptying the bladder fully and regularly, and wiping the genital region from front to back. If the UTI is painful, affects the quality of life, and keeps recurring, it is important to consult the doctor to get it checked and to avoid the infection from spreading. If being administered an antibiotic course, the patient must ensure to complete the full course of the medication for it to be effective and to prevent antibiotic-resistant bacteria from growing. Finally, the new bacterial vaccines against UTIs which can help prevent recurrent infections and which also have cost benefits might be considered.

Skin Reactions after Radiation Therapy for Cancer Treatment

What Is the Main Idea?

Radiation therapy is a common treatment for cancer. Skin reactions or dermatitis due to the radiation is prevalent. Currently, the interventions are altering radiation procedures or symptomatic relief. Through this blog post, based on the research article “The Preventive Effects of Boron-Based Gel on Radiation Dermatitis in Patients Being Treated for Breast Cancer: A Phase III Randomized, Double-Blind, Placebo-Controlled Clinical Trial” published in the journal Oncology Research and Treatment, we discuss a potential new intervention module proven to clinically reduce the occurrence of dermatitis after radiation.

What Else Can You Learn?

The different types of skin reactions that occur after radiation therapy and their severity are discussed here. The current treatment procedures being used along with which is reported to work better are explained.

Skin Reactions during Radiation Therapy

Radiation therapy is a cancer treatment that uses radiation to kill cancerous cells. It is used for many cancer types including breast cancer. This treatment has many side effects, depending on the location of the treatment field on the body (e.g., when two skin surfaces are in contact with each other). The common and general ones are fatigue, skin problems and hair loss. Depending on the severity, all these reduce the quality of life for the patient whose body is already going through a lot of trauma.

Dermatitis which describes skin-related irritation can occur in 90–95% of patients undergoing radiation therapy. The kind of skin issues that occur includes a type of skin rash called erythema where blood capillaries get inflamed. This can lead to scaly, flaking, broken skin called dry squamation. A severe reaction could lead to moist squamation in patches or in folds and creases. In the case of moist squamation, the epidermal layer gets removed, exposing the dermal layer, thus leading to severe blisters, pain and potentially infections. With the possibility of these severe symptoms, it is important to understand and address dermatitis in the best possible ways.

Current Treatments for Radiation Dermatitis

While there are different strategies being explored to minimize dermatitis or treat it post-therapy, there are no specific guidelines for clinicians to manage or prevent this condition. There are interventions involved in preventing or reducing the occurrence of dermatitis like switching and using alternate radiation techniques, including those with low-level lasers. There are post-therapy symptomatic treatments such as using steroidal or nonsteroidal topical agents, topical emollients, barrier films and dressings as well as following proper care of the skin.

In analyzing the many different techniques used, a review concluded that steroid creams are useful for patients at high risk for skin infections but under specific conditions of cancer and radiation therapy type. Topical emollients as an effective treatment strategy do not have enough evidence. An alternative to radiation therapy called photobiomodulation therapy has been shown to have potential but needs further research.

Use of Boron-Based Gel as a Pre-Treatment Intervention

Apart from the above-mentioned interventions to help reduce or treat radiation dermatitis, the use of a boron-based gel has been recently studied. In a phase III clinical trial study conducted for the first time, the authors tested the effectiveness of using a boron-based gel in reducing the different skin reactions to radiation therapy in breast cancer patients. They particularly used a Carbopol gel containing 3% sodium pentaborate pentahydrate.

The trial involved testing breast cancer patients who were undergoing the same kind of radiation therapy. The gel was applied on the site of radiation 15 mins before each radiation therapy session. The gel with the boron-based compound was used on some patients, while other patients (the control group) got the same gel without the boron compound. Neither the clinicians nor the patients were informed about what was being administered. The skin condition was recorded in these patients at the beginning of the treatment and was followed up and checked after 25 days. The patients who were given the boron-based gel had only 9.9% chance of getting dermatitis compared to 98.7% of patients in the control group. This reduction was seen in all types of reactions from erythema, dry squamation or moist squamation. Moreover, the skin toxicity in patients in the treatment group was also lower.

The treatment was proven to have significant potential in taking forward. Since the gel is applied before the radiation therapy, the compliance was also high. The main problem with the study was that the patient-reported outcome was not collected. Further, long-term issues of using the boron-based gel need to be studied.

How Can This Help a Radiation Therapy Patient?

Radiation therapy is one of the common treatments for cancer including breast cancer. There are reports of high chances of getting radiation dermatitis with radiation therapy which additionally depends on the history of the patient. Unfortunately, these skin reactions reduce the quality of life and discourage patients from continuing with therapy. This can be highly detrimental to their health. Understanding these side effects and possible treatment options is important. The patient can discuss the possible interventions for dermatitis, including this new study, with their oncologist. Together they can create a pre- and post-therapy treatment plan which will require proper monitoring. These interventions can significantly improve the quality of life of the patient and the adherence to the radiation therapy procedure.

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

World Kidney Day 2022: Focus on Bridging the Gap in Health Education and Literacy

What Is the Main Idea?

Chronic kidney disease affects 1 in 10 adults worldwide. To bring awareness to the needs of the patients and to improve their quality of life, international kidney organizations together celebrate World Kidney Day. This year the focus of the World Kidney Day Joint Steering Committee is on improving health education and literacy for all. Thus, they have published the special report “Kidney Health for All: Bridging the Gap in Kidney Health Education and Literacy”, e.g. in the American Journal of Nephrology and in Nephron, describing the problems in this area and various ways of improving literacy. These have been summarized in this blog post.

What Else Can You Learn?

The blog post further describes how imparting health literacy requires more involvement by healthcare workers. Further, it explains how health literacy is also important to bring policy changes and advocacy and how patients can be involved in every step.

World Kidney Day

Celebrated every year on the second Thursday of March, World Kidney Day is organized by a joint committee formed by the International Society of Nephrology and the International Federation of Kidney Foundations. Their goal is to raise awareness of the disease and also advocate for better care for patients by all, including policymakers, healthcare workers, caregivers, and patients themselves. The World Kidney Day committee help by researching and assessing the current needs, clearly communicating them and feeding the information to organizations involved in policy changes at all levels, i.e. local, national and international. This year the theme is “Kidney Health for All”.

Chronic kidney disease, as described earlier, is a condition where the kidney’s function to eliminate waste deteriorates. It is a long-term disease that often deteriorates through 5 stages, as described in an earlier blog post. Since the condition requires a lot of lifestyle changes, it can reduce the quality of life for the patient and affect the families and caregivers. It indirectly puts a burden on society. Last year, the World Kidney Day campaign focused on improving the quality of life by focusing on patient-centric interventions and empowering care partners. This year, through their campaign “Kidney Health for All”, the organizers promote understanding kidney disease and health literacy to everyone involved.

Health Literacy and Chronic Kidney Disease

Health literacy is the ability of a person to understand kidney health problems and use the knowledge to make informed decisions and act accordingly. In the case of kidney diseases, the condition can change all the time, and thus the process needs to be dynamic. While practically, the need for health literacy makes sense, there are currently no studies to conclusively indicate that with a higher literacy rate, the mortality reduces or access to transplantation increases. This is because most studies researching literacy usually look at the functional knowledge of the patient but not at the patient-reported outcomes (which give more details of how the patient is responding to the disease or intervention). The World Health Organization has a Health Literacy Questionnaire which takes this into account. The World Kidney Day committee recommends using this questionnaire and also advocates for research to be conducted on how health literacy affects the disease outcome in the patient.

Co-Creating Interventions for Imparting Health Literacy

Since the disease and its progression is quite complex, low health literacy is a universal problem and does not depend on socio-economic status. It is also found that good interventions start from top-down by initiating policies regarding national health literacy action plans. While the need to improve health literacy is the same universally, the local culture needs to be considered when creating the actual plans and implementing them. An effective way of doing it would be through co-creation, where the participants, either patients or the health care workers, are involved in the process of creating the action plans in the desired location or community.

Involving Physicians and Healthcare Workers in Imparting Health Literacy

The main method currently used to impart literacy to kidney disease patients is web-based educational platforms targeted at individual patients and their caregivers. However, this is not enough. There is an important requirement and evidence for doctors and physicians who are treating the patients to participate actively in the education. This interaction will help patients understand their health better and adhere to the treatments. The patients themselves can then start participating in the decision-making by asking appropriate questions and advocating for their needs. This imparting of education needs to be extended by other healthcare workers, too, from nurses and physician assistants to dieticians, pharmacists, therapists, and other allied professionals. They often spend more time with the patient than the physicians and, hence, have more chance of explaining and empowering them with knowledge about the disease and the treatment.

Using the Power of Social Media

Social media is a powerful tool for communication that is now being used in kidney disease by many healthcare workers. There are a few ways it helps with literacy and communication:

  • by building networks of patient support groups and advocacy groups,
  • by communicating kidney health information,
  • for healthcare providers to build their networks and exchange information.

Since social media is in the public domain, it needs to be used responsibly. Some guidelines have been outlined in the above-mentioned special report which are mainly regarding maintaining the confidentiality of the patients, their conditions, the healthcare professionals, and the healthcare system itself.

Policy, Advocacy, Communication, and the Patient

Advocating and introducing policy changes are essential for systemic changes to happen in increasing the rate of health literacy. These cannot happen without authentic information and communication being provided by various stakeholders to the governments. After policies are created, formulating the problems, seeking scientific advice, and implementing the solutions taking into account the local cultural needs are vital. Finally, evaluation and making changes are important. At every step, education and communication become vital for the success of the intervention.

As patients, it is possible to participate in various steps like educating oneself, advocating for changes, joining support networks, participating in research studies and even engaging in social media. When done together with key kidney advocacy groups, a change can be brought about in the system to help patients with kidney disease lead better quality lives.

Understanding Allergic Rashes Caused by Medication

What Is the Main Idea?

The skin can react to certain medications by erupting into rashes called fixed drug eruptions. In this blog post, based on the open access article “Fixed Drug Eruption Associated with Nonsteroidal Anti-Inflammatory Drugs for Menstrual Pain: A Case Report” published in Case Reports in Dermatology, the condition itself along with the causes and difficulty in diagnosing is described. The case study gives a good example of how a patient is finally identified to have the condition.

What Else Can You Learn?

This post explains what can potentially cause the rash, when and where it might occur, how the doctors identify it, and how the patient can also help with the same.

What Are Fixed Drug Eruptions?

Side-effects of drugs are unexpected secondary problems that occur in the body when the person is on a course of medication to treat a specific condition. Some of the mild side-effects observed with different medications are headaches, nausea, diarrhea, and skin-related problems. Among the skin-related problems, fixed drug eruption is one of them.

Fixed drug eruptions are allergic reactions on the skin that occur due to specific drug usage. The main differentiating feature of this versus other skin reactions is that this will occur every time with a similar reaction when the same offending drug is repeatedly taken. It is characterized by the appearance of patches or lesions on the skin like rashes or fluid-filled blisters. It can be accompanied by burning or itching. Another characteristic feature is that after healing, the skin is hyperpigmented, that is, it has more melanin and appears darker.

What Causes These Rashes and How Is It Diagnosed?

Antibiotics and non-steroidal anti-inflammatory drugs (NSAID) are the most common drugs to cause fixed drug eruptions. The other medicines that have been seen to cause this are anti-fungal, anti-psychotic and herbal substances, and there have been cases reported from many other medicines.

Diagnosis is difficult because in many cases it is hard to differentiate this specific condition from other skin conditions. If fixed drug eruption is suspected, the main way to give a confirmed diagnosis is to do a skin biopsy and check for a reaction to different medications the patient is taking at that time.

When and Where in the Body Do You Get the Fixed Drug Eruptions?

Fixed drug eruptions can appear 30 min to 8 hours after ingesting the drug causing it. The most common places where it occurs on the body are the face, hands, legs, and genitals. The oral mucosa including the lips, tongue, and hard palate are other common sites of occurrence. Repeated usage of the offending medication can cause the sites of the rash to increase.

How Is It Treated?

After the condition is diagnosed and the drug causing the problem is identified, the main step is to avoid using and eliminating the offending drug from the patient. Beyond that, it mostly involves symptomatic treatment of the rash as recommended by the doctor or dermatologist. After the rash heals, the skin may seem darker due to hyperpigmentation. If the problem occurs in the mouth, there will not be any hyperpigmentation.

Case of Fixed Drug Eruption due to Menstrual Pain NSAID Medication

In a recently published case study, the authors describe how a 33-year-old woman had come to the doctor with blisters and soreness in the lips and mouth. She had complained that it repeatedly came (and went away) for over 2 years. She was treated for a viral disease and then for an autoimmune condition. When neither treatment resolved the issue, the authors investigated further. They found lesions in the right groin, too. Upon interviewing her, they found a pattern of skin condition occurring when she was having her menstrual cycle. She also informed that she regularly took 3 types of anti-inflammatory (NSAID) medications for menstrual pain. The doctors, suspecting fixed drug eruptions, asked the patient to stop taking all the medication immediately and instead recommended paracetamol for pain. This immediately solved her skin issues, and she did not have any more skin problems during her menstrual cycle. Unfortunately, in this case, the authors were not able to confirm which drug caused the condition because the lab tests were not conclusive.

Take-Home Message

Certain medications can cause skin allergic reactions for some people which, although minor and resolving easily, can affect the quality of life. Diagnosing this can be difficult because often the skin reaction between different diseases or conditions can be similar. It is important that the patient keeps a record of all medications being taken and informs the doctor about them when going for any consultation, including for skin conditions. Taking it a step further, if the patient suspects any relation between medication intake and appearance of the skin problems, then he/she should report it and talk to the doctor about fixed drug eruptions. It is an easily curable condition if diagnosed correctly. Wherever possible, an alternate medication will be prescribed to the patient.

Omega-3 Fatty Acid Intake In Cardiovascular and Chronic Kidney Diseases

What Is the Main Idea?

Omega-3 is an important fatty acid that has proven health benefits. The extent of its benefit to be used as an intervention in chronic diseases, especially kidney diseases, is still being explored by researchers. Here, based on the article “Dietary Omega-3 Fatty Acid Intake and Mortality in CKD Population: A 1999–2014 NHANES Analysis” published in the American Journal of Nephrology, we describe how higher intake of omega-3 correlated with lower mortality in chronic kidney disease patients.

What Else Can You Learn?

Omega-3 fatty acids in cardiovascular diseases have been studied more extensively, and some of the results are described here. Moreover, the basic role of omega-3 in the cells, its benefits, and the sources to add them to the diet are explained.

What Are Omega-3 Fatty Acids?

Fatty acids are molecules that are required for maintaining cell membranes as well as various cell signaling processes and are a source of energy. Depending on their chemical structure, they come in many different forms – mainly saturated fatty acids, monounsaturated fatty acids and poly-unsaturated fatty acids (PUFA). In general, unsaturated fatty acids are healthier than saturated fatty acids. Poly-unsaturated fatty acids, which include omega-3 and omega-6, have been shown to help various functions of the body including cardiovascular health, fighting depression, and improving brain and eye health.

Many of the fatty acids can be produced by the body but poly-unsaturated fatty acids, including omega-3 and omega-6, cannot be built by the body. They must be taken in from the diet. There are 3 kinds of omega-3 fatty acids that are primarily consumed – alpha-linolenic acid (ALA), which can be obtained from plant sources like nuts, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), which are present in marine sources like phytoplanktons, algae and fish.

Omega-3 Fatty Acid and Cardiovascular Diseases

Starting from population studies in the 1970s, it has been observed that in primarily fish-eating populations like in Greenland or Japan, the risk of cardiovascular diseases has been low. Since then, studies have shown that omega-3 helps in lowering other fatty acids (triglycerides), blood pressure and platelet aggregation which in turn can help reduce cardiovascular issues. Some (but not all) clinical studies on understanding the effect of omega-3 intake on overall reduction in cardiac-related deaths have shown reduced deaths when patients were supplemented with omega-3.

In general, most of the research shows that the positive effect of omega-3 is higher when the patient already has a cardiac-related issue. Also, the quantity of omega-3 intake affects how the patients’ cardiovascular parameters change. Since cardiovascular diseases occur alongside other chronic diseases like kidney disease or diabetes, it is important to start investigating the role of omega-3 in these cases.

Study on Omega-3 Intake in Chronic Kidney Disease Patients

Chronic kidney disease goes through multiple changes with the final stage being end-stage renal disease, as described in another post on The Waiting Room. As the disease gets progressively worse, the patients are at higher risk of other health issues including cardiovascular diseases and related death. However, the root causes for the cardiovascular problems are different. It can be due to inflammation, oxidative stress and changes in metabolizing minerals, leading to artery calcification due to kidney malfunction.

Since omega-3 has shown promising results in some studies related to cardiovascular problems, the authors of “Dietary Omega-3 Fatty Acid Intake and Mortality in CKD Population: A 1999–2014 NHANES Analysis” decided to check the effect of omega-3 on chronic kidney disease patients based on already available data. They followed the health data from approximately 3,000 patients over 8 years. During this time, there were 864 deaths (of varied causes). The authors correlated the information collected regarding the patients’ nutritional intake with their death. There was a significant correlation of lower rate of death in patients who were taking higher amounts of omega-3. Beyond 2 grams of omega-3 per day the number of deaths did not decrease. Interestingly, there was a stronger correlation of this in kidney disease patients who also had hypertension and higher body mass index.

Though the research had a few issues due to the limitation of data available, it shows a first promising step for considering the use of omega-3 as an intervention in chronic kidney disease patients.

Talking to the Doctor to Incorporate Omega-3 Fatty Acid

More research is required to confirm the extent of the effect omega-3 can have on the course of disease in chronic kidney disease patients. However, the positive effect of adding omega-3 to the diet of patients with already existing cardiovascular or other health issues cannot be denied. As mentioned earlier, there are primarily 3 different types of omega-3. The plant sources include flaxseeds, chia seeds, walnuts and soyabean oil. Fish, like salmon, herring and trout, are a primary source for the longer chain omega-3 (EPA and DHA). Omega-3 can also be taken as supplements. In case you have a kidney disease or cardiovascular disease, talk to your doctor about adding omega-3 to your diet and about the appropriate dosages.

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

Bacterial Infection after a Tattoo

What Is the Main idea?

Tattooing involves pricking the body and introducing ink into the skin. In a small number of cases, bacterial infection can occur, requiring a course of antibiotic treatment. Here, we discuss what we need to be aware of when considering getting a tattoo, especially regarding infections. As reported in the open access article “Tattoo-Associated Cutaneous Mycobacterium mageritense Infection: A Case Report and Brief Review of the Literature” published in Case Reports in Dermatology, there are also chances of getting an atypical infection due to mycobacteria which is harder to identify, as we describe here in the blog post.

What Else Can You Learn?

The sources, symptoms, and general treatment for bacterial infections occurring around a tattoo are explained here. Further, important points to note for the prevention of infections when getting a tattoo are detailed.

Tattoos and Bacterial Infections

Tattooing is a process that involves pricking the body thousands of times to inject ink into a deeper tissue layer of the skin. This is almost equivalent to minor surgery and, ideally, has to be performed under proper, sterile conditions. In one study, the authors report that in 2.1% of cases there can be tattoo-related skin issues which include inflammation, allergic reaction or infection. In rare cases, the infection can be severe.

One of the functions of the skin is to prevent microorganisms from infecting the body. However, with tattooing, when done under non-ideal conditions, there is the possibility of microorganisms infecting the skin. It can be due to bacteria, viruses, or fungi. The most common infections are due to bacteria and specifically, bacteria that cause pus formation like Staphylococcus and Streptococcus. In the recent past, there have been reports of infections around tattoos due to mycobacteria, which is a family of slow-growing, immobile bacteria with thicker cell walls.

Symptoms and Sources of Infection

The main symptoms on the skin are different kinds of lesions around the tattooed area – like rashes, inflammation, pus-filled bumps, or raised red spots, usually in a cluster. There is also the possibility of having fever, aches, pains, or swelling of the infected area. For mycobacterial infections, itchy and painful bumps can also be present.

Where do these infections come from? There are multiple sources. At the parlor, the tattoo artists and the other people present can pass on an infection. If the instruments are not sterilized properly, including between every use, infections can occur. The environment in the parlor, including the furniture, could hold infectious bacteria. Finally, an important source of infection is the ink and water (used to dilute the ink). Tattoo ink usually comes in a bottle and is used for multiple customers. There is usually no expiry date on it, making it an unregulated part of the tattoo process.

In the case of a common bacterial infection, the symptoms might show up immediately within hours or a few days of tattooing. However, there are some bacteria like mycobacteria that have a long incubation time so that the infection shows up only after weeks or months.

Fighting the Infection

In people with higher immunity and depending on the bacteria, the body can be naturally resistant to the infection. However, with other bacterial strains or a lowered immunity level of the person, the resistance to infection can be low and the symptoms as described above will show up. In these cases, visiting a doctor and identifying the infection is a must. Antibiotics are the first line of treatment. Firstly, the doctor will take a swab from the site of infection to identify the microorganisms. Simultaneously, they will also check for which antibiotics can work against the infection and which do not. Identifying these antibiotics is equally important to start with proper treatment and for faster recovery.

For mycobacteria, it is a little harder to identify with regular tests. Therefore, when common bacteria are not identified, the tests should include testing for atypical bacteria. Unfortunately, in these cases, the infection can take longer to be properly identified as they grow slowly. Most often, a combination of medication and prolonged durations of treatment are required to get rid of these infections.

Report of Tattoo-Related Mycobacterial Infection

As reported in a case study, a 25-year-old man had red, pus-filled rashes 4 weeks after getting a tattoo. The rash was located near the grey-inked area of the tattoo. After 2 months, when the topical anti-bacterial creams did not work, the doctors tested the infection for typical and atypical bacteria. It took 2 weeks to identify it as mycobacteria and further 2 weeks to know the exact kind. Further, they found that this species of mycobacteria is resistant to the common antibiotic clarithromycin. After further tests and consulting with an infectious disease specialist, a combination antibiotic treatment was recommended for 3 months. Improvements were observed within 5 weeks. The doctors were also able to narrow down the cause of infection to the water used to dilute the black ink to obtain the grey color ink. This was the first of this species of mycobacterial infection seen after tattooing in Australia.

Things to Note

While in most cases tattooing does not cause a problem, there is a small risk factor involved, as described above. For those who are immunocompromised, this needs to be especially considered before getting a tattoo. It is also extremely important to get the tattoo done at a reputed parlor that follows all safety and hygiene protocols. Further, one can look for a licensed parlor and check if the tattooist has passed a tattoo hygiene course, if they are available, and if it is applicable in the country of the parlor. After the tattooing is done, proper after-care instructions as given by the tattooist must be followed. The tattooist should communicate well and clear any doubts during this period of after-care.

If there is an infection, it is important to immediately check with a doctor. If the first line of medications does not work, then checking for atypical infection must be done. At this point, consulting with an infectious disease specialist is recommended.

Finally, it will be good to consider bringing in more regulation to the tattoo industry. While the standards in the tattoo industry have generally increased and there are a lot of guidelines recommended, there is no strict vigilance. This is probably because the risk of death is extremely low. However, a guideline of reporting by doctors and tattoo parlors about the breakout of infections needs to be present and followed. This will help to quickly take action on the further spread of infection and also potentially identify new aggressive strains of bacteria that might come from the tattoo industry. For now, the patients with the tattoo can also play an active role in reporting it to authorities to ensure the safety of all.

The Role of Curcumin in Neurodegenerative Disease Treatment

What Is the Main Idea?

Progressive neurodegenerative diseases have no cure but, in some cases, can be slowed down or controlled. Astrocytes, a type of neuronal cell abundant in the brain, play an important role in each of the disease progressions, and there is evidence that curcumin’s properties can help astrocytes overcome the disease progression. Based on the free access review article “The Functional Roles of Curcumin on Astrocytes in Neurodegenerative Diseases”, published in the journal Neuroimmunomodulation, this idea of the role of curcumin in neurodegenerative diseases is discussed here.

What Else Can You Learn?

A basic overview of 5 different neurodegenerative diseases, along with their symptoms, is given. Overall, curcumin seems to be a promising option in the treatment of neurodegenerative diseases. However, further studies are needed in order to enable the use of curcumin.

What Is Curcumin?

Curcumin is a bright yellow compound produced in the plant called Curcuma longa (turmeric) which is part of the ginger family. It has been used for centuries in traditional medicines. More recently, it has been found to have antimicrobial, anti-inflammatory, antioxidant, and anticarcinogenic properties. These properties make it a potential therapeutic agent for a variety of diseases. In addition, curcumin is easily available, safe, and inexpensive.

Interestingly, curcumin is a molecule that can cross the barrier between blood and brain too, which makes it attractive to use in neurodegenerative diseases.

So, then why is it not already being used extensively for treatments? The main reason is that curcumin is poorly absorbed and it is immediately broken down by the liver and excreted. Therefore, the availability for the body is limited (as low as 1%). Scientists are working on circumventing this problem by adding curcumin to a stable carrier (that doesn’t break down easily) or by using inhibitors to curcumin metabolism.

Neurodegenerative Diseases and Astrocytes

Neurodegenerative diseases are diseases that progressively affect the central nervous system which comprises of the brain and the spinal cord. The brain controls almost all functions of the body including movement, awareness, memory, and speech. Any disruption in this system can have very serious adverse effects in daily life.

Astrocytes are a type of neuronal cell abundant in the brain. They help with creating synapses (the contact area between 2 neurons), maintaining the neurons, and supporting neuronal growth and reorganization.

Additionally, they play a crucial role in connecting the brain with the blood vessels and in maintaining this blood-brain barrier. This helps the selective passage of nutrients, water, and small molecules between the cells. Also, when there is a disease or injury to cells in the brain, the astrocytes help keep away toxic factors and fix the blood-brain barrier if damaged.

When it comes to inflammation, astrocytes play a dual role. Through one mechanism they prevent inflammation but under certain conditions, they are capable of also promoting inflammation.

What Does This Mean to Neurodegenerative Diseases?

Neurodegenerative diseases vary in kind and mostly occur due to misfolding and accumulation of proteins, inflammation, oxidative damage, and sometimes due to mutations in specific genes in the body. Based on the recent review article, we show the role of astrocytes in 5 neurodegenerative diseases and how curcumin can possibly help.

Alzheimer’s Disease

It is the most common progressive neuronal disease and causes memory loss as well as cognitive decline. It can also lead to dementia. The disease is characterized by the presence of aggregates of a protein called beta-amyloid which is a subunit of a bigger protein called amyloid precursor protein. Astrocytes play an important role in reducing the aggregate formation by taking it up, degrading, and clearing it. Therefore, disruption of the normal function of the astrocytes is one of the reasons for the progression of the disease.

Curcumin is shown to decrease an inflammatory marker in astrocytes in Alzheimer’s disease. Further, in rats having an Alzheimer’s-like condition, spatial memory was shown to improve with curcumin. A study showed that a low dose of curcumin for a longer period was better than a higher dosage for a short period. Another study even identified the molecular mechanism through which curcumin potentially acts to prevent the inflammation caused by the aggregate proteins. Therefore, the role of curcumin in Alzheimer’s disease has been well established.

Parkinson’s Disease

The second most common neurodegenerative disease causes movement disorders, memory loss, and depression. Parkinson’s is characterized by a clump of proteins called Lewy body and an abnormal expression of a protein called alpha-synuclein. It can lead to loss of the neuronal hormone, dopamine. Experiments showed that interaction between astrocytes and neurons is important in this disease’s progression. Through different molecular mechanisms, astrocytes help prevent oxidative damage and help prolong the onset of the disease.

Curcumin was shown to help upregulate a gene that was downregulated, causing the loss of neurons that release dopamine. Further, the anti-inflammatory properties aided in reducing oxidative stress in Parkinson’s disease.

Multiple Sclerosis

This autoimmune disease is characterized by the removal of the protein layer surrounding a neuron (myelin), which normally helps in transmitting information faster in a neuron. This causes an increase in oxidative stress, too. A person with multiple sclerosis can have difficulties with coordination and balance as well as visual problems. Astrocytes with increased markers indicating stress conditions were observed in the clumps of cells that had a loss of myelin.

Through its anti-inflammatory properties and ability to prevent free radical production and oxidative stress, curcumin has the potential to be included in multiple sclerosis treatment. More work has to be done to understand this better.

Huntington’s Disease

It is a fatal disorder that is caused by the aggregation of a mutated version of a protein called Huntington’s protein. It causes motor abnormalities and mental decline. The mutated version of the protein has an increased number of glutamine (a type of amino acid) repeats. Astrocytes under normal conditions have the ability to remove the glutamine present. When there is an excess of the mutant proteins present, the astrocytes are not capable of removing it, making it harmful to the astrocytes and other neuronal cell health. In yeast, curcumin was shown to inhibit aggregation of mutant Huntington’s protein.

Amyotrophic Lateral Sclerosis

This is a fatal disorder in adults causing weakening of voluntary muscle movement. As the disease progresses, moving, speaking, swallowing, and even breathing become difficult. The most common reason for this is a mutation in a specific gene. Inflammation is also central to this disease’s progression, and curcumin can play a role in preventing this specific inflammation as seen in experiments with mice.

However, clinical trials in humans with curcumin to treat a condition with an increase of the same inflammatory molecule did not help reduce the inflammation.

To Summarize

Curcumin has the potential for treating many neurodegenerative diseases through its anti-inflammatory and antioxidant properties. The molecular mechanisms of the role of curcumin have also been identified. However, most of this work has been done in cultured cells or animals. In humans, firstly, the bioavailability of curcumin has to be increased to administer it as a therapeutic. Secondly, it has to be tested in humans against all neurodegenerative conditions to understand its effectiveness. Meanwhile, since it is available and safe for humans, talk to a neurologist about curcumin and if supplements that are already available should be taken.

Right Diet Choices Can Help in Treating Polycystic Ovary Syndrome (PCOS)

What Is the Main Idea?

Polycystic ovary syndrome (PCOS) affects 5–20% of women of reproductive age worldwide. When left untreated, this can lead to issues from metabolic dysfunction to reproductive complications. Diet is found to help women control PCOS and improve their health. Based on the open-access review article “Dietary Interventions: A Promising Treatment for Polycystic Ovary Syndrome” published in the journal Annals of Nutrition and Metabolism, different diets and their effect on PCOS are discussed here.

What Else Can You Learn?

Through this post, learn about PCOS, the symptoms, causes, and effects.

What Is Polycystic Ovary Syndrome (PCOS)?

PCOS is a hormone-related condition in menstruating women. The main symptoms are irregular periods or issues related to the excess male hormone, androgen. The irregular periods occur because the ovaries develop multiple follicles (little fluid-filled sacs that can mature into eggs) instead of one and an egg is not released on time. The excess androgen can further increase the difficulty for ovaries to release eggs. It also causes extra facial and body hair growth and severe acne.

What Are The Causes And Effects of PCOS?

The exact reason for PCOS is not known. However, it has been seen that obesity increases the chance of having it. Another major factor seen is excess insulin (a hormone that helps cells break down sugar). When cells become resistant to insulin action, the sugar level rises. In response, insulin levels also rise and that increases androgen production. Apart from these, low-grade inflammation and heredity could also be reasons for developing PCOS.

If left untreated, PCOS can lead to further issues like infertility, diabetes, metabolic issues (high blood pressure, abnormal cholesterol, etc.), abnormal bleeding, and even depression.

Treating PCOS

The most common medical treatments for PCOS include birth control pills, a medication that treats diabetes (to control insulin resistance), and other symptomatic relief. However, the main recommendation is lifestyle changes, specifically diet and activity. Obesity, excess insulin, low-grade inflammation, and excess androgen can be connected to both.

Unhealthy diets are found to be one of the underlying causes for most issues related to PCOS. Therefore, much study has gone into how different diets can potentially help with regulating PCOS. In a recent open-access review article, the authors analyzed the different dietary interventions and their effect on PCOS. Here is a summary of what they found regarding each diet.

  • Mediterranean diet (MedDiet): This diet consists of higher consumption of unsaturated fat and dietary fiber apart from a balanced intake of vegetables, fruits, and low glycemic index carbohydrates. Mediterranean diet consists primarily of plant polyphenols present in extra-virgin olive oil, grains, nuts, seeds, vegetables, and fruits. This has been considered as one of the healthiest diets and has been prescribed for insulin-resistance disorders including obesity, cardiovascular problems, and diabetes. Women with PCOS were found to have a lower intake of extra-virgin olive oil, legumes, fish, and nuts. Instead, they consumed more simple carbohydrates, saturated fats, and n-6 polyunsaturated fats (or Omega 6). Instead, when n-3 polyunsaturated fats (or Omega 3) were supplemented, insulin resistance was better controlled. The polyphenols like resveratrol found in grapes, berries, and wine reduce androgen production. Overall, adhering to the Mediterranean diet showed lowering of PCOS severity and improved ovarian health by controlling obesity, insulin resistance, and hyperandrogenism. With all these advantages, the Mediterranean diet is surely a diet to try for treating PCOS.
  • Ketogenic diet (Keto): This is predominantly a high-fat and low-carbohydrate diet. When a person stops the intake of carbohydrates and excess protein, the stored fat starts breaking down and helps in weight loss. Different studies show that in women with PCOS who are overweight or have obesity, the ketogenic diet helps in reducing weight and testosterone levels and in improving insulin resistance. The levels of hormones related to ovarian function are also normalized. While all these results are positive, due to the high-fat intake, the ketogenic diet can have negative effects on the metabolic state and fat storage in the body in the long term. Therefore, instead of the regular ketogenic diet, a very-low-calorie ketogenic diet is recommended. However, this requires more studies to understand its long-term effects.
  • Dietary Approaches to Stop Hypertension (DASH): This is a low-glycemic index and low energy-dense diet designed for lowering blood pressure. It focuses on the consumption of vegetables, fruits, low-fat dairy, whole grains and nuts, and legumes. It requires reducing sodium and saturated fat. The diet has higher antioxidants, magnesium, calcium, and folate. When on this diet, women with PCOS (and in some cases with obesity) showed a reduction in weight and resistance to insulin, improved ovarian function, and an increase in antioxidant capacity.
  • Low-Glycemic Index (GI) diets: Glycemic index refers to the rate at which carbohydrates are digested. In a low-glycemic index diet, the carbohydrates consumed digest slowly. Therefore, there is a slower increase in blood sugar and insulin secretion. This helps in lowering insulin resistance. In the case of PCOS, this diet has helped patients lower their weight, increase insulin sensitivity, and improve the ovulation cycle. While low-glycemic index food helps PCOS, with a lot of variability in the rest of the diet, it is hard to implement only this one approach and get similar results in all women. Combining it instead with other interventions as in the Mediterranean diet or DASH diet might be better.
  • Pulse-based diets: Pulses are high in protein and fiber as well as low in fat and glycemic index. They also have a lot of vitamins and minerals. In women with PCOS, this diet reduces cardiometabolic risk. Pulses have an anti-cancer effect. With chances of endometrial cancer increasing 3-fold with PCOS, this is a diet that must be studied further in the context of helping PCOS.

In Short

Lifestyle changes are required to reduce the effects of PCOS and for long-term health. Along with increased physical activity, diet is one of the important things that women can alter. With many different diet choices, women with PCOS should make an informed decision by discussing them with a doctor or dietician. Doctors and PCOS patients can even consider combining different diets to make it more specific for PCOS and the patient. Most importantly, it needs to be ensured that the diet is sustainable and adhered to in the long term.

Will Digital Patient-Reported Outcomes Become The Standard of Cancer Patient Care?

What Is the Main Idea?

With many current cancer treatments involving at-home medication and not necessarily requiring a hospital stay, the onus of cancer management falls on the patient. A way of guiding them through the process is using digital patient-reported outcomes. These are followed up with required care and treatment by the healthcare practitioners. So, firstly, what does patient-reported outcome mean and how does it work digitally? Do we know if this helps in making the patient’s treatment better? The free access review article “Digital Health for Optimal Supportive Care in Oncology: Benefits, Limits, and Future Perspectives”, published in the journal Kompass Nutrition & Dietetics, helps us to answer these questions.

What Else Can You Learn?

There are different parameters that can be reported by patients depending on the condition and cancer treatment strategy. Some of these are listed below. Also, we can understand what helps patients to adopt these digital interventions and what deters them from doing so. Patients undergoing cancer treatment should check with their cancer specialists if they are trialing or utilizing a digital patient-reported outcome platform. Participating and working with the system will help to take cancer care to the next level.

What Are Patient-Reported Outcomes?

Patient-reported outcomes is information that patients directly report about their health status regarding a certain disease condition and treatment they are undergoing. The healthcare professionals are not involved in the process of this reporting but receive these reports and can respond accordingly. The patients are most often given a questionnaire to record various parameters. The parameters can be related to symptoms they are experiencing, their general ability to do daily activities, quality of life and some questions more specific to the condition.

Mostly, patient-reported outcomes were used in clinical trials since it helps get personal feedback from the patients about a new treatment apart from the follow-ups in the hospitals. However, with digitalization, implementing these measures outside of clinical trials is promising and real-time monitoring is possible.

Why Are Patient-Reported Outcomes Required in Cancer Treatment?

Cancer affects millions around the world yearly and the burden of new cancer cases is only increasing. With new cancer treatments often involving oral medications to be taken at home, patients need to take more responsibilities in their health management. This also means that any side effects or symptoms resulting from the medication, or the disease needs to be monitored at home and then reported. The quality of life of cancer patients has also always been an issue. Finally, with the number of cancer patients increasing, there is potential for a shortage of healthcare providers. This will demand alternate patient care management.

Digital Health Solution to Patient-Reported Outcomes

In helping solve the above-stated issues, patient-centered care which is supportive and integrates treatment information is also required. This could help in improving the survival rate and more importantly the quality of life. Ideally, by providing good patient management, the cost of the healthcare involved can also be reduced.

As indicated by the review article, there are a lot of digital health solutions collecting patient-reported outcome measures that are being tested now. These are in the form of smartphone apps or web-based solutions. These solutions have one or multiple features of the following: symptom recording, monitoring vitals (like blood pressure, heart rate) through wearables, personalized interaction tailored to the treatment, knowledge sharing, telemedicine or other communication features, monitoring mental health status, and assessing quality of life.

What Are the Benefits and Problems of Adopting These Solutions?

The major benefits that encourage the patients to adopt and use these solutions are the ease of use, patients feeling empowered, ability to report symptoms in real time and to communicate with healthcare providers, receiving system alerts, and responses to the alerts. However, there are barriers to using these digital interventions. This includes difficulty in using technology, poor connectivity, finding its usefulness limited, and lack of clarity.

What Is the Evidence That These Solutions Work in Cancer Treatment?

In a report that looked at multiple clinical studies using digital patient-reported outcomes, the authors found that patients benefited from this digital reporting by a reduction in cancer-related fatigue and depression and improved quality of living. Similarly, multiple other studies reported reduced severity of symptoms, depression, and distress. In a different study, an internet-based exercise program was introduced to a sub-group of patients and compared them to patients who were not involved in the exercise program. The patients who were doing the exercise program reported better overall health, physical health, and cognitive function.

To test whether the self-reporting by the patients was accurate, a recent study asked cancer patients to report their nutrition status (since nutritional deterioration is a problem in cancer) and other parameters. When compared to the nutrition risk assessed by a dietician, this self-nutrition report was 89% in agreement. This proved that self-reporting by patients works. Interestingly, 38.2% of participants also asked for nutrition intervention on the same day of identifying an issue.

Different studies showed that using digital health solutions also helped in increasing the overall survival rate by 5 to 8 months. This was probably helped through faster interventions when required due to the reporting by the patient. This overall survival rate has to be studied further and through different interventions.

Future of Digital Health Solutions in Cancer

The advantages of digital patient-reported outcomes are immense. Imagine being treated for a sudden side-effect or symptom of cancer treatment without delay because of real-time monitoring of the patient through their reports and through wearables that monitor vital parameters like blood pressure and breathing rate. These digital health solutions are already being developed but have to be tested and go through different trials. To have a higher adoption rate by patients, the healthcare practitioners will also have to commit to it with their time and use of technology. Further, the hospitals will have to integrate these reports into their system ensuring that data privacy and security are maintained. Lastly, even with these interventions, patients and doctors must ensure that in-person communication is maintained.

Can Mothers Transmit SARS-CoV-2 to the Fetus or Newborns?

What Is the Main Idea?

This blog post answers the query that most pregnant women who are tested as SARS-CoV-2-positive have: “Will my baby get the virus from me? Can I breastfeed my newborn?” The free access paper “Perinatal Transmission and Outcome of Neonates Born to SARS-CoV-2-Positive Mothers: The Experience of 2 Highly Endemic Italian Regions”, published in the journal Neonatology, addresses these questions using evidence from 2 hospitals in Italy.

What Else Can You Learn?

The blog post describes if and how the virus is transmitted to the newborn and what precautions need to be taken. Also, the symptoms most mothers and newborns have when they are SARS-CoV-2 positive are addressed here.

COVID-19 and Pregnancy

COVID-19 is the disease caused by the novel coronavirus SARS-CoV-2 that has affected many around the world including causing millions of deaths. From the onset of the COVID-19 pandemic in early 2020, pregnant women have been precautionarily put in the moderate or high-risk category of developing complications due to COVID-19. While they are not at a higher risk of getting infected, the risk of complications post-infection may be higher.

What symptoms do mothers have? Depending on the study, 15–80% of SARS-CoV-2-positive pregnant women were asymptomatic. Among those who had symptoms, the most common symptoms were fever, cough, loss of taste and smell, nausea, and shortness of breath. Less than 5% of pregnant women had to be admitted to the intensive care unit (ICU) due to COVID-19.

What Does This Mean to the Fetus and Newborn Child?

SARS-CoV-2 in Newborns Seems to Be Rare

Vertical transmission occurs if the mother passes on the infection to the baby when it is still in the womb. Since a lot about SARS-CoV-2 was unknown, doctors tested babies soon after they were born for possible transmission. A review from November 2020 stated that 92% of newborns (born to SARS-CoV-2-positive mothers) were SARS-CoV-2-negative. In a more recent article, where the authors followed the course of SARS-CoV-2-positive mothers in 2 hospitals in Italy, they found that in one hospital 100% of children born were negative for the virus while 94% of children were negative in the other hospital. Therefore, the risk of vertical transmission is low. The authors believe it could be that the placenta prevents the virus to transfer from the mother to the fetus. More studies must be conducted to verify this.

A correlation for vertical transmission that was seen was hypothyroidism (i.e., the thyroid gland doesn’t make enough thyroid hormones to meet your body’s needs). 4 out of 6 women who had hypothyroidism seemed to have passed on the virus to the newborn. However, this again needs to be studied further and verified.

What about transmission after birth? When the authors of the Italian study checked the newborns after 1 month, 97% of newborns tested negative for SARS-CoV-2. This again shows that the incidence of newborns getting the virus is low.

Symptoms in Newborns

In general, COVID-19 is less severe in children. However, in a small number of cases multi-inflammatory syndrome and even fatalities have been reported, as was written in a previous blog post. So, what about newborns?

In the study from the 2 Italian hospitals, all the newborns who tested positive for the virus were asymptomatic. In a previous report, for newborns who were symptomatic, the symptoms mostly reported were fever, shortness of breath, and vomiting.

Breastfeeding When SARS-CoV-2-Positive

The other worry for most mothers who have the virus is whether they can breastfeed. Again, evidence from the Italian hospitals showed that after childbirth when rooming in with the baby and breastfeeding, there was no increased risk of transmitting the virus. Even at the one-month review, where 75% of mothers were breastfeeding, the rate of transmission was low.

When testing the breast milk for the virus, the reports mostly found no virus in it. So, the main mode of transmission of the virus to the newborn, if at all, would be through contact and droplet transmission. To avoid this risk, it is best to follow good practices of washing hands and using a surgical mask when breastfeeding.

With evidence from these studies, right after childbirth, rooming-in with the newborn must be considered. It will help promote breastfeeding and mother-child bonding. Breastfeeding has huge benefits including providing nutrition, antibodies, and other anti-inflammatory factors.

In Short

With rare direct transmission of the virus from mother to fetus and with little evidence of the virus in the breast milk, a SARS-CoV-2-positive mother should be encouraged to provide skin-to-skin contact and breastfeed the baby after taking all precautionary measures.

Chronic Kidney Disease and Mental Health

What Is the Main Idea?

Mental health problems are an issue in patients with different chronic diseases. End-stage renal disease has also been associated with cognitive impairment and depression. However, what happens in the earlier stages of cancer? In this blog, we discuss the research from the open access article “Association between Psychiatric Disorders and Glomerular Disease”, published in the journal Glomerular Diseases, where the authors studied patients of different age groups in the early stages of kidney disease and the onset of mental health issues in them.

What Else Can You Learn?

Chronic kidney disease has different stages, and this is explained briefly. We also discuss what could be the reasons for psychiatric disorders in chronic kidney disease patients.

Psychiatric Disorders in Chronic Diseases

As chronic diseases are getting more prevalent, research shows that mental health issues in patients with these diseases have increased. For example, with diabetes patients, there is a 25% increase in the rate of depression. While studying each chronic disease, such as asthma, diabetes, cystic fibrosis, etc., it was seen that the extent of disease management, age and stage of disease all play a role in the development of associated psychiatric disorders. The mental health issues themselves can range from depression and anxiety to emotional and behavioral issues. Eventually, with psychiatric disorders added, the chronic disease patients have poor health outcomes and an increase in other health issues.

For example, in the case of asthma patients, anxiety or conduct issues were higher if the asthma was poorly controlled as opposed to those who had it well-controlled. In cystic fibrosis patients, depression was seen at a higher rate compared to healthy patients. Chronic kidney disease is another chronic condition with long-term lifestyle changes and where the quality of life can get disrupted. In this case, too, there are reports about cognitive abilities being severely affected. Let us dive deeper into what this is.

Chronic Kidney Disease

Before going further, we will first look at the different stages of kidney disease. The main function of the kidney is to filter waste and excess fluid from the blood. When there is any kind of damage to the kidneys, this function slowly starts getting disrupted before eventually not working at all. Depending on the filtration rate, chronic kidney diseases are divided into 5 stages. As the filtration rate goes down, the disease condition worsens.

  • In Stage 1 to Stage 3, where the filtration rates are higher, the disease is mainly controlled through lifestyle changes and some medication. The symptoms, like swelling of the feet and hands or changes in urination, progressively start to get worse. At Stage 3, as waste builds up, the patient can experience other health issues.
  • By Stage 4, the patient needs to be in constant contact with the nephrologist for proper treatment plans and preparation for the next stages.
  • Stage 5 is called end-stage renal disease where the kidneys completely fail to function. Patients will need to go for dialysis treatment or kidney transplant at this point.

What Do We Know about Mental Health in Kidney Disease Patients?

Most research about mental health has been restricted to end-stage renal disease. At this stage, there have been studies showing that up to 60% of patients have some form of cognitive impairment. Depression is also a common problem at this stage of the disease. An increase in uremic toxins (due to improper waste removal) has been identified as one of the main reasons. Apart from this, an increase in reactive oxygen species or inflammatory molecules, changes in blood flow, sleep disorders, and anemia could all play a role in affecting cognitive abilities.

While this is all known to occur at Stage 5 of kidney disease, not much work has gone into studying psychiatric disorders in the early stages of kidney disease.

Psychiatric Disorders in Early Stages of Chronic Kidney Disease

In the above-mentioned research article, the authors looked at close to 1,000 patients who were in the early stages of chronic kidney disease. They belonged to different age groups and were checked for when they had an onset of psychiatric disorder. The authors found that around 1 in 8 patients had a psychiatric disorder after the onset of the kidney disease. Interestingly, adolescents are affected the most. Similar results were seen when looking at individual mental health issues like anxiety and mood disorders. Adolescence is already a critical time for the development of emotional and social habits which affect mental well-being. Added to this, the authors argue that the stress of a chronic disease which affects lifestyle increases the risk of a psychiatric disorder.

This research also supported some earlier work which found that the onset of psychiatric disorder was associated with progression to end-stage renal disease.

Final Takeaway

Patients with kidney-related diseases need to be monitored for mental health-related issues as part of the disease management regimen from the early stages of the disease. This becomes especially important in the adolescent age group.

 

Note: Some of the authors of the paper declared that they have financial relationships 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 referenced paper.

Why Is a Baby’s Gut Microbiota Altered after Cesarean-Section Delivery?

What Is the Main Idea?

From the time they are born, it is important for humans to have a good composition of gut microbes to help with digestion, immune function, and long-term health. However, the method of delivery (vaginal or Cesarean section (C-section)) significantly affects this composition, as described in the free access review article “Impact of Delivery Mode on Infant Gut Microbiota” published in the journal Annals of Nutrition and Metabolism. Based on the review, in this article, we also discuss the potential ways of rectifying the change in composition.

What Else Can You Learn?

What kind of bacteria is seen in vaginally born babies and how does it change in babies born through C-section. Also, what does this mean to the baby’s health in the short and long term?

Importance of the Gut Microbiome

The gut microbiome is the flora of microorganisms (bacteria, fungi, viruses and other microbes) that occupy the digestive tract of the body. These microorganisms have a symbiotic relationship with the human body. The human body gives them a place to thrive, and if the microbes are present in the right composition, they support the host in multiple ways. They help in the digestion of food and in maintaining a healthy immune system. In previous blog posts, we have also discussed its effects on mental health and irritable bowel syndrome.

Of the different microorganisms, the bacterial population is the most well-studied and understood. Where do these organisms come from, though? How do they start populating our gut? Below are some answers based on the recent free access review on the same topic.

The Gut Microbiome in Babies

While currently there is some research evidence that the fetus might already contain some gut microbiome, the most accepted consensus is that babies do not have microbes in their body till they start coming out of the womb. During vaginal delivery, the baby starts taking in the microbes from the mother’s vaginal tract, fecal matter and skin.

Surprisingly, though the gut bacteria composition usually differs between individuals, the bacteria populating babies through the initial years follows a general pattern across countries. All the microbes that they come in contact with during delivery do not necessarily populate in the baby’s body. For example, the vaginal microbes do not have the right conditions to grow in the baby. Even amongst the other microbes, the bacteria that help to digest human milk oligosaccharides like bifidobacteria and Bacteroides are the ones that populate the gut of babies. This is for obvious reasons. The other bacteria that can be pathogenic (cause diseases) are present initially, but their levels go down as the baby ingests more breast milk. Since Bacteroides can live off a wide variety of food (substrates) that we ingest, they are present from birth through adulthood.

Interestingly, the bacteria transferred from mothers during vaginal delivery are seen in the child through their life. So, what happens when a child is delivered via C-section?

Delivery Method Affects the Gut Microbe Composition

While it may not be the first choice of delivery for the mother, often conditions necessitate doing a C-section. With C-section, during the delivery, the baby does not come in contact with the vaginal or fecal microbiome of the mother. This has been shown to alter the gut bacterial composition, especially in the first 6–12 months. The most significant feature is the low quantity of bifidobacteria, almost complete absence of Bacteroides and increased pathogenic bacteria.

These differences between vaginal and C-section delivery mostly level out after 1 year but some researchers found differences in bacterial composition all the way to young adults. More studies have to be conducted to determine the exact long-term effects of this difference in the gut microbiome due to the delivery method.

Impact of Altered Microbiota

Since the bifidobacteria, which breaks down human milk oligosaccharides, is in low abundance in C-section babies, their ability to digest and derive energy from breast milk is lowered. It can also cause the intestinal barrier to be weakened. Combining this with an increased abundance of pathogenic bacteria, the babies can be prone to inflammation, pain and distress. The effect on the immune system can also potentially lead to allergic diseases, obesity and other chronic diseases later in childhood or adulthood.

Ways of Correcting the Disrupted Bacterial Composition

Having understood the changes in microbiome composition, researchers are now working towards finding a solution on how to restore the bacterial composition.

The 3 ways that can potentially work are:

  1. Use of probiotics: Studies showed that probiotics, supplements with live strains of Bifidobacterium and Lactobacillus, successfully improved gut microbiome composition and reduced the incidence of allergic reactions. However, the caveat to this intervention is that it is still not the maternal microbiome.
  2. Breastfeeding: Exclusive breastfeeding was shown to improve the bifidobacterial composition in the gut. In one study where they were supplementing with probiotics, it was seen that along with probiotics, only breastfed babies were able to restore the bifidobacterial composition.
  3. Fecal Microbiota Transfer: In a promising pilot study, the babies were given the mother’s fecal matter (after removing pathogens) diluted in breast milk soon after delivery. This helped restore the complete microbiota composition as seen in vaginal delivery.

The above studies prove to be promising for mothers who are planning C-section or even have to do an emergency C-section. Though many of the studies in restoring the gut microbiota are in the preliminary stages, the mothers should talk to the pediatricians about these and try to implement what is safe and possible for the mother and child. This can benefit the child’s health both in the short and long term.

 

Note: The author of the paper has declared receiving support from a nutrition institute. 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.

Improving the Quality of Life of Chronic Kidney Disease Patients through Peer Mentoring

What Is the Main Idea?

Outside of the doctor-patient interaction, patients with chronic disease need support to navigate their medical and mental journey with their new life changes. Here, we discuss how peer mentoring can help the patients through the journey. Based on the open access research article “Effect of Peer Mentoring on Quality of Life among CKD Patients: Randomized Controlled Trial” in the journal Kidney Diseases, we address how online mentoring has helped improve the quality of life of chronic kidney disease patients.

What Else Can You Learn?

From this article, one can understand what exactly is peer mentoring and the different forms of peer mentoring. This can help people with chronic diseases decide if it is something they would like to pursue.

Peer Mentoring in Chronic Diseases

Mentoring is the process where less experienced people receive guidance from more experienced individuals to achieve their goals. Mentoring can happen at different levels. In peer mentoring for health conditions, the mentors are people who have or have previously gone through similar health issues. They have both experiential knowledge and are trained regarding the particular disease condition. Having lived through the condition, they bring in the human connection that is required, and the relationship is non-hierarchical, reciprocal, and entirely patient-centric.

How Does Peer Mentoring Help the Quality of Life?

Many diseases, especially chronic diseases, reduce the quality of life drastically. Upon diagnosis or treatment of the disease, patients require to change their daily habits and lifestyle. There could also be pain and other health issues to concurrently deal with. This leads to issues of firstly being able to adhere to the new routine and medical regimen, and secondly, having your social circle understand your new lifestyle. Poor adherence can lead to the health getting worse, and dealing with lifestyle changes can take a mental toll. While doctors prescribe and give information about what must be done, when actually putting it into practice, patients end up having many queries. They also need support emotionally.

When it comes to chronic kidney disease, as written in the earlier article “World Kidney Day: Advocacy for Patient-Centered Wellness”, it is important to empower patients and help them to be able to participate in daily activities to improve their quality of life.

Peer mentoring is one solution that can help with these issues. The patients get support to deal with disease-related issues such as fear of going through certain procedures like dialysis. Peer mentoring also helps with mental support as they can get tips and guidance on how to handle the disease and social situations.

What Are the Different Kinds of Peer Mentoring?

There are many models to peer mentoring, such as described by Heisler:

  1. Group self-management programs – here the group sets their goals and a leader helps in facilitating it. These are usually face-to-face programs.
  2. Peer coaches – this is a one-on-one program where the coaches are given some initial training on the health condition.
  3. Community health workers – they are people who bridge the local social and cultural aspects within the community and the healthcare system. They may or may not be peers for the disease itself but are trained to give necessary support and help guide and connect patients to additional support.
  4. Telephone-based peer support – when distance is an issue, telephone-based mentoring is an alternative. This support can also be an add-on to other programs like group self-management.
  5. Web- and email-based peer program – when distance is again an issue, with modern technology, one can create video-based web programs similar to the face-to-face programs.

New Study Shows Online Peer Mentoring for Chronic Kidney Disease Works Best

For the first time, researchers had a systematic look at how the quality of life improved in chronic kidney disease patients in multiple peer mentoring scenarios. The 3 different interventions that were tried were face-to-face mentoring, online mentoring and a control group. All groups were given access to a textbook on “Patient and Family Partner Program”. In online mentoring, mentors and mentees could communicate through a secure online interactive platform with content developed specifically for the program and requirements of the patients. There were weekly reminders by the mentors for the action plan and more meetings were arranged as required. The quality-of-life questionnaire was used as a way to assess different aspects of their life. The online mentoring showed significantly better improvement in the quality of life in all parameters examined of the patients at 18 months compared to face-to-face mentoring or no external mentoring.

What Does It Mean to a Person with a Chronic Disease?

If a person with chronic disease feels the need for help outside of the doctor-patient interaction, you should check with your hospital, community or even online for these peer mentoring programs. While living with the disease is not necessarily easy, you can take steps to improve your quality of living and self-care by using the available facilities.

Sarcopenia Obesity, Postmenopausal Women and High Protein Intake: What Is the Connection?

What Is the Main Idea?

In old age, with muscle mass loss and increased weight gain, there are increased health risks like falling, fracturing, and being susceptible to other diseases. Due to gender and age-related hormonal changes, this is especially true for postmenopausal women. In the open access review article with the rather long title “Impact of Protein Intake during Weight Loss on Preservation of Fat-Free Mass, Resting Energy Expenditure, and Physical Function in Overweight Postmenopausal Women: A Randomized Controlled Trial”, published in the journal Obesity Facts, the authors find that high protein alone doesn’t significantly help in improving muscle mass during weight reduction.

What Else Can You Learn?

Sarcopenia obesity is a condition that encompasses all these problems. Learn more about this, the causes, and the interventions for this.

What Is Sarcopenia?

Sarcopenia, a condition of loss of muscle mass and physical function due to old age, is derived from two Greek words – “sarx” which means “flesh” and “penia” which means “loss”. Starting with 1–2% loss at 30 years, by the time one reaches 80 years, those affected can lose up to 30% of their muscle mass. Since we are talking about muscles, loss of this mass leads to loss of strength. This makes old people weaker, less mobile and functional, and more susceptible to falls and fractures. Overall, it results in a poor quality of life.

What Does Obesity Have to Do with Sarcopenia?

In some people, the loss of muscle mass happens along with an increase in the fat (adipose) tissue. This shift in the composition of the body can slowly lead to a combined situation which is called sarcopenia obesity. The duality of these problems leads to making all effects of sarcopenia worse and further increases the risk of comorbidities like osteoarthritis, type 2 diabetes, and even depression. Unfortunately, the condition has not yet been well defined but with an aging population and a rise in obesity, there is more research being done to understand sarcopenia obesity.

From what we currently know, what are the potential factors that cause sarcopenia obesity? Age-related changes in body composition, less physical activity, and hormonal changes are some factors that lead to this condition. At the molecular level too, as we age, certain inflammatory pathways, reduced ability to detoxify and changes in the muscle composition can further worsen sarcopenia obesity.

Why Should Postmenopausal Women Care about This Condition?

With changes in body composition, postmenopausal women are already more susceptible to being obese. In the USA, 40% of women aged 65–74 years were obese, and in Germany, 61% of women aged 50–59 years were overweight, with 27% being obese. In addition, the lower estrogen levels in postmenopause can lead to inflammatory responses that damage skeletal muscle. On the other hand, the presence of estrogen can stimulate cell proliferation. In fact, in a study in Korea, the authors found that the use of hormone therapy in postmenopausal women for 13 months or more helped in increasing muscle mass and reducing sarcopenia. Since hormone therapy has other effects, more studies have to be conducted to make it a definitive treatment for sarcopenia obesity in postmenopausal women.

Meanwhile, let us look into interventions for sarcopenia obesity in general and what can be adapted for postmenopausal women.

How Is This Condition Treated?

While there are emerging novel therapies targeting muscle function, weight loss, and hormonal therapies, the primary strategies currently are still related to physical activity or dietary changes. For each therapy, there are many things to consider like the age of the individual, the gender, and the current physical ability. Some studies showed that to improve physical function, the combination of the physical activity with a weight loss intervention was more effective than doing any one separately.

When it comes to helping overcome sarcopenia obesity, the interventions of weight loss are an important treatment strategy. However, it is important to consider that along with weight loss, loss of muscle mass (part of fat-free mass) can occur which can make sarcopenia worse. Since the energy spent at rest is directly related to the fat-free mass, with lower fat-free mass, this energy spent will go down. Therefore, an important intervention is increasing protein intake during weight loss regimens. This is one of the dietary changes recommended. Moreover, the authors of a study found that increasing protein intake can help improve physical function even without physical exercise.

Does a High-Protein Diet for Postmenopausal Overweight Women Work?

To understand the impact of a high-protein diet in postmenopausal overweight women, the authors of the above-mentioned open access paper conducted a study in Germany with 54 women in this category. Half of them were given a high-protein (1.5 g protein/kg weight) and the other half were given a normal-protein (0.8 g protein/kg weight) diet for a period of 12 weeks and then were monitored for 6 months. There was significant weight loss in both groups, including in the follow-up.

Surprisingly, however, there was no significant difference in net weight loss or the fat-free mass loss between the 2 groups. So, the high-protein diet did not really help in preserving the fat-free mass. The only significant difference between the 2 groups was that higher protein intake helped in improving physical function, as in the earlier study. The authors concluded that compared to a normal-protein diet, a high-protein diet without any physical exercise does not help the postmenopausal overweight women preserve their muscle mass during weight loss.

So, How Does This Matter to a Postmenopausal Obese Woman?

With an increased risk of sarcopenia obesity, this group should look for a holistic treatment of physical exercise and nutrition changes. They should talk to their doctor or nutritionist about creating a program for them. When it comes to physical exercise, they should consider including both aerobic exercise and resistance training. For nutrition changes, along with high-protein, low-calorie diet, they should consider vitamin D and calcium supplements.

Encouraging Healthy Drinking by Using Psychology

What Is the Main Idea?

Sugar-sweetened beverages are often consumed for hydration over healthier drinks. How the drink is represented and experiences around it are known to direct an individual’s choice. However, understanding the psychology behind this consumption and how to use it to potentially encourage healthy behavior is what we discuss here. It is based on the freely available article “The Psychology of Desire and Implications for Healthy Hydration” in the journal Annals of Nutrition and Metabolism.

What Else Can You Learn?

Through examples you will learn how different factors affect consumers’ choices. This includes features like taste, texture, social context, and how short-term satisfaction is perceived more than long-term health benefits. You will also understand what all this means to you when switching to healthier hydration choices.

Issues with Consuming Sugar-Sweetened Beverages

Sugar-sweetened beverages are drinks that are sweetened with different kinds of sugar like raw sugar, brown sugar, glucose, high-fructose corn syrup, and many others.

As many probably know, consuming sugar-sweetened beverages has multiple issues – from affecting dental health to adding empty calories. These beverages have been correlated with weight gain, issues with metabolism, type 2 diabetes, and other heart-related issues. In fact, interventions to reduce consumption have been shown to help in preventing weight gain.

Despite this, the consumption of these beverages has been high. For example, in the USA, half the adults and two-thirds of the children consume at least 1 sugar-sweetened beverage per day. Even the Dietary Guidelines for Americans recommend drinking beverages with no added sugar. Obviously, a recommendation is not sufficient. The question arises about how we can get people to make healthier choices. Before that, we need to understand what makes people choose sugar-sweetened beverages.

What Makes Any Drink Attractive?

Among adolescents, drinking these beverages is often accompanied by other behaviors like watching TV and consuming a high amount of fast food. Pricing, availability, and exposure to soda commercials are other contributing factors to consuming these drinks. Adults and adolescents drink sugar-sweetened beverages also because they find them tasty, it quenches their thirst and due to habit formation.

While these are the correlations and reasons for consuming sugar-sweetened beverages, the details of the psychology or cognitive reasoning behind this behavior is a question that arises.

What Is the Thought Process Behind Consuming Sugar-Sweetened Beverages?

A theory in cognitive sciences is that when food or drinks are consumed, the incident is stored in the memory as a complete picture starting from the taste, texture, and appearance to the feeling it creates and external factors like the surroundings and the people present. Subsequently, when the same food or drink is seen or consumed again in a different scenario, the mind can recreate some of the past experiences even though it might be absent, which leads to an anticipated pleasure. In other words, just viewing a soft drink or an attractive food like chips that was consumed in an earlier context can lead to the anticipated pleasure (including salivation) and desire to consume.

To further understand the consuming behavior, researchers asked the participants to list “typical features” of the food or drink they are consuming. For alcoholic drinks, which were highly represented, the social context was most relevant. Sugar-sweetened beverages were highly consumed, with the typical features giving a sense of reward simulation.

For sugary beverages, the typical features that were highlighted were “sweet, cold, bubbly, nice” whereas water is described as “boring, convenient, clean and available”. Interestingly, “thirst-quenching” was described more for water than sugary drinks. In general, the participants of the research did not describe any drinks for their health benefit. Another interesting fact is that although in the research they only simulated the drink but didn’t give actual drinks, most people went for sugary drinks based on desire and anticipation from experience.

How Can We Use This Knowledge about Psychology to Get People to Switch to Healthy Drinking?

Experiences and anticipation play a heavy role in choosing a drink. So, for those who drink sugar-sweetened beverages regularly, the experience makes them want to consume them again. How can this chain be broken? In the case of representing food, it was found that images and language can be used to provide a rewarding experience. Labeling healthy foods with sensory characteristics like sweet and tangy was more rewarding and had higher expectations as compared to labeling with health terms like vitamin-rich. Similarly, in creating images, just showing a yogurt was less inviting than showing it with a spoon ready to be eaten. These ideas can be applied to drinking and hydration, too. Moreover, from responses to the “typical features”, talking about short-term rewarding benefits is much more important than long-term health benefits.

The key features that consumers see as rewards need to be highlighted. For alcohol, the social context was the salient feature whereas for sugary drinks it was taste and texture. For water, the salient feature is thirst-quenching. Highlighting this and finding other such features that give the right rewarding experience needs to be used when trying to get people to switch drinking behavior.

Lastly, it must be noted that drinking is a static, habitual behavior. It may take time to create a new habit, and the daily routine should be taken into context when encouraging a change.

Healthy Hydration and You

While all of this is in the context of making broader decisions for consumers, the same principles can be applied to individuals around you or even yourself. Think of how you can habitually change what drink you consume by looking at the immediate rewards like thirst-quenching and feeling healthier. Also, ensure you create a good experience around the situation for making the habit sustain in the long term.

Understanding COVID-19-Associated Multisystem Inflammatory Syndrome in Children

What Is the Main Idea?

In the recent COVID-19 pandemic, children have been mildly affected by the disease itself. However, in rare cases, children have been affected by a syndrome termed multisystem inflammatory syndrome after the infection. Based on the free access article “Multisystem Inflammatory Syndrome in Children Associated with COVID-19: A Review with an Emphasis on Mucocutaneous and Kawasaki Disease-Like Findings” published in the journal Dermatology, we describe what is currently known about this syndrome.

What Else Can You Learn?

Find out the symptoms of the multisystem inflammatory syndrome, details about who is more likely to be affected, and how it is usually treated.

Coronavirus and Related Inflammatory Issues in Children

Unlike widely thought, coronavirus and the disease caused by it, COVID-19, occur not only in adults but also in children. The children can get infected with the virus and even spread it but are very often asymptomatic or have mild symptoms. Though many reasons have been suggested, the exact reason for this is still unclear. There have also been cases of children getting a severe infection and requiring critical care but the number dying from COVID-19 has been extremely low.

While that is encouraging, there have been rare cases of a related issue in children – multisystem inflammatory syndrome (MIS-C). During the initial wave of COVID-19, the hospitals in many countries including the USA, the UK, and Italy noticed that there was an increased number of children getting admitted with symptoms like those of Kawasaki disease, which causes inflammation of blood vessels. Incidentally, clusters of children coming with this similar-looking disease occurred approximately 4–6 weeks after a peak of COVID-19 infections. It was also seen that about 75–100% of these children had antibodies to COVID-19. It is known that a trigger for some inflammatory diseases could be a viral infection. This strongly suggested that the multisystem inflammatory syndrome that they were observing was a consequence of COVID-19 infection.

What Does Multisystem Inflammatory Syndrome Related to COVID-19 Look Like?

The main symptoms of the multisystem inflammatory syndrome are similar to that of Kawasaki disease with multiple organs showing inflammation. The symptoms include fever (in almost all cases), swollen lymph nodes, rashes on the skin, chapped lips, vomiting, and diarrhea. The main difference between this and Kawasaki disease is that the latter occurs mostly in children under 5 years whereas this COVID-19-related inflammatory syndrome occurred in older children. Also, the gastrointestinal symptoms and the inflammation were stronger. Unlike Kawasaki disease which is seen more in Asian children, this syndrome is seen more in children of African and Hispanic origin. Incidentally, though the syndrome is related to COVID-19 infection in most cases, respiration- and lung-related symptoms were not prominent.

Since the inflammation affects blood vessels, eventually cardiovascular-related issues are inevitable. In short, the main organ systems affected and showing symptoms are the stomach and intestines, skin and mucous membrane close to it, and the heart and blood vessels.

Unfortunately, these inflammatory diseases do not have tests to identify them, so doctors use the symptoms presented and described to identify the disease.

Details of How the Skin and Mucous Membranes Are Affected

Understanding the symptoms is important to identify the condition early and get treatment. Rash and conjunctivitis were the most common skin issues observed. From the different reports that are summarized in the article, rash occurred in 50–60% of the patients and conjunctivitis in 45–55% of the patients. The other symptoms affecting the skin and mucosal layers were red cracked lips, swollen hands and feet, and red, swollen, and bumpy tongue. Oral ulceration was also described as an early symptom. In a study in the USA, the authors found that under the age of 12, 80% of patients showed these symptoms whereas only 56% of children older than 12 had them. This indicated that the skin-related symptoms of this inflammatory disorder occur more often in younger children.

Though there were some characteristic types of rash and conjunctivitis seen in these patients, no unique feature has yet been identified to differentiate multisystem inflammatory syndrome from Kawasaki disease or other viral diseases.

Multisystem Inflammatory Syndrome Can Be Treated

The most important aspect of treating the syndrome is to identify it, and preferably early because it involves multiple organs at the same time. Since it primarily affects the blood vessels, controlling it quickly before it damages the heart and main arteries should be the goal. After identifying the syndrome, the treatment requires giving supportive care for the symptoms and antibodies in the form of intravenous immunoglobulins to stop the inflammation. The patients can also be given medicines that modify blood flow or, if required, steroids. There are other medications that can be given based on the symptoms and condition of the patient. The survival rate from this syndrome has been very high but its long-term effects on the body are not known yet.

Check with Your Doctor Early on Regarding Any Symptoms

With the number of infections of COVID-19 still increasing worldwide, the number of children with the multisystem inflammatory syndrome has also increased. This has helped experts study this syndrome better because the symptoms related to this disease are wide and varied. It is vital to report all symptoms when meeting a doctor for the correct and timely diagnosis to be made in treating the syndrome.

Improved Quality of Life in Breast Cancer Patients Undergoing Chemotherapy with NEPA Treatment

What Is the Main Idea?

Nausea and vomiting are common side effects of chemotherapy, especially in the treatment of breast cancer. A recently approved treatment for these side effects called NEPA has been effective in clinical trials. To observe how this treatment works in real-world settings in breast cancer patients, the authors of a recent paper conducted a study. Here, we look at the results, published under the title “Quality of Life Effects of an Oral Fixed Combination of Netupitant and Palonosetron in Chemotherapy-Induced Nausea and Vomiting Prevention: Real-World Evidence in Patients with Breast Cancer Receiving Anthracycline-Cyclophosphamide-Based Chemotherapy” in the journal Breast Care.

What Else Can You Learn?

From this article, we can understand the safety of the NEPA treatment and its effectiveness in preventing vomiting and nausea. Also, one can learn how these breast cancer patients responded regarding their quality of life with the treatment.

Nausea and Vomiting: Side Effects of Chemotherapy

Since the 1970s, a common treatment for breast cancer involves chemotherapy using a combination of anthracycline and cyclophosphamide, commonly referred to as AC chemotherapy. Unfortunately, this therapy is known to have strong side effects like nausea and vomiting soon after (1–5 days) the treatment. For patients who are already under stress because of cancer and must undergo multiple chemotherapy rounds, these side effects reduce their quality of life even further. These side effects are further pronounced in patients with breast cancer because many of them are women of younger age and usually undergo AC chemotherapy (Osoba et al., Dranitsaris et al.). This can also lead to some patients discontinuing the treatment. Recognizing these issues, guidelines for treating chemotherapy-induced nausea and vomiting have been recommended by various organizations.

Therapy to Reduce the Side Effects

There are multiple drugs that researchers have shown to help prevent vomiting and nausea but each helps only to a certain extent. Additionally, some medications recommended have complex scheduling for administration which could lead to poor adherence.

Interestingly, studies showed that combining different medications helped to reduce vomiting and nausea better than single drugs. One such combination that has been approved and recommended for certain chemotherapy treatments is NEPA (netupitant (300 mg) with palonosetron (0.5 mg)) along with dexamethasone. An important guideline to prevent nausea and vomiting after AC chemotherapy is to administer the NEPA treatment before the chemotherapy begins. Following these recommendations and in line with keeping treatment administration simple, NEPA along with dexamethasone is usually given as a single dose on the day of chemotherapy. The effect of the treatment can last up to 5 days.

Clinical trials, which are done under specific conditions, smaller sample size, and with a control condition to compare, showed positive results in terms of safety and effectiveness in preventing vomiting and nausea with NEPA. Most importantly, compared to the control treatment, significantly more patients who got the NEPA treatment reported that chemotherapy did not impact their daily life. This is a big improvement in helping patients have a better quality of life despite chemotherapy. The next step was to look at how this treatment works outside of controlled trials.

Safety and Effectiveness of NEPA Treatment in Real-World Testing

Since the treatment got approved and is being administered to patients, it was important to check how the NEPA treatment changed the quality of life of patients in real-world settings. The authors conducted the study in 162 centers in Germany with more than 2,000 patients who were undergoing AC chemotherapy and were given NEPA with dexamethasone 1 hour before it. For this study, the authors focused on a subgroup of 1,197 patients who had breast cancer and specifically looked at what happened in the first 3 rounds of the treatment.

With regards to safety, 10% of patients reported some adverse effects related to NEPA treatment. The main issues were constipation and fatigue. More serious side effects were reported in less than 1% of cases, and there were no deaths. Overall, the treatment proved to be safe in real-world settings, too.

Next, the authors looked at the effectiveness of NEPA treatment. With more than 93% of patients not experiencing vomiting across different rounds of chemotherapy, the treatment already proved helpful. However, more patients had nausea, with about 60% of patients reporting to have “no significant nausea” and only approximately 31% patients saying they had no nausea at all. These numbers increased only marginally over chemotherapy rounds. However, due to low vomiting rates, further medications to help with these side effects were required only in 10–15% of the patients. So, rating the treatment overall, more than 84% of both doctors and patients rated this treatment as “good” or “very good”.

What about Effects on Quality of Life?

When it came to affecting their quality of life, 84% reported that vomiting did not affect them and 53% reported nausea not affecting them in daily life. Overall, 64% of the patients felt their quality of life was not affected by nausea or vomiting with the NEPA treatment. Interestingly, for the patients below 60 years, despite the treatment, nausea and vomiting occurred a little more frequently, reducing the effectiveness of NEPA treatment and their quality of life.

NEPA Treatment Helps Reduce Vomiting and Nausea in Real-World Settings

Even though you cannot have a direct comparison to a control condition, real-world testing is important to understand the true effect of a treatment. When compared to previous clinical trials, in this real-world study of NEPA treatment, the patients were affected by vomiting to a similar extent but more patients were affected by nausea. The authors believe that the reason for more nausea-related issues in the real-world test is that in controlled trials, they excluded patients with other comorbidities and those otherwise prone to nausea. Despite this, they believe that the NEPA treatment has been successful in real-world testing when it comes to safety, effectiveness, and improving the quality of life of patients.

Note: Some of the authors of the paper declared that they have received honoraria, travel expenses and support 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.

Patient-Centric Holistic Treatment of the Fungal Infection Onychomycosis

What Is the Main Idea?

Onychomycosis is a fungal infection that deforms and discolors the nails. Through this post based on the free-access review article “A Paradigm Shift in the Treatment and Management of Onychomycosis” in the journal Skin Appendage Disorders we highlight and explain different aspects of the treatment procedure that we should know and which are required to ensure the success of keeping the fungus away.

What Else Can You Learn?

To ensure complete removal of the fungal infection in the long term, it is important to take a holistic approach. What is this approach? You will understand the importance of diagnostics, different treatment procedures, and, most importantly, sanitization and lifestyle changes required for long-term care.

Understanding Onychomycosis

Onychomycosis is a fungal infection that primarily affects nails of both hands and feet. The infection causes the nails to be deformed (thick and brittle) and discolored with white or yellow patches. Though it is a low-risk infection, it has a significant emotional and social impact. The sufferers feel socially excluded, embarrassed because of the appearance, and are also worried about spreading the infection. In some countries, approximately 5–10% of the population have reported having had onychomycosis, and the rate goes up to 20% or more for the 60 years and older category. This higher rate in the older population is mainly due to reduced blood circulation, comorbidities like diabetes, and weakened immune system. Onychomycosis also occurs often along with another fungal infection called athlete’s foot (tinea pedis) which affects the skin between the toes.

Why Is a Holistic Approach Required?

Treatment for onychomycosis has been mainly through antifungal medicines and topical therapies. While the therapies help get rid of infections in most cases, there are issues of antifungal treatment resistance and reinfections in many cases (10–53%). The authors of the article “A Paradigm Shift in the Treatment and Management of Onychomycosis” describe how there needs to be a shift by healthcare professionals from treating patients with just antifungal agents to a holistic, patient-centric approach. This approach requires starting from testing and making a proper diagnosis to administering appropriate treatment and finally avoiding reinfection by looking beyond just the nail.

Test, Identify, and Diagnose Onychomycosis

Doctors traditionally identify onychomycosis by visual inspection or with simple laboratory tests using microscopy, fungal culture, and biochemistry tools. This infection is most often caused by fungi that infect keratinous tissue like nails but in some cases, fungi that do not depend on keratinous tissue can also cause the infection, or there could be a mixed infection of both fungi. The clinical diagnosis of these fungi that do not depend on keratin is different and identifying it through proper testing and diagnosis becomes relevant for treating it.

There can also be cases where the first line of antifungal treatment (terbinafine therapy) does not work. In these situations, testing for susceptibility of the infected fungi to different antifungal agents and the concentration required to get rid of the infection needs to be identified by using laboratory testing and diagnostic tools.

Find Appropriate Treatment Methods

When the routine treatment strategy fails, the fungus is considered resistant to the treatment. Using the diagnostic reports, the treatment strategy will have to be modified. The reasons for failure could be due to:

  • the treatment itself not being effective because of the wrong diagnosis, drug concentration issues, treatment length or the patient not taking medicines as prescribed,
  • the fungus having learned to live in the presence of the antifungal agent.

In the first case, as described above, changing treatment based on diagnostics and ensuring compliance to medication can correct the treatment course. In the second case, a different class of antifungal agents (azoles) can be tried as an alternative treatment strategy. This holds true for infections with the other classes of fungi and mixed infections, too. In some cases, combination therapy of different antifungal agents or oral medicine along with topical medication might be required to get rid of infections when other techniques fail. In those cases where the patient also has athlete’s foot infection, it is required to treat that simultaneously to be able to successfully treat onychomycosis.

Continue with Post-Treatment Care

The rate of relapse and recurrence of onychomycosis is high and can occur within 30 months of treatment of the previous infection. It could be due to family history and physiological reasons or environmental and lifestyle issues. Hence, it is as important to follow post-treatment care as it was following antifungal therapy.

What Does Post-Treatment Care Involve?

Firstly, ensuring that footwear and clothes are sanitized. With sweat and skin cells trapped in the footwear, they can act as a source of fungal reservoirs. Hence, it is recommended to replace contaminated footwear with a new pair and to change socks frequently (1–2 times/day). It also helps if the socks are of absorbent material or made of antimicrobial fabric like copper-impregnated socks. Footwear can be sterilized by devices developed for this purpose, including those that use techniques like ozone gas disinfection or ultraviolet sanitization. Clothes require to be laundered at high temperatures, and it needs to be ensured that contaminated clothes are separated from sterile ones to reduce further contamination. The laundry machine also needs to be kept properly sterilized.

Secondly, certain lifestyle changes need to be made. It is important to keep nails short and clean. Footwear needs to be worn in high-risk areas like swimming pools where chances of catching infections are high. Keeping feet dry and wearing footwear of the right size is also important.

Lastly, to prevent recurrence of infection, the person could continue topical or oral antifungal treatment at a lower dosage for weeks to years based on the person’s health and doctor’s suggestion. Concurrently, preventive treatment of athlete’s foot using all of the above methods is also required.

Treat Onychomycosis Holistically

Onychomycosis occurs in a significant percentage of the population, affecting their normal life. It is important to treat it by using a holistic approach. This involves ensuring required laboratory tests are done and correct diagnosis is made specifically regarding resistant infections. Post active antifungal treatment, the healthcare professionals should continue to advise the patient to make appropriate lifestyle adjustments and take preventive treatments to avoid relapse and reinfections.

Note: Some of the authors of the paper declared that they have received grants and personal fees from pharmaceutical companies for work outside the review article. 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.

Effect of Nutrition on Depression

What Is the Main Idea?

Recent research shows that the microorganisms in the gut communicate and affect brain health and depression. In the paper “Personalized Nutrition for Depression: Impact on the Unholy Trinity” published in the journal Neuroimmunomodulation, the authors explain how, through personalized nutrition, the microorganism composition could be modulated to help with the therapy for depression.

What Else Can You Learn?

  • The microorganisms present in the gut are strongly dependent on the nutrition intake.
  • Personalized nutrition based on microbiota (composition of microorganisms) can have five different outcomes:
    • Improving richness of gut microbiota
    • Promoting stress resilience
    • Modulating immunity
    • Maintaining strong gut outer layer barrier
    • Improving response to antidepressants
  • Consider gut microbiota and rethink your nutrition if you have depression.

Major Depressive Disorder

Depression is a mental health condition where symptoms include lack of interest in life, insomnia, and even suicidal thoughts. Major depressive disorder is a clinical condition with prolonged symptoms of depression which occurs most commonly due to inflammation of the nervous tissue. This condition severely affects the quality of life of an individual. In 2017, there were 25.8 million cases of depression worldwide, of which nearly 94% had major depressive disorder. The cause of depression is complex, with multiple factors playing a role, for example chemical imbalance, stress, medications and even genetics.

Microbiota-Gut-Brain Axis

Along with the factors described above, the authors of the article explain how, in the last couple of decades, there have been studies showing a strong correlation between microorganisms in the gut (microbiota), brain health and depression. The composition of the microorganisms differs between individuals and is dependent on their nutrition intake. Therefore, it becomes important to personalize the nutrition treatment for each person, taking into account their pre-existing microbiota composition, their general diet and their body and brain functions. Hence, to combat major depressive disorder, the authors have proposed five main ways in which the microbiota can help.

How Can Gut Microorganisms Help Depression?

  • Improving richness of gut microbiota: Nutrition can directly affect and help the growth of a diverse and healthy community of microorganisms. A ‘westernized diet’ (rich in animal proteins and sugar) is associated with stress, depression, and low microbiota diversity. Whereas a ‘non-westernized diet’, which is rich in fibers, causes microorganisms to release important molecules that act as messengers between the gut and the brain, and improve mental and gut health. The authors report that a study found that when patients with depression consumed a Mediterranean diet for 12 weeks, their depressive symptoms reduced when compared to patients with only social support.
  • Promoting stress resilience: Stress is one of the main factors in depression. Certain bacteria are known to promote stress, versus others that are known to make body resilient to stress. Therefore, shifting the microbiota towards these stress-resilient promoting microorganisms using a personalized nutrition plan can help combat depression.
  • Modulating the immunity: Inflammatory components of the immune system are associated with depression. Molecules released by certain gut microorganisms are known to reduce the production of these inflammatory components. Promoting these microorganisms through personalized nutrition is important.
  • Maintaining strong gut outer layer barrier: The gut microorganisms, both good and bad, need to remain within the gut and must be prevented from leaking into the blood stream. Some bacteria, if in the blood stream or the central nervous system, will induce an inflammatory response, which can cascade into behavioral changes related to depression. To prevent the gut microorganisms from leaking out of the gut, a healthy gut and a high-fiber diet is required.
  • Improving response to antidepressants: Antidepressants are the main treatment for depression. Unfortunately, not everyone responds positively to the treatment. Research is being conducted now to understand if the microorganisms in the gut and the molecules they release affect the outcome of treatment using antidepressants. Preliminary research shows that patients with major depressive disorder who responded to antidepressants had a different composition of microorganisms than those who did not respond. The precise link of the microorganisms with the medication is not yet known, but in the future, it could help in developing better antidepressant treatments, potentially supplementing this with microorganisms for the gut.

Conclusion

Major depressive disorder affects millions of people worldwide. It is important to recognize that gut microorganisms interact with brain health in many ways and, hence, further research into the exact molecular mechanism and their nutritional impact is required. Based on the research, along with currently available treatments, modifying nutrition and the gut microorganisms of an individual could be used as a standard treatment method for patients with major depressive disorder in the future.

Train Your Body towards Tolerance of Food Allergens

What Is the Main Idea?

There is an increase in the prevalence of food allergies. Rather than relying on complete food avoidance, how can the body be trained to tolerate the food allergen? In the free-access review “Fighting Food Allergy by Inducing Oral Tolerance: Facts and Fiction” in the journal International Archives of Allergy and Immunology, the authors address these questions, which are summarized in this blog.

What Else Can You Learn?

Tolerance to food allergens can be attained in multiple ways. Firstly, by modulating the immune system, which plays a central role in the body’s allergic reaction. Further, you can understand how the gut health and the processed nature of food allergens can be altered to reduce allergies and improve tolerance.

Food Allergy

Food allergy is an adverse immune reaction to certain food or food types that is usually harmless to human beings. It mostly manifests as a reaction in the skin as well as the digestive or respiratory systems. The allergies differ vastly across ages and demographics. Younger children, especially in developed countries, have a high rate of food allergies of about 4–11% compared to a prevalence in adults of 0.2–4.1%. The allergen (the substance that causes the allergy) also differs geographically, with peanuts being more prevalent in developed countries and milk and eggs being universal.

Oral Tolerance

Food allergies occur because the body’s defense system gets triggered by certain ingredients in the food that it thinks is harmful to the body. This can be detected by the increase in a specific type of defense proteins in the body. The best method to prevent allergy has been to completely avoid the allergen. However, in the long run, this could be an issue due to a potential lack of specific nutrition or a severe reaction due to a chance contact with the allergen. Instead, the goal would be for the body to not react to the food allergens, which is termed as oral tolerance. In case of certain allergies, oral tolerance is sometimes arrived at naturally. For example, young children with food allergies like milk and egg often outgrow them by the time they enter school. Another way to restore oral tolerance is by introducing the allergen in gradually increasing doses. In a study to restore egg tolerance using this method, it was found that, after 6 months, 9 out of 10 children achieved tolerance while in the group without treatment no children achieved tolerance. Unfortunately, these methods are not yet standardized and also long-term tolerance has not been studied.

To understand further methods to avoid allergy or restore tolerance, we need to look closer at what makes the food an allergen.

Different Targets for Oral Tolerance

Immune System in the Intestines

The intestine has a complex job of ensuring that the good part of the food enters the body, while any harmful substances like infectious agents are gotten rid of. For this job, the intestine works closely and maintains a balance with the immune system. In the case of food allergy, there can be an error in the behavior of the immune system which causes the harmless molecules to be “seen” as harmful. There can also be an imbalance in the immune cells present due to different triggers. To combat this, clinical therapy is used to retrain the immune system to treat the allergen as dangerous. The therapy also helps restore the balance in the different immune cells towards encouraging oral tolerance.

Gut Microorganisms

From when a child is born, microbes start accumulating in the gut. These microbes help shape gut health by helping maintain a good barrier and communication with the immune system. These same functions make the microbes critical to avoid food allergies, too.

In this context, a study indicated the importance of breastfeeding, since infants receive 27.7% of breast milk bacteria and 10.3% of bacteria from the area around the nipple. Another study showed that this bacteria from the breastmilk helps reduce the risk of food sensitization in the baby when they are a year old.

The introduction of solid food and potential allergens at an early age is being debated. While the gut and immune system might not be ready for an early introduction (below 6 months) to food, studies show that peanuts being introduced early helps reduce allergy towards them. Only 1.9% of children who started consuming peanuts when they were less than a year old were allergic at 5 years compared to 13.9% in the group that avoided peanuts. More research needs to be done in different demographics to understand the best time to introduce the allergens.

Processing Method of Food

The allergic response to food is found to depend, in some cases, on the way the ingredient is processed. While the immune changes and the different processes need to be extensively researched, there are already many reports on egg-allergic and milk-allergic people being tolerant to baked egg and baked milk, respectively. The more interesting result is that over time, some people who are tolerant to the processed forms of egg and milk can become tolerant to the raw form. This provides yet another natural way of reaching oral tolerance to certain food allergies. However, those who are not tolerant to the baked or processed forms of milk and eggs should be treated carefully when trying any such therapy, as they can have adverse reactions.

What Did We Learn?

Instead of complete food allergen avoidance, people with food allergies can train their bodies towards oral tolerance. This can be achieved – naturally, through the gradual introduction of allergens, using immunotherapy, improving diversity in gut microorganisms or by introducing a processed form of food allergens. It is important to discuss the best suitable oral tolerance therapy with the doctor based on the specific food allergy and health condition of the patient.

Effects of Smoking on Hair Health

What Is the Main Idea?

Smoking, apart from affecting the internal organs, can also affect skin and hair health. In the article “The Effects of Smoking on Hair Health: A Systematic Review” published in the journal Skin Appendage Disorders, the authors collate 32 different research studies and show that there is a positive association between those who have male or female pattern baldness or premature hair graying, and their smoking behavior.

What Else Can You Learn?

From the various studies they discuss, it is found that it is not just the act of smoking but the quantity and history of smoking that directly affect this correlation with hair loss and graying. Therefore, when patients go to doctors regarding these hair issues, environmental factors like smoking or exposure to smoke should be addressed. Conversely, people can be discouraged from smoking by discussing the ill effects on their hair health.

Smoking: A Factor in Hair Health

Among other hair problems, male or female pattern baldness and premature hair graying are issues that can start affecting people at an early age, even below 30 years. At that early age, these hair problems can lead to issues of self-esteem and interfere with social communication. Genetics and hormones play a major role in these hair-related issues. But understanding the external factors, like smoking, can help bring in an additional level of treatment. Smoking affects different organs and systems within the body, including lungs and heart, but can also affect skin health and hair growth. Multiple studies have now looked at how smoking and related molecules like nicotine particles affect the hair. In humans, to understand if there is a correlation between hair loss or premature graying and smoking, research groups around the world have conducted studies in different settings and demography. In the free access review article, the authors have collated information from 32 individual studies to get a more holistic picture of this association; the results are described below.

Male or Female Pattern Baldness and Smoking

Male or female pattern baldness is one of the most common types of hair loss. However, it differs from men to women. In men, there is hair loss in the front, mid-scalp and/or crown of the head. For women, there is a more diffused hair loss and thinning of the hair. To assess the effect of smoking on this type of hair loss, studies from various demographics, including Asia and the UK, showed a strong correlation between the quantity (packs per day) of smoking and hair loss. These studies were corroborated in different settings, including a study that had 1,000 men, half of whom smoked more than 10 cigarettes per day. In this study, about 85% of those who smoked had male pattern baldness, compared to only 40% of those who did not smoke. Some studies did not show a significant correlation between hair loss of smokers and non-smokers. The issues with these studies are that they were limited by the number of participants or lack of information of smoking history or age, and in some cases, lower age of participants with shorter smoking history.

Premature Hair Graying and Smoking

Premature hair graying occurs when a person has gray hair below the age of 30. It occurs because the molecules that impart color to the hair become defective. This could be due to an imbalance between the molecules that cause cellular damage and ‘antioxidants’ that can protect from the damage. The authors of the article describe seven studies that showed a positive association between smoking and premature hair graying, including one study which showed that there is two times more risk of graying prematurely in smokers. In another study, patients with premature hair graying had a history of smoking compared to non-smokers. There were a few studies that did not show a correlation between premature hair graying and smoking but here, again, the age of participants was low, potentially without enough history of smoking.

Conclusion

While the different studies described above show an association between smoking and hair health, the exact mechanism of how smoking affects hair loss or graying is not understood yet. Despite this, when going to a dermatologist regarding issues with the hair, especially regarding premature graying and hair loss, it is important to consider and discuss the patient’s smoking history or exposure to cigarette smoke. This can factor into the treatment given for hair health. Alternatively, smoking which is harmful to general health can be discouraged further by explaining the ill effects on hair health and potential social implications.

Microorganism Composition Affects Wheezing and Rhinitis in Children

What Is the Main Idea?

Inflammation of mucous membrane due to cold or allergies (rhinitis) and wheezing frequently affects both children and adults. How does the colony of microorganisms living in the upper respiratory tract decide the likelihood of getting these respiratory issues? In this post, you can get some insights based on the free-access review article “Role of Upper Respiratory Microbiota and Virome in Childhood Rhinitis and Wheeze” in the journal International Archives of Allergy and Immunology.

What Else Can You Learn?

From when the child is born, their airways start getting populated with different types of bacteria and virus – some beneficial and others harmful. Discover how this composition differs between children and what it means to their susceptibility to wheezing and rhinitis.

Microorganisms and Their Role in Humans

Microorganisms are known to inhabit different parts of the human body. While the organisms get a place to live and nutrients to feed on, the human hosts might or might not benefit from their presence. When they benefit, it is because the organisms help prevent inflammations and support the immune system. However, some microorganisms (both bacteria and virus) can be harmful, causing inflammations leading to disorders. These different kinds of microorganisms and their role in the gut are well known. Recent studies show how based on their presence in respiratory airways, different respiratory disorders may occur.

Development of Healthy Nasal Microorganism Composition in Early Childhood

The upper respiratory tract, starting at the nostrils, is the entry point to microorganisms. By the time we are young adults, a healthy diverse composition of microorganisms occupies the upper respiratory tract in most people. This composition in children varies drastically from birth to infant stage. Few weeks after they are born, in healthy babies, the back of the nose is predominantly occupied by two species of bacteria called Corynebacteriaceae and Staphylococcaceae. By 24 months, the population of these species reduce, and different bacteria populate. There are also differences in organisms present based on the season. The authors of the article believe this occurs due to seasonal infections from harmful bacteria which disturb the healthy composition of microorganisms. Lactobacillacea, though present in smaller quantities, also help prevent infections and disorders.

Overall, these bacteria are associated with protecting the child against respiratory infections in later childhood. The main ways these organisms help is by:

  1. occupying sites in the respiratory tract and not giving space to the harmful bacteria,
  2. producing inhibitory molecules or depleting nutrients to prevent the growth of the pathogens.

Shift in the Healthy Composition of Microorganisms Causes Respiratory Disorders

In general, lower diversity of microorganisms is associated with inflammation of the mucous membrane (rhinitis) and wheezing. Compared to healthy infants, it was observed that children with rhinitis or wheezing had a lower abundance of bacteria like Corynebacteriaceae and Staphylococcaceae. These bacteria usually prevent the harmful bacteria from colonizing by using different techniques.

Instead of these healthy bacteria, if the airway is populated with harmful bacteria that cause inflammation, the children had a higher risk of wheezing or asthma later in childhood. A few studies (Bisgaard et al.; von Linstow et al.; Tang et al.) showed that one-month-old children who had flu-like bacteria but did not show symptoms subsequently had acute or chronic wheezing in the first 2 years of life. In another study, 7- to 9-week-old children with an abundance of Streptococcus bacteria were associated with chronic wheezing by 5 years. Therefore, the establishment of harmful bacteria in the respiratory tract as babies could predispose the children to rhinitis and wheezing in early childhood.

How Do Harmful Pathogens Cause Mucous Inflammation and Wheezing?

The bacteria multiply and grow into thin films. The harmful pathogens coordinate and intersperse themselves in these films, making them stronger and resistant to antimicrobial agents. They may also release molecules that makes them adhere better. Further, they induce an inflammatory response in the host by activating the immune system. Children with this inflammatory response were shown to be at a higher risk of asthma at the age of 7 years.

Role of Viruses and Conclusion

Viruses are also part of the microorganisms in the respiratory tract. Currently, only the harmful viruses causing acute respiratory tract infections have been studied in detail. While causing mucous inflammation and wheezing during the infection, they also increase the risk of children getting recurrent wheezing later in childhood. The benefits of viruses that attack bacteria have not been well studied yet.

Together, we learn that the composition of the bacteria and virus from the newborn to the infancy and toddler stage can play a significant role in respiratory health in later childhood. Therefore, more research should be done to understand details of how the microorganisms function and to help devise methods to reduce the burden of an inflamed mucous membrane, wheezing or asthma.

World Kidney Day: Advocacy for Patient-Centered Wellness

What Is the Main Idea?

World Kidney Day is a yearly campaign to raise awareness about kidney health. For 2021, the steering committee has chosen the theme of ‘Living Well with Kidney Disease’. In the article ‘Living Well with Kidney Disease by Patient and Care-Partner Empowerment: Kidney Health for Everyone Everywhere’ published in the American Journal of Nephrology, the authors discuss their campaign ideas.

What Else Can You Learn?

  • Depending on the stage of the disease, treatments can range from lifestyle changes to dialysis and kidney transplant.
  • The disease and treatments have a huge impact on the daily life of a patient and their care-partners.
  • Patients with chronic kidney disease need to be empowered and engaged. They should learn to manage their condition and be able to thrive by participating in regular life activities.
  • Empowerment of patients in lower and lower-middle income countries is a challenge.

Chronic Kidney Disease

Chronic kidney disease is a condition where the kidney’s function gradually deteriorates. This means that the kidney does not filter out waste and excess fluid properly, causing its accumulation, and related issues. Early diagnosis of the disease can help in early interventions including lifestyle changes, such as diet. If the disease worsens, dialysis or a kidney transplant can be required. In all cases, chronic kidney disease requires the patients and their caretakers to adapt to a new normal, which can create constraints in their daily living and impair their quality of life.

World Kidney Day (WKD) 2021

The International Federation of Kidney Foundation – World Kidney Alliance (IFKF-WKA), in a joint initiative with the International Society of Nephrology, run a global campaign, World Kidney Day, to raise awareness about kidney health. It was held on March 11th in 2021. In the article, the authors discuss the theme of 2021, ‘Living Well with Kidney Disease’, and its implications. In this campaign, they specifically highlight ways to empower the patient and care-partners through education and engagement. The authors further emphasize this requirement for patients everywhere, including low and lower-middle income countries.

Life Participation and Patient Empowerment

A study, conducted by Standardised Outcomes in Nephrology (SONG) spanning 70 countries and 9,000 patients, family members and healthcare workers, found that patients gave higher priority to symptoms and life impact, whereas healthcare workers gave priority to mortality and hospitalization. Therefore, along with research, the need to address the patient’s priorities and goals in this potentially lifelong disease has been recognized.
Life participation is the ability of a patient to go beyond just managing their health condition and to participate in daily activities like work, family responsibilities and social and recreational activities. In a study published in 2020, some patients specifically mention how they would like to not just live but also be able to do more in life. For achieving this, the World Kidney Day Steering Committee recommends that patient-related outcomes should be addressed in the context of life participation. Further, they report that it will help if regulatory agencies could use life participation as a metric for their studies. They also recommend that funding agencies provide focused grants on research towards life participation for chronic kidney disease patients.
Beyond life participation, patients can be empowered by educating them about their health. This will enable them to participate in decision making about their treatment and symptom management with their healthcare practitioners. The World Kidney Day Steering Committee also advocates strengthening patient engagement in research and policy making. Additionally, they believe in using an approach where instead of concentrating on the pathology and the problem, focusing on patient awareness, building support and similar strength-based ideas can help patients live healthier lives.

Care-Partner Health

The care-partners, often being family members, play an integral role in the life of the patient. They are burdened with ensuring that the patient’s treatment is adhered to and enabling the patient towards life participation. In the process, the care-partners can be physically and mentally overworked. Often their own life participation is hampered. Therefore, the World Kidney Day Steering Committee recommends that empowering and engaging care-partners in treatment procedures, research and policy making are equally important.

Empowerment in Lower Income Settings

Patients in lower income settings often are entirely dependent on the healthcare provider and caregiver. Unfortunately, in many such places, there are not enough healthcare providers or specialists in the area to identify and address the chronic kidney disease early. Hence, these patients often get diagnosed at a late stage, which, along with health complications, increases their financial burden and drastically reduces quality of life. To address these issues, the World Kidney Day Steering Committee advises to:

  • extend education to these patients and care-partners,
  • utilize telehealth strategies for knowledge dissemination in both patient and kidney care providers,
  • use strategies to encourage retention of kidney health providers in these settings.

Conclusion

This year, the World Kidney Day steering Committee would like to direct the policy makers to focus their plans and resources towards patient-centered wellness. Patient-centered wellness can come in the form of empowering them to make informed decisions, providing the appropriate support for treatment, offering required assistance for life participation and much more. Ensuring healthcare providers and researchers also engage with and address problems from the patients’ perspective will provide an immense health and cost benefit.

Note: Some of the authors of the paper declared that they have received honoraria and personal fees 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.

Treating Cancer by Harnessing the Immune System and Microbiota

What Is the Main Idea?

The authors of the review article ‘Immune System Efficiency in Cancer and the Microbiota Influence’ in the journal Pathobiology investigate the role of the immune system during cancer and how microorganisms affect the treatment process. This review helps to understand the role of microbiota (community of microorganisms) in the immunotherapy treatment of cancer.

What Else Can You Learn?

  • The immune system is an integral part of curing diseases, including cancer.
  • Boosting the immune system through immunotherapy has gained momentum in recent years.
  • The immune system is complex with multiple modalities, with some deterring and others promoting tumor progression.
  • Providing the appropriate microbiota modulates the tumor microenvironment, leading to more effective immunotherapy treatment.

Cancer and the Immune System

Cancer is the second leading cause of death worldwide. It occurs due to changes in DNA that accumulate and cause aberrant cell growth, causing a tumor to grow. The most common treatments for cancer are surgery, radiotherapy, and chemotherapy.

The immune system is the complex defense mechanism that the body has developed to combat anything perceived as foreign to the body. This is done by constant patrolling, recognizing aberrant or foreign cells and recruiting specific defense molecules and cells to destroy them. When it comes to cancer, the body’s immune system usually recognizes these errors and impairs their development. Based on the nature of the tumor, sometimes the immune system fails or can even aid tumor progression.

How does the immune system interact with cancerous growth? The area around the tumor is called the tumor microenvironment which includes blood vessels, immune cells and signaling molecules. These molecules mediate communication between the cells. Based on the type of molecules present, the immune cells in the tumor microenvironment can change their characteristics. In some cases, they suppress the tumor growth but in other cases they can promote it. Therefore, knowing the tumor microenvironment is of significance to deliver any intervention to suppress cancer.

Immunotherapy

Advances in research and understanding of the immune system have led to the development of a new class of cancer treatment called immunotherapy. Immunotherapy is a technique used to boost the immune system by utilizing and modulating the components of the immune system. It aids by directly limiting or eliminating cancerous growth or preventing cancer from spreading. To achieve this, substances that are either produced by the body or manufactured in a laboratory are used. They are applied to improve how the body recognizes, suppresses, and destroys cancer cells.

An immunotherapy that has been approved for clinical use utilizes immune checkpoint inhibitors. Immune checkpoints are proteins that stop immune cells from attacking the body’s own normal cells, thus preventing issues like autoimmune diseases. Tumors utilize this same mechanism to evade the immune system from attacking them by introducing checkpoint proteins in the tumor microenvironment. Immune checkpoint inhibitors are drugs that block the checkpoint proteins and allow the immune cells to carry out their function, like attacking and destroying tumor cells. Recent research has gone further to study the composition of the tumor microenvironment to understand factors that affect immune checkpoint inhibitor mechanism. A factor identified is the microbiota.

Microbiota

From the time we are born, microorganisms colonize all surfaces of the body exposed to external environment. This microbiota (community of microorganisms) is commonly known to aid in digestion. Recent data show that it also plays a role in the function of the immune system. The microbiota releases molecules known to have anti-tumor effects. At the same time, there are certain other microorganisms (if present in the body) that release molecules that promote tumors. Therefore, it is crucial to understand the microbiota composition and its effect on the tumor microenvironment. It is important to see how it can be modulated to benefit tumor suppression.

Microbiota in Immunotherapy

Microbiota, depending on its composition, can be an important modulator of success of anti-cancer treatments such as immunotherapy. Two recent preclinical studies on the use of immune checkpoint inhibitors tested how the microbiota modulates the outcome of the therapy. In one study, it was found that when mice were germ-free or treated with antibiotics, the therapy failed. Upon administering a cocktail of certain bacteria, the efficacy of the therapy was restored. In another study, the efficacy of a different immune checkpoint inhibitor was tested in mice having different microbiota. While the treatment worked in one, it failed in the other. Introducing the microbiota in the non-responsive mice with Bifidobacterium species, which was present in the responsive mice, restored the efficacy of the treatment.
While the research is still in its infancy, the data and the importance of appropriate microbiota in modulating the immunotherapy treatment is undeniable. This requires future studies to look at modulating the gut microbiome (by introducing probiotics, fecal microbial transplants, or with specific diets) in cancer patients while administering different immunotherapy treatments.

Conclusion

Immunotherapy in treating cancer has gained a lot of traction in recent years. Learning how to modulate current therapies to make them more effective is key to the health outcome in the patient. Recently, the microbiome has been shown to play a significant role in general health and in cancer, too. In the age of personalized medicine and therapy, understanding a patient’s microbiome and then utilizing it to provide better treatments will be the way forward.

Gayatri Muthukrishnan

Gayatri Muthukrishnan is currently a science communicator and entrepreneur. She obtained her Ph.D. in Bioengineering from Penn State University, USA, and continued with postdoctoral research work at National Centre for Biological Sciences, Bangalore, India. Now living in Zurich, Switzerland, she is a freelance science communicator and writes for Miyara Health and Namaste Switzerland. As part of the Dance Your Science Company, she uses dance as a medium to communicate different scientific topics through presentations and workshops. As an entrepreneur, she is the co-founder of Miyara Health which develops digital solutions for improving health management at home. Alongside these pursuits, she loves travelling the world with her husband and two kids.

Photo: Ajay Shankar

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