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Tag: Heart

  • Understanding postural tachycardia syndrome in cardiovascular care

    Understanding postural tachycardia syndrome in cardiovascular care

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    Announcing a new article publication for Cardiovascular Innovations and Applications journal. Postural tachycardia syndrome (POTS) is a chronic autonomic disorder characterized by excessive heart rate elevation upon standing or head-up tilt, in the absence of orthostatic hypotension.

    This debilitating condition affects primarily young to middle-aged individuals, particularly women, and substantially influences quality of life. The main presenting symptoms are lightheadedness, palpitations, exercise intolerance, and cognitive impairment. POTS is of particular importance to cardiologists, given its prominent cardiovascular symptoms.

    The diagnostic criteria for POTS include a sustained heart rate increase of more than 30 beats per minute upon standing or head-up tilt; symptoms of orthostatic intolerance lasting at least 3 months; and exclusion of other causes. The exact etiology of POTS is unknown, but multiple possible etiologies leading to a similar clinical phenotype have been proposed. Early intervention and appropriate management can improve symptoms.

    Treatment strategies include lifestyle modifications, pharmacotherapy, and tailored conditioning programs. Non-pharmacologic options are the first line treatment. Prognosis varies widely: POTS can be a temporary condition for some individuals but a chronic and debilitating condition for others. Further research is necessary to elucidate the pathophysiology and optimize treatment strategies for this condition.

    Source:

    Journal reference:

    , A., et al. (2024) Overview of Postural Orthostatic Tachycardia Syndrome (POTS) for General Cardiologists. Cardiovascular Innovations and Applications. doi.org/10.15212/CVIA.2023.0098.

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  • Study suggests high levels of vitamin B3 breakdown products are linked to higher risk of mortality, heart attacks, and stroke

    Study suggests high levels of vitamin B3 breakdown products are linked to higher risk of mortality, heart attacks, and stroke

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    In a recent study published in Nature Medicine, researchers utilized an untargeted metabolomics technique to look for new compounds and pathways that may contribute to residual cardiovascular disease (CVD) risk.

    Study: A terminal metabolite of niacin promotes vascular inflammation and contributes to cardiovascular disease risk. Image Credit: Dragana Gordic/Shutterstock.com
    Study: A terminal metabolite of niacin promotes vascular inflammation and contributes to cardiovascular disease risk. Image Credit: Dragana Gordic/Shutterstock.com

    Background

    CVD is a worldwide health problem, with only a tiny proportion of the risk linked to known risk factors. Despite breakthroughs in therapeutics, the risk of CVD remains high, indicating the presence of other unidentified variables.

    Niacin, an essential vitamin in dietary staples, is critical in CVD. Treatment groups had mean LDL levels <50 mg/dl but significant cardiovascular event rates. Individuals with high inflammatory markers have an increased chance of developing CVD. However, dietary niacin intake has increased due to the increasing consumption of processed and fast food, raising concerns regarding the efficiency of therapeutic niacin in lowering CVD risk.

    About the study

    In the present study, researchers used untargeted mass spectrometry technology to identify circulating small molecules that predict incident CVD event risks without established risk factors.

    The researchers investigated clinical, genetic, and mechanistic links between the terminal breakdown products of excess niacin and the incidence of major adverse cardiac events (MACE). They conducted untargeted metabolomics analyses on fasting plasma from stable cardiac patients in a prospective discovery cohort and subjects with elective diagnostic cardiac examinations.

    The researchers postulated that the putative MACE-related analyte with m/z values of 153 Da may be a combination of two co-eluted structural isomers: the N1-methyl-2-pyridone-5-carboxamide (or 2PY) metabolite and the N1-methyl-4-pyridone-3-carboxamide (or 4PY) metabolite. They chemically synthesized both metabolite standards and conducted several chemical characterization tests.

    The team used stable-isotope-dilution liquid chromatography with tandem mass spectrometry (LC-MS/MS) to examine the relationship between structural isomer levels in circulation and new-onset major-type adverse cardiovascular event risk in two validation populations [United States (US) cohort of 2,331 individuals and the European cohort of 832 individuals]. They performed a sensitivity analysis on validation cohort data to account for confounding with known risk variables.

    The researchers used a genome-wide association study (GWAS) approach and meta-analyses to investigate the genetic determinants of circulating 2PY and 4PY levels. They combined the study results from the United States validation cohort with publicly available summary statistics for 2PY and 4PY levels from various multi-ancestry datasets. They reduced Acmsd expression in vivo by injecting mice with a liver-tropic adeno-associated virus (AAV) expressing either a short hairpin RNA (shRNA) targeting Acmsd or a scrambled control shRNA to directly test the notion that ACMSD influences 2PY and 4PY levels.

    The researchers also used Mendelian randomization (MR) analysis to determine if genetically higher 2PY and 4PY levels were causally associated with CVD outcomes. They conducted in vitro and in vivo functional studies to investigate whether 2PY or 4PY would induce VCAM-1 expression on endothelial cells. They used in vivo methods to investigate the immediate effects of 2PY or 4PY on arterial VCAM-1 expression and function.

    Results

    Niacin metabolites were associated with an increase in major adverse CVD events (MACEs). Chemical production of authentic 2PY and 4PY standards and additional chemical characterization tests demonstrated that the MACE-associated blood ‘analyte’ with m/z values of 153 Da was a combination of the co-eluting structural isomers 2PY and 4PY with the same elemental composition.

    In the US and European validation cohorts, serological 2PY and 4PY levels showed associations with increased three-year major-type adverse cardiovascular event risk [adjusted hazard ratios (HRs) for 2PY of 1.6 and 2.0, respectively; and for the 4PY metabolite: 1.9 and 2.0, respectively). Elevated 4PY levels were still strongly related to the incidence of major-type adverse cardiovascular event risk in both persons with relatively maintained and compromised renal function.

    A phenome-level association study of the rs10496731 genetic variant, strongly correlated with both metabolite levels, found a link to soluble-type vascular adhesion molecule 1 (sVCAM-1). A meta-analysis found a link between rs10496731 and sVCAM-1 in 106,000 individuals, including 53,075 women. The validation group (974 individuals, 333 females) showed a significant correlation between sVCAM-1 expression and the niacin metabolites.

    4PY metabolite (but not 2PY) administration in physiological amounts increased VCAM-1 expression and leukocyte adhesion to the vascular endothelial cells in murine animals. Both niacin metabolites were related to residual cardiovascular disease risk. The team also proposed an inflammation-dependent mechanism for the clinical connection between the 4PY metabolite and major adverse CVD events.

    The study findings showed that two terminal metabolites of niacin and NAD metabolism, 2PY and 4PY, are associated with CVD regardless of established risk factors. Both metabolites genetically link to vascular inflammation, with a gene variation strongly associated with circulating 2PY and 4PY levels and sVCAM-1 levels. Excess niacin, particularly 4PY, is linked to increased MACE risks and may contribute to residual cardiovascular disease risk via inflammatory pathways. Further research is required to improve understanding of these relationships.

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  • Study links finger length ratio to oxygen metabolism efficiency in athletes

    Study links finger length ratio to oxygen metabolism efficiency in athletes

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    The efficiency of oxygen supply to tissues is a factor in the severity of important diseases such as Covid-19 and heart conditions.

    Scientists already know that the relationship between the length of a person’s index and ring fingers, known as the 2D:4D ratio is correlated with performance in distance running, age at heart attack and severity of Covid-19.

    Now Swansea University digit ratio expert Professor John Manning has been working with colleagues to look more closely at the subject.

    Their findings have just been published by the prestigious American Journal of Human Biology.

    The research analyzed 133 professional football players as they underwent a series of body measurements which included measuring digit lengths from hand scans. They also completed an incremental cardiopulmonary test to exhaustion on a treadmill.

    With our partners from the Cyprus campus of the University of Central Lancashire, we have clarified the relationship between 2D:4D and oxygen metabolism in a sample of well-trained athletes.


    The players with long ring digits (4D) relative to their index digits (2D) have efficient oxygen metabolism such that they reach very high maximal oxygen consumption in an incremental cardiopulmonary test to exhaustion on a treadmill.”


    Professor Manning, of the Applied Sports, Technology, Exercise and Medicine (A-STEM) research team

    Long ring digits relative to index digits are thought to be a marker of high testosterone levels in the womb. Testosterone has effects on oxygen metabolism through its influence on the energy producers (mitochondria) within cells.

    He added: “Our findings are consistent with those from distance running, where long 4D is related to high performance, and heart disease and Covid-19 where long 4D is linked to low severity of disease.

    “Overall, our study illustrates the value of using healthy well-trained athletes to clarify metabolic processes that are important in disease outcomes.”

    The team say further work is now necessary to quantify these associations in women.

    Professor Manning’s previous research has examined how the difference in finger length between a person’s left and right hand may provide vital information concerning outcomes from contracting Covid-19.

    Source:

    Journal reference:

    Parpa, K., et al. (2024). The associations between digit ratio (2D:4D and right – left 2D:4D), maximal oxygen consumption and ventilatory thresholds in professional male football players. American Journal of Human Biology. doi.org/10.1002/ajhb.24047.

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  • Early detection may help Kentucky tamp down its lung cancer crisis

    Early detection may help Kentucky tamp down its lung cancer crisis

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    Anthony Stumbo’s heart sank after the doctor shared his mother’s chest X-ray.

    “I remember that drive home, bringing her back home, and we basically cried,” said the internal medicine physician, who had started practicing in eastern Kentucky near his childhood home shortly before his mother began feeling ill. “Nobody wants to get told they’ve got inoperable lung cancer. I cried because I knew what this meant for her.”

    Now Stumbo, whose mother died the following year, in 1997, is among a group of Kentucky clinicians and researchers determined to rewrite the script for other families by promoting training and boosting awareness about early detection in the state with the highest lung cancer death rate. For the past decade, Kentucky researchers have promoted lung cancer screening, first recommended by the U.S. Preventive Services Task Force in 2013. These days the Bluegrass State screens more residents who are at high risk of developing lung cancer than any state except Massachusetts — 10.6% of eligible residents in 2022, more than double the national rate of 4.5% — according to the most recent American Lung Association analysis.

    The effort has been driven by a research initiative called the Kentucky LEADS (Lung Cancer Education, Awareness, Detection, and Survivorship) Collaborative, which in 2014 launched to improve screening and prevention, to identify more tumors earlier, when survival odds are far better. The group has worked with clinicians and hospital administrators statewide to boost screening rates both in urban areas and regions far removed from academic medical centers, such as rural Appalachia. But, a decade into the program, the researchers face an ongoing challenge as they encourage more people to get tested, namely the fear and stigma that swirl around smoking and lung cancer.

    Lung cancer kills more Americans than any other malignancy, and the death rates are worst in a swath of states including Kentucky and its neighbors Tennessee and West Virginia, and stretching south to Mississippi and Louisiana, according to data from the Centers for Disease Control and Prevention.

    It’s a bit early to see the impact on lung cancer deaths because people may still live for years with a malignancy, LEADS researchers said. Plus, treatment improvements and other factors may also help reduce death rates along with increased screening. Still, data already shows that more cancers in Kentucky are being detected before they become advanced, and thus more difficult to treat, they said. Of total lung cancer cases statewide, the percentage of advanced cases — defined as cancers that had spread to the lymph nodes or beyond — hovered near 81% between 2000 and 2014, according to Kentucky Cancer Registry data. By 2020, that number had declined to 72%, according to the most recent data available.

    “We are changing the story of families. And there is hope where there has not been hope before,” said Jennifer Knight, a LEADS principal investigator.

    Older adults in their 60s and 70s can hold a particularly bleak view of their mortality odds, given what their loved ones experienced before screening became available, said Ashley Shemwell, a nurse navigator for the lung cancer screening program at Owensboro Health, a nonprofit health system that serves Kentucky and Indiana.

    “A lot of them will say, ‘It doesn’t matter if I get lung cancer or not because it’s going to kill me. So I don’t want to know,’” said Shemwell. “With that generation, they saw a lot of lung cancers and a lot of deaths. And it was terrible deaths because they were stage 4 lung cancers.” But she reminds them that lung cancer is much more treatable if caught before it spreads.

    The collaborative works with several partners, including the University of Kentucky, the University of Louisville, and GO2 for Lung Cancer, and has received grant funding from the Bristol Myers Squibb Foundation. Leaders have provided training and other support to 10 hospital-based screening programs, including a stipend to pay for resources such as educational materials or a nurse navigator, Knight said. In 2022, state lawmakers established a statewide lung cancer screening program based in part on the group’s work.

    Jacob Sands, a lung cancer physician at Boston’s Dana-Farber Cancer Institute, credits the LEADS collaborative with encouraging patients to return for annual screening and follow-up testing for any suspicious nodules. “What the Kentucky LEADS program is doing is fantastic, and that is how you really move the needle in implementing lung screening on a larger scale,” said Sands, who isn’t affiliated with the Kentucky program and serves as a volunteer spokesperson for the American Lung Association.

    In 2014, Kentucky expanded Medicaid, increasing the number of lower-income people who qualified for lung cancer screening and any related treatment. Adults 50 to 80 years old are advised to get a CT scan every year if they have accumulated at least 20 pack years and still smoke or have quit within the past 15 years, according to the latest task force recommendation, which widened the pool of eligible adults. (To calculate pack years, multiply the packs of cigarettes smoked daily by years of smoking.) The lung association offers an online quiz, called “Saved By The Scan,” to figure out likely eligibility for insurance coverage.

    Half of U.S. patients aren’t diagnosed until their cancer has spread beyond the lungs and lymph nodes to elsewhere in the body. By then, the five-year survival rate is 8.2%.

    But regular screening boosts those odds. When a CT scan detects lung cancer early, patients have an 81% chance of living at least 20 years, according to data published in November in the journal Radiology.

    Some adults, like Lisa Ayers, didn’t realize lung cancer screening was an option. Her family doctor recommended a CT scan last year after she reported breathing difficulties. Ayers, who lives in Ohio near the Kentucky border, got screened at UK King’s Daughters, a hospital in far eastern Kentucky. The scan didn’t take much time, and she didn’t have to undress, the 57-year-old said. “It took me longer to park,” she quipped.

    She was diagnosed with a lung carcinoid tumor, a type of neuroendocrine cancer that can grow in various parts of the body. Her cancer was considered too risky for surgery, Ayers said. A biopsy showed the cancer was slow-growing, and her doctors said they would monitor it closely.

    Ayers, a lifelong smoker, recalled her doctor said that her type of cancer isn’t typically linked to smoking. But she quit anyway, feeling like she’d been given a second chance to avoid developing a smoking-related cancer. “It was a big wake-up call for me.”

    Adults with a smoking history often report being treated poorly by medical professionals, said Jamie Studts, a health psychologist and a LEADS principal investigator, who has been involved with the research from the start. The goal is to avoid stigmatizing people and instead to build rapport, meeting them where they are that day, he said.

    “If someone tells us that they’re not ready to quit smoking but they want to have lung cancer screening, awesome; we’d love to help,” Studts said. “You know what? You actually develop a relationship with an individual by accepting, ‘No.’”

    Nationally, screening rates vary widely. Massachusetts reaches 11.9% of eligible residents, while California ranks last, screening just 0.7%, according to the lung association analysis.

    That data likely doesn’t capture all California screenings, as it may not include CT scans done through large managed care organizations, said Raquel Arias, a Los Angeles-based associate director of state partnerships at the American Cancer Society. She cited other 2022 data for California, looking at lung cancer screening for eligible Medicare fee-for-service patients, which found a screening rate of 1%-2% in that population.

    But, Arias said, the state’s effort is “nowhere near what it needs to be.”

    The low smoking rate in California, along with its image as a healthy state, “seems to have come with the unintended consequence of further stigmatizing people who smoke,” said Arias, citing one of the findings from a 2022 report looking at lung cancer screening barriers. For instance, eligible patients may be reluctant to share prior smoking habits with their health provider, she said.

    Meanwhile, Kentucky screening efforts progress, scan by scan.

    At Appalachian Regional Healthcare, 3,071 patients were screened in 2023, compared with 372 in 2017. “We’re just scratching the surface of the potential lives that we can have an effect on,” said Stumbo, a lung cancer screening champion at the health system, which includes 14 hospitals, most located in eastern Kentucky.

    The doctor hasn’t shed his own grief about what his family missed after his mother died at age 51, long before annual screening was recommended. “Knowing that my children were born, and never knowing their grandmother,” he said, “just how sad is that?”




    Kaiser Health NewsThis article was reprinted from khn.org, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF – the independent source for health policy research, polling, and journalism.

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  • Groundbreaking study sheds light on the potential of the heart to achieve self-repair and regeneration

    Groundbreaking study sheds light on the potential of the heart to achieve self-repair and regeneration

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    A groundbreaking scientific study published in Nature Cardiovascular Research has unveiled a remarkable discovery that may have far-reaching implications for the treatment of heart disease.

    The intensive investigations utilizing single-cell genomics and genetic experiments were conducted by a team of renowned scientists in the Cardiomyocyte Renewal Laboratory and McGill Gene Editing Laboratory at The Texas Heart Institute, including James F. Martin Vivian L. Smith Chair in Regenerative Medicine and Vice Chairman and Professor of Molecular Physiology and Biophysics at Baylor College of Medicine, and co-first authors Xiao Li, PhD, and Rich Gang Li, PhD. Titled “YAP Induces a Neonatal Like Pro-Renewal Niche in the Adult Heart,” this research sheds light on the potential of the human heart to achieve self-repair and regeneration.

    Heart disease remains a leading cause of death worldwide, with myocardial infarction, also known as a heart attack, causing irreparable damage to cardiac muscle cells. While current treatments focus on alleviating symptoms and improving blood flow, they fall short in addressing the crucial issue of lost cardiomyocytes (CMs), leading to further complications such as heart failure. However, this groundbreaking study offers hope for a paradigm shift in regenerative medicine.

    Heart disease remains a leading cause of death worldwide, with myocardial infarction, also known as a heart attack, causing irreparable damage to cardiac muscle cells. While current treatments focus on alleviating symptoms and improving blood flow, they fall short of addressing the crucial issue of lost cardiomyocytes (CMs), leading to further complications such as heart failure. However, this groundbreaking study offers hope for a paradigm shift in regenerative medicine.

    Contrary to longstanding beliefs, the study reveals that regeneration of CMs requires a complex microenvironment, where a dynamic synergy between CMs, resident immune cells, and cardiac fibroblasts is the driving force behind cardiac renewal. Through intricate signaling mechanisms, these cell types coordinately instruct and support each other, facilitating CM proliferation and effectively repairing damaged heart tissue.

    “Understanding heart regeneration on a molecular level is an important step towards developing innovative therapeutics that can facilitate CM regeneration,” said the team in their lay summary. “Our study challenges the existing paradigm, suggesting that targeting the microenvironment rather than a specific cell type is instrumental in healing the injured heart.”

    The implications of this groundbreaking discovery are immense, offering glimpses of a future where heart disease may no longer be an irreversible condition but a challenge that can be overcome through medical intervention. The potential for developing novel therapies that leverage the body’s innate regenerative capacity holds great promise for millions of individuals affected by heart disease worldwide.

    “YAP Induces a Neonatal Like Pro-Renewal Niche in the Adult Heart” is a milestone in cardiac research. It unlocks a new avenue for scientific exploration and fosters hope for a future where damaged hearts can mend themselves. This remarkable study, published in a prestigious journal like Nature Cardiovascular Research, confirms the significance and impact of these findings.

    Source:

    Journal reference:

    Li, R. G., et al. (2024). YAP induces a neonatal-like pro-renewal niche in the adult heart. Nature Cardiovascular Research. doi.org/10.1038/s44161-024-00428-w.

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  • Managing migraines and menopausal symptoms to reduce cardiovascular risks in middle-aged women

    Managing migraines and menopausal symptoms to reduce cardiovascular risks in middle-aged women

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    For middle-aged women plagued by migraines, or hot flashes and night sweats, another worry may linger in the backs of their minds: whether these experiences have set them up for a heart attack, a stroke or another cardiovascular crisis.

    After all, past research suggesting such a link during and after menopause has gotten a lot of attention.

    But a pair of new studies in the journal Menopause suggest that most of them don’t need to worry as much, especially if they don’t have both migraines and long-term hot flashes and night sweats.

    Instead, they should focus on tackling the other factors that can raise their cardiovascular risk by getting more sleep, exercise and healthy foods, quitting tobacco, and minding their blood pressure, blood sugar, cholesterol and weight.

    For women who have experienced both migraines and hot flashes or night sweats over many years, one of the new studies does suggest an extra level of cardiovascular risk. That makes heart disease and stroke prevention even more important in this group, says study leader Catherine Kim, M.D., M.P.H., of the University of Michigan.

    And for women currently in their 20s and 30s who experience migraines, the new research suggests that they might be heading for a higher risk of long-term menopause-related symptoms when they get older.

    Long-term study yields important insights

    Kim and her colleagues at Michigan Medicine, U-M’s academic medical center, published the new pair of studies based on an in-depth analysis of data from a long-term study of more than 1,900 women who volunteered to have regular physical exams and blood tests, and to take yearly health surveys, when they were in their late teens to early 30s.

    Those women, now in their 50s and 60s, have provided researchers with a priceless view of what factors shape health in the years leading up to menopause and beyond, through their continued participation in the CARDIA study.

    “The anxiety and dread that women with migraines and menopausal symptoms feel about cardiovascular risk is real – but these findings suggest that focusing on prevention, and correcting unhealthy habits and risk factors, could help most women,” said Kim, who is an associate professor of internal medicine at U-M and a primary care physician.

    “For the subgroup with both migraines and early persistent hot flashes and night sweats, and for those currently experiencing migraines in their early adulthood, these findings point to an added need to control risks, and address symptoms early,” she adds.

    Just over 30% of the middle-aged women in the study reported they had persistent hot flashes and night sweats, which together are called vasomotor symptoms or VMS because they relate to changes in the diameter of blood vessels.

    Of them, 23% had reported also having migraines. This was the only group for whom Kim and her colleagues found extra risk of stroke, heart attack or other cardiovascular events that couldn’t be explained by other risk factors that have long been known to be linked to cardiovascular problems.

    In addition to those with persistent vasomotor symptoms starting in their 40s or before, 43% of the women in the study had minimal levels of such symptoms in their 50s, and 27% experienced an increase in VMS over time into their 50s and early 60s.

    The latter two groups had no excess cardiovascular risk once their other risk factors were taken into account, whether or not they had migraines. Use of hormone-based birth control and estrogen to address medical issues did not affect this risk.

    Controlling destiny

    In the study of data from the same women in their earlier stages of life, the researchers found that the biggest factors in predicting which ones would go on to have persistent hot flashes and night sweats were having migraines, having depression, and smoking cigarettes, as well as being Black or having less than a high school education.

    These two studies, taken together, underscore that not all women have the same experiences as they grow older, and that many can control the risk factors that might raise their chances of heart disease and stroke later in life. In other words, women can do a lot to control their destiny when it comes to both menopause symptoms and cardiovascular diseases.”


    Catherine Kim, M.D., M.P.H., University of Michigan

    She notes that the American Heart Association calls these risk factors the “Essential 8” and offers guides for what women, men and even children and teens can do to address them.

    Evolving knowledge and treatment

    The long-term study that the two new findings come from was specifically designed to look at cardiovascular risks when it launched in the mid-1980s. CARDIA stands for Coronary Artery Risk Development in Young Adults.

    Back in the 80s, knowledge about the biology of blood vessels, down to the cellular and molecular level, was nowhere near where it is today. Both vasomotor symptoms in menopause and migraines have to do with blood vessel contraction and dilation.

    But decades of research has shown the microscopic impacts on blood vessels of years of smoking, poor sleep, poor eating habits and lack of activity, as well as a person’s genetic inheritance, life experiences and hormonal history.

    Newer injectable migraine medications called calcitonin gene-related peptide (CGRP) antagonists have reached the market in recent years.

    Using monoclonal antibodies, they target a key receptor on the surface of blood vessel cells to prevent migraines and cluster headaches. But they are expensive and not covered by insurance for all people with migraines.

    While the new study is based on data from years before these medications became available, Kim said she recommends them to her patients with persistent migraines, as well as working with them to understand what triggers their migraines and how to use other medications including pain relievers and antiseizure medications to prevent them.

    She also notes that the paper on future risk of persistent hot flashes and night sweats echoes the recent trend of using antidepressant medications to try to ease these menopause effects.

    Kim also says that evidence has grown about the importance of healthy sleep habits for reducing hot flashes, as well the short-term use of estradiol-based hormone therapy patches, which have not been shown to have a link to cardiovascular risk. And, she notes that research has not shown any over-the-counter supplement or herbal remedy to be effective, and that these are far less regulated than medications.

    Additional authors:

    Kim and Deborah Levine, M.D., M.P.H., senior author of the paper on cardiovascular risk, are both on the faculty in the Division of General Medicine, and members of the U-M Institute for Healthcare Policy and Innovation. Levine heads the Cognitive Health Services Research Program or COG-HSR. Other authors on this paper are Pamela J. Schreiner, Ph.D., of the University of Minnesota, Zhe Yin, M.S., formerly of IHPI, Rachael Whitney, Ph.D., lead statistician at COG-HSR; Stephen Sidney, MD, MPH, of Kaiser Permanente Northern California and Imo Ebong, M.D. of the University of California, Davis.

    Schreiner is the senior author of the paper on later persistent VMS risk in younger women. Other authors on that paper are U-M’s Abbi Lane, Ph.D.; Zhe Yin, M.S.; Hui Jiang, Ph.D. and Richard Auchus, M.D., Ph.D.; as well as Thanh-Huyen Vu M.D., Ph.D. of Northwestern University and Cora Lewis, M.D. of the University of Alabama.

    The study was funded by the National Heart, Lung and Blood Institute (HL169167), which also sponsors the CARDIA study.

    Source:

    Michigan Medicine – University of Michigan

    Journal reference:

    Kim, C., et al. (2024) Migraines, vasomotor symptoms, and cardiovascular disease in the Coronary Artery Risk Development in Young Adults study. Menopause. doi.org/10.1097/GME.0000000000002311.

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  • Mediterranean and vegetarian diets boost heart health by improving novel CVD markers

    Mediterranean and vegetarian diets boost heart health by improving novel CVD markers

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    In a recent study published in the journal Nutrition & Metabolism, researchers evaluated the impact of the lacto-ovo vegetarian diet (VD) and Mediterranean diet (MD) on apolipoprotein levels and cardiovascular disease (CVD) risk factors among low-moderate-risk individuals.

    CVD is the leading cause of global mortality, necessitating the development of novel biomarkers for prevention, early diagnosis, and treatment. Apoproteins, which regulate lipoprotein metabolism, are considered a risk marker for CVD. The European Society of Cardiology (ESC) recommends ApoB as a CVD risk marker. ApoA-I, mainly found in high-density lipoprotein (HDL) lipids, play protective roles in reverse cholesterol transport. However, data on diet’s influence on apolipoproteins is limited.

    Study: Effects of a dietary intervention with lacto-ovo-vegetarian and Mediterranean diets on apolipoproteins and inflammatory cytokines: results from the CARDIVEG study. Image Credit: Brian A Jackson / ShutterstockStudy: Effects of a dietary intervention with lacto-ovo-vegetarian and Mediterranean diets on apolipoproteins and inflammatory cytokines: results from the CARDIVEG study. Image Credit: Brian A Jackson / Shutterstock

    About the study

    In the present study, researchers assessed the influences of MD and VD diets on circulating apolipoproteins and their association with cardiovascular disease risk estimators, such as inflammatory cytokine levels and lipid profiles.

    The study included 52 participants (39 women; mean age of 49 years) in the Cardiovascular Prevention with Vegetarian (CARDIVEG) diet randomized, crossover clinical trial. All individuals were at low-moderate CVD risk (<5.0% at ten years, using the ESC guidelines) and selected from the Clinical Nutrition Department of Careggi Hospital, Italy.

    Eligibility individuals were overweight or obese with body mass index (BMI) ≥25 kg/m2 and ≥1.0 cardiovascular disease risk factors: low-density lipoprotein (LDL) beyond 115 mg dL-1; triglyceride levels above 150 mg dL-1; total cholesterol above 190 g/dL; and fasting blood glucose ranging from 110 to 125.0 mg dL-1. The researchers excluded individuals with unstable medical conditions, medication prescriptions, expecting or breastfeeding women, and those who consumed poultry, fish, meat, or meat products or participated in weight loss programs in the previous six months.

    The participants followed the MD (27 individuals) and VD (25 individuals) diets for three months. Both diets comprised 50% to 55% carbohydrates, 15% to 20% proteins, and 25% to 30% total fats (≤7.0% of saturated fat, less than 300 milligrams of cholesterol). The team provided the participants with one-week menu plans, different recipes, and precise data on foods to consume and avoid.

    The primary outcomes were changes in body weight, fat mass, and BMI, and the secondary outcomes included changes in circulating CVD risk markers and apolipoprotein levels. The team obtained medical history, demographics, comorbidities, risk factors, lifestyle, and dietary data at study initiation. They collected blood samples with body composition and BMI data before and after the interventions.

    The team used the Medi-Lite and National Health and Nutrition Examination Survey (NHANES) questionnaires to assess adherence to MD and VD diets, respectively. They conducted a primary analysis using general linear modeling, evaluating differences in apolipoprotein levels by sex, age, and CVD risk factors. They used linear regressions to examine the association between these changes and lipid profiles, inflammatory profiles, and dietary components.

    Results

    MD and VD improved lipid profiles and anthropometric variables, reducing total energy, fats, and cholesterol and increasing total carbohydrates. VD lowered protein and increased dietary fiber, while MD decreased body weight, fat mass, and BMI. VD also reduces fat-free body mass. VD reduced LDL by 5.0%, while MD reduced serum triglycerides by 9.0%. Both diets lowered inflammatory parameters, with MD significantly decreasing interleukin-10 by 37% and interleukin-17 by 49%.

    Both diets reduced inflammatory parameters, with significantly higher (24%) ApoC-I levels after VD. Both diets increased ApoA-I (2.7% by VD and 6.1% by MD), ApoC-I (24% by VD and 11% by MD), and ApoD (6.5% by VD and 6.2% by MD) levels. However, ApoB/ApoA-I ratios reduced by 1.9% and 7.4% after VD and MD, respectively. Conversely, the team observed opposite trends for ApoB (+0.7% by VD and −1.6% by MD), ApoC-III (−5.6% by VD and +1.8% by MD), and ApoE (+14% by VD and −1.6% by MD).

    The team found negative correlations between apolipoprotein C-III and carbohydrates after MD and between ApoD levels and saturated fats after VD. In contrast, they found positive correlations between HDL and ApoD after VD and between serum triglycerides, ApoCI, and ApoD after MD. IL-17 positively correlated with ApoB and ApoC-III after VD. However, they found significant negative correlations between ApoC-III and carbohydrate percentage after MD and between ApoD and saturated fat percentage after VD. Serum triglycerides showed positive correlations with ApoC-I and ApoD levels after MD.

    HDL changes positively correlated with ApoD levels after VD. Linear regressions confirmed the results, adjusted for potential confounders such as weight change and the treatment order. The subgroup analyses showed that both diets positively influenced circulating apolipoproteins, especially in women aged ≥50 years with less than three cardiovascular disease risk factors.

    The study findings showed that VD and MD improve cardiovascular disease risk in low-moderate CVD-risk individuals by regulating lipid and inflammatory profiles. MD more positively affects apolipoprotein levels, especially in women, individuals aged >50 years, and those with one or two CVD risk factors. The study also found differences in associations between apolipoprotein levels and specific nutrients, with an unexpected inverse association between carbohydrate intake and ApoC-III after MD.

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  • GoFundMe has become a health care utility

    GoFundMe has become a health care utility

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    GoFundMe started as a crowdfunding site for underwriting “ideas and dreams,” and, as GoFundMe’s co-founders, Andrew Ballester and Brad Damphousse, once put it, “for life’s important moments.” In the early years, it funded honeymoon trips, graduation gifts, and church missions to overseas hospitals in need. Now GoFundMe has become a go-to platform for patients trying to escape medical billing nightmares.

    One study found that, in 2020, the annual number of U.S. campaigns related to medical causes — about 200,000 — was 25 times the number of such campaigns on the site in 2011. More than 500 current campaigns are dedicated to asking for financial help for treating people, mostly kids, who have spinal muscular atrophy, a neurodegenerative genetic condition. The recently approved gene therapy for young children with the condition, by the drugmaker Novartis, has a price tag of about $2.1 million for the single-dose treatment.

    Perhaps the most damning aspect of this is that paying for expensive care with crowdfunding is no longer seen as unusual; instead, it is being normalized as part of the health system, like getting bloodwork done or waiting on hold for an appointment. Need a heart transplant? Start a GoFundMe to get on the waiting list. Resorting to GoFundMe when faced with bills has become so accepted that, in some cases, patient advocates and hospital financial aid officers recommend crowdfunding as an alternative to being sent to collections. My inbox and the “Bill of the Month” project (a collaboration by KFF Health News and NPR) have become a kind of complaint desk for people who can’t afford their medical bills, and I’m gobsmacked every time a patient tells me they’ve been advised that GoFundMe is their best option.

    GoFundMe acknowledges the reliance of patients on its platform. Ari Romio, a spokesperson for the company, said that “medical expenses” is the most common category of fundraiser it hosts. But she declined to say what proportion of campaigns are medically related, because people starting a campaign self-select the purpose of the fundraiser. They might choose the family or travel category, she said, if a child needs to go to a different state for treatment, for example. So although the company has estimated in the past that roughly a third of the funds raised on the site are related to costs for illness or injury, that could be an undercount.

    Andrea Coy of Fort Collins, Colorado, turned to GoFundMe in 2021 as a last resort after an air-ambulance bill tipped her family’s finances over the edge. Sebastian, her son who was then a year old, had been admitted with pneumonia to a local hospital and then transferred urgently by helicopter to Children’s Hospital Colorado in Denver when his oxygen levels dropped. REACH, the air-ambulance transport company that contracted with the hospital, was out-of-network and billed the family nearly $65,000 for the ride — more than $28,000 of which Coy’s insurer, UnitedHealthcare, paid. Even so, REACH continued sending Coy’s family bills for the balance, and later began regularly calling Coy to try to collect — enough so that she felt the company was harassing her, she told me.

    Coy made calls to her company’s human resources department, REACH, and UnitedHealthcare for help in resolving the case. She applied to various patient groups for financial assistance and was rejected again and again. Eventually, she got the outstanding balance knocked down to $5,000, but even that was more than she could afford on top of the $12,000 the family owed out-of-pocket for Sebastian’s actual treatment.

    That’s when a hospital financial aid officer suggested she try GoFundMe. But, as Coy said, “I’m not an influencer or anything like that,” so the appeal “offered only a bit of temporary relief — we’ve hit a wall.” They have gone deep into debt and hope to climb out of it.

    In an emailed response, a spokesperson for REACH noted that they could not comment on a specific case because of patient-privacy laws, but that, if the ambulance ride occurred before the federal No Surprises Act went into effect, the bill was legal. (That act protects patients from such air-ambulance bills and has been in force since Jan. 1, 2022.) But the spokesperson added, “If a patient is experiencing a financial hardship, we work with them to find equitable solutions.” What is “equitable” — and whether that includes seeking an additional $5,000, beyond a $28,000 insurance payment, for transporting a sick child — is subjective, of course.

    In many respects, research shows, GoFundMe tends to perpetuate socioeconomic disparities that already affect medical bills and debt. If you are famous or part of a circle of friends who have money, your crowdfunding campaign is much more likely to succeed than if you are middle-class or poor. When the family of the former Olympic gymnast Mary Lou Retton started a fundraiser on another platform, *spotfund, for her recent stay in the intensive care unit while uninsured, nearly $460,000 in donations quickly poured in. (Although Retton said she could not get affordable insurance because of a preexisting condition — dozens of orthopedic surgeries — the Affordable Care Act prohibits insurers from refusing to cover people because of their medical history, or charging them abnormally high rates.)

    And given the price of American health care, even the most robust fundraising can feel inadequate. If you’re looking for help to pay for a $2 million drug, even tens of thousands can be a drop in the bucket.

    Rob Solomon, CEO of GoFundMe from 2015 to March 2020, who in 2018 was named one of Time magazine’s 50 most influential people in health care, has said that he “would love nothing more than for ‘medical’ to not be a category on GoFundMe.” He told KFF Health News that “the system is terrible. It needs to be rethought and retooled. Politicians are failing us. Health care companies are failing us. Those are realities.”

    Despite the noble ambitions of its original vision, however, GoFundMe is a privately held for-profit company. In 2015, the founders sold a majority stake to a venture-capital investor group led by Accel Partners and Technology Crossover Ventures. And when I asked about medical bills being the most common reason for GoFundMe campaigns, the company’s current CEO, Tim Cadogan, sounded less critical than his predecessor of the health system, whose high prices and financial cruelty have arguably made his company famous.

    “Our mission is to help people help each other,” he said. “We are not, and cannot, be the solution to complex, systemic problems that are best solved with meaningful public policy.”

    And that’s true. Despite the site’s hopeful vibe, most campaigns generate only a small fraction of the money owed. Most medical-expense campaigns in the U.S. fell short of their goal, and some raised little or no money, a 2017 study from the University of Washington found. Campaigns made an average of about 40% of the target amount, and there is evidence that yields — measured as a percentage of their targets — have worsened over time.

    Carol Justice, a recently retired civil servant and a longtime union member in Portland, Oregon, turned to GoFundMe because she faced a mammoth unexpected bill for bariatric surgery at Oregon Health & Science University.

    She had expected to pay about $1,000, the amount left of her deductible, after her health insurer paid the $15,000 cap on the surgery. She didn’t understand that a cap meant she would have to pay the difference if the hospital, which was in-network, charged more.

    And it did, leaving her with a bill of $18,000, to be paid all at once or in monthly $1,400 increments, which were “more than my mortgage,” she said. “I was facing filing for bankruptcy or losing my car and my house.” She made numerous calls to the hospital’s financial aid office, many unanswered, and received only unfulfilled promises that “we’ll get back to you” about whether she qualified for help.

    So, Justice said, her health coach — provided by the city of Portland — suggested starting a GoFundMe. The campaign yielded about $1,400, just one monthly payment, including $200 from the health coach and $100 from an aunt. She dutifully sent each donation directly to the hospital.

    In an emailed response, the hospital system said that it couldn’t discuss individual cases but that “financial assistance information is readily available for patients, and can be accessed at any point in a patient’s journey with OHSU. Starting in early 2019, OHSU worked to remove barriers for patients most in need by providing a quick screening for financial assistance that, if a certain threshold is met, awards financial assistance without requiring an application process.”

    This tale has a happy-ish ending. In desperation, Justice went to the hospital and planted herself in the financial aid office, where she had a tearful meeting with a hospital representative who determined that — given her finances — she wouldn’t have to pay the bill.

    “I’d been through the gamut and just cried,” she said. She said she would like to repay the people who donated to her GoFundMe campaign. But, so far, the hospital won’t give the $1,400 back.




    Kaiser Health NewsThis article was reprinted from khn.org, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF – the independent source for health policy research, polling, and journalism.

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  • UT Health San Antonio School of Dentistry opens special-care dental clinic in South Texas

    UT Health San Antonio School of Dentistry opens special-care dental clinic in South Texas

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    The UT Health San Antonio School of Dentistry has opened a special-care dental clinic, the first of its kind in an academic setting in South Texas that will serve people of all ages with intellectual, developmental, cognitive or physical disabilities.

    With spacious, specially designed treatment rooms featuring adjustable sound and lighting and even a “Zen Den” multi-sensory room to help reduce anxiety, the Phil and Karen Hunke Special Care Clinic occupies approximately 4,300 square feet on the first floor of the school’s Center for Oral Health Care and Research, at 8210 Floyd Curl Drive. The clinic is named for San Antonio-area philanthropists who provided seed money for the project. Phil Hunke, DDS, is a retired pediatric dentist.

    The state-of-the-art space includes seven dental treatment rooms and five rooms equipped with the capability to deliver conscious sedation, all to accommodate those with special needs and provide services for up to 40 patients per day. The clinic will serve the community and provide training for students.

    Numerous barriers exist in the current oral health care delivery model for individuals with special needs. At the heart of the issue is a lack of workforce trained and willing in the provision of services for this population.”


    Jennifer Farrell, DDS, DABSCSD, inaugural director of the clinic

    In one study, only 10% of dentists responding to a survey reported treating individuals with special needs and only one in four students had hands-on experience with those patients while in dental school.

    “Dental education institutions are the vital link in building a clinician base that will deliver services to this significantly underserved population,” said Peter M. Loomer, DDS, PhD, MBA, dean of the UT Health San Antonio School of Dentistry.

    Serving vital roles

    The clinic serves three vital roles. In addition to seeing patients from throughout South Texas, the facility will provide academic and clinical training to students in special-care dentistry across several disciplines, including dental and dental hygiene, medical, physician assistant and nursing. The clinic will serve as a resource for community dentists and social service providers, not only as a referral source but also for dissemination of information and advances in the treatment of individuals with special needs.

    The clinic builds on the region’s most comprehensive integrated dental practice, where patients receive care from experienced dentists, renowned specialists, advanced graduate residents or dental students overseen by faculty of the state’s top-ranked dental school.

    In addition to the generous support provided by the namesake donors, a $2 million federal Health Resources and Services Administration grant over five years is funding personnel and operating costs, and provider education. Also, $2.3 million from the Oral Health Improvement Program (OHIP) of the Texas Department of State Health Services is supporting the goal of expanding oral care for those with special health care needs.

    The roomy treatment areas allow multiple points of access based on the management needs of the patients, and with ample room for the patients and their families or caregivers, while being private. The Zen Den and a bubble wall offer sensory-regulating features.

    Entrances, the reception area and corridors also are designed to allow easy access, and with hallways that include railing and wheelchair bumpers. Patients will have access to a wheelchair tilt if needed, though most patients will be able to receive treatment in their wheelchairs without a tilt.

    Compehensive exams will determine what level of sedation is most appropriate for a patient, with five suites specially designed with the latest equipment to deliver full treatment along with conscious sedation. The clinic’s location inside the Center for Oral Health Care and Research gives access to additional treatment spaces that allow full sedation if necessary.

    “We provide a full range of preventive, routine and comprehensive dental care for all ages and dental needs,” said Micaela Gibbs, DDS, MHA, clinical associate professor and chief dental officer of the UT Health San Antonio School of Dentistry. “Customized care plans are created based on a patient’s unique set of circumstances and tolerance for treatments.”

    What to expect

    The first visit typically will include a comprehensive oral evaluation, X-rays, cleaning, fluoride application, tailored instructions for home oral hygiene care and nutritional guidance, and development of a tentative plan for ongoing care – and will take from one to two hours.

    The clinic accepts Medicaid for qualified patients under the age of 21 and select dental insurance. Third-party financing options are available for patients requiring a payment plan.

    As the clinic’s founding director, Farrell brings more than 30 years of experience providing care for patients with disabilities. Before joining here, she was director of the Special Patient Care Dental Program at Advocate Illinois Masonic Medical Center in Chicago for 13 years and treated patients with special needs through that program for more than 28 years.

    In 2021, Farrell received the Lawrence J. Chasko Distinguished Service Award from the Special Care Dentistry Association.

    Source:

    University of Texas Health Science Center at San Antonio

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  • Blocking artery plus surgery offers hope for reducing reoperations in brain hematoma patients

    Blocking artery plus surgery offers hope for reducing reoperations in brain hematoma patients

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    Injection of a substance to block an artery feeding the dura (protective sack around the brain) along with surgery to remove pooled blood reduced the risk that patients will require repeat surgery compared to surgical drainage alone, according to preliminary late-breaking science presented today at the American Stroke Association’s International Stroke Conference 2024. The meeting, held in person in Phoenix Feb. 7 – 9, 2024, is a world premier meeting for researchers and clinicians dedicated to the science of stroke and brain health.

    A subdural hematoma occurs when there is a tear in one of the thin blood vessels that stretch between the surface of the brain and the overlying membranes that protect the brain. A subdural hematoma can occur because of physical trauma such as a car accident, however, it may also develop slowly in the days or weeks after the injury. This study explored treatment for subacute or chronic subdural hematoma. Subacute subdural hematoma occurs following less severe trauma, such as a concussion – with symptoms such as weakness, numbness, tingling, seizure, headache, confusion or dizziness that develops over hours or days after the event. Chronic subdural hematoma can result from slow bleeding after minimal trauma that the patient may not even remember – symptoms may be subtle and/or may take weeks to be noticeable enough to seek treatment.

    Chronic subdural hematoma is one of the most common neurosurgical conditions and is likely to increase in the future since we have a sizeable aging population, with many taking blood thinners to manage various medical conditions. These hematomas often form in the elderly because as we age, the brain shrinks and pulls away from the inside of the skull, stretching the veins that form a bridge between the dura and the brain, which makes them more likely to tear after a small trauma and leak blood into the protective space between the brain and skull, the dura.”


    Jason Davies, M.D., Ph.D., study co-author, associate professor in the departments of neurosurgery and biomedical informatics at the State University of New York, Buffalo

    Treatment for subacute or chronic subdural hematoma may involve a surgical procedure to drain pooled blood from the area or closely monitoring symptoms to determine if and when intervention may be necessary. The challenge is that even with surgery, repeat surgery may be needed in up to 20% of cases of subdural hematomas.

    The EMBOLISE clinical trial tested whether a subacute or chronic subdural hematoma is less likely to require additional surgery if, in addition to surgical drainage, a substance is injected to block, or embolize, one of the arteries supplying blood to the dura. The OnyxTM liquid embolic system, tested in this trial, is already used prior to surgery to reduce bleeding in people having an operation to correct an abnormal connection between arteries and veins in the brain.

    Between December 2020 and August 2023, researchers enrolled 400 adults (average age of 72; 27% women) at 39 centers (including both community and academic hospitals). All were about to undergo surgery for subacute or chronic subdural hematoma and were considered able to care for themselves and likely to survive at least one year. Patients were randomly assigned to receive either surgery alone or surgery plus embolization using the liquid embolic system to help reduce the progression or recurrence of subdural hematoma.

    The primary outcome was how frequently there was reaccumulation of blood (a recurrence) that required surgical drainage within 90 days.

    The analysis found:

    • Subsequent subdural hematoma within 90 days and need for surgical drainage occurred in 4.1% of patients who had surgery plus embolization and 11.3% of those who had surgery alone.

    • At 90 days after surgery, increasing disability and neurological dysfunction was found to be comparable (statistically the same) in both groups, with 11.9% of patients who had surgery plus embolization and 9.8% of patients who had surgery alone.

    • Serious adverse events attributed to embolization occurred in 2% of patients who received it.

    “The EMBOLISE trial showed that there was a nearly 3-fold reduction in re-operation for patients that were treated with surgery plus embolization,” Davies said. “Fewer trips to the operating room mean less potential for pain, complications, recovery and expense for the patient. Furthermore, we see that the complications related to the embolization procedure were low and that there was no increase in neurological problems.” 

    Study details and background:

    • The EMBOLISE (Embolization of the Middle Meningeal Artery With OnyxTM Liquid Embolic System in the Treatment of Subacute and Chronic Subdural Hematoma) study was conducted at multiple hospitals and health centers in the United States.

    • The liquid embolic system treatment starts as an injectable soft solid, flows as a liquid when force is applied, and then returns to a soft solid state to stop the leaking blood vessel.

    • Other arms of the EMBOLISE study, which included patients not undergoing surgery and randomized to either receive the liquid embolic system or not, are ongoing and not being presented at ISC 2024.

    • Additional measures to gauge success of the liquid embolic system treatment included the number of hospital readmissions; change in hematoma (pooling of blood) volume or thickness; and change in midline shift (when a hematoma pushes brain tissue out of alignment), all assessed at 90 days after treatment.

    • Safety endpoints included the incidence of neurological death or serious adverse events occurring within 30, 90 and 180 days after treatment.

    The main limitation was a relatively high loss to follow up. “One of the challenges of conducting this trial was dealing with a frail elderly population, especially in the middle of the pandemic. Tracking patients down for follow up is always a challenge, and these were compounded by the various COVID-era restrictions that many of our sites faced,” Davies said.

    Source:

    American Heart Association

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