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May 16, 2016

Young Children With Sleep Apnea May Face Learning Difficulties: Study

– Sleep apnea in young children may affect youngsters’ attention, memory and language development, a new study suggests.

The researchers added that as sleep apnea worsens, the risk of these problems also may increase.

“Although evidence suggesting the presence of cognitive deficits in children with sleep apnea has been around for quite some time, the relatively small groups studied made it difficult to demonstrate a strong relationship between increasing cognitive issues and increasing sleep apnea severity,” said Dr. Leila Gozal, from the University of Chicago.

Sleep apnea causes people to experience repetitive pauses in breathing while they sleep. This causes oxygen levels to drop temporarily, according to the U.S. National Heart, Lung, and Blood Institute.

While the new study with children did not prove cause-and-effect, previous research has shown that sleep apnea in adults is associated with trouble concentrating, memory issues, poor decision-making, depression and stress.

The new study involved almost 1,400 public schoolchildren with sleep apnea. The kids ranged in age from 5 to 7. Some, but not all, of the children snored.

The researchers divided the children into four groups based on the severity of their sleep apnea.

The kids participated in an overnight sleep study and answered detailed questions about their sleep. The children also completed tests to measure certain aspects of brain function, including language and decision-making skills.

After comparing the results in each group, the researchers found that even mild problems such as snoring had a negative effect on children’s thinking abilities, the researchers reported in a news release from the American Thoracic Society.

Gozal said the findings suggest that the development of simple brain function tests that could be used along with current clinical evaluation of children with habitual snoring might help guide the treatment of children with sleep apnea.

May 8, 2016

Zika Destroys Fetal Brain Cells, Lab Study Finds

The terrible birth defects caused by Zika virus appear to be the result of an immune system response that triggers prenatal brain cell suicide and obstructs fetal brain development, a new lab study reports.

The virus apparently activates an immune receptor called TLR3, which the body uses to identify and defend against invading viruses, said lead researcher Tariq Rana. He is a professor of pediatrics and genetics at the University of California, San Diego.

The hyper-activated TLR3 then proceeds to turn off genes that fetal stem cells need to specialize into brain cells, and appears to switch on genes that trigger cell suicide, Rana said.

“We all have an innate immune system that evolved specifically to fight off viruses, but here the virus turns that very same defense mechanism against us,” Rana explained. “By activating TLR3, the Zika virus blocks genes that tell stem cells to develop into the various parts of the brain.”

These findings help explain how Zika causes microcephaly, an abnormally small brain and skull development, and other neonatal brain-related birth defects, Rana said. They also show why there’s no similar effect in adults, since their brains are already fully developed.

There’s also good news for the potential prevention of brain birth defects due to Zika. Rana and his team successfully blocked this process in laboratory stem cell samples by using a chemical that inhibits the action of TLR3.

A drug that safely blocks TLR3 could possibly save babies from birth defects if given to Zika-infected women during the early stages of pregnancy, he said.

“If some mom comes into the clinic and the doctor thinks there is a Zika infection established, you could give this med, and once the first trimester is done, you can take them off the med,” Rana suggested.

Zika is the first mosquito-borne virus ever proven to cause birth defects, according to the U.S. Centers for Disease Control and Prevention.

To figure out why this happens, Rana and his team used human embryonic stem cells to create a laboratory model of a first-trimester human brain, also called a “cerebral organoid.” The model’s stem cells were designed to specialize and grow into the various different cells in the brain, much the same as they do during a fetus’ first trimester.

Researchers then infected their model with Zika and found that a developing brain shrinks when exposed to the virus.

Five days after infection, Zika-infected organoids had decreased in size by an average 16 percent, the researchers found. By comparison, healthy brain organoids in a control sample had grown an average of 22.6 percent.

Rana’s team noticed that the TLR3 gene had been activated in the Zika-infected model brains.

TLR3’s job is to sense viruses and activate an immune response. But the researchers found TLR3 activation influenced 41 genes in the fetal brain and caused a disastrous chain-reaction that both prompted cells to die off and interfered with stem cells’ ability to grow into different brain cells.

By adding a chemical TLR3 inhibitor, Rana’s team found they could partially protect developing brain cells against Zika, although the virus still wound up doing some damage to their model brain.

Rana said this research has only been conducted in human and mouse cells, and needs to be replicated in actual organisms before it can be used to create any therapy to counter Zika.

But infectious disease expert Dr. Amesh Adalja called the work an “elegant study that begins to unravel how Zika is capable of causing microcephaly in the developing fetus.”

Adalja, a senior associate with the University of Pittsburgh Medical Center’s Center for Health Security, said, “We had known prior to this study that Zika had the capacity to infect neural progenitor cells and cause damage.”

With this study, he added, “we now have an elucidation of one mechanism that the virus uses, TLR3. This discovery opens up avenues for further understanding of the entire cascade of changes in gene expression that are caused by Zika infection.”

April 23, 2016

New Guidelines Issued on Breast, Genital Plastic Surgery for Teen Girls

A growing interest among teenaged girls in plastic surgery on their breasts or genitals has prompted a leading ob/gyn group to recommend that doctors first talk to these young women about “normal” sexual development.

“Our membership has been telling us this is coming up more and more frequently with their adolescent patients,” said Dr. Julie Strickland. She is chair of the Adolescent Health Care Committee of the American College of Obstetricians and Gynecologists (ACOG).

The new recommendations also suggest that physicians screen these patients for body dysmorphic disorder, which is an obsession with an imagined or slight defect in appearance.

There are already guidelines from the American Society of Plastic Surgeons (ASPS) on breast augmentation and reduction among teenagers. If it’s strictly for cosmetic reasons, the society recommends surgery should generally be delayed until age 18.

But, Strickland said, there’s no guidance for cases where teenagers want labiaplasty — where surgery is used to reduce the inner labia, the folds of skin that surround the vaginal opening.

Normal labia come in all sizes and shapes, Strickland said, and there’s no widely accepted definition of labial “hypertrophy,” or enlargement. Nor are there clear guidelines on when surgery might be appropriate for teenagers.

The new guidelines appear in the May issue of Obstetrics & Gynecology.

When girls are worried about the appearance of their breasts or genitals, Strickland said, the anxiety can often be “diffused” by letting them know there is a wide variation in “normal” development.

Even in this day and age, she noted, many girls do not know what their genitals are “supposed” to look like. “Despite all of the anatomy books that have been published over the years, we’re lacking in descriptions of normative female genital development,” Strickland said.

Nationwide, about 8,000 13- to 19-year-olds underwent breast augmentation in 2014, according to the ASPS. Statistics on breast reduction are harder to come by, but in 2010 about 4,600 were performed on 13- to 19-year-olds.

The ASPS does not track labiaplasty figures, and it’s not clear how many teenagers have the procedure each year, according to ACOG.

No one knows exactly why teenagers are voicing more concerns about their labial development, either, Strickland said.

“One theory is that girls these days are seeing images of ‘idealized’ bodies,” Strickland said. “There have also been cultural changes, with more girls grooming their pubic hair. That may make them more self-conscious about the appearance of their genitals.”

Then there are the yoga pants and other form-fitting clothes that can either make girls scrutinize their appearance, or be physically uncomfortable, she added.

And it is actually physical discomfort that seems to be the main issue for teenage girls who want labiaplasty, said Dr. David Song, president of the ASPS. Song is also chief of plastic and reconstructive surgery at the University of Chicago.

“It’s pretty rare to have a teenager coming in for cosmetic reasons,” Song said.

When the inner labia protrude from the outer labia, he explained, it can be “very uncomfortable” to wear tighter clothing, or to exercise at all. In those cases, surgery to reduce the inner labia may help a girl feel better physically and emotionally, Song said.

He agreed that it’s important to be sure teenagers are mature enough, and fully informed of the risks, before any plastic surgery. With labiaplasty, ACOG says, the potential risks include infection, scarring, and pain during sex.

According to Song, board-certified plastic surgeons are also trained to screen for body dysmorphic disorder and other mental health issues, like depression.

“They understand when they should be referring patients to a mental health professional,” Song said.

That’s why it’s key, he added, for parents and young women to make sure they’re seeing a surgeon who is board-certified.

When it comes to breast surgery, the ASPS does recommend that it generally be delayed to age 18. But, Song said, the issue is “not black-and-white,” and there are cases where earlier may be better.

An example, he said, would be a younger teen whose breast growth is far out of proportion to the rest of her body — to the point that it’s causing her physical discomfort.

According to Strickland, the bottom line for parents is this: Listen to your daughter’s concerns about her development, and be able to reassure her that she’s going through normal changes. If you’re not sure of what’s “normal,” talk to your pediatrician or family doctor, Strickland said.

“It’s typical for teenagers to question whether they’re ‘normal’ or not,” she noted. “So we shouldn’t be ‘horrified’ if they come to us with these questions. We need to respond sensitively and honestly.”

April 2, 2016

Endometriosis linked to increased risk of coronary heart disease

Women with endometriosis, a painful uterus condition, may be at a higher risk for coronary heart disease (CHD), a new study suggests.

The link was found to be strongest among young women. Having had a hysterectomy or oophorectomy was also tied to a higher risk of CHD, which explained partially the association between endometriosis and CHD.

Researchers analysed the potential connection between laparoscopically confirmed endometriosis and subsequent CHD among 116,430 women in the Nurses’ Health Study II (1989–2009). Excluded from the study were those with a history of heart disease and stroke.

Women with endometriosis had a higher risk of myocardial infarction, angiographically confirmed angina, coronary artery bypass graft surgery/coronary angioplasty procedure/stent, or any of these CHD endpoint combined when compared with women without the gynecologic disease.

The result was independent of potential demographic, anthropometric, family history, reproductive, and lifestyle confounders.

Relative risk for the combined CHD endpoint was highest among women aged ≤40 years and decreased as age increased (40<age≤50 years, 50<age≤55 years and age >55 years.

Women who had hysterectomy/oophorectomy had a higher risk of combined CHD compared with those who had not undergone the procedure. Greater frequency of hysterectomy/oophorectomy and earlier age at surgery after endometriosis diagnosis explain the 42 percent association between the gynaecologic condition and CHD.

March 29, 2016

Managing dengue fever in primary care

Dengue fever is caused by the dengue virus and borne by the Aedes mosquito. The disease is now endemic in over 100 countries, according to the World Health Organization, but is still most common in Southeast Asian and countries in the Western Pacific. The virus causes flu-like symptoms that generally resolve on their own with supportive care but severe cases require further management and possibly hospitalization. Primary care doctors are frequently the first point of contact for people with dengue fever.

Dengue fever is a mosquito borne infection caused by the dengue virus, the most common mosquito borne viral infection in the world. We no longer talk about dengue as a disease affecting Asian countries – at least half of the world population is at risk for dengue because of where they live and their exposure to the virus from mosquitoes bites.

Since 2013, the total number of dengue cases recorded in Singapore has remained high at more than 10,000 cases annually. This is likely the result of a combination of factors such as high mosquito population, warmer weather, increasing urban density and low herd immunity in the Singapore local resident population.

Primary care doctors probably play the biggest role in identifying and caring for patients with dengue fever. Most of the time patients will go to their family doctor to seek medical advice first, as the symptoms of early dengue infection cannot be differentiated from other viral illnesses. If dengue is suspected, nonsteroidal anti-inflammatory drugs (NSAIDS) and intramuscular injections should be avoided due to the risk of bleeding. The family physician should monitor the patient regularly throughout the course of illness. If the doctor is concerned that the patient may be at risk for severe dengue, the doctor should then refer the patient to hospital for further medical evaluation.

Dengue fever: running the course

Dengue fever is a self-limiting illness. Once a person is bitten by a virus-carrying mosquito he/she will come down with flu-like symptoms after an incubation period of 3-7 days. The patient may experience high fever, body aches and pains, loss of appetite and, in some cases, nausea and vomiting. Most patients will recover from the infection after about a week of illness.

One of the hallmarks of dengue fever occurs around day 4-5 of illness – the fever begins to improve but the blood platelet count starts to fall. This might cause patients to present with petechial rashes, which are small capillary bleeds just under the skin that look like small red dots. They are harmless but can be alarming and usually send patients back to the doctor who, under suspicion of dengue fever, would refer the patient to a hospital or polyclinic for a blood test.

Depending on how low the platelet levels are, and if the patient is otherwise well (if they are young, healthy, and able to drink sufficient fluids), they can be sent home and instructed to rest. Polyclinic doctors can continue to monitor the patient without referring to a hospital.

However, if the platelets are low and the patient is unwell, has poor appetite, is not able to drink sufficient fluids, or if there is a worry of dengue complications that may result in severe dengue, doctors may refer the patient to hospital for further management.

Plasma leaks and bleeding

The most important thing about dengue virus is its ability to cause severe disease. It is not well understood how the virus interacts with the cell lining of blood vessels but in severe dengue, plasma leaks into the surrounding tissues and accumulates. Fluid can accumulate in the lungs as well, resulting in hypotension and shock if the person does not receive fluid resuscitation in time.

The other feared complication is bleeding. Bleeding can occur in the gut, gums, urinary tract and brain. Women may also experience heavy menstrual bleeds.

Patients over 65 years, those with other medical conditions such as diabetes, pregnant women, and young children may be at risk for more severe forms of dengue infection. However, who is at risk for bleeding is not well understood.

Some other clues that a patient might be experiencing severe dengue include restlessness, abdominal pain, persistent vomiting, and bleeding of the gums or blood in the vomitus or stool. These are important symptoms for a primary care doctor to look out for to decide if a patient can be sent home to rest or come to hospital attention. If in doubt, medical practitioners should refer the patient to the hospital for further assessment.

No “magic bullet” for dengue

There is no curative treatment for dengue infection. Rather, medications are given to alleviate the signs and symptoms. Aspirin should not be given to patients. It can cause severe bleeding. Paracetamol are usually prescribed to relieve fever, muscle and joint aches, and headache. Bed rest is essential and the patient should consume plenty of water which will help to alleviate the illness.

In general, dengue fever is self-limiting. Death rarely occurs in severe cases and most well developed countries have trained medical personnel and proper care facilities to manage severe disease. The fatality rate is less than 1 percent in such countries.

Theoretically, a person may contract dengue fever four times as there are four different serotypes of virus. It is not uncommon to get dengue fever at least twice in a lifetime for people living in endemic areas. However, patients cannot fall ill with the same serotype twice as they will have developed antibodies against that serotype.

Evaluation of the usefulness of the Sanofi Pasteur dengue vaccine is ongoing. It is currently not approved for use in Singapore. The vaccine was found to be safe and among individuals aged 9 years and older, efficacy was higher than in younger children with an overall efficacy against any of the four serotypes of 60 percent.

Conclusion

Dengue fever is the most common mosquito borne viral infection worldwide. Most of the time, it is a self-limiting illness though its presentation cannot be differentiated from other viral illnesses. Severe dengue can occur in a subgroup of patients at high risk and is characterized by plasma leakage and/or bleeding. It is important to recognize the symptoms of severe disease early so that patients can be referred for proper medical care at the critical stages of illness to prevent complications and death.

March 19, 2016

Adjunct antibiotic therapy improves outcomes of abscess drainage

Antibiotic therapy after surgical drainage of abscesses improves cure rates, even in the presence of methicillin-resistant Staphylococcus aureus (MRSA), according to results of a recent US study.

Eighty percent of individuals given trimethoprim and sulfamethoxazole achieved clinical cure compared to 73.6 percent of patients given placebo after surgical drainage of a cutaneous abscess.

Adjunct antibiotic treatment also reduced the need for subsequent drainage (3.4 percent in the treatment group vs 8.6 percent in the placebo group), skin infections at a different site (3.1 vs 10.3 percent) and infections among household members (1.7 vs 4.1 percent) 7 to 14 days post-treatment.

There was a higher incidence of adverse events in the treatment arm, though these were mostly mild gastrointestinal problems.

“Adjunctive oral treatment with trimethoprim-sulfamethoxazole, which is inexpensive, appears to be safe, and is associated with a high cure rate of the primary lesion, offers the possibility of lower rates of costly subsequent medical visits, surgeries, and hospitalizations and of new infections among patients and their household contacts,” said the study authors.

Participants of this double-blind, randomized trial were 1,265 patients aged >12 years who presented at 5 US Emergency Departments (EDs) with uncomplicated cutaneous abscesses which were treated with drainage. Among them, 45.3 percent had wound cultures that were positive for MRSA. Participants were given a combination of trimethoprim (320 mg) and sulfamethoxazole (1600 mg) twice daily for 7 days or a placebo.

While previous small studies have shown that adjuvant therapy with trimethoprim-sulfamethoxazole helped prevent the formation of new lesions in the short-term, they were not recommended for widespread use.

“Traditional teaching has been that the only treatment needed for most skin abscesses is surgical drainage – and that antibiotics don’t provide an extra benefit,” said Dr. Gregory Moran, Clinical Professor of Emergency Medicine at the David Geffen School of Medicine, University of California, Los Angeles (UCLA), California, US, and one of the authors of the present study. He hoped that the results would help guide doctors in treating abscesses.

According to the authors, adjunctive antibiotics are recommended for patients with coexisting conditions such as diabetes and cellulitis and those who have infected lesions that are larger than 5 cm. In the case of this study, many participants met the criteria for the use of antibiotics, said the authors.

March 12, 2016

High coronary artery calcium increases dementia risk among the elderly

High levels of the atherosclerosis marker coronary artery calcium (CAC) may be a good predictor of mortality and coronary heart disease (CHD) risk as well as myocardial infarction in individuals aged 80 and older without cardiovascular disease (CVD), according to a US-based observational study.

Researchers looked at 532 participants to determine whether CAC levels correlated with death, dementia and CHD among the elderly. CAC was defined as deposits that can narrow arteries and increase heart attack risk.

Of the total number of participants, 36 percent had CAC scores that were greater than the highest level (>400). Women and African-Americans showed lower CAC scores than men. CAC score and number of coronary calcifications directly correlated to age-adjusted total mortality and CHD. Age-specific incidence of dementia was higher than of CHD.

About 25 percent of deaths were attributed to CHD and 16 percent to dementia. Of the total deaths reported, 64 percent were of individuals with prior diagnosis of dementia. White women with low CAC scores had a significantly decreased incidence of dementia.

The findings suggest that the prevalence of dementia in older populations will likely increase as prevention and treatment of CHD improve and increase the longevity of the general population. A zero or very low CAC score could be associated with a low risk of dementia and cardiovascular risk factors such as high blood pressure, diabetes, smoking and sedentary behaviour leading to the development of atherosclerosis and eventually CHD could also affect progression of brain pathology, such as dementia risk.

The study highlights that people who reach older ages can expect a significant increase in the risk of dementia, although the small sample size necessitates replication of the results in other studies of the elderly.

March 5, 2016

Daily Low-Dose Aspirin Linked to Reduced Risk of Certain Cancers

The effect was seen most strongly with colon, gastrointestinal tumors, researchers report

Taking low-dose aspirin every day may lower the overall risk of cancer by 3 percent, mostly because of larger reductions that were seen in the risk for colon and gastrointestinal tumors, researchers are reporting.

But the benefit was only seen after six years of taking aspirin almost daily, the study authors said.

“That makes sense, because cancers don’t typically develop overnight. They take years to develop, so you would have to take aspirin for a long time to prevent cancer,” said senior researcher Dr. Andrew Chan, from Massachusetts General Hospital in Boston.

“There is scientific evidence that aspirin has an effect on certain biological pathways that can result in cancer,” he said. And it also reduces inflammation and the amount of some cancer-causing proteins.

This study shows only that taking aspirin is associated with a reduction in the risk of cancer, not that it prevents the disease, Chan said. However, other studies have come to the same conclusion, he added.

“The evidence has reached the point that it may be useful to consider using aspirin to prevent colon cancer,” he said. “But we are still not at a point where the general population should take aspirin for cancer prevention.”

The report was published online March 3 in the journal JAMA Oncology.

Dr. Ernest Hawk is vice president of the division of cancer prevention and population sciences at the University of Texas MD Anderson Cancer Center, in Houston. He said, “This is another study suggesting reductions in gastrointestinal and colon cancers among people who take aspirin for other reasons, such as reducing the risk of heart attacks or treating arthritis and relieving pain.” Hawk co-authored an editorial that accompanied the research.

For the study, Chan and colleagues looked at the link between aspirin and cancer among more than 130,000 women and men who took part in the long-term Nurses’ Health Study and the Health Professionals Follow-up Study.

During more than 30 years of follow-up, there were more than 20,000 cancers among more than 88,000 women, and more than 7,500 cancers among nearly 48,000 men, the study found.

Taking low-dose aspirin two times or more per week was associated with a 3 percent lower risk for cancer overall, mostly due to a 15 percent lower risk for gastrointestinal cancers and a 19 percent lower risk for cancers of the colon and rectum, the findings showed.

Aspirin, however, was not associated with a lower risk for other major cancers, such as breast, prostate or lung cancer, the investigators found.

Taking aspirin regularly might prevent 17 percent of colon cancers among those who are not screened with colonoscopy and 8.5 percent of colon cancers among those who are, the research indicated.

“Aspirin may serve as a relatively low-cost primary prevention for gastrointestinal and colon cancers, with reductions in cancers complementing recommended cancer screening,” Hawk said.

Although the evidence is mounting that aspirin may reduce the risk of colon and other cancers, the American Cancer Society does not currently have recommendations for or against aspirin use, said Eric Jacobs, the cancer society’s strategic director for pharmacoepidemiology.

People who have had a heart attack or stroke are usually prescribed aspirin unless there is a good reason not to, such as a recent history of stomach ulcers, Jacobs said.

“People who have not had a heart attack or stroke need to consider the overall balance of risks and benefits, including lower risk of heart disease and colon cancer, but higher risk of serious stomach bleeding,” he said. “This makes more sense than thinking about taking aspirin just for prevention of cancer.”

People who are wondering if they should start taking aspirin should first talk to their physician. The doctor will be able to take into account the patient’s risk for heart disease, as well as reasons why regular aspirin use might not be right for them, Jacobs said.

Aspirin is not a substitute for getting screened for colon cancer, he said. “All Americans 50 or older should talk to their doctor about getting tested for colon cancer so that polyps can be detected and removed before they get a chance to develop into cancer,” Jacobs explained.

SOURCES: Andrew Chan, M.D., M.P.H., Massachusetts General Hospital, Boston; Ernest Hawk, M.D., M.P.H., vice president, division of cancer prevention and population sciences, University of Texas MD Anderson Cancer Center, Houston; Eric Jacobs, Ph.D., strategic director, pharmacoepidemiology, American Cancer Society; March 3, 2016, JAMA Oncology, online

February 28, 2016

Zika in Early Pregnancy May Be More Dire, CDC Suggests

A small case study released today by the Centers for Disease Control and Prevention (CDC) supports the agency’s suspicion that when pregnant women contract the Zika virus there is higher risk for adverse outcomes for the fetus, including microcephaly.

That risk appears especially associated with a Zika infection in the first trimester of pregnancy.

The discouraging news came on the same day that the CDC issued a new travel alert recommending that pregnant women not go to the Summer Olympics in Brazil, which is experiencing surges in both Zika infections and infants with microcephaly. The agency also announced that it is establishing a special registry for pregnant women in the United States who contract the virus to better understand this public health threat.

In the latest edition of the agency’s Morbidity and Mortality Weekly Report (MMWR), CDC investigators outline the cases of nine pregnant women who became infected with the Zika virus after traveling to an area of active transmission. None of them died or were hospitalized. One woman who experienced Zika symptoms in her third trimester delivered a healthy infant, as did a woman whose symptoms appeared in the second trimester. The pregnancy of another woman with second-trimester symptoms is continuing.

For six women who reported Zika symptoms in their first trimester, the outcomes were mostly grim. Two of them miscarried, two aborted their pregnancies, and another delivered an infant with microcephaly. The sixth woman has yet to deliver her child.

One woman chose to end her pregnancy after an ultrasound suggested the absence of the corpus callosum, ventriculomegaly, and brain atrophy at the 20-week mark. A follow-up fetal MRI revealed severe brain atrophy. Reverse transcription polymerase chain reaction testing detected the RNA of Zika virus in the woman’s amniotic fluid.

The MMWR article did not provide details about the other woman who had an abortion, or the health status of her fetus. Denise Jamieson, MD, MPH, a member of the agency’s Zika response team, said at a news conference today that there was no additional information on the second terminated pregnancy. Dr Jamieson coleads a section of the team focused on pregnancy and birth defects.

The results of the case study, small as it was, were surprising, she said.

“We did not expect to see these brain abnormalities in this small case series of US pregnant travellers,” Dr Jamieson said. “It is…greater than what we would have expected.”

CDC Director Tom Frieden, MD, MPH, reiterated at the news conference that although the Zika virus is strongly suspected of causing microcephaly, based on a growing body of evidence, “there’s no definite proof that it’s the sole cause.” The CDC and public health authorities in Brazil are conducting larger studies into the relationship, but the results could be months away.

The CDC hopes to glean insights from a voluntary registry it is launching on pregnant women here who contract the Zika virus. The CDC will collect data from public health agencies and individual clinicians.

Sexual Transmission of Virus More Common Than Once Believed

Another study published today in MMWR confirmed that the Zika virus spreads through sexual relations, and does so more commonly than once believed.

The article reported on 14 cases of suspected sexual transmission. In each one, a man who had traveled to an area of active virus transmission developed symptoms within 2 weeks of his female sexual partner becoming ill. Study findings moved some of the cases beyond the realm of mere suspicion.

According to the MMWR article, lab tests confirmed Zika infections in two of the women, while four others had probably contracted the virus. The CDC eliminated the cases of two women based on additional information. The investigation into the six remaining cases continues.

“We did not…anticipate that we would see this many sexually transmitted cases of Zika,” Dr Frieden said at today’s news conference.

After a separate case of sexually transmitted Zika — not included in the MMWR study — surfaced in Texas earlier this month, the CDC advised men who have a pregnant partner to use a condom or practice abstinence for the duration of the pregnancy if they have visited, or live in, a Zika zone.

“Today’s report underscores that recommendation,” Dr Frieden said.

A Cloud Over the Summer Olympics

Concern about the suspected link between the Zika virus and microcephaly prompted the CDC last month to recommend that pregnant women postpone visiting areas of active virus transmission, which include most of Latin America and the Caribbean. In a significant expansion of its travel guidance, the agency today recommended that pregnant women consider not attending the Summer Olympics in Rio de Janeiro, Brazil, scheduled for August 5 through August 21, or the Paralympic Games, scheduled for September 7 through September 18.

If pregnant women decide to go, anyway, they should consult their clinician first and, along with their partner, strictly follow steps to avoid mosquito bites, such as applying mosquito spray and wearing long-sleeve shirts and long pants, according to the CDC.

The agency encourages women who are trying to become pregnant to talk to their clinician about the risks for a Zika virus infection and precautions against mosquito bites before traveling to the Summer Olympics.

The CDC also urges precautions for sexual relations. If men travel to the Olympics, and they have a pregnant partner, they should abstain from vaginal, anal, or oral sex, or else use condoms for the duration of the pregnancy.

The CDC travel alert included other recommendations for Olympic goers, such as getting up to date on routine vaccines, traveling with a companion for safety’s sake, and only during the day; and steering clear of food sold by street vendors.

February 22, 2016

In Obese Kids, Reflux Symptoms May Be Mistaken for Asthma

NEW YORK (Reuters Health) – Obese youngsters and their doctors may be incorrectly attributing gastroesophageal reflux symptoms to asthma, researchers say.

In their pediatric asthma cohort, reflux symptoms were seven times more common in obese kids than in lean kids.

Writing online February 1 in Thorax, the researchers urge that especially for obese patients, “questionnaires that query symptoms that are more specific to asthma (‘whistling in the chest’) may improve the accuracy of symptom monitoring,” and newer portable spirometers for home use might also improve management.

Helping patients distinguish gastroesophageal reflux disease (GERD) from true lower airway symptoms will reduce medication overuse and side effects, unnecessary escalation of controller drugs and unnecessary usage for asthma, Dr. Jason E. Lang of Nemours Children’s Hospital in Orlando, Florida and colleagues say.

In previous research, Dr. Lang’s group had found that while obese and lean children with asthma had similar lung function, the obese kids were more likely to self-medicate with short-acting beta-agonists.

Of the 56 children in this new study, 23 were obese, 12 were overweight, and 21 were lean. All were between the ages of 10 and 17 and recruited between 2008 and 2010.

Symptoms and quality of life were assessed with validated tools, including the modified Asthma Control Questionnaire (ACQ6), the Asthma Control Test, the Pediatric Asthma Quality of Life Questionnaire, and the Pediatric Caregiver’s Asthma Quality of Life Questionnaire. Patients were also evaluated with the GERD Symptom Assessment Questionnaire (GSAQ), lung spirometry, FENO maneuvers, and a methacholine challenge.

The research team also attempted to replicate the GERD and asthma quality of life questionnaire results in a separate cohort of 306 children with severe asthma and no previous reflux disease.

The odds of reporting several GERD symptoms were more than seven times greater in the obese group (OR=7.7, p for interaction=0.004).

Asthma symptoms were tied to GERD scores in obese children (r=0.815, p<0.0001) but not in lean children (r=0.291, p=0.200; p for interaction=0.003). Objective tests linked higher GERD scores to higher FEV1-percent predicted (p=0.003), lower airway resistance (R10, p=0.025), improved airway reactance, (X10, p=0.005), but far worse asthma control as recorded on the Asthma Control Questionnaire (p=0.007).

In an interview, Dr. Lang suggested to Reuters Health that the symptom misattribution may be an effect of the “short doctor-patient visit.” He explained: “The underlying message for doctors and nurses is that we need to ask about specific asthma and specific reflux symptoms. We need to not jump to conclusions and thoroughly assess symptoms.”

Dr. Deepa Rastogi, a pediatric pulmonologist at the Children’s Hospital of Montefiore and the Albert Einstein College of Medicine, Bronx, New York told Reuters Health in an interview, “This is a very well-conducted study with outcomes of interest to all of us. It really shows us that it is worthwhile to look for disease entities other than asthma.”

She added, “Using objective measures and patient self report, we may do better at treatment.”

Is there a place for proton pump inhibitors if GERD underlies the asthma-like symptoms?

“Once we all realize that misattribution can be a problem, we can focus more carefully on making the right diagnosis of the symptoms and can employ other confirmatory testing like using spirometry or response to albuterol (rescue inhalers),” Dr. Lang said. “If the child truly has GER that is causing pain and discomfort, the GER should absolutely be evaluated and a discussion needs to occur weighing the risks and benefits of GER medicines.”

He continued, “Some patients who learn their chest symptoms are likely from GER and it’s not causing too many problems may elect to not treat and adopt proven lifestyle interventions. On the other hand, if GER are more bothersome or leading to coughing, then lifestyle changes plus intermittent use of an anti-GER may be the right choice. I am concerned about the side-effects of long-term use of PPIs since which we have shown that PPI appears to worsen asthma control in patients who are slow metabolizers of the drug.”