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Sunday, April 7, 2019

Real cost of heart attacks and strokes: Double the direct medical expense

The full financial cost of a heart attack or stroke is twice as much as the medical costs when lost work time for patients and caregivers is included.
That’s the finding of research published today, World Health Day, in the European Journal of Preventive Cardiology, a journal of the European Society of Cardiology (ESC).1 The study concludes that victims of  and stroke who return to work are 25% less productive in their first year back.
In the year after the event, heart patients lost 59 workdays and caregivers lost 11 workdays, for an average cost of €13,953, and ranging from €6,641 to €23,160 depending on the country. After stroke, 56 workdays were lost by patients and 12 by caregivers, for an average €13,773, ranging from €10,469 to €20,215.
Study author Professor Kornelia Kotseva, of Imperial College London, UK, said: “Patients in our study returned to work, meaning their events were relatively mild. Some still had to change jobs or careers, or work less, and caregivers lost around 5% of . Not included in our study are those with more severe events who quit work altogether and presumably need even more help from family and friends.”
The study enrolled 394 patients from seven European countries—196 with  (86% heart attack, 14% unstable chest pain) and 198 with stroke—who returned to work 3 to12 months after the event. Patients completed a questionnaire2,3 during a visit to a cardiologist, neurologist, or stroke physician. Hours lost were valued according to country labour costs in 2018. The average age of patients was 53 years.
According to published estimates for Europe, the direct  of acute coronary syndrome are €1,547 to €18,642, and €5,575 to €31,274 for stroke.4 “This is the metric commonly used to estimate the costs of medical conditions while  from  are often not taken into account by clinicians, payers or policymakers,” said Professor Kotseva. “Taken together, the actual burden on society is more than twice the amount previously reported.”
Reasons for lost productivity were consistent across countries: 61% was the initial hospitalisation and sick leave after discharge; 23-29% was absence from work after the initial sick leave (for medical appointments and shorter sick leave); 9-16% was being unable to work at full capacity because of feeling unwell.
Even more workdays were lost in the first year after the event for patients with previous events or established cardiovascular disease. When adding days lost by patients and caregivers together, this was 80 for acute coronary syndrome and 73 for stroke, costing €16,061 and €14,942, respectively.
In the study, 27% of heart patients and 20% of stroke patients were obese, while 40% of  and 27% of stroke  were current smokers.
“Productivity loss associated with cardiovascular events is substantial and goes beyond the patient,” said Professor Kotseva. “Preventing acute coronary syndrome and  is the key to improving health and longevity and avoiding the myriad of  that come with such an event. The true tragedy is that so many heart attacks and strokes could be averted by not smoking, being physically active, eating healthily, and controlling blood pressure and cholesterol. The evidence could not be stronger.”
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More information: Kornelia Kotseva et al, Patient and caregiver productivity loss and indirect costs associated with cardiovascular events in Europe, European Journal of Preventive Cardiology (2019). DOI: 10.1177/2047487319834770Clazien Bouwmans et al. The iMTA Productivity Cost Questionnaire, Value in Health (2015). DOI: 10.1016/j.jval.2015.05.009
Gina Nicholson et al. Patient-level costs of major cardiovascular conditions: a review of the international literature, ClinicoEconomics and Outcomes Research (2016). DOI: 10.2147/CEOR.S89331
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New hope for preventing dangerous diabetes complication


New hope for preventing dangerous diabetes complication
Severe hypoglycemia can increase the risk of more hypoglycemic episodes in the following days and leads to a decreased awareness of the symptoms that typically allow a person to sense falling blood sugar levels. Credit: Stephen Grote
People with diabetes who use insulin to control their blood sugar can experience a dangerous condition called hypoglycemia when blood sugar levels fall too low. New insights into a recently discovered protein called neuronostatin could lead to new ways to treat and prevent hypoglycemia, which is sometimes deadly for people with diabetes.
Stephen Grote, a working with Gina Yosten, Ph.D., at Saint Louis University School of Medicine, will present the research at the American Physiological Society’sannual meeting during the 2019 Experimental Biology meeting to be held April 6-9 in Orlando, Fla.
For people with diabetes, taking too much insulin can lead to , causing dizziness and sleepiness. Symptoms may progress to confusion, seizures and loss of consciousness if  continue to fall. Severe  can also increase the risk of more hypoglycemic episodes in the following days and leads to a decreased awareness of the symptoms that typically allow a person to sense falling blood  levels.
“There are very few options for preventing hypoglycemia or treating hypoglycemia unawareness other than avoiding low blood sugar as much as possible,” Grote said. “Understanding what neuronostatin does and how it works will provide valuable information for preventing hypoglycemia and provide more complete knowledge into how the pancreas manages blood sugar normally.”
In previous work, Yosten’s research group discovered neuronostatin. Their work has shown that the protein protects against hypoglycemia by causing the pancreas to release less insulin and make more glucagon, a hormone that helps regulate blood sugar levels.
In a new rat study, the researchers observed that neuronostatin injections caused an increase in blood sugar. They also examined human pancreas tissue and found that it released more neuronostatin when blood sugar levels were low and that neuronostatin increased even more with glucagon treatment. The new research points to neuronostatin as a potential therapeutic target for the treatment and prevention of hypoglycemia in people with diabetes.
“Neuronostatin is a truly novel factor, and everything we find about it pushes our knowledge of its therapeutic potential just a bit further,” said Grote. “We believe that studying neuronostatin could ultimately reveal a way to use it to help prevent and reverse vicious cycles of hypoglycemia by helping the body respond appropriately to the low blood sugar with more glucagon.”
The researchers are now working to better understand how neuronostatin affects glucagon and insulin release from human islets and how the body regulates neuronostatin secretion. They are also using experimental approaches that disrupt the body’s response to low  sugar to investigate how this affects neuronostatin levels and to determine if neuronostatin can be used to better manage low .
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More information: Stephen Grote will present this research during the Experimental Biology Welcome Reception on Saturday, April 6 at 7 p.m. in the Valencia Ballroom ABCD, Orange County Convention Center and on Monday, April 8, from 10:15 a.m.-12:15 p.m. in Exhibit Hall-West Hall B (poster E621 756.1) (abstract).
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New guide to fill ‘information vacuum’ on new cannabis products for medicinal use

A clinical review, published today for the BMJ, provides new interim advice for doctors and clinicians in prescribing cannabis-based products and cannabinoids to treat certain conditions.
Since a in November 2018, specialist doctors registered with the General Medical Council (GMC), have been permitted to prescribe  which derive from cannabis. Yet, research into these products has, to date, been limited creating an ‘information vacuum’ about these medicines, their benefits or harms.
A new review authored by leading scientists and clinicians from the University of Bath and University College London (UCL) points to the array of different cannabis-based products and cannabinoids available, and a clear need to educate both patients and clinicians into what these different products do and how they might help.
In particular, it points to important differences between products containing THC (the main psychoactive and intoxicating constituent of cannabis) versus CBD (the non-intoxicating element). Although in certain medicines CBD and THC are combined for clinical benefit, in others these components can work independently, playing different roles in improving certain symptoms.
For example, several studies have found that a combination of THC and CBD can alleviate symptoms of chronic pain, while CBD alone may be effective for treatment-resistant epilepsy. By contrast THC alone may be effective for treating nausea and vomiting caused by chemotherapy. THC and CBD are both ‘cannabinoids’ that act in different ways on the body’s endogenous cannabinoid system.
The cannabis plant produces over 144 different cannabinoids such as THC or CBD. Some medicinal products contain THC and/or CBD derived from the cannabis plant, while others contain synthetically produced cannabinoids. CBD is also available in non-medicinal products such as oils and tinctures.
Lead author, Dr. Tom Freeman of the University of Bath’s Addiction and Mental Health Group explains: “In this complex and rapidly evolving field, there are several different cannabis-based and cannabinoid medicinal products. These differ in their THC and CBD content, who can prescribe them, and the conditions they may be used to treat. Here we provide an update for clinicians in advance of forthcoming NICE guidelines.
“A key message is that CBD products widely sold online and in health food shops lack quality standards and should not be treated as .”
Research on cannabis was previously restricted because it was listed in Schedule 1, implying that it had no medical value. Cannabis was recently moved to Schedule 2 in the UK.
Dr. Freeman adds: “Research on unlicensed cannabis products has been limited to date. The rescheduling of cannabis and allocation of dedicated UK research funding will improve the evidence we have to guide clinical decision-making.”
Co-author, Dr. Michael Bloomfield Head of Translational Psychiatry at University College London (UCL) added: “There have been leaps and bounds in our scientific knowledge in recent years, which combined with confusing claims about the medicinal uses of these drugs can be potentially perplexing for doctors and patients. We hope that our new guidance is helpful to doctors and patients worldwide. Much more research is needed into this new class of medicine.”
Co-author Dr. Chandni Hindocha of the Clinical Psychopharmacology Unit at UCL added: “Resources must be made available to update and educate clinicians about cannabis and  based medicines. We would like to encourage doctors to maintain a compassionate and evidence-based approach when engaging with their patients in this rapidly developing field, in order to provide the best standard of care.”
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More information: Tom P Freeman et al, Medicinal use of cannabis based products and cannabinoids, BMJ (2019). DOI: 10.1136/bmj.l1141
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Common food additive may weaken defenses against influenza

Research conducted in mice suggests the food additive tert-butylhydroquinone (tBHQ)—found in many common products from frozen meat to crackers and fried foods—suppresses the immune response the body mounts when fighting the flu. In addition to increasing the severity of flu symptoms, the study found evidence that tBHQ exposure could reduce the effectiveness of the flu vaccine through its effects on T cells, a vital component of the immune system.
Researchers say the connection may help explain why  continues to pose a major health threat worldwide. An estimated 290,000-650,000 people globally die from flu-related respiratory problems each year.
“Our studies showed that mice on a tBHQ diet had a weakened immune response to influenza (flu) infection,” said Robert Freeborn, a fourth-year Ph.D. candidate at Michigan State University. “In our , tBHQ suppressed the function of two types of T , helper and killer T cells. Ultimately, this led to more severe symptoms during a subsequent influenza infection.”
Freeborn will present the research at the American Society for Pharmacology and Experimental Therapeutics annual meeting during the 2019 Experimental Biology meeting, held April 6-9 in Orlando, Fla.
When a person is infected with , helper T cells direct other parts of the immune system and help coordinate an appropriate response, while killer T cells hunt down infected cells and clear them from the body. In their experiments, the researchers found mice eating a tBHQ-spiked diet were slower to activate both helper T cells and killer T cells, resulting in slower clearance of the virus.
“Right now, my leading hypothesis is that tBHQ causes these effects by upregulating some proteins which are known to suppress the immune system,” said Freeborn. “Expression of these proteins, CTLA-4 and IL-10, was upregulated in two different models we use in the lab. However, more work is necessary to determine if upregulation of these suppressive proteins is indeed causative for the effects of tBHQ during influenza infection.”
What’s more, when the mice were later re-infected with a different but related strain of influenza, those on the tBHQ diet had a longer illness and lost more weight. This suggests that tBHQ impaired the “memory response” that typically primes the immune system to fight a second infection, Freeborn said. Since the memory response is central to how vaccines work, impairment of this function could potentially reduce the efficacy of the flu vaccine.
T cells are involved in the  to a variety of diseases, so tBHQ could also play a role in other types of infectious diseases, Freeborn added.
tBHQ is an additive used to prevent spoilage, with a maximum allowed concentration of 200 parts per million in food products. It is unclear how much tBHQ people are exposed to, though estimates based on model diets have suggested some U.S. consumers eat almost double the maximum allowable amount of tBHQ suggested by the Joint FAO/WHO Expert Committee on Food Additives and that people in other parts of the world may consume up to 11 times the maximum allowable amount. The level of tBHQ exposure in Freeborn’s studies falls within estimates of human exposure.
“It can be hard to know if you are consuming tBHQ, as it is not always listed on ingredient labels,” said Freeborn, adding that this is often the case when tBHQ is used in food preparation, such as in the oil used to fry a chip. “The best way to limit tBHQ exposure is to be cognizant about food choices. Since tBHQ is largely used to stabilize fats, a low-fat diet and cutting down on processed snacks will help reduce tBHQ consumption.”
Freeborn emphasized that getting a yearly flu shot remains the best way to prevent influenza infection. Though it is possible to contract the flu after getting the vaccine, being vaccinated has been shown to significantly reduce the length and severity of the illness.
Building on their studies conducted in mice, the researchers plan to use human blood samples to further investigate how tBHQ affects T cell activity.
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More information: Robert Freeborn will present this research on Sunday, April 7, from 9 a.m.-4 p.m. in Exhibit Hall-West Hall B, Orange County Convention Center (abstract).
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Do Breast Cancer Patients Skip Follow-Up?

Within the 5 years following a diagnosis for stage I or II breast cancer, 21% of patients stop seeing physicians for follow-up care, according to a study in the Journal of Oncology Practice.
Breast cancer is the second most common form of cancer for women in the U.S., with about 12% of women developing the condition, according to the American Cancer Society. Breast cancer has a high level of lethality, and only lung cancer kills more women annually.
Study co-author Dawn Hershman, MD, of Columbia University Medical Center in New York, , explained why follow-up care is crucial for recovery.
“It is important for patients to know that, during follow-up appointments, they are being evaluated for recurrence, evaluated for early detection of new primary tumors, and to make sure they are up-to-date with other cancer prevention activities,” she said. “In addition, information is rapidly changing, so keeping up with the oncologist is important to make sure the care is current.”
Hershman and colleagues examined data from more than 30,000 patients, ages ≥65, and reported several key points:
  • In year 1 after diagnosis, 85.8% of patients saw a medical oncologist and 71.9% saw a radiation oncologist in addition to a surgeon
  • Two-thirds of the patients visited all three kinds of providers in the first year after diagnosis
  • In the 5 years after diagnosis, 21% of patients stopped follow-up visits
Factors predictive of discontinued follow-up care included older age, single relationship status, patients with low-grade tumors, and patients with hormone receptor-negative breast cancer.
Surgeons and oncology specialists can take steps to increase follow-up care for breast cancer, the researchers noted.
“Coordination of follow-up care between oncology specialists and other providers may reduce discontinuation rates as well as the redundancy of visits, thereby increasing clinical efficiency. Identifying patients who are at risk for early discontinuation of follow-up will eventually allow for the promotion of public health initiatives to improve access to care,” they wrote.
Hormone therapy should be a focal point of public health efforts, Hershman said. “The most important thing we do during follow-up is to make sure women on hormone therapy stay on their hormone therapy. Making sure these treatments are available to everyone is an important public health initiative.”
Educating breast cancer patients about the seriousness of follow-up care is essential, she said. “As a provider, it is hard to know when patients stop following up. Sometimes, patients move or change providers. Patients need to be active in making sure they follow with at least one provider.”

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Escalating Opioid Doses in Chronic Pain

Increases in prescription opioid doses were unrelated to most clinical outcomes among chronic pain patients, according to a 2-year prospective cohort study.
Moreover, patients who had been prescribed a stable dose of long-term opioid therapy demonstrated few clinically significant changes in pain-related outcomes over time, reported Benjamin Morasco, PhD, of Oregon Health & Science University in Portland, and colleagues, at the American Pain Society Scientific Meeting.
Long-term opioid therapy is a common treatment for chronic pain, and “little data are available about the benefits and harms associated with increasing opioid dose,” Morasco told MedPage Today. “It’s unclear to what extent escalating opioid doses can improve pain, yet still have the risk-benefit ratio of a lower dose.”
For this study, Morasco and colleagues recruited 517 adults with a chronic musculoskeletal pain from the Kaiser Permanente Northwest and Veteran Affairs (VA) Portland health care system who were prescribed a stable dose of long-term opioid therapy. The researchers excluded patients who were receiving opioids for cancer treatment or palliative care, had pending a disability claim related to a pain condition, had enrolled in an opioid substitution program in the past year, had a current opioid dose >120 mg, or whose opioid prescriptions were solely tramadol or buprenorphine.
Participants were an average age of about 60, and just under half were female. All participants completed standardized questionnaires — including measurements of pain intensity and pain interference on 100-point scales — every 6 months for 2 years. Researchers reviewed medical records each week; patients who had an opioid dose increase completed an additional questionnaire within 4 weeks of dose escalation.
The average daily opioid dose at baseline was 36.2 mg morphine equivalent dose (MED). Of the 517 participants who enrolled, 19.5% (n=101) had a prescription opioid dose increase of 15% or more from their baseline dose. The baseline dose of these 101 patients was 27 MED; the baseline dose of patients who didn’t have an increase (n=416) was 39 MED. The average increase in prescription opioid dose from baseline was 104%.
After controlling for covariates — medical comorbidities, alcohol and substance use, pain catastrophizing, pain self-efficacy, complementary and integrative treatments for chronic pain, and other factors — the researchers found no significant changes in pain intensity or pain interference over time, and no differences based on dose escalation status. Specifically:
  • Average pain intensity score decreased by 0.79 points a year, and there was no difference in average pain intensity based on dose increase status
  • Average pain interference increased by 1.42 points per year; this also showed no difference based on dose increase status
  • No significant changes in depression severity or sexual functioning over time emerged, and no difference was seen based on dose increase status
  • On average, those in the dose increase group had higher scores on risk for prescription opioid misuse, but they also had greater average reductions in risk over time
  • Those in the dose increase group had poorer sleep functioning compared to those in the stable dose group on average, and there were no differences in change over time
  • The average score for short-term medication-related side effects such as constipation, nausea, and vomiting decreased over time, and there was no difference based on dose increase status
“Clinically, we are seeing more and more people having increases in opioid doses,” said Morasco. “This is one of the first prospective studies to see the outcomes of opioid dose escalation.”
“We didn’t really see long-term improvements,” Morasco added. “People may have had changes in pain intensity soon after dose escalation, but when we really follow them for up to a year after their dose escalation, we don’t see long-term changes.”
The study was supported by the National Institute of Drug Abuse.
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Illumina (ILMN) Results Should Include Upside From Large Deals – Piper Jaffray

Piper Jaffray analyst William Quirk reiterated an Overweight rating and $384.00 price target on Illumina (NASDAQ: ILMN) after channel checks
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