A new study from King’s College London published in Nature Medicine reveals a new relationship between lipids and diseases impacting  metabolism in children, which could serve as an early warning system for conditions like liver disease.

Using machines that test blood plasma in babies that already exist in hospitals, the researchers suggest this could help doctors spot early signs of disease in children quicker and help them access the right treatment.

The findings also contest the common idea that cholesterol is a leading cause of complications around obesity in children, identifying new lipid molecules which contribute to health risks like blood pressure but are not only correlated with a child’s weight.

Lipids have traditionally been thought to be fatty acids in the body, either good or bad types of cholesterol or triglycerides, fats found in the bloodstream that is the most common in the human body. Recent studies from the same group of scientists have suggested that the picture is more complex.

Using a technique associated with chemistry called mass spectrometry, current evidence puts the types of different lipid present in the body in the thousands, each with separate functions.

Taking a control sample of 1,300 children with obesity, the team assessed their lipids in blood. Afterwards 200 of them were put on the HOLBAEK-model for a year, a lifestyle intervention for people with obesity popular in Denmark.

Subsequent readings showed that amongst the intervention group, counts of lipids tied to diabetes risk, insulin resistance and blood pressure decreased, despite limited improvements in some children’s BMI.

Dr Cristina Legido-Quigley, a group leader in Systems Medicine at King’s College London, Head of Systems Medicine at the Steno Diabetes Centre Copenhagen (SDCC) and principal author, said: “For decades, scientists have relied on a classification system for lipids that have split them into good and bad cholesterol, but now with a simple blood test we can assess a much broader range of lipid molecules that could serve as vital early warning signs for illness. In the future, this has the potential to be an entirely new way to evaluate someone’s personal risk of disease and by studying how to change lipid molecules in the body, we could even prevent metabolic diseases like diabetes altogether.”

Obesity continues to be a risk factor for conditions like fatty liver disease, but the team hope that doctors can use these measurements to treat children when they are at risk and not just a little larger than their peers.

Dr Karolina Sulek, who was part of the study and performed analysis at the SDCC, said: “Early recognition of children at risk for these life-threatening diseases is crucial. The study provides strong evidence of the great need for obesity management and gives parents confidence to intervene in their children’s life more compassionately, helping them to lose weight.”

The next step for the researchers is to help understand how genetics affects lipids and what this means for metabolic diseases, as well as how these lipids can be changed to improve health.

The research, led by Durham University, found that almost half of dyslexia professionals in the study believed at least one unproven indicator for dyslexia, which could lead to children being misdiagnosed.

In a survey of 275 dyslexia professionals, the most common myth – which is not backed up by solid evidence – was that people with dyslexia read letters in reverse order, believed by 61 per cent of specialists.

Just over 30 per cent of professionals also believed that letters jumping around is a key feature of dyslexia. However, there is currently no evidence to show that either of these are reliable indicators of dyslexia.

The survey targeted a range of UK professionals involved in assessing students for dyslexia, such as dyslexia specialists, specialist assessors and educational psychologists. They were asked about the assessments they used, how they make their decisions on diagnosis and what they believe to be indicators of dyslexia.

Although over 75 per cent of professionals used assessments which are recommended by the Specific Learning Difficulty (SpLD) Assessment Standards Committee (SASC), more than 82 per cent of respondents also used additional measures. A further 71 different measures were listed by participants, indicating that there are many different tests used by professionals during the assessment process.

In the UK, there is currently no official policy guidance on defining and identifying students with dyslexia or other learning difficulties. Instead, the onus of developing diagnostic procedures and standards relies heavily on various independent professional organisations.

The researchers are calling for evidence-based knowledge to be built into the assessment procedures and for this to be guided by government policy.

The study, funded by the British Educational Research Association (BERA), is published in Annals of Dyslexia and involved researchers from Durham University and National Taiwan Normal University.

Lead author, Dr Johny Daniel from the School of Education at Durham University, said:

“Our findings show that there is a need for government policy to guide how students with reading disabilities should be assessed, based on reliable evidence.

“It’s also important that dyslexia and psychological associations in the UK ensure that any misconceptions amongst professionals are directly addressed in their guidelines so that children are assessed in a consistent way across the board.”

It’s estimated up to one in every 10 people in the UK has some degree of dyslexia.

The research uncovered a general lack of consensus amongst assessors on the process of identifying someone with dyslexia. Many did subscribe to the notion of dyslexia being a deficit in core areas of reading, but several others saw it as a discrepancy between individuals’ reading and cognitive abilities.

The dyslexia specialists in the study also used a number of other unsubstantiated dyslexia indicators such as high levels of creativity (17 per cent), motor skills issues or clumsiness (17 per cent), and difficulty with reading words in certain colours (15 per cent) or fonts (12 per cent). Empirical data do not support these to be indicators of dyslexia.

Dr Daniel added: “Early identification is absolutely crucial so that support can be put in place as quickly as possible. However, our study shows there is significant variability in the methods used for identifying reading disabilities such as dyslexia, which could lead to children being misdiagnosed or missed altogether.”

It is often important to get cancer patients to quit smoking, but it is not always that easy.

“Data suggest that between 15 and 60 per cent of people who smoked before they were diagnosed with cancer continue to smoke after their diagnosis. It is crucial to help people with cancer quit smoking, because it will lead to better cancer treatment prognoses, prevent secondary cancer, and increase quality of life,” says Rubén Rodríguez-Cano, an associate professor at the Norwegian University of Science and Technology (NTNU’s) Department of Psychology.

Degree of addiction

Because smoking and cancer often go hand-in-hand, it is especially useful to determine how addicted people are to smoking. That makes it possible to estimate how likely it is that people will manage to quit, and consequently predict cancer patients’ chances of surviving.

The researchers may also be able to use a similar approach to estimate the risk that smokers who are still healthy have of developing cancer at a later date.

“We are currently conducting another study on the risk of developing lung cancer, which is being led by Professor Oluf Dimitri Røe. Among the variables are nicotine addiction, smoking history and BMI,” says Rodríguez-Cano.

However, investigating smoking addiction requires considerable resources. Therefore, Rodríguez-Cano wanted to find out whether there is a more efficient way of measuring the degree of a smoker’s addiction.

He collaborated with people from one of the foremost cancer hospitals in the world, the University of Texas MD Anderson Cancer Center in Houston, Texas.

Long and short tests

Several tests can be used to ascertain smoking addiction. The gold standard is the Fagerström Test for Cigarette Dependence (FTCD).

“But this test is too extensive when we want to check a large number of patients to assess smoking risk at group level,” says Rodríguez-Cano.

So, is a longer test really necessary? A simplified version called the Heaviness of Smoking Index (HSI) comprises only two questions:

• How many cigarettes do you smoke per day?
• How soon after you wake up do you smoke your first cigarette?

And these two questions are sufficient. Try it yourself.

A simplified test is often sufficient

“We investigated nearly 6000 cancer patients to see if it made any difference whether they took the full test or the simplified one,” says Rodríguez-Cano.

It generally did not make a difference.

“The results in predicting cigarette addiction were equally good for both the full and the simplified tests.

In addition, the simplified test is just as good at predicting the smoking abstinence at 3, 6, and 9 months after quitting smoking following specialised treatment,” says Rodríguez-Cano. However, it is not that straight forward.

…but not for all smokers

For some reason, the simplified test does not work as well for everyone.

“The effectiveness of the simplified test for men and women depends on the patient’s race,” Rodríguez-Cano explains.

Basically, the shortest test did not work as well for Non-Hispanic Black people with a cancer diagnosis. The researchers do not know whether this is due to social or genetic factors – or a combination of both.

“Both the full test and the simplified test are useful tools, but our research shows that it may be necessary to tailor the tests for different groups,” says Rodríguez-Cano.

Nevertheless, the research may make it easier to investigate smoking addiction than before. This can reduce the burden on the healthcare system as well as on cancer patient treatment.

Reference: Rubén Rodríguez-Cano, George Kypriotakis, Jason D Robinson, Maher Karam-Hage, Janice A Blalock, Jennifer A Minnix, Diane Beneventi, Paul M Cinciripini, Comparing the Fagerström Test and Heaviness of Smoking Index in Predicting Smoking Abstinence in Cancer Patients, Nicotine & Tobacco Research, 2024; ntae120, https://doi.org/10.1093/ntr/ntae120

Why community pharmacists need skills in differential diagnosis

By 2026 all pharmacy graduates will have an independent prescribing qualification and there will be a increasing emphasis on clinical activities in community pharmacy.  Professor Rutter’s new book uses a case-study format and emphasises the importance of clinical reasoning to reach a diagnosis.

The WWHAM mnemonic is no longer adequate to guide consultations, he explains.

WWHAM stands for:

• Who: Who is the medicine for?
• What: What are the symptoms?
• How long: How long have the symptoms been present?
• Action: What action has been taken?
• Medication: Are you taking any other medication?

How clinical reasoning underpins effective consultations

Professor Rutter’s new book follows a case study format because this is an effective way to “contextualise facts and figures and knowledge into something more ‘real life’”, he says. For example, a symptom such as cough would be approached very differently in a 75-year-old man from a 5-year-old child. The objective of the consultation is to sift out from the list of possible causes of cough those that are most likely in the patient in question. Clinical reasoning is flexible and responsive and allows the practitioner to take a long list of conditions and narrow it down into a smaller number of possibilities in a logical way.

Clinical reasoning – the challenge of moving from novice to expert

The Pharmacy First scheme allows the pharmacist access to medicines which otherwise would be prescription only medicines (POMs), in specific situations. Clinical reasoning is important in establishing a diagnosis which is the first step in the Pharmacy First service.  Professor Rutter envisages that the Pharmacy First service will be extended in future as part of the movement to make pharmacy a more clinical profession. This will call for more expertise in clinical reasoning and feedback on pharmacists’ performance will be essential to raise their “ceiling of competence”, he explains.

In future, community pharmacists’ clinical role will be extended further and the traditional dispensing role will diminish. In addition, “I think the digital side of pharmacy will increase and that will hopefully allow greater communication between pharmacy and general practice services so they’re better integrated”, he says.

About Paul Rutter

Paul Rutter is  Professor of Pharmacy Practice at Portsmouth University. His main area of interest is differential diagnosis of minor conditions for pharmacists and his academic teaching deals mainly with this topic. He is the author of the textbook, Symptoms, Diagnosis and Treatment in Community Pharmacy, now in its fifth edition. His new book, Differential diagnosis for non-medical prescribers, nurses and pharmacists: A case-based approach, was published in August 2024.

Read and watch the full series on our website or on YouTube.

Link to Pharmacy First 

The Pharmacy First scheme allows the pharmacist access to medicines which otherwise would be prescription only medicines (POMs), in specific situations. This is expected to relieve some pressure on GP services. However, “You’ve still got to make that diagnosis, you’ve still got to get to the point that you are confident that you are dealing with condition X and then you can use the Pharmacy First service to supply the appropriate medicine”, says Professor Rutter. The pharmacist is still responsible for making the diagnosis and the new book “will  help pharmacists establish the diagnosis with more confidence and more accuracy”, he adds.

Clinical Reasoning and Artificial Intelligence

Clinical reasoning and decision making is now creeping in to the undergraduate pharmacy curriculum as independent prescribing is becoming embedded. It is already a feature of post-graduate independent prescribing courses.

In future, artificial intelligence (AI) will undoubtedly play a role in teaching and delivery of services but is unlikely to take over clinical reasoning activities, says Professor Rutter. “Clinical reasoning is fundamentally a thinking and cognitive process that you have to do yourself. So, I think AI will be used to create test cases to give students opportunities to practice this clinical reasoning in a safe environment where they can build up their experience. I think it will augment and supplement how we teach clinical reasoning but the actual process of how you do clinical reasoning has still got to be thought through by the student themselves – so I don’t think AI will ever replace that”, he explains.

Clinical reasoning: from novice to expert

Professor Rutter envisages that the Pharmacy First service will be extended as part of the movement to make pharmacy a more clinical profession. Inevitably, the ways in which pharmacists arrive at a differential diagnosis will come under scrutiny, particularly from GPs who will have been taught clinical reasoning as part of the way they make a diagnosis. When they see that pharmacists are approaching the activity in the same way that they themselves would, it should give pharmacists more credibility and enable GPs to have more confidence in what they do, he says.

Clinical reasoning is, in some ways, a new activity for community pharmacists and it will take time for them to become experts. The development of expertise depends on experience – the more cases of a similar condition that a practitioner sees, the more his or her understanding of the way the condition presents develops. “The biggest challenge for pharmacists is how do you get that feedback …  to know you’re doing a good job”, says Professor Rutter.  If the diagnosis is uncertain then, as a community pharmacist , he would refer the patient to the GP but then rarely receives any feedback. “Most times in community pharmacy you don’t get feedback from the patient or the doctor to tell you whether you were right or wrong. Now for us to become good at clinical reasoning and more expert that loop needs to be closed. I think it’s important that pharmacists try to talk to their GPs when they’re making these referrals to say, “Well, I’m referring this case to you because I think it might be this but I’m not sure. I’d really appreciate it if you could tell me what you think so that I can improve for next time”, and by doing that you’re able to raise your ceiling of competence. …. [If] you get feedback on cases, over time your ceiling of competence goes up and up and up and you’re able to treat more and more patients”, he explains.

Vision for the future

In 10 years’ time, Professor Rutter foresees that community pharmacists’ clinical role will be extended further and most pharmacists will be independent prescribers. Dispensing in community pharmacies will be limited to items required immediately  and much will be done remotely with medicines delivered by post. Pharmacists will the be free to concentrate their efforts on management of long-term conditions for stable patients. “Many of the roles that GPs currently perform I think will be performed in a pharmacy and patients will be directed to the pharmacy more and more rather than the GP. So, I only see the clinical side of pharmacy growing and the traditional kind of dispensing side of pharmacy disappearing. I think we will, at that point, in 10 years’ time, be a very clinical, patient-facing profession. I think the digital side of pharmacy will increase and that will hopefully allow greater communication between pharmacy and general practice services so they’re better integrated”, he says.

About Paul Rutter

Paul Rutter is  Professor of Pharmacy Practice at Portsmouth University. His main area of interest is differential diagnosis of minor conditions for pharmacists and his academic teaching deals mainly with this topic. He is the author of the textbook, Symptoms, Diagnosis and Treatment in Community Pharmacy, now in its fifth edition. His new book, Differential diagnosis for non-medical prescribers, nurses and pharmacists: A case-based approach, was published in August 2024.

Read and watch the full series on our website or on YouTube.

Professor Rutter’s new book follows a case study format because this is an effective way to “contextualise facts and figures and knowledge into something more ‘real life’”, he says. For example, a symptom such as cough would be approached very differently in a 75-year-old man from a 5-year-old child.

Clinical reasoning plays a critical role here. “It’s about bringing forward to the conscious level your thinking. So, it’s about testing a hypothesis,  it’s about thinking “Well, if I’ve got a 5-year-old child with a cough, what’s the likely diagnosis?” and then testing that hypothesis by asking those questions which are pertinent at that time in the conversation. And the type of question will change depending on the context and it will depend on the response of the patient as to what question you would then ask next”, he explains.  “Clinical reasoning is very flexible it responds to what the patient says and you as the clinician are directed to ask your next question based on the information that’s been provided by the patient”, he adds. Each clinician might use a different series of questions for a given problem, depending on their experiences and the way in which they process the information from the patient, but should arrive at the same endpoint.

Returning to the examples above – a 5-year-old child who’s had a cough for a couple of weeks and a 75-year- old man who’s had a cough for three weeks – would call for slightly different questions. Whereas asking about the number of cigarettes smoked daily might be routine for an adult, it would not be appropriate for a 5-year-old child. The objective of the consultation is to sift out from the list of possible causes of cough those that are most likely in the patient in question. Clinical reasoning “allows you to take that long list of conditions and narrow it down into a smaller number of possible conditions which you then can test as to what is it likely to be. So, you might have 20 conditions which cause cough but straight away by the person that you’re talking to and the context that they present in – i.e. how long they’ve had it or things like that – you can go down from say 20 conditions to two or three or four quite quickly, but then you’re very targeted in the questions that you ask”, says Professor Rutter.

About Paul Rutter

Paul Rutter is  Professor of Pharmacy Practice at Portsmouth University. His main area of interest is differential diagnosis of minor conditions for pharmacists and his academic teaching deals mainly with this topic. He is the author of the textbook, Symptoms, Diagnosis and Treatment in Community Pharmacy, now in its fifth edition. His new book, Differential diagnosis for non-medical prescribers, nurses and pharmacists: A case-based approach, was published in August 2024.

Read and watch the full series on our website or on YouTube.

Professor Rutter’s main area of interest is differential diagnosis of minor conditions for pharmacists. His own career started in community pharmacy where he says he “really enjoyed interacting with patients”. He became a teacher/practitioner with Boots the Chemist and found that he also enjoyed teaching. He gained a PhD and started his academic career at Portsmouth University. After spells at Wolverhampton University and the University of Central Lancashire he returned to Portsmouth to take up the post of Professor of  Pharmacy Practice.

Professor Rutter is probably best known for his book on symptoms diagnosis and treatment in Community Pharmacy, now in its fifth edition. His new book, Differential diagnosis for non-medical prescribers, nurses and pharmacists: A case-based approach, is intended to fill a gap that is not covered by the earlier book.  As the scope of practice for community pharmacists expands, skills in differential diagnosis of signs and symptoms will become increasingly important, he says. “We all know that we’re going to have a prescribing workforce – by 2026 all [pharmacy] graduates will have that IP (independent prescribing) qualification and this book is trying to address that extended role for pharmacy”, he explains. The book uses a case-study format and emphasises the importance of clinical reasoning to reach a diagnosis.

Hitherto, pharmacists have relied on the WWHAM (or 2-WHAM) mnemonic to guide consultations. WWHAM stands for:

• Who: Who is the medicine for?
• What: What are the symptoms?
• How long: How long have the symptoms been present?
• Action: What action has been taken?
• Medication: Are you taking any other medication?

Although WWHAM elicits some information from patients it is not a good diagnostic tool. “If you think about the questions that it asks, at least two of those five questions are more to do with management and treatment planning rather than the diagnosis so it doesn’t actually ask many questions to establish the differential diagnosis”, says Professor Rutter. The role of pharmacy in the community has now developed further. “Because we are now being expected to do a lot more in pharmacy, we need to adopt new ways of thinking and new ways of getting information from the patient – and that’s where clinical reasoning comes in”, he explains. The new book is focused on the use of clinical reasoning in order to establish a differential diagnosis, he adds.

WWHAM still has a  place – ideally it is a tool that should be used by pharmacy counter assistants to obtain basic information that can be given to a  pharmacist prior to a consultation, says Professor Rutter.

About Paul Rutter

Paul Rutter is  Professor of Pharmacy Practice at Portsmouth University. His main area of interest is differential diagnosis of minor conditions for pharmacists and his academic teaching deals mainly with this topic. He is the author of the textbook, Symptoms, Diagnosis and Treatment in Community Pharmacy, now in its fifth edition. His new book, Differential diagnosis for non-medical prescribers, nurses and pharmacists: A case-based approach, was published in August 2024.

Read and watch the full series on our website or on YouTube.

Cervical cancer screening is essential for early detection and prevention. Most countries have a very extensive screening program that starts with testing for different variants of the human papillomavirus (HPV) that causes cervical cancer. In the case of an HPV-positive test, this is followed by so-called cytological analysis, the examination of gynaecological cell samples by microscopy, which is dependent on human interpretation.

The new molecular test WID-qCIN, which could replace the cytological analysis, can automatically analyse epigenetic changes in cells – changes that affect which genes are active and which are not. These changes are influenced by factors such as environment, lifestyle, and aging, and can increase the risk of cancer and other diseases.

The study included more than 28,000 women over the age of 30 who underwent screening in Stockholm between January and March 2017. The researchers analysed a total of 2,377 HPV-positive samples with the WID-qCIN test combined with a test for two high-risk HPV types (HPV 16 and 18). In this way, they were able to detect 100 per cent of all invasive cervical cancer and 93 per cent of all serious precancerous lesions that occurred within a year of sampling.

In addition, the new test, in combination with the HPV 16/18 test, was able to predict 69 per cent of all cancers and precancerous lesions up to six years after the sample was taken. This can be compared with only 18 per cent with today’s screening method.

‘By integrating the WID-qCIN test into our screening programmes, we would be able to identify more cancer cases while reducing the need for invasive procedures,’ says Prof Joakim Dillner, Karolinska Institutet and co-author of the study.

When cell changes are detected in today’s screening programme, the woman undergoes a vaginal examination, a so-called colposcopy, where the gynaecologist looks at the cervix with the help of a microscope and, if necessary, takes a biopsy. The study suggests that implementation of the WID-qCIN test could reduce the number of colposcopy examinations by 40 per cent.

‘This would mean a significant improvement compared to today’s screening methods, which were introduced in the 1960s,’ says Prof Martin Widschwendter, University of Innsbruck and visiting Professor at the Karolinska Institutet. ‘With its simplicity and objective assessment, the WID-qCIN test can improve the effectiveness of these programs and support the global strategy to eliminate cervical cancer.’

The test, developed by a team from the Broad Institute of MIT and Harvard and Princeton University, and supported by the US Centers for Disease Control and Prevention, uses CRISPR to distinguish between the two main types of seasonal flu, influenza A and B, as well as seasonal flu subtypes H1N1 and H3N2. It can also identify strains that resist antiviral treatment, and with further work, could potentially detect swine and avian flu strains, including H5N1, which is currently infecting cattle.

Appearing in The Journal of Molecular Diagnostics, the results could help improve outbreak response and clinical care by bringing tests that are accurate, low-cost, and fast to doctors’ offices and labs across the US and in other countries.

“Ultimately, we hope these tests will be as simple as rapid antigen tests, and they’ll still have the specificity and performance of a nucleic acid test that would normally be done in a laboratory setting,” said Cameron Myhrvold, co-senior author on the study along with Pardis Sabeti, an institute member at the Broad and a professor at Harvard University and the Harvard T.H. Chan School of Public Health, as well as a Howard Hughes Medical Institute investigator. Myhrvold, who is currently an assistant professor at Princeton University, was a postdoctoral researcher in Sabeti’s lab when the study began.

SHINE a light 

The test is based on a technology called SHINE, which was developed by Sabeti’s lab in 2020 and uses CRISPR enzymes to identify specific sequences of viral RNA in samples. The researchers first used SHINE to test for SARS-CoV-2, and later to distinguish between the Delta and Omicron variants. Then, in 2022, they began adapting the assay to detect other viruses they knew were always circulating: influenzas. They wanted to create tests that could be used in the field or in clinics rather than hospitals or diagnostic labs with expensive equipment.

“Using a paper strip readout instead of expensive fluorescence machinery is a big advancement, not only in terms of clinical care but also for epidemiological surveillance purposes,” said Ben Zhang, co-first author on the study, a medical student at Harvard Medical School and an undergraduate researcher in Sabeti’s lab when the study began.

Typical diagnostic approaches such as polymerase chain reaction (PCR) require lengthy processing times, trained personnel, specialized equipment, and freezers to store reagents at -80°C, whereas SHINE can be conducted at room temperature in about 90 minutes. Currently, the assay only requires an inexpensive heat block to warm the reaction, and the researchers are working to streamline the process with the goal of returning results in 15 minutes.

The researchers also adapted SHINE to distinguish between different flu strains. In the future, they say the assay could be adapted to detect two different viruses with similar symptoms, such as influenza and SARS-CoV-2.

“Being able to tease apart what strain or subtype of influenza is infecting a patient has repercussions both for treating them and public health interventions,” said Jon Arizti-Sanz, a postdoctoral researcher in Sabeti’s lab and co-first author on the study.

For example, the tests could help clinicians decide whether to use Oseltamivir, a common antiviral that is effective for only some strains, Arizti-Sanz added. In the field, rapid testing could also help scientists collect samples more strategically during an outbreak to better monitor how the virus is spreading.

Next, the researchers are adapting SHINE to test for both avian and swine influenza strains. “With SARS-CoV-2 and now flu, we’ve shown that we can easily adapt SHINE to detect new or evolving viruses,” Arizti-Sanz said. “We’re excited to apply it to H5N1.”

Paper cited
Zhang YB, Arizti-Sanz J, et al. CRISPR-based assays for point of need detection and subtyping of influenza. The Journal of Molecular Diagnostics. Online June 18, 2024. DOI: 10.1016/j.jmoldx.2024.04.004.

Marina Walther-Antonio, Ph.D., and colleagues at Mayo Clinic’s Center for Individualized Medicine are on a mission to catch these cancers early.

Their research dives deep into the microbiome, a community of trillions of microorganisms — including bacteria, fungi and viruses — that influence health and disease. Through their investigations, they have uncovered specific microbial signatures linked to endometrial and ovarian cancers and are working toward developing innovative home swab tests for women to assess their susceptibility.

“Screening the microbiome for early detection may improve patient outcomes,” says Dr. Walther-Antonio, also a researcher at the Departments of Surgery and Obstetrics and Gynecology, and the Mayo Clinic Comprehensive Cancer Center.

The team discovered a cluster of 17 bacterial microbes associated with the presence of endometrial cancer, with a “lightning rod” in the group: Porphyromonas somerae.

To validate this connection, they drew parallels between Porphyromonas somerae and its closest relative, which is known to be linked to oral cancer. The team hypothesized that Porphyromonas somerae might play a similarly invasive role in endometrial cancer. After extensive testing, they confirmed the ability of this microbe to invade endometrial cells and alter their function, especially under estrogen exposure — a common risk factor for endometrial cancer.

In their research on ovarian cancer, the team found a distribution of microbes in the reproductive tract of women with the disease. They also revealed changes in the microbiome compositions that are correlated with patient treatment outcomes. These findings may open investigation avenues into applicability of these markers to detecting and predicting treatment response.

According to World Cancer Research Fund International, endometrial cancer ranks as the sixth most common cancer among women globally, with 417,367 new cases and 97,370 deaths reported in 2020. Ovarian cancer follows as the eighth most common, recording 313,959 new cases and 207,252 deaths in the same year.

The Mayo scientists are also collaborating with the Waitematā District Health Board officials on Pacific Islander and Māori populations in New Zealand, which has one of the highest incidences of endometrial cancer globally. Factors such as high obesity rates, a known risk factor, are a likely contributor, but the high incidence rates among younger women remain unresolved.

In the U.S., there is a long-term initiative designed to engage Black women, particularly those who are postmenopausal. “Black women don’t have a higher incidence rate of endometrial cancer, but they have a higher mortality rate and morbidity rates. This is influenced by several factors, including limited access to healthcare.  Symptoms frequently go unrecognized or are mistakenly attributed to other conditions, such as fibroids, which are common among Black women,” Dr. Walther-Antonio says.

Through the long-term study, Mayo’s scientists hope to engage participants to contribute samples every six months for three years, including vaginal swabs and environmental samples to identify potential risk factors.

Ultimately, Dr. Walther-Antonio and her team hope to use these microbiome signatures to predict and intervene in the development of cancer before it materializes.

Mayo Clinic has a financial interest in the swabs mentioned in this article.

Although nausea and vomiting are common in pregnancy, affecting as many as 70% of pregnancies, severe vomiting and nausea can prevent people from eating and drinking sufficiently, leading to weight loss and dehydration.

“[Hyperemesis gravidarum] can have detrimental effects on maternal quality of life and may lead to short- and long-term adverse outcomes among offspring,” writes Dr. Larissa Jansen, Amsterdam Reproduction and Development Research Institute, Erasmus MC, Rotterdam, the Netherlands, with coauthors. “Management of hyperemesis gravidarum requires considerable health care resources, as it is a common reason for hospital admission and emergency department visits in the first trimester.”

The cause of hyperemesis gravidarum is not completely understood, but risk factors include pregnancy at a young age, female fetus, multiple or molar pregnancy, underlying medical conditions, and history of the condition during previous pregnancies.

Treatment is aimed at relieving symptoms and includes starting an antiemetic (anti-nausea) drug and other medications if the antiemetic is not effective. Remedies such as ginger products may alleviate mild nausea and vomiting for some people, but the evidence on its effectiveness in people with hyperemesis gravidarum is uncertain.

The authors caution against using cannabis for hyperemesis gravidarum.

“Use of cannabis in pregnancy has been associated with adverse neurocognitive outcomes in offspring, as well as other adverse pregnancy outcomes. Therefore, we advise against the use of cannabis in pregnancy.”

The authors note that there are many unanswered questions about how to prevent and manage hyperemesis gravidarum and that more research is needed.

To address this challenge, investigators from Massachusetts General Hospital, a founding member of the Mass General Brigham healthcare system, recently developed and validated a computer program that can be incorporated into electronic medical record systems to help clinicians diagnose mpox (formerly known as monkeypox).

The research is published in Infection Control and Healthcare Epidemiology.

“We built a novel decision support tool embedded in the electronic medical record that guides clinicians on crucial features of the physical examination and on important questions to ask patients with possible mpox,” said lead author Jacob Lazarus, MD, PhD, a physician investigator in the Division of Infectious Diseases within Massachusetts General Hospital’s Department of Medicine, and an instructor in Medicine at Harvard Medical School.

The clinical decision support system, called EvalMpox, proved useful in patients presenting to medical care with a rash. Its utility was assessed in 668 patient visits from more than 100 clinical locations across Greater Boston, Nantucket, Martha’s Vineyard, western Massachusetts, and southern New Hampshire.

EvalMpox guided clinicians in asking patients about potential mpox exposures, about symptoms of mpox, and in performing a physical examination to look for the characteristic mpox rash. EvalMpox was then able to use these answers to classify a patient as “likely to have mpox” or “unlikely to have mpox.”

The investigators found that the patients deemed likely to have mpox had similar characteristics compared with patients confirmed to have mpox. These patients were then prioritized for testing, and they were significantly more likely to test positive for mpox than patients deemed unlikely to have mpox.

“Our program identified nearly all cases of mpox diagnosed in the MGB system during the study period, underscoring the value of clinical decision support tools in assisting clinicians with early identification, isolation, and management of patients with communicable diseases like mpox,” said senior author Erica S. Shenoy, MD, PhD, Chief of Infection Control for Mass General Brigham and an associate professor of Medicine at Harvard Medical School.

The tool also had a high negative predictive value, meaning that if EvalMpox indicated that a person was low risk for mpox, it was very unlikely that they had the infection. “The tool’s high negative predictive value is also important,” emphasized Dr. Shenoy. “While the importance of early identification and isolation to prevent risk of transmission of disease cannot be overemphasized, we also know that it is critically important to have efficient ways to determine when isolation can be discontinued, and to reassure patients that they are unlikely to have an infection.”

Similar tools may help to assist clinicians in the identification, evaluation, and management of diverse infectious diseases now and in the future.

“Leveraging insights gained during the COVID-19 pandemic and the mpox outbreak, we are developing new decision support tools for diagnosing other emerging infections such as Ebola, Lassa Fever, and Marburg Virus Disease, as well as to support evaluation and management of patients with more ‘routine’ infections that impact delivery of healthcare based on requirements for patient isolation,” said Lazarus.

Authorship:

Jacob E. Lazarus, MD, PhD, Chloe V. Green, MURP, Michelle S. Jerry, BS, Lindsay Germaine, MPH, Dustin S. McEvoy, BS, Caitlin M. Dugdale, MD, MSc, Kristen M. Hysell, MD, MPH, Rebecca L. Craig, RN, MPH, CIC, Molly L. Paras, MD, Howard M. Heller, MD, MPH, Kevin L. Ard, MD, MPH,  John S. Albin, MD, PhD, Hang Lee, PhD, and Erica S. Shenoy, MD, PhD.

Funding:

This work was supported by a cooperative agreement from the Centers for Disease Control and Prevention. The Centers for Disease Control and Prevention had no involvement in the preparation, submission, or review of the manuscript.

Paper cited:

Lazarus J et al.  “Separating the Rash from the Chaff: Novel Clinical Decision Support Deployed During the Mpox Outbreak” Infection Control and Healthcare Epidemiology DOI: https://doi.org/10.1017/ice.2024.51