Wednesday, February 28, 2024

Environmental Health

Key Points

Question Is there an association between early life exposure to air pollution and the risk of asthma by early and middle childhood, and is this association modified by individual and community-level characteristics?

Findings In this cohort study of 5279 children, mean fine particulate matter (PM_2.5) and mean nitrogen dioxide (NO₂) air pollution during the first 3 years of life were associated both with asthma incidence by early and by middle childhood, after adjusting for individual-level characteristics. The association of ambient pollution (PM_2.5 or NO₂) with incident asthma was modified by community-level and individual-level socioeconomic circumstances, including maternal education and race.

Meaning These findings suggest that exposure to PM_2.5 or NO₂ air pollution during early childhood may play a role in the development of childhood asthma, with higher risk among minoritized families living in densely populated communities characterized by fewer opportunities and resources and multiple environmental coexposures.

Abstract

Importance Exposure to outdoor air pollution contributes to childhood asthma development, but many studies lack the geographic, racial and ethnic, and socioeconomic diversity to evaluate susceptibility by individual-level and community-level contextual factors.

Objective To examine early life exposure to fine particulate matter (PM_2.5) and nitrogen oxide (NO₂) air pollution and asthma risk by early and middle childhood, and whether individual and community-level characteristics modify associations between air pollution exposure and asthma.

Design, Setting, and Participants This cohort study included children enrolled in cohorts participating in the Children’s Respiratory and Environmental Workgroup consortium. The birth cohorts were located throughout the US, recruited between 1987 and 2007, and followed up through age 11 years. The survival analysis was adjusted for mother’s education, parental asthma, smoking during pregnancy, child’s race and ethnicity, sex, neighborhood characteristics, and cohort. Statistical analysis was performed from February 2022 to December 2023.

Exposure Early-life exposures to PM_2.5 and NO₂ according to participants’ birth address.

Main Outcomes and Measures Caregiver report of physician-diagnosed asthma through early (age 4 years) and middle (age 11 years) childhood.

Results Among 5279 children included, 1659 (31.4%) were Black, 835 (15.8%) were Hispanic, 2555 (48.4%) where White, and 229 (4.3%) were other race or ethnicity; 2721 (51.5%) were male and 2596 (49.2%) were female; 1305 children (24.7%) had asthma by 11 years of age and 954 (18.1%) had asthma by 4 years of age. Mean values of pollutants over the first 3 years of life were associated with asthma incidence. A 1 IQR increase in NO₂ (6.1 μg/m³) was associated with increased asthma incidence among children younger than 5 years (HR, 1.25 [95% CI, 1.03-1.52]) and children younger than 11 years (HR, 1.22 [95% CI, 1.04-1.44]). A 1 IQR increase in PM_2.5 (3.4 μg/m³) was associated with increased asthma incidence among children younger than 5 years (HR, 1.31 [95% CI, 1.04-1.66]) and children younger than 11 years (OR, 1.23 [95% CI, 1.01-1.50]). Associations of PM_2.5 or NO₂ with asthma were increased when mothers had less than a high school diploma, among Black children, in communities with fewer child opportunities, and in census tracts with higher percentage Black population and population density; for example, there was a significantly higher association between PM_2.5and asthma incidence by younger than 5 years of age in Black children (HR, 1.60 [95% CI, 1.15-2.22]) compared with White children (HR, 1.17 [95% CI, 0.90-1.52]).

Conclusions and Relevance In this cohort study, early life air pollution was associated with increased asthma incidence by early and middle childhood, with higher risk among minoritized families living in urban communities characterized by fewer opportunities and resources and multiple environmental coexposures. Reducing asthma risk in the US requires air pollution regulation and reduction combined with greater environmental, educational, and health equity at the community level.

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Early-Life Exposure to Air Pollution and Childhood Asthma Cumulative Incidence in the ECHO CREW Consortium |

Despite its elimination in the US in 2000, measles cases are being reported across the country. As of February 22, 35 cases have been reported this year in Arizona, California, Florida, Georgia, Indiana, Louisiana, Maryland, Minnesota, Missouri, New Jersey, New York City, Ohio, Pennsylvania, Virginia, and Washington, according to the US Centers for Disease Control and Prevention (CDC).

The CDC cautioned in a January alert that between December 1, 2023, and January 23, 2024, the agency was informed of 23 confirmed cases, most among children and adolescents who were eligible for vaccination but had not received the vaccine. Seven of those cases were imported by international travelers—travel-related cases present a danger to people who are unvaccinated and undervaccinated.

The measles virus.

James Cavallini/sciencesource.com

Tina Tan, MD, president-elect of the Infectious Diseases Society of America, said it’s important to understand how quickly measles can spread. “We live in a very mobile world where I don’t think people realize that an infectious disease can travel from one side of the world to the other in less than 24 hours,” she said in an interview with JAMA.

According to the CDC, clinicians should especially watch for measles symptoms among patients who traveled abroad to countries with ongoing outbreaks. As of early February, Yemen, Azerbaijan, Kazakhstan, India, Ethiopia, and Russia had the world’s highest case numbers.

Understanding the Cases

Clinicians at the Children’s Hospital of Philadelphia (CHOP) diagnosed the state’s first confirmed measles case this past December—an infant too young to be vaccinated who had traveled outside the US. During the hospital stay, 3 individuals without measles immunity were exposed and later tested positive for measles, according to Lori Handy, MD, MSCE, the associate director of the Vaccine Education Center at CHOP, where she is also an attending physician in the Division of Infectious Diseases.

CHOP “recommended home isolation for 21 days, which didn’t happen,” Paul Offit, MD, director of the Vaccine Education Center and professor of pediatrics in the Division of Infectious Diseases at CHOP, said in an interview with JAMA. At least 7 more cases followed in Philadelphia, he noted.

When clinicians diagnosed the initial patient at CHOP, “most young physicians had never seen measles, so they didn’t really know what to look for,” Offit said. To help them, “we described what a morbilliform rash looks like and explained the 3 C’s: cough, congestion, and conjunctivitis.”

Before the first measles vaccine became available in the US in 1963, most children contracted the disease by age 15 years. Annually, about 48 000 people were hospitalized, and between 400 and 500 died.

Measles resurged about 2 decades after it was eliminated as an endemic disease from the US, with more than 1200 confirmed cases across 31 states in 2019. And in late 2022, more than 70 cases were reported in Ohio alone.

The uptick in outbreaks isn’t exclusive to the US. A joint report from the CDC and the World Health Organization published this past November estimated that compared with 2021, 2022 saw an 18% increase in measles cases and a 43% increase in measles-related deaths worldwide.

“Even one case of measles is worrisome because it’s highly, highly contagious,” Offit said. Direct contact isn’t necessary for measles to spread. The CDC notes that about 9 out of 10 unprotected people exposed to measles become infected; 1 in 5 cases in which the patient isn’t vaccinated results in hospitalization.

Vaccination Strategies

The CDC recommends that patients 12 months or older be vaccinated against measles; those traveling abroad can be vaccinated as early as 6 months. A single dose of the measles-mumps-rubella vaccine is approximately 93% effective at preventing measles; 2 doses boost protection to about 97%.

“This immunity is lifelong,” Handy said. “While an imported case in an international traveler may occur intermittently, spread within the US population should be preventable when we maintain herd immunity.”

That’s why clinicians should actively encourage vaccination, said Tan, who is also an attending physician in the Division of Infectious Diseases at Ann & Robert H. Lurie Children’s Hospital of Chicago as well as a professor of pediatrics at Northwestern University’s Feinberg School of Medicine.

“You have to use motivational interviewing techniques where you listen to why people don’t want to get vaccinated,” she explained. “Acknowledge that you hear what these individuals are saying, and then explain the facts: that measles is still present, and unvaccinated persons are much more likely to acquire the disease if they’re exposed.”

In the US, “vaccination rates are decreasing below what is needed for population-level protection through herd immunity,” which requires about 95% of the population to be vaccinated, added Handy, an assistant professor of clinical pediatrics at the University of Pennsylvania’s Perelman School of Medicine. The CDC’s Morbidity and Mortality Weekly Report published in January 2023 showed that measles vaccination rates among kindergarteners for the 2021 to 2022 school year was only 93%.

That worries Offit. “As more kindergarteners are starting to become exempt from school-mandated vaccines, measles could make a comeback,” he warned.

COVID-19 is partially to blame for the measles outbreak. Because of the pandemic, 61 million doses of measles vaccines were delayed or missed between 2020 and 2022, the CDC reported.

“The measles vaccine, at some level, is a victim of its own success,” said Offit, who is also a professor of vaccinology at the Perelman School of Medicine. “I think people don’t see the disease, and so they don’t fear it.”

As for the outlook for 2024, Handy wrote that, “it’s always challenging to predict how a disease will spread in a given year, but current vaccination rates of US kindergarteners raise concern that we will see increased outbreaks instead of isolated cases.”

Although numerous reasons exist for low vaccination uptake, clinicians and public health authorities need to recognize that there isn’t a one-size-fits-all approach to increasing rates, Handy explained. “It takes a concerted effort to talk with patients and local communities to understand their specific hesitancies and design interventions specific to their needs,” she wrote. And most importantly, “a strong recommendation from a clinician for vaccination is one of the most impactful actions that can be taken to increase vaccination rates.”

Published Online: February 28, 2024. doi:10.1001/jama.2024.1949

Conflict of Interest Disclosures: Dr Handy reported receiving honoraria from Grand Rounds at Children’s Health Network of Minnesota for presenting on the topic of vaccine hesitancy, including hesitancy surrounding the measles-mumps-rubella vaccine. Dr Tan reported being the vice president of the Lurie Medical/Dental Staff at Ann & Robert H. Lurie Children’s Hospital of Chicago; being the medical director of Lurie Children’s International Patient and Destination Services Program; being editor in chief of Contemporary Pediatrics; being editor of the American Academy of Pediatrics Redbook Atlas of Pediatric Infectious Diseases; having research grants from AstraZeneca, GSK, Pfizer, and Sanofi Pasteur; being a member of the vaccine advisory boards for GSK, Merck, Moderna, Novavax, Pfizer, and Sanofi Pasteur; and serving on the US Centers for Disease Control and Prevention’s board of scientific counselors. No other disclosures were reported

Women's Health

Yoga Can Effectively Treat Chronic Low Back Pain

Benefits seen for pain intensity and flexion-relaxation phenomenon

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WEDNESDAY, Feb. 28, 2024 (HealthDay News) -- Tele-yoga asana might have a positive impact on pain intensity in women with chronic low back pain (LBP), according to a study published online Feb. 21 in the Journal of Orthopaedic Research.

Nicola Marotta, M.D., from the University of Catanzaro "Magna Graecia" in Italy, and colleagues evaluated the impact of yoga asana on the flexion-relaxation phenomenon in women with nonspecific LBP. The analysis included 11 healthy women and 10 women with chronic nonspecific LBP who underwent an eight-session yoga asana program, with the first session conducted in clinic and the rest delivered with a tele-approach.

The researchers found that the repeated-measures test in the chronic nonspecific LBP group showed a significant decrease in pain intensity after the four-week follow-up (visual analog scale: 6.80 versus 3.30) and an improvement in the flexion-relaxation ratio after the intervention (5.12 versus 9.49), with effect sizes of 0.77 and 0.47, respectively.

"Our findings demonstrated the feasibility and safety of a tele-delivered yoga intervention that could be integrated in a rehabilitation plan for patients with nonspecific LBP," the authors write. "Further research is warranted to confirm the long-term effects of yoga for managing LB

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Meditation could help menopausal women with anxiety and depression

Experts said they were not suggesting such therapies should replace hormone replacement therapy (HRT), but could be considered alongside pills and patches.

Jane Kirby, PA Health Editor

28 FEB 2024

(Image: PA Wire/PA Images)

A study suggests that meditation could help ease anxiety and depression symptoms in women going through menopause. Doctors might consider offering mindfulness and cognitive behavioural therapy (CBT) to these women, according to the research.

The study analysed 30 studies involving 3,501 women and found that mindfulness and CBT could provide some relief for symptoms. The researchers clarified that they are not suggesting these therapies should replace hormone replacement therapy (HRT), but could be used alongside it.

The research was carried out by University College London (UCL) and published in the Journal of Affective Disorders. It involved data from 14 countries, including the UK and US.Read more: ITV Vera's most 'unexpected' guest stars including Sam Fender, The Bill legend and 90s TV icon
Keep up to date with all the latest breaking news and top stories from the North East with our free newsletter

Ten of the studies looked at the effect of CBT on menopausal symptoms, while nine focused on mindfulness, a type of meditation where people concentrate on their current feelings and sensations.

Other studies examined various interventions, such as "acceptance", group counselling, and marital support. Women's symptoms were measured using internationally recognised questionnaires, covering areas like lack of interest in activities, sleep problems, low mood, and anxiety.

The findings showed that women's low mood "significantly benefited" from CBT and mindfulness. The study looked at data from 11 studies and found that treatments like CBT (Cognitive Behavioural Therapy) and mindfulness can help a bit with anxiety.

CBT had a small effect on anxiety by itself, while doing mindfulness helped a medium amount. For depression, CBT helped a small to medium amount, and mindfulness had a small effect.

Both CBT and mindfulness made people's quality of life better by a medium to large amount. The researchers also saw a small improvement in memory and concentration, but they said the information about this isn't very strong. They weren't sure how long these good effects would last for women.

Professor Aimee Spector, who led the study, mentioned that mindfulness could be used with HRT (Hormone Replacement Therapy) for women. She said some places in the NHS already use it to help with depression.

Professor Spector stressed: "The message we want to be really clear about is that with that we are not in any sense suggesting this as an alternative or recommending this instead of HRT. My personal experience of HRT has been extremely positive."

"I think what we know is that HRT doesn't get to everyone and not everyone wants it, and not everyone's eligible for it, so we do need to consider other things."

She suggested that treatments like CBT could provide extra help for women returning to work, "but I don't think we at any point want to say that addressing the hormone imbalance isn't probably the most important thing that can be done for many people".

Dr Roopal Desai, the senior author, added: "We're not advocating for this instead of HRT. I think it's just an additional tool that women can have as an option."

Prof Spector mentioned that about 30% of women going through menopause experience their first depressive episode, while "anxiety is highly prevalent" and half of women report feeling tense, nervous or irritable.

"In terms of HRT, we know it's not clinically indicated for everyone such as breast cancer survivors, and that its usage is variable depending on certain factors," she added.

"We know in certain ethnic groups such as south-east Asian and Afro-Caribbean populations, there seems to be a much lower uptake, and those who are socially disadvantaged often don't get access to HRT. So I think our message is that having holistic interventions can provide options for people who maybe aren't eligible, don't want HRT, possibly as an addition to HRT, and and they can support the psychosocial aspects as well as the biological."

Last year, draft guidance for the NHS said women should be offered talking therapy to combat the symptoms of the menopause. The National Institute for Health and Care Excellence (Nice) has said that women should be given a better understanding of the risks and benefits of HRT.

HRT replaces hormones like oestrogen, progestogen, or both. It can be given using gels, creams, pessaries, tablets or sprays. According to the NHS website, the risk of developing serious side effects from HRT is "very low". However, it can lead to a small increase in the risk of breast cancer.

Dr Louise Newson, a GP and menopause specialist, said it's not surprising that the new study found some improvements after mindfulness and CBT. But she reminded us that menopause is due to a hormone deficiency affecting the whole body.

She explained that this deficiency leads many women to experience "numerous physical as well as psychological symptoms". Long-term health risks associated with low hormones include "an increased risk of heart disease, dementia, diabetes, clinical depression, schizophrenia, osteoporosis and early death".

Dr Newson added: "First-line treatment of perimenopause and menopause for most women is replacing the missing hormones by prescribing the right dose and type of HRT."

She questioned why women must accept symptoms when there is a clear treatment (HRT) that is safe and effective available to them. And the specialist added: "The most cost-effective and easily accessible treatment should be HRT, yet globally only the minority of menopausal women, around 5%, are prescribed it."

Three quarters of women struggle to sleep peacefully due to period pain

Discomfort while trying to sleep is a common struggle for women when they're on their period, according to research

Three quarters of women experience an interrupted night’s sleep when they’re on their period, research has found.

A poll, of 1,000 women who menstruate, found 53% get anxious at night-time when on their period and will do whatever they can for a peaceful night’s sleep.

It also emerged that of those having an interrupted night, they’re waking up to five times, spending up to 30 minutes awake on each occasion (71%).

Sleeping in the fetal position and wearing extra layers of clothing are among the things women do to try and improve their sleep. When asked what’s causing these ‘period wakeups’, 38% said it’s because they’re worried about leaks, getting up to change their protection (30%) or general discomfort when lying down (25%).

Half of women say there needs to be more awareness of the impact menstruation on their sleep

'Gender pain gap' is widening, according to pain relief brand, Nurofen

Four in ten women see health issues like abortion or menopause as 'private matters'

Four in 10 (41%) said getting a good night’s sleep is more important to them when on their period than any other time of their menstrual cycle, and 85% admit to trying “period hacks” to avoid leaks and get a better night’s sleep.

These include wearing multiple pads (22%) and even sleeping on towels (20%).

The research was commissioned by Always, which has joined forces with Silentnight’s in-house sleep expert, Hannah Shore, to give advice on how to get a better night's sleep while on your period.

She said: “Not getting enough sleep can have a profound effect not just emotionally, but physically too. The less sleep we get, the more our pain tolerance decreases, meaning the worse our sleep gets and the worse our cramps are likely to get.

“That’s why I wanted to empower women to reclaim a night of uninterrupted sleep and share my top tips to help.”

READ MORETeachers feel they need more training - when it comes to puberty education, study finds

The impact of a bad night’s sleep is also felt the next day with 68% admitting they feel more irritable and 51% unable to concentrate, and 47% said it takes them between a few days and a week to catch up on sleep following their period.

Half of those surveyed (50%) also feel there isn’t enough awareness about the impact menstruation has on their sleep quality.

Farah Azmy, from Always UK, which has launched its Ultra Size 6 night pads, designed to help prevent leaks at night, added: ‘’We’ve all experienced period leaks during restless nights and had to deal with the period hangover the next morning.

“Sleep is so important, but even more so during your period when your body needs the rest. It’s become evident that there is a growing need for a solution, to help relieve over-night worries instead of managing with complex and uncomfortable period hacks.”

HANNAH SHORE’S TOP TIPS TO GETTING A GOOD NIGHT’S SLEEP ON YOUR PERIOD:

Regulate your temperature - Our bodies run hot during our periods, and when we are asleep our core body temperature needs to drop a couple of degrees to get access to the good quality sleep we need. Avoid hot showers/baths (warm is ok and can be relaxing) or exercise before bed and wear light, cool pyjamas. If you struggle with overheating throughout the night regularly try avoiding things like memory foam mattresses, as these can hold onto heat and make you hotter. A cold damp flannel or cold glass of water can help on particularly bad nights.

Establish a sleep routine - Routine is key when it comes to sleep. We should be going to sleep and waking up every day at the same time, even on weekends. This means our bodies will be used to producing the right hormones at the right time of day (sleep hormones such as melatonin in the evening and wake promoting hormones such as cortisol for the day). Producing the right hormones at the right time means we will fall asleep easier and wake up easier, leaving us feeling more refreshed.

Light - Light is important when it comes to sleep; we sleep when its dark for a reason. Light is our main external cue that regulates our sleep/wake hormone production. Bright morning light supresses the sleep hormones leaving you feeling more awake. Dull, darker evening light prompts the body to produce sleep hormones such as melatonin which will help you drift off to sleep easier.

Keep pain relief to hand - Getting up to seek out pain relief (turning on the lights to do so) will disturb your sleep cycle and make you feel more awake. Keep pain relief next to your bed or in an easily accessible place. If you experience very painful periods, it is recommended that you speak to your GP.

Find a period product that works for you - Sleeping on towels or using multiple period products can increase body temperature and add to your discomfort. Having a period product that works for you / you feel confident in will not only make you feel more comfortable but also reduce stress and worry. Stress and worry are sleeps worst enemy; they produce wake promoting hormones, which when they are in the system, will cause us to struggle to get to and stay asleep.

Women's Health

Number of Abortions Performed Per Month in U.S. Unchanged Since Fall of Roe v. Wade

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Monthly abortion rates across the United States haven't changed significantly since the fall of Roe v. Wade
The percentage of abortions involving medications appears to be on the rise
Many women living in states with abortion bans may be traveling to adjacent states for the procedure

WEDNESDAY, Feb. 28, 2024 (HealthDay News) -- The historic overturning of Roe v. Wade in 2022 has not had any significant effect on the number of abortions performed each month in the United States, new data shows.

The #WeCount report tracks abortion rates across the country for the nonprofit Society of Family Planning, a group promoting research on abortion and contraception.

It found that between 81,150 and 88,620 abortions took place each month between July and September of 2023 (the most recent period for which numbers are available).

That's only a slight decline from the monthly average of about 86,800 abortions performed from April through June 2022 -- just before Roe v. Wade was overturned.

The report also found that, increasingly, women are turning to medical abortion (pills) instead of surgical procedures. Pills now account for one-sixth of all abortions, according to the most recent data.

All of this could mean that, “even when a state bans abortion, people continue to need and seek abortion care,” report co-chair Alison Norris, a professor at Ohio State University’s College of Public Health, said in a statement. “We can’t let the overall consistent number of abortions nationally obscure the incredible unmet need and disastrous impact of abortion bans on people who already have the least access.”

Despite the lack of change in numbers, the report estimates that 120,000 more abortions would have happened over the survey period in the 14 states where the procedure is now banned, had bans not been put in place.

Women who need an abortion may simply be traveling, the report suggests. It found a rise in the number of abortions performed in certain states (Florida, Illinois and Kansas) that border states that have bans in effect.

More information

Find out more about the availability of abortion in the United States at the Guttmacher Institute.

SOURCE: #WeCount, Society for Family Planning, report, Feb. 28, 2024

About 98% of people experienced complete abortions without needing any additional interventions after receiving abortion medication provided via telehealth, according to electronic records from more than 6000 abortions provided in 20 states by 3 virtual clinics. The study, published in Nature Medicine, is among the first to establish the safety and effectiveness of no-test medication abortions—abortions that are monitored remotely and don’t include in-person ultrasonography or blood tests, the researchers noted.

The patients received 200 mg of mifepristone and 1600 μg or less of misoprostol. Approximately 0.2% of patients experienced a serious adverse event, such as a blood transfusion or a hospital admission requiring an overnight stay. This rate is similar to abortions delivered in-person.

Researchers also compared asynchronous telehealth abortions, in which clinicians communicated with their patients through secure messages, with synchronous telehealth abortions that took place in real time. Both were equally safe and effective.

These findings suggest that “policies that restrict telehealth abortion owing to concerns or claims about effectiveness or safety need to be revisited and revised to ensure equitable access to this essential healthcare service,” the researchers wrote.

Published Online: February 28, 2024. doi:10.1001/jama.2024.1123

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Wednesday, February 28, 2024

Early-Life Exposure to Air Pollution and Childhood Asthma Cumulative Incidence in the ECHO CREW Consortium

Measles Cases Are Spreading in the US—Here’s What to Know

Number of Abortions Performed Per Month in U.S. Unchanged Since Fall of Roe v. Wade

Telehealth Abortions as Safe and Effective as In-Person Ones

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