Feature

The COVID-19 prevention effort in children enters its next phase as June draws to a close, while new pediatric cases continued on a downward trend and hospitalizations continued to rise.

The COVID-19 vaccines from Pfizer-BioNTech and Moderna were approved for use in children as young as 6 months, the Centers for Disease Control and Prevention announced on June 18.

“We know millions of parents and caregivers are eager to get their young children vaccinated. ... I encourage parents and caregivers with questions to talk to their doctor, nurse, or local pharmacist to learn more about the benefits of vaccinations,” CDC Director Rochelle P. Walensky, MD, MPH, said in a written statement.

There are, however, indications that many parents are not that eager. A survey conducted in April by the Kaiser Family Foundation showed that only about 18% of parents were eager to get their children under age 5 years vaccinated right away and 27% said they would “definitely not” get their children vaccinated. Another 11% said “they will only do so if they are required,” Kaiser noted.

The vaccination experience with children aged 5-11 years seems to agree with those numbers. As of June 16, more than 7 months after the vaccine became available, just over 36% had received at least one dose and about 30% were fully vaccinated, CDC data show.

There are, according to the American Academy of Pediatrics, still five states where less than 20% of eligible 5- to 11-year-olds have received an initial vaccination. Among children aged 12-17, uptake has been much higher: 70% have received at least one dose and 60% are fully vaccinated, the CDC said.

Trends for new cases, hospitalizations diverging

COVID incidence in children, meanwhile, dropped for the second time in 3 weeks. There were 83,000 new cases reported during June 10-16, a decline of 4.8% from the previous week, according to the AAP and the Children’s Hospital Association.

New cases had risen by a very slight 0.31% during the week of June 3-9 after dropping 22% the week before (May 27 to June 2). Total cases in children have surpassed 13.6 million, which represents 18.8% of cases in all ages since the start of the pandemic, the AAP and CHA said in their weekly COVID report.

New admissions of children with confirmed COVID-19, however, have continued to climb since early to mid April. On June 16, the rate for children aged 0-17 years was up to 0.31 per 100,000, compared with the 0.13 per 100,000 recorded as late as April 11, the CDC said on its COVID Data Tracker.

rfranki@mdedge.com

The COVID-19 prevention effort in children enters its next phase as June draws to a close, while new pediatric cases continued on a downward trend and hospitalizations continued to rise.

The COVID-19 vaccines from Pfizer-BioNTech and Moderna were approved for use in children as young as 6 months, the Centers for Disease Control and Prevention announced on June 18.

“We know millions of parents and caregivers are eager to get their young children vaccinated. ... I encourage parents and caregivers with questions to talk to their doctor, nurse, or local pharmacist to learn more about the benefits of vaccinations,” CDC Director Rochelle P. Walensky, MD, MPH, said in a written statement.

There are, however, indications that many parents are not that eager. A survey conducted in April by the Kaiser Family Foundation showed that only about 18% of parents were eager to get their children under age 5 years vaccinated right away and 27% said they would “definitely not” get their children vaccinated. Another 11% said “they will only do so if they are required,” Kaiser noted.

The vaccination experience with children aged 5-11 years seems to agree with those numbers. As of June 16, more than 7 months after the vaccine became available, just over 36% had received at least one dose and about 30% were fully vaccinated, CDC data show.

There are, according to the American Academy of Pediatrics, still five states where less than 20% of eligible 5- to 11-year-olds have received an initial vaccination. Among children aged 12-17, uptake has been much higher: 70% have received at least one dose and 60% are fully vaccinated, the CDC said.

Trends for new cases, hospitalizations diverging

COVID incidence in children, meanwhile, dropped for the second time in 3 weeks. There were 83,000 new cases reported during June 10-16, a decline of 4.8% from the previous week, according to the AAP and the Children’s Hospital Association.

New cases had risen by a very slight 0.31% during the week of June 3-9 after dropping 22% the week before (May 27 to June 2). Total cases in children have surpassed 13.6 million, which represents 18.8% of cases in all ages since the start of the pandemic, the AAP and CHA said in their weekly COVID report.

New admissions of children with confirmed COVID-19, however, have continued to climb since early to mid April. On June 16, the rate for children aged 0-17 years was up to 0.31 per 100,000, compared with the 0.13 per 100,000 recorded as late as April 11, the CDC said on its COVID Data Tracker.

rfranki@mdedge.com

The COVID-19 prevention effort in children enters its next phase as June draws to a close, while new pediatric cases continued on a downward trend and hospitalizations continued to rise.

The COVID-19 vaccines from Pfizer-BioNTech and Moderna were approved for use in children as young as 6 months, the Centers for Disease Control and Prevention announced on June 18.

“We know millions of parents and caregivers are eager to get their young children vaccinated. ... I encourage parents and caregivers with questions to talk to their doctor, nurse, or local pharmacist to learn more about the benefits of vaccinations,” CDC Director Rochelle P. Walensky, MD, MPH, said in a written statement.

There are, however, indications that many parents are not that eager. A survey conducted in April by the Kaiser Family Foundation showed that only about 18% of parents were eager to get their children under age 5 years vaccinated right away and 27% said they would “definitely not” get their children vaccinated. Another 11% said “they will only do so if they are required,” Kaiser noted.

The vaccination experience with children aged 5-11 years seems to agree with those numbers. As of June 16, more than 7 months after the vaccine became available, just over 36% had received at least one dose and about 30% were fully vaccinated, CDC data show.

There are, according to the American Academy of Pediatrics, still five states where less than 20% of eligible 5- to 11-year-olds have received an initial vaccination. Among children aged 12-17, uptake has been much higher: 70% have received at least one dose and 60% are fully vaccinated, the CDC said.

Trends for new cases, hospitalizations diverging

COVID incidence in children, meanwhile, dropped for the second time in 3 weeks. There were 83,000 new cases reported during June 10-16, a decline of 4.8% from the previous week, according to the AAP and the Children’s Hospital Association.

New cases had risen by a very slight 0.31% during the week of June 3-9 after dropping 22% the week before (May 27 to June 2). Total cases in children have surpassed 13.6 million, which represents 18.8% of cases in all ages since the start of the pandemic, the AAP and CHA said in their weekly COVID report.

New admissions of children with confirmed COVID-19, however, have continued to climb since early to mid April. On June 16, the rate for children aged 0-17 years was up to 0.31 per 100,000, compared with the 0.13 per 100,000 recorded as late as April 11, the CDC said on its COVID Data Tracker.

rfranki@mdedge.com

A rapid, saliva-based test for COVID-19 could enable testing, diagnosis, and prescribing to take place in a single office visit by immediately confirming whether a patient has the infection and needs to be treated, researchers say. The test has sparked commercial interest and earned additional funding from the Canadian government.

The test uses a DNA aptamer – a short, synthetic oligonucleotide that binds to a specific molecular target – that shows high affinity for the SARS-CoV-2 spike protein and its variants. The approach “can be rapidly adapted to different threats,” as well, Leyla Soleymani, PhD, an associate professor of engineering physics at McMaster University, Hamilton, Ontario, Canada, told this news organization. Her team invented the approach.
 

Adaptable to other pathogens

Current gold-standard COVID-19 tests are based on reverse transcription-polymerase chain reaction (RT-PCR), which are sensitive but costly, complicated, and require waiting at least a couple of days for results, according to Dr. Soleymani and colleagues. Rapid nucleic acid and antigen tests have only “moderate” sensitivity and specificity, particularly when viral loads are low. None have been shown to work well with saliva samples.

By contrast, the new test “uses a reader and test cartridges, similar to the glucose reader,” said Dr. Soleymani, who is also Canada Research chair in Miniaturized Biomedical Devices. A small sample of saliva is added to a chemical reagent and inserted into the reader, which is attached to a smartphone. Once commercialized, the point-of-care test is expected to be performed quickly in a physician’s office or in a clinic.

“The same reader can be applied to a variety of infectious diseases or infection panels by developing new cartridges,” Dr. Soleymani explained. “Noroviruses and bacteria such as C. difficile are on our list” to examine next.What’s more, she added, “this test is ideally positioned for settings where access to centralized labs is not possible, such as less developed countries.”

The team’s recent studies seem to support the promise. A study published last year in the international edition of Angewandte Chemie documents the development of the test, which at that point could detect wild-type SARS-CoV-2 and its Alpha and Delta variants in unprocessed saliva samples in 10 minutes with 80.5% sensitivity and 100% specificity.

This study was followed in January 2022 by a paper in Chemistry showing that the device also detected Alpha, Gamma, Epsilon, Kappa, and Omicron variants, demonstrating its potential for recognizing rapidly evolving targets such as those found in SARS-CoV-2.

In another demonstration of its versatility, the technology was recently adapted and successfully detected animal viruses from saliva samples.
 

Commercial and government funding

The findings prompted Zentek, an intellectual property development and commercialization company in Guelph, Ont., to license the technology, with plans to invest more than $1 million in the next 5 years to scale up production of the test components and adapt the technology for other forms of infection.

Furthermore, the collaborative efforts required to develop the test and move it forward gained funding from Canada’s Natural Sciences and Engineering Research Council, which is investing nearly $1.5 million in the form of two grants: $1 million to further streamline the technology development in preparation for the next pandemic and $488,440 (including $140,000 from Zentek) to get the current test to market as quickly as possible.

Meanwhile, Dr. Soleymani is urging clinicians “to be open to nontraditional diagnostic approaches even if the traditional tests do the job. Such tests are more rapid and can be used to enable personalized medicine. Our success relies on collaboration and support from clinicians.”
 

Further validation needed

Daniel Kuritzkes, MD, chief of infectious diseases at Brigham and Women’s Hospital and the Harriet Ryan Albee Professor of Medicine at Harvard Medical School, Boston, commented on the study in response to a request from this news organization.

While “it’s always good to have more testing options available,” he said, “we don’t yet have very much information about performance characteristics of the test – that is, its sensitivity and specificity. I’d like to see the performance characteristics of this test compared to PCR tests and to the current rapid antigen tests using a large number of patient samples with currently circulating variants, and tests over time to see how soon tests become positive after symptom onset and for how long they remain positive.”

“Further validation studies and emergency use authorization or approval by regulatory authorities are needed before we will see this test implemented in the field,” Dr. Kuritzkes concluded.

A version of this article first appeared on Medscape.com.

A rapid, saliva-based test for COVID-19 could enable testing, diagnosis, and prescribing to take place in a single office visit by immediately confirming whether a patient has the infection and needs to be treated, researchers say. The test has sparked commercial interest and earned additional funding from the Canadian government.

The test uses a DNA aptamer – a short, synthetic oligonucleotide that binds to a specific molecular target – that shows high affinity for the SARS-CoV-2 spike protein and its variants. The approach “can be rapidly adapted to different threats,” as well, Leyla Soleymani, PhD, an associate professor of engineering physics at McMaster University, Hamilton, Ontario, Canada, told this news organization. Her team invented the approach.
 

Adaptable to other pathogens

Current gold-standard COVID-19 tests are based on reverse transcription-polymerase chain reaction (RT-PCR), which are sensitive but costly, complicated, and require waiting at least a couple of days for results, according to Dr. Soleymani and colleagues. Rapid nucleic acid and antigen tests have only “moderate” sensitivity and specificity, particularly when viral loads are low. None have been shown to work well with saliva samples.

By contrast, the new test “uses a reader and test cartridges, similar to the glucose reader,” said Dr. Soleymani, who is also Canada Research chair in Miniaturized Biomedical Devices. A small sample of saliva is added to a chemical reagent and inserted into the reader, which is attached to a smartphone. Once commercialized, the point-of-care test is expected to be performed quickly in a physician’s office or in a clinic.

“The same reader can be applied to a variety of infectious diseases or infection panels by developing new cartridges,” Dr. Soleymani explained. “Noroviruses and bacteria such as C. difficile are on our list” to examine next.What’s more, she added, “this test is ideally positioned for settings where access to centralized labs is not possible, such as less developed countries.”

The team’s recent studies seem to support the promise. A study published last year in the international edition of Angewandte Chemie documents the development of the test, which at that point could detect wild-type SARS-CoV-2 and its Alpha and Delta variants in unprocessed saliva samples in 10 minutes with 80.5% sensitivity and 100% specificity.

This study was followed in January 2022 by a paper in Chemistry showing that the device also detected Alpha, Gamma, Epsilon, Kappa, and Omicron variants, demonstrating its potential for recognizing rapidly evolving targets such as those found in SARS-CoV-2.

In another demonstration of its versatility, the technology was recently adapted and successfully detected animal viruses from saliva samples.
 

Commercial and government funding

The findings prompted Zentek, an intellectual property development and commercialization company in Guelph, Ont., to license the technology, with plans to invest more than $1 million in the next 5 years to scale up production of the test components and adapt the technology for other forms of infection.

Furthermore, the collaborative efforts required to develop the test and move it forward gained funding from Canada’s Natural Sciences and Engineering Research Council, which is investing nearly $1.5 million in the form of two grants: $1 million to further streamline the technology development in preparation for the next pandemic and $488,440 (including $140,000 from Zentek) to get the current test to market as quickly as possible.

Meanwhile, Dr. Soleymani is urging clinicians “to be open to nontraditional diagnostic approaches even if the traditional tests do the job. Such tests are more rapid and can be used to enable personalized medicine. Our success relies on collaboration and support from clinicians.”
 

Further validation needed

Daniel Kuritzkes, MD, chief of infectious diseases at Brigham and Women’s Hospital and the Harriet Ryan Albee Professor of Medicine at Harvard Medical School, Boston, commented on the study in response to a request from this news organization.

While “it’s always good to have more testing options available,” he said, “we don’t yet have very much information about performance characteristics of the test – that is, its sensitivity and specificity. I’d like to see the performance characteristics of this test compared to PCR tests and to the current rapid antigen tests using a large number of patient samples with currently circulating variants, and tests over time to see how soon tests become positive after symptom onset and for how long they remain positive.”

“Further validation studies and emergency use authorization or approval by regulatory authorities are needed before we will see this test implemented in the field,” Dr. Kuritzkes concluded.

A version of this article first appeared on Medscape.com.

A rapid, saliva-based test for COVID-19 could enable testing, diagnosis, and prescribing to take place in a single office visit by immediately confirming whether a patient has the infection and needs to be treated, researchers say. The test has sparked commercial interest and earned additional funding from the Canadian government.

The test uses a DNA aptamer – a short, synthetic oligonucleotide that binds to a specific molecular target – that shows high affinity for the SARS-CoV-2 spike protein and its variants. The approach “can be rapidly adapted to different threats,” as well, Leyla Soleymani, PhD, an associate professor of engineering physics at McMaster University, Hamilton, Ontario, Canada, told this news organization. Her team invented the approach.
 

Adaptable to other pathogens

Current gold-standard COVID-19 tests are based on reverse transcription-polymerase chain reaction (RT-PCR), which are sensitive but costly, complicated, and require waiting at least a couple of days for results, according to Dr. Soleymani and colleagues. Rapid nucleic acid and antigen tests have only “moderate” sensitivity and specificity, particularly when viral loads are low. None have been shown to work well with saliva samples.

By contrast, the new test “uses a reader and test cartridges, similar to the glucose reader,” said Dr. Soleymani, who is also Canada Research chair in Miniaturized Biomedical Devices. A small sample of saliva is added to a chemical reagent and inserted into the reader, which is attached to a smartphone. Once commercialized, the point-of-care test is expected to be performed quickly in a physician’s office or in a clinic.

“The same reader can be applied to a variety of infectious diseases or infection panels by developing new cartridges,” Dr. Soleymani explained. “Noroviruses and bacteria such as C. difficile are on our list” to examine next.What’s more, she added, “this test is ideally positioned for settings where access to centralized labs is not possible, such as less developed countries.”

The team’s recent studies seem to support the promise. A study published last year in the international edition of Angewandte Chemie documents the development of the test, which at that point could detect wild-type SARS-CoV-2 and its Alpha and Delta variants in unprocessed saliva samples in 10 minutes with 80.5% sensitivity and 100% specificity.

This study was followed in January 2022 by a paper in Chemistry showing that the device also detected Alpha, Gamma, Epsilon, Kappa, and Omicron variants, demonstrating its potential for recognizing rapidly evolving targets such as those found in SARS-CoV-2.

In another demonstration of its versatility, the technology was recently adapted and successfully detected animal viruses from saliva samples.
 

Commercial and government funding

The findings prompted Zentek, an intellectual property development and commercialization company in Guelph, Ont., to license the technology, with plans to invest more than $1 million in the next 5 years to scale up production of the test components and adapt the technology for other forms of infection.

Furthermore, the collaborative efforts required to develop the test and move it forward gained funding from Canada’s Natural Sciences and Engineering Research Council, which is investing nearly $1.5 million in the form of two grants: $1 million to further streamline the technology development in preparation for the next pandemic and $488,440 (including $140,000 from Zentek) to get the current test to market as quickly as possible.

Meanwhile, Dr. Soleymani is urging clinicians “to be open to nontraditional diagnostic approaches even if the traditional tests do the job. Such tests are more rapid and can be used to enable personalized medicine. Our success relies on collaboration and support from clinicians.”
 

Further validation needed

Daniel Kuritzkes, MD, chief of infectious diseases at Brigham and Women’s Hospital and the Harriet Ryan Albee Professor of Medicine at Harvard Medical School, Boston, commented on the study in response to a request from this news organization.

While “it’s always good to have more testing options available,” he said, “we don’t yet have very much information about performance characteristics of the test – that is, its sensitivity and specificity. I’d like to see the performance characteristics of this test compared to PCR tests and to the current rapid antigen tests using a large number of patient samples with currently circulating variants, and tests over time to see how soon tests become positive after symptom onset and for how long they remain positive.”

“Further validation studies and emergency use authorization or approval by regulatory authorities are needed before we will see this test implemented in the field,” Dr. Kuritzkes concluded.

A version of this article first appeared on Medscape.com.

The long-term health consequences of COVID-19 have refocused our attention on post–acute infection syndromes (PAIS), starting a discussion on the need for a complete understanding of multisystemic pathophysiology, clinical indicators, and the epidemiology of these syndromes, representing a significant blind spot in the field of medicine. A better understanding of these persistent symptom profiles, not only for post-acute sequelae of SARS-CoV-2 infection (PASC), better known as long COVID, but also for other diseases with unexplainable post-acute sequelae, would allow doctors to fine tune the diagnostic criteria. Having a clear definition and better understanding of post–acute infection symptoms is a necessary step toward developing an evidence-based, multidisciplinary management approach.

PAIS, PASC, or long COVID

The observation of unexplained chronic sequelae after SARS-CoV-2 is known as PASC or long COVID.

Long COVID has been reported as a syndrome in survivors of serious and critical disease, but the effects also persist over time for subjects who experienced a mild infection that did not require admission to hospital. This means that PASC, especially when occurring after a mild or moderate COVID-19 infection, shares many of the same characteristics as chronic diseases triggered by other pathogenic organisms, many of which have not been sufficiently clarified.

PAIS are characterized by a set of core symptoms centering on the following:

• Exertion intolerance
• Disproportionate levels of fatigue
• Neurocognitive and sensory impairment
• Flu-like symptoms
• Unrefreshing sleep
• Myalgia/arthralgia

A plethora of nonspecific symptoms are often present to various degrees.

These similarities suggest a unifying pathophysiology that needs to be elucidated to properly understand and manage postinfectious chronic disability.
 

Overview of PAIS

A detailed revision on what is currently known about PAIS was published in Nature Medicine. It provided various useful pieces of information to assist with the poor recognition of these conditions in clinical practice, a result of which is that patients might experience delayed or a complete lack of clinical care.

The following consolidated postinfection sequelae are mentioned:

• Q fever fatigue syndrome, which follows infection by the intracellular bacterium Coxiella burnetii
• Post-dengue fatigue syndrome, which can follow infection by the mosquito-borne dengue virus
• Fatiguing and rheumatic symptoms in a subset of individuals infected with chikungunya virus, a mosquito-borne virus that causes fever and joint pain in the acute phase
• Post-polio syndrome, which can emerge as many as 15-40 years after an initial poliomyelitis attack (similarly, some other neurotropic microbes, such as West Nile virus, might lead to persistent effects)
• Prolonged, debilitating, chronic symptoms have long been reported in a subset of patients after common and typically nonserious infections. For example, after mononucleosis, a condition generally caused by Epstein-Barr virus (EBV), and after an outbreak of Giardia lamblia, an intestinal parasite that usually causes acute intestinal illness. In fact, several studies identified the association of this outbreak of giardiasis with chronic fatigue, irritable bowel syndrome (IBS), and fibromyalgia persisting for many years.
• Views expressed in the literature regarding the frequency and the validity of posttreatment Lyme disease syndrome are divided. Although substantial evidence points to persistence of arthralgia, fatigue, and subjective neurocognitive impairments in a minority of patients with Lyme disease after the recommended antibiotic treatment, some of the early studies have failed to characterize the initial Lyme disease episode with sufficient rigor.

Symptoms and signs

The symptoms and signs which, based on the evidence available, are seen more frequently in health care checks may be characterized as the following:

• Exertion intolerance, fatigue
• Flu-like and ‘sickness behavior’ symptoms: fever, feverishness, muscle pain, feeling sick, malaise, sweating, irritability
• Neurological/neurocognitive symptoms: brain fog, impaired concentration or memory, trouble finding words
• Rheumatologic symptoms: chronic or recurrent joint pain
• Trigger-specific symptoms: for example, eye problems post Ebola, IBS post Giardia, anosmia and ageusia post COVID-19, motor disturbances post polio and post West Nile virus

Myalgic encephalomyelitis/chronic fatigue syndrome

Patients with this disorder experience worsening of symptoms following physical, cognitive, or emotional exertion above their (very low) tolerated limit. Other prominent features frequently observed in myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) are neurocognitive impairments (colloquially referred to as brain fog), unrefreshing sleep, pain, sensory disturbances, gastrointestinal issues, and various forms of dysautonomia. Up to 75% of ME/CFS cases report an infection-like episode preceding the onset of their illness. Postinfectious and postviral fatigue syndromes were originally postulated as subsets of chronic fatigue syndrome. However, there appears to be no clear consensus at present about whether these terms should be considered synonymous to the ME/CFS label or any of its subsets, or include a wider range of postinfectious fatigue conditions.

Practical diagnostic criteria

From a revision of the available criteria, it emerges that the diagnostic criteria for a PAIS should include not only the presence of symptoms, but ideally also the intensity, course, and constellation of symptoms within an individual, as the individual symptoms and symptom trajectories of PAIS vary over time, rendering a mere comparison of symptom presence at a single time point misleading. Furthermore, when a diagnosis of ME/CFS is made, attention should be given to the choice of diagnostic criteria, with preference given to the more conservative criteria, so as not to run the risk of overestimating the syndrome.

Asthenia is the cornerstone symptom for most epidemiological studies on PAIS, but it would be reductive to concentrate only on this rather than the other characteristics, such as the exacerbation of symptoms following exertion, together with other characteristic symptoms and signs that may allow for better identification of the overall, observable clinical picture in these postinfection syndromes, which have significant impacts on a patient’s quality of life.

This article was translated from Univadis Italy. A version of this article appeared on Medscape.com.

The long-term health consequences of COVID-19 have refocused our attention on post–acute infection syndromes (PAIS), starting a discussion on the need for a complete understanding of multisystemic pathophysiology, clinical indicators, and the epidemiology of these syndromes, representing a significant blind spot in the field of medicine. A better understanding of these persistent symptom profiles, not only for post-acute sequelae of SARS-CoV-2 infection (PASC), better known as long COVID, but also for other diseases with unexplainable post-acute sequelae, would allow doctors to fine tune the diagnostic criteria. Having a clear definition and better understanding of post–acute infection symptoms is a necessary step toward developing an evidence-based, multidisciplinary management approach.

PAIS, PASC, or long COVID

The observation of unexplained chronic sequelae after SARS-CoV-2 is known as PASC or long COVID.

Long COVID has been reported as a syndrome in survivors of serious and critical disease, but the effects also persist over time for subjects who experienced a mild infection that did not require admission to hospital. This means that PASC, especially when occurring after a mild or moderate COVID-19 infection, shares many of the same characteristics as chronic diseases triggered by other pathogenic organisms, many of which have not been sufficiently clarified.

PAIS are characterized by a set of core symptoms centering on the following:

• Exertion intolerance
• Disproportionate levels of fatigue
• Neurocognitive and sensory impairment
• Flu-like symptoms
• Unrefreshing sleep
• Myalgia/arthralgia

A plethora of nonspecific symptoms are often present to various degrees.

These similarities suggest a unifying pathophysiology that needs to be elucidated to properly understand and manage postinfectious chronic disability.
 

Overview of PAIS

A detailed revision on what is currently known about PAIS was published in Nature Medicine. It provided various useful pieces of information to assist with the poor recognition of these conditions in clinical practice, a result of which is that patients might experience delayed or a complete lack of clinical care.

The following consolidated postinfection sequelae are mentioned:

• Q fever fatigue syndrome, which follows infection by the intracellular bacterium Coxiella burnetii
• Post-dengue fatigue syndrome, which can follow infection by the mosquito-borne dengue virus
• Fatiguing and rheumatic symptoms in a subset of individuals infected with chikungunya virus, a mosquito-borne virus that causes fever and joint pain in the acute phase
• Post-polio syndrome, which can emerge as many as 15-40 years after an initial poliomyelitis attack (similarly, some other neurotropic microbes, such as West Nile virus, might lead to persistent effects)
• Prolonged, debilitating, chronic symptoms have long been reported in a subset of patients after common and typically nonserious infections. For example, after mononucleosis, a condition generally caused by Epstein-Barr virus (EBV), and after an outbreak of Giardia lamblia, an intestinal parasite that usually causes acute intestinal illness. In fact, several studies identified the association of this outbreak of giardiasis with chronic fatigue, irritable bowel syndrome (IBS), and fibromyalgia persisting for many years.
• Views expressed in the literature regarding the frequency and the validity of posttreatment Lyme disease syndrome are divided. Although substantial evidence points to persistence of arthralgia, fatigue, and subjective neurocognitive impairments in a minority of patients with Lyme disease after the recommended antibiotic treatment, some of the early studies have failed to characterize the initial Lyme disease episode with sufficient rigor.

Symptoms and signs

The symptoms and signs which, based on the evidence available, are seen more frequently in health care checks may be characterized as the following:

• Exertion intolerance, fatigue
• Flu-like and ‘sickness behavior’ symptoms: fever, feverishness, muscle pain, feeling sick, malaise, sweating, irritability
• Neurological/neurocognitive symptoms: brain fog, impaired concentration or memory, trouble finding words
• Rheumatologic symptoms: chronic or recurrent joint pain
• Trigger-specific symptoms: for example, eye problems post Ebola, IBS post Giardia, anosmia and ageusia post COVID-19, motor disturbances post polio and post West Nile virus

Myalgic encephalomyelitis/chronic fatigue syndrome

Patients with this disorder experience worsening of symptoms following physical, cognitive, or emotional exertion above their (very low) tolerated limit. Other prominent features frequently observed in myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) are neurocognitive impairments (colloquially referred to as brain fog), unrefreshing sleep, pain, sensory disturbances, gastrointestinal issues, and various forms of dysautonomia. Up to 75% of ME/CFS cases report an infection-like episode preceding the onset of their illness. Postinfectious and postviral fatigue syndromes were originally postulated as subsets of chronic fatigue syndrome. However, there appears to be no clear consensus at present about whether these terms should be considered synonymous to the ME/CFS label or any of its subsets, or include a wider range of postinfectious fatigue conditions.

Practical diagnostic criteria

From a revision of the available criteria, it emerges that the diagnostic criteria for a PAIS should include not only the presence of symptoms, but ideally also the intensity, course, and constellation of symptoms within an individual, as the individual symptoms and symptom trajectories of PAIS vary over time, rendering a mere comparison of symptom presence at a single time point misleading. Furthermore, when a diagnosis of ME/CFS is made, attention should be given to the choice of diagnostic criteria, with preference given to the more conservative criteria, so as not to run the risk of overestimating the syndrome.

Asthenia is the cornerstone symptom for most epidemiological studies on PAIS, but it would be reductive to concentrate only on this rather than the other characteristics, such as the exacerbation of symptoms following exertion, together with other characteristic symptoms and signs that may allow for better identification of the overall, observable clinical picture in these postinfection syndromes, which have significant impacts on a patient’s quality of life.

This article was translated from Univadis Italy. A version of this article appeared on Medscape.com.

The long-term health consequences of COVID-19 have refocused our attention on post–acute infection syndromes (PAIS), starting a discussion on the need for a complete understanding of multisystemic pathophysiology, clinical indicators, and the epidemiology of these syndromes, representing a significant blind spot in the field of medicine. A better understanding of these persistent symptom profiles, not only for post-acute sequelae of SARS-CoV-2 infection (PASC), better known as long COVID, but also for other diseases with unexplainable post-acute sequelae, would allow doctors to fine tune the diagnostic criteria. Having a clear definition and better understanding of post–acute infection symptoms is a necessary step toward developing an evidence-based, multidisciplinary management approach.

PAIS, PASC, or long COVID

The observation of unexplained chronic sequelae after SARS-CoV-2 is known as PASC or long COVID.

Long COVID has been reported as a syndrome in survivors of serious and critical disease, but the effects also persist over time for subjects who experienced a mild infection that did not require admission to hospital. This means that PASC, especially when occurring after a mild or moderate COVID-19 infection, shares many of the same characteristics as chronic diseases triggered by other pathogenic organisms, many of which have not been sufficiently clarified.

PAIS are characterized by a set of core symptoms centering on the following:

• Exertion intolerance
• Disproportionate levels of fatigue
• Neurocognitive and sensory impairment
• Flu-like symptoms
• Unrefreshing sleep
• Myalgia/arthralgia

A plethora of nonspecific symptoms are often present to various degrees.

These similarities suggest a unifying pathophysiology that needs to be elucidated to properly understand and manage postinfectious chronic disability.
 

Overview of PAIS

A detailed revision on what is currently known about PAIS was published in Nature Medicine. It provided various useful pieces of information to assist with the poor recognition of these conditions in clinical practice, a result of which is that patients might experience delayed or a complete lack of clinical care.

The following consolidated postinfection sequelae are mentioned:

• Q fever fatigue syndrome, which follows infection by the intracellular bacterium Coxiella burnetii
• Post-dengue fatigue syndrome, which can follow infection by the mosquito-borne dengue virus
• Fatiguing and rheumatic symptoms in a subset of individuals infected with chikungunya virus, a mosquito-borne virus that causes fever and joint pain in the acute phase
• Post-polio syndrome, which can emerge as many as 15-40 years after an initial poliomyelitis attack (similarly, some other neurotropic microbes, such as West Nile virus, might lead to persistent effects)
• Prolonged, debilitating, chronic symptoms have long been reported in a subset of patients after common and typically nonserious infections. For example, after mononucleosis, a condition generally caused by Epstein-Barr virus (EBV), and after an outbreak of Giardia lamblia, an intestinal parasite that usually causes acute intestinal illness. In fact, several studies identified the association of this outbreak of giardiasis with chronic fatigue, irritable bowel syndrome (IBS), and fibromyalgia persisting for many years.
• Views expressed in the literature regarding the frequency and the validity of posttreatment Lyme disease syndrome are divided. Although substantial evidence points to persistence of arthralgia, fatigue, and subjective neurocognitive impairments in a minority of patients with Lyme disease after the recommended antibiotic treatment, some of the early studies have failed to characterize the initial Lyme disease episode with sufficient rigor.

Symptoms and signs

The symptoms and signs which, based on the evidence available, are seen more frequently in health care checks may be characterized as the following:

• Exertion intolerance, fatigue
• Flu-like and ‘sickness behavior’ symptoms: fever, feverishness, muscle pain, feeling sick, malaise, sweating, irritability
• Neurological/neurocognitive symptoms: brain fog, impaired concentration or memory, trouble finding words
• Rheumatologic symptoms: chronic or recurrent joint pain
• Trigger-specific symptoms: for example, eye problems post Ebola, IBS post Giardia, anosmia and ageusia post COVID-19, motor disturbances post polio and post West Nile virus

Myalgic encephalomyelitis/chronic fatigue syndrome

Patients with this disorder experience worsening of symptoms following physical, cognitive, or emotional exertion above their (very low) tolerated limit. Other prominent features frequently observed in myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) are neurocognitive impairments (colloquially referred to as brain fog), unrefreshing sleep, pain, sensory disturbances, gastrointestinal issues, and various forms of dysautonomia. Up to 75% of ME/CFS cases report an infection-like episode preceding the onset of their illness. Postinfectious and postviral fatigue syndromes were originally postulated as subsets of chronic fatigue syndrome. However, there appears to be no clear consensus at present about whether these terms should be considered synonymous to the ME/CFS label or any of its subsets, or include a wider range of postinfectious fatigue conditions.

Practical diagnostic criteria

From a revision of the available criteria, it emerges that the diagnostic criteria for a PAIS should include not only the presence of symptoms, but ideally also the intensity, course, and constellation of symptoms within an individual, as the individual symptoms and symptom trajectories of PAIS vary over time, rendering a mere comparison of symptom presence at a single time point misleading. Furthermore, when a diagnosis of ME/CFS is made, attention should be given to the choice of diagnostic criteria, with preference given to the more conservative criteria, so as not to run the risk of overestimating the syndrome.

Asthenia is the cornerstone symptom for most epidemiological studies on PAIS, but it would be reductive to concentrate only on this rather than the other characteristics, such as the exacerbation of symptoms following exertion, together with other characteristic symptoms and signs that may allow for better identification of the overall, observable clinical picture in these postinfection syndromes, which have significant impacts on a patient’s quality of life.

This article was translated from Univadis Italy. A version of this article appeared on Medscape.com.

When 29-year-old Sakeenah Fowler was pregnant with her first child, doctors kept a close watch. Ms. Fowler has lupus, high blood pressure, a history of blood clotting, and kidney problems that all could have endangered her or the health of her unborn baby.

She saw maternal-fetal specialists who could keep watch of her high-risk pregnancy, and she collected urine samples every 24 hours to make sure her kidneys were functioning properly from her home in Roebuck, S.C.

But the pregnancy ultimately proved uneventful; even her kidneys remained stable. So Ms. Fowler said she was shocked when her doctors ordered an emergency cesarean delivery after she had gone into active labor.

“I was already dilated all the way to 6 cm,” but the baby’s heart rate had decreased by a small amount, she says. “They thought it was best to just go ahead with a C-section.”

Ms. Fowler, who is Black, said she believes the surgical intervention was unnecessary and that she wasn’t given a chance to discuss her options for a vaginal childbirth.  

“They already had it in their minds that I wasn’t going to make it through the pregnancy without any issues; then when I did, it was like they wanted to find something that made me have to have a C-section,” Ms. Fowler said. “It was close to the holidays; everybody was ready to go home. It was just like I was pushed to do what they wanted me to do.”

Ms. Fowler’s sense of a lack of choice is important beyond the measure of patient experience. While cesarean deliveries can be a lifeline for mother and baby, they can put up massive roadblocks to maternal and infant health when not necessary.

“The risk of hemorrhage, infection – on average, all of these go up when you have surgery instead of a vaginal delivery,” says Kimberly B. Glazer, PhD, a perinatal epidemiologist at the Icahn School of Medicine at Mount Sinai, New York.

“Birth is one of the most salient experiences you can have. People want to feel like their values and preferences – whatever they may be – were honored and respected. Even if the delivery goes a different way than you wanted, feeling like your values were taken into account is very important.”

More than 1 million women undergo cesarean deliveries in the United States every year, composing over 31% of all births in 2020, according to the Centers for Disease Control and Prevention.

The World Health Organization, meanwhile, recommends a rate of cesarean delivery of no more than 15% per region. Whether or not all the U.S. procedures were medically warranted is unclear, however.

Black women have higher odds of undergoing a cesarean: 36% undergo surgical deliveries annually, compared with about 30% of White women. Black women are also about three times more likely to die of pregnancy-related causes than White women.
 

Risk becomes reality

Ms. Fowler eventually developed an infection in her cesarean surgical wound, but her doctors initially insisted her alternating chills and fever were merely postpartum hormonal swings, she says.

“I thought something had to be wrong, but they just kept saying nothing was wrong,” she says.

By the time her doctors caught the infection, Ms. Fowler was readmitted to the hospital for several days of IV antibiotic therapy. The infection “almost got into my bloodstream and could have killed me,” she says.  

While cesarean deliveries are associated with decreases in maternal, neonatal, and infant mortality, the benefits are only seen up to a certain threshold. The WHO, for instance, has reported that over the 15% threshold, that lower mortality benefit disappears.

“When medically necessary, cesarean delivery can improve outcomes for mother and baby. But the fact that cesarean section rates have increased in recent years without a corresponding improvement in health outcomes indicates overreliance on the procedure,” Dr. Glazer says.
 

Clinical discretion leads to biased judgment calls

Rates of cesarean deliveries are even higher among low-risk pregnancies in women of color than in White women. Between 2016 and 2019, the overall rate of cesarean deliveries for low-risk births was 23%, according to a recent analysis. But the rate was almost 18% higher among Black women than among White women (27% vs. 22%).

“When you see data about these subjective indications varying by race and ethnicity, I think that’s pointing us toward some answers,” Dr. Glazer says. “Once you adjust for all these measures, prepregnancy characteristics, and risk factors, the research identifies variation in quality and outcomes that is rooted in structural and systemic racism in health care, implicit bias from clinicians.”

Researchers investigating cesarean deliveries have found that Black women are more likely to undergo the surgery for reasons that are highly subjective, such as fetal distress.

“There is a huge range of how concerning a fetal heart rate can be, and some health providers might perform a C-section for only minor changes in the fetal heart rate, while others might wait until it is much worse,” said Rebecca Hamm, MD, an assistant professor of obstetrics and gynecology at the Perelman School of Medicine at the University of Pennsylvania.

At least some of the differences in care can be explained by where women deliver their babies, studies have shown. Women of color disproportionately deliver at hospitals with poorer quality outcomes for moms and babies.
 

Dealing with the aftermath

There can be costs that reverberate throughout the life of a mother, child, and their family as the result of surgical delivery.

“Cesarean sections cost a lot more,” says Jamila Taylor, PhD, director of health care reform and a senior fellow with The Century Foundation, a progressive policy think tank in Washington, D.C. The cost of a cesarean delivery averages about $17,000, compared with about $12,200 for a vaginal birth; for uninsured patients, surgical deliveries cost about $9,000 more than vaginal deliveries.

Dr. Taylor, who has studied the historical mistreatment of Black women in obstetrics, noted that this cost includes not just the bill for surgery but also a prolonged recovery time that is often spent in a hospital bed.

Beyond the detrimental effect that a large hospital bill for delivery and aftercare can have on families, other costs can crop up later. Infants delivered by cesarean surgery are more likely to develop an infection, breathing problems, and to spend time in the neonatal intensive care unit than babies born vaginally. Although studies suggest these outcomes may result from a medically necessary health concern that spurred the cesarean surgery, they often stem from the delivery itself.  

Babies born surgically also miss out on the benefits of passing through the birth canal, such as supporting a newborn’s immune system and preparing their lungs to breathe oxygen after birth.

Most of the efforts to reduce inequities in maternal care are happening at the clinical level, aimed at both patients and providers, Dr. Taylor says.

“As advocates, we’re talking about how we can help Black women be advocates for themselves in the health care system – if the physician suggests a C-section, getting a second opinion, or walking through what a [surgical delivery] will mean and what their recovery will look like,” she says.

Women are also increasingly choosing non-hospital settings to deliver when possible, Dr. Taylor says. Including doulas or midwife practitioners in the maternal care team can reduce unnecessary cesarean deliveries among Black women, according to Camille Clare, MD, chair of the New York chapter of the American College of Obstetricians and Gynecologists.

Also, last year, race was removed from the vaginal birth after C-section (VBAC) calculator, which is used to gauge the safety of vaginal delivery in women with a history of surgical birth. The original calculator included race-based correction factors for Black women and Hispanic women. It predicted a lower likelihood of successful vaginal deliveries for women who already had a C-section and who identify as Black or Hispanic than for White women with otherwise identical characteristics, such as age, weight, and a history of cesarean delivery.

“Those are things that over time should reduce the high rates of cesarean section for Black women in particular,” Dr. Clare says.

In addition to embracing the updated calculator and including nurse-midwives and doulas in their obstetrics services, Penn Medicine, Philadelphia received a federal grant to study the impact of creating a standard plan for deliveries. This includes standardizing the induction of labor and any effect that might have on reducing C-section rates.

“This idea that biases lead to difference in decisionmaking, and that by standardizing practices we could address these differences – people were somewhat resistant at first,” Dr. Hamm says. “They didn’t believe there were differences in their practices.”

People struggle to recognize those differences, she says, and “it takes active participation in reducing disparities to make that happen.”

At the community level, Synergistic Sisters in Science (SIS), a group of maternal health experts and health equity advocates, is working on a project called PM3, to reduce maternal mortality through mobile technology.

The smartphone app will provide information for new moms to empower them to start conversations with health care providers. It also connects users to social support and resources. SIS is especially hoping to engage Black women living in rural areas.

“There is so much mistrust due to things like unnecessary C-sections and the fact that Black women feel they aren’t heard,” said Natalie Hernandez, PhD, executive director of the Center for Maternal Health Equity at Morehouse School of Medicine, Atlanta. “Here is a tool that gives a woman information that’s culturally centered, looks like her, and was informed by her voice.”

A version of this article first appeared on WebMD.com.

When 29-year-old Sakeenah Fowler was pregnant with her first child, doctors kept a close watch. Ms. Fowler has lupus, high blood pressure, a history of blood clotting, and kidney problems that all could have endangered her or the health of her unborn baby.

She saw maternal-fetal specialists who could keep watch of her high-risk pregnancy, and she collected urine samples every 24 hours to make sure her kidneys were functioning properly from her home in Roebuck, S.C.

But the pregnancy ultimately proved uneventful; even her kidneys remained stable. So Ms. Fowler said she was shocked when her doctors ordered an emergency cesarean delivery after she had gone into active labor.

“I was already dilated all the way to 6 cm,” but the baby’s heart rate had decreased by a small amount, she says. “They thought it was best to just go ahead with a C-section.”

Ms. Fowler, who is Black, said she believes the surgical intervention was unnecessary and that she wasn’t given a chance to discuss her options for a vaginal childbirth.  

“They already had it in their minds that I wasn’t going to make it through the pregnancy without any issues; then when I did, it was like they wanted to find something that made me have to have a C-section,” Ms. Fowler said. “It was close to the holidays; everybody was ready to go home. It was just like I was pushed to do what they wanted me to do.”

Ms. Fowler’s sense of a lack of choice is important beyond the measure of patient experience. While cesarean deliveries can be a lifeline for mother and baby, they can put up massive roadblocks to maternal and infant health when not necessary.

“The risk of hemorrhage, infection – on average, all of these go up when you have surgery instead of a vaginal delivery,” says Kimberly B. Glazer, PhD, a perinatal epidemiologist at the Icahn School of Medicine at Mount Sinai, New York.

“Birth is one of the most salient experiences you can have. People want to feel like their values and preferences – whatever they may be – were honored and respected. Even if the delivery goes a different way than you wanted, feeling like your values were taken into account is very important.”

More than 1 million women undergo cesarean deliveries in the United States every year, composing over 31% of all births in 2020, according to the Centers for Disease Control and Prevention.

The World Health Organization, meanwhile, recommends a rate of cesarean delivery of no more than 15% per region. Whether or not all the U.S. procedures were medically warranted is unclear, however.

Black women have higher odds of undergoing a cesarean: 36% undergo surgical deliveries annually, compared with about 30% of White women. Black women are also about three times more likely to die of pregnancy-related causes than White women.
 

Risk becomes reality

Ms. Fowler eventually developed an infection in her cesarean surgical wound, but her doctors initially insisted her alternating chills and fever were merely postpartum hormonal swings, she says.

“I thought something had to be wrong, but they just kept saying nothing was wrong,” she says.

By the time her doctors caught the infection, Ms. Fowler was readmitted to the hospital for several days of IV antibiotic therapy. The infection “almost got into my bloodstream and could have killed me,” she says.  

While cesarean deliveries are associated with decreases in maternal, neonatal, and infant mortality, the benefits are only seen up to a certain threshold. The WHO, for instance, has reported that over the 15% threshold, that lower mortality benefit disappears.

“When medically necessary, cesarean delivery can improve outcomes for mother and baby. But the fact that cesarean section rates have increased in recent years without a corresponding improvement in health outcomes indicates overreliance on the procedure,” Dr. Glazer says.
 

Clinical discretion leads to biased judgment calls

Rates of cesarean deliveries are even higher among low-risk pregnancies in women of color than in White women. Between 2016 and 2019, the overall rate of cesarean deliveries for low-risk births was 23%, according to a recent analysis. But the rate was almost 18% higher among Black women than among White women (27% vs. 22%).

“When you see data about these subjective indications varying by race and ethnicity, I think that’s pointing us toward some answers,” Dr. Glazer says. “Once you adjust for all these measures, prepregnancy characteristics, and risk factors, the research identifies variation in quality and outcomes that is rooted in structural and systemic racism in health care, implicit bias from clinicians.”

Researchers investigating cesarean deliveries have found that Black women are more likely to undergo the surgery for reasons that are highly subjective, such as fetal distress.

“There is a huge range of how concerning a fetal heart rate can be, and some health providers might perform a C-section for only minor changes in the fetal heart rate, while others might wait until it is much worse,” said Rebecca Hamm, MD, an assistant professor of obstetrics and gynecology at the Perelman School of Medicine at the University of Pennsylvania.

At least some of the differences in care can be explained by where women deliver their babies, studies have shown. Women of color disproportionately deliver at hospitals with poorer quality outcomes for moms and babies.
 

Dealing with the aftermath

There can be costs that reverberate throughout the life of a mother, child, and their family as the result of surgical delivery.

“Cesarean sections cost a lot more,” says Jamila Taylor, PhD, director of health care reform and a senior fellow with The Century Foundation, a progressive policy think tank in Washington, D.C. The cost of a cesarean delivery averages about $17,000, compared with about $12,200 for a vaginal birth; for uninsured patients, surgical deliveries cost about $9,000 more than vaginal deliveries.

Dr. Taylor, who has studied the historical mistreatment of Black women in obstetrics, noted that this cost includes not just the bill for surgery but also a prolonged recovery time that is often spent in a hospital bed.

Beyond the detrimental effect that a large hospital bill for delivery and aftercare can have on families, other costs can crop up later. Infants delivered by cesarean surgery are more likely to develop an infection, breathing problems, and to spend time in the neonatal intensive care unit than babies born vaginally. Although studies suggest these outcomes may result from a medically necessary health concern that spurred the cesarean surgery, they often stem from the delivery itself.  

Babies born surgically also miss out on the benefits of passing through the birth canal, such as supporting a newborn’s immune system and preparing their lungs to breathe oxygen after birth.

Most of the efforts to reduce inequities in maternal care are happening at the clinical level, aimed at both patients and providers, Dr. Taylor says.

“As advocates, we’re talking about how we can help Black women be advocates for themselves in the health care system – if the physician suggests a C-section, getting a second opinion, or walking through what a [surgical delivery] will mean and what their recovery will look like,” she says.

Women are also increasingly choosing non-hospital settings to deliver when possible, Dr. Taylor says. Including doulas or midwife practitioners in the maternal care team can reduce unnecessary cesarean deliveries among Black women, according to Camille Clare, MD, chair of the New York chapter of the American College of Obstetricians and Gynecologists.

Also, last year, race was removed from the vaginal birth after C-section (VBAC) calculator, which is used to gauge the safety of vaginal delivery in women with a history of surgical birth. The original calculator included race-based correction factors for Black women and Hispanic women. It predicted a lower likelihood of successful vaginal deliveries for women who already had a C-section and who identify as Black or Hispanic than for White women with otherwise identical characteristics, such as age, weight, and a history of cesarean delivery.

“Those are things that over time should reduce the high rates of cesarean section for Black women in particular,” Dr. Clare says.

In addition to embracing the updated calculator and including nurse-midwives and doulas in their obstetrics services, Penn Medicine, Philadelphia received a federal grant to study the impact of creating a standard plan for deliveries. This includes standardizing the induction of labor and any effect that might have on reducing C-section rates.

“This idea that biases lead to difference in decisionmaking, and that by standardizing practices we could address these differences – people were somewhat resistant at first,” Dr. Hamm says. “They didn’t believe there were differences in their practices.”

People struggle to recognize those differences, she says, and “it takes active participation in reducing disparities to make that happen.”

At the community level, Synergistic Sisters in Science (SIS), a group of maternal health experts and health equity advocates, is working on a project called PM3, to reduce maternal mortality through mobile technology.

The smartphone app will provide information for new moms to empower them to start conversations with health care providers. It also connects users to social support and resources. SIS is especially hoping to engage Black women living in rural areas.

“There is so much mistrust due to things like unnecessary C-sections and the fact that Black women feel they aren’t heard,” said Natalie Hernandez, PhD, executive director of the Center for Maternal Health Equity at Morehouse School of Medicine, Atlanta. “Here is a tool that gives a woman information that’s culturally centered, looks like her, and was informed by her voice.”

A version of this article first appeared on WebMD.com.

When 29-year-old Sakeenah Fowler was pregnant with her first child, doctors kept a close watch. Ms. Fowler has lupus, high blood pressure, a history of blood clotting, and kidney problems that all could have endangered her or the health of her unborn baby.

She saw maternal-fetal specialists who could keep watch of her high-risk pregnancy, and she collected urine samples every 24 hours to make sure her kidneys were functioning properly from her home in Roebuck, S.C.

But the pregnancy ultimately proved uneventful; even her kidneys remained stable. So Ms. Fowler said she was shocked when her doctors ordered an emergency cesarean delivery after she had gone into active labor.

“I was already dilated all the way to 6 cm,” but the baby’s heart rate had decreased by a small amount, she says. “They thought it was best to just go ahead with a C-section.”

Ms. Fowler, who is Black, said she believes the surgical intervention was unnecessary and that she wasn’t given a chance to discuss her options for a vaginal childbirth.  

“They already had it in their minds that I wasn’t going to make it through the pregnancy without any issues; then when I did, it was like they wanted to find something that made me have to have a C-section,” Ms. Fowler said. “It was close to the holidays; everybody was ready to go home. It was just like I was pushed to do what they wanted me to do.”

Ms. Fowler’s sense of a lack of choice is important beyond the measure of patient experience. While cesarean deliveries can be a lifeline for mother and baby, they can put up massive roadblocks to maternal and infant health when not necessary.

“The risk of hemorrhage, infection – on average, all of these go up when you have surgery instead of a vaginal delivery,” says Kimberly B. Glazer, PhD, a perinatal epidemiologist at the Icahn School of Medicine at Mount Sinai, New York.

“Birth is one of the most salient experiences you can have. People want to feel like their values and preferences – whatever they may be – were honored and respected. Even if the delivery goes a different way than you wanted, feeling like your values were taken into account is very important.”

More than 1 million women undergo cesarean deliveries in the United States every year, composing over 31% of all births in 2020, according to the Centers for Disease Control and Prevention.

The World Health Organization, meanwhile, recommends a rate of cesarean delivery of no more than 15% per region. Whether or not all the U.S. procedures were medically warranted is unclear, however.

Black women have higher odds of undergoing a cesarean: 36% undergo surgical deliveries annually, compared with about 30% of White women. Black women are also about three times more likely to die of pregnancy-related causes than White women.
 

Risk becomes reality

Ms. Fowler eventually developed an infection in her cesarean surgical wound, but her doctors initially insisted her alternating chills and fever were merely postpartum hormonal swings, she says.

“I thought something had to be wrong, but they just kept saying nothing was wrong,” she says.

By the time her doctors caught the infection, Ms. Fowler was readmitted to the hospital for several days of IV antibiotic therapy. The infection “almost got into my bloodstream and could have killed me,” she says.  

While cesarean deliveries are associated with decreases in maternal, neonatal, and infant mortality, the benefits are only seen up to a certain threshold. The WHO, for instance, has reported that over the 15% threshold, that lower mortality benefit disappears.

“When medically necessary, cesarean delivery can improve outcomes for mother and baby. But the fact that cesarean section rates have increased in recent years without a corresponding improvement in health outcomes indicates overreliance on the procedure,” Dr. Glazer says.
 

Clinical discretion leads to biased judgment calls

Rates of cesarean deliveries are even higher among low-risk pregnancies in women of color than in White women. Between 2016 and 2019, the overall rate of cesarean deliveries for low-risk births was 23%, according to a recent analysis. But the rate was almost 18% higher among Black women than among White women (27% vs. 22%).

“When you see data about these subjective indications varying by race and ethnicity, I think that’s pointing us toward some answers,” Dr. Glazer says. “Once you adjust for all these measures, prepregnancy characteristics, and risk factors, the research identifies variation in quality and outcomes that is rooted in structural and systemic racism in health care, implicit bias from clinicians.”

Researchers investigating cesarean deliveries have found that Black women are more likely to undergo the surgery for reasons that are highly subjective, such as fetal distress.

“There is a huge range of how concerning a fetal heart rate can be, and some health providers might perform a C-section for only minor changes in the fetal heart rate, while others might wait until it is much worse,” said Rebecca Hamm, MD, an assistant professor of obstetrics and gynecology at the Perelman School of Medicine at the University of Pennsylvania.

At least some of the differences in care can be explained by where women deliver their babies, studies have shown. Women of color disproportionately deliver at hospitals with poorer quality outcomes for moms and babies.
 

Dealing with the aftermath

There can be costs that reverberate throughout the life of a mother, child, and their family as the result of surgical delivery.

“Cesarean sections cost a lot more,” says Jamila Taylor, PhD, director of health care reform and a senior fellow with The Century Foundation, a progressive policy think tank in Washington, D.C. The cost of a cesarean delivery averages about $17,000, compared with about $12,200 for a vaginal birth; for uninsured patients, surgical deliveries cost about $9,000 more than vaginal deliveries.

Dr. Taylor, who has studied the historical mistreatment of Black women in obstetrics, noted that this cost includes not just the bill for surgery but also a prolonged recovery time that is often spent in a hospital bed.

Beyond the detrimental effect that a large hospital bill for delivery and aftercare can have on families, other costs can crop up later. Infants delivered by cesarean surgery are more likely to develop an infection, breathing problems, and to spend time in the neonatal intensive care unit than babies born vaginally. Although studies suggest these outcomes may result from a medically necessary health concern that spurred the cesarean surgery, they often stem from the delivery itself.  

Babies born surgically also miss out on the benefits of passing through the birth canal, such as supporting a newborn’s immune system and preparing their lungs to breathe oxygen after birth.

Most of the efforts to reduce inequities in maternal care are happening at the clinical level, aimed at both patients and providers, Dr. Taylor says.

“As advocates, we’re talking about how we can help Black women be advocates for themselves in the health care system – if the physician suggests a C-section, getting a second opinion, or walking through what a [surgical delivery] will mean and what their recovery will look like,” she says.

Women are also increasingly choosing non-hospital settings to deliver when possible, Dr. Taylor says. Including doulas or midwife practitioners in the maternal care team can reduce unnecessary cesarean deliveries among Black women, according to Camille Clare, MD, chair of the New York chapter of the American College of Obstetricians and Gynecologists.

Also, last year, race was removed from the vaginal birth after C-section (VBAC) calculator, which is used to gauge the safety of vaginal delivery in women with a history of surgical birth. The original calculator included race-based correction factors for Black women and Hispanic women. It predicted a lower likelihood of successful vaginal deliveries for women who already had a C-section and who identify as Black or Hispanic than for White women with otherwise identical characteristics, such as age, weight, and a history of cesarean delivery.

“Those are things that over time should reduce the high rates of cesarean section for Black women in particular,” Dr. Clare says.

In addition to embracing the updated calculator and including nurse-midwives and doulas in their obstetrics services, Penn Medicine, Philadelphia received a federal grant to study the impact of creating a standard plan for deliveries. This includes standardizing the induction of labor and any effect that might have on reducing C-section rates.

“This idea that biases lead to difference in decisionmaking, and that by standardizing practices we could address these differences – people were somewhat resistant at first,” Dr. Hamm says. “They didn’t believe there were differences in their practices.”

People struggle to recognize those differences, she says, and “it takes active participation in reducing disparities to make that happen.”

At the community level, Synergistic Sisters in Science (SIS), a group of maternal health experts and health equity advocates, is working on a project called PM3, to reduce maternal mortality through mobile technology.

The smartphone app will provide information for new moms to empower them to start conversations with health care providers. It also connects users to social support and resources. SIS is especially hoping to engage Black women living in rural areas.

“There is so much mistrust due to things like unnecessary C-sections and the fact that Black women feel they aren’t heard,” said Natalie Hernandez, PhD, executive director of the Center for Maternal Health Equity at Morehouse School of Medicine, Atlanta. “Here is a tool that gives a woman information that’s culturally centered, looks like her, and was informed by her voice.”

A version of this article first appeared on WebMD.com.

Heat waves are getting hotter and becoming more frequent because of rising rates of air pollution, putting children’s health at risk, a wide-ranging new report finds.

An article in the New England Journal of Medicine reviews current research to take a sweeping inventory of how air pollution and climate change interact to adversely affect people’s health, especially that of kids. It examined the link between fossil fuel emissions and a variety of consequences of climate change – including extreme weather events; wildfires; vector-borne illnesses such as malaria, Zika, and Lyme disease; and heat waves, a topic at the forefront of many people’s minds.

This month, for example, record-high temperatures have been reported across the United States, affecting more than 100 million people and touching locations from the Gulf Coast to the Great Lakes, the Southwest, the mid-Atlantic, and the Midwest.

In Texas, Austin has already experienced an 8-day streak of temperatures above the 100° F mark in June, according to the Austin American-Statesman.

These patterns are an important reality to note, said Frederica Perera, DrPH, PhD, the article’s lead author. “My concern is that the threats are rising as temperature is rising,” Dr. Perera, a professor at Columbia University’s Mailman School of Public Health, New York, told KHN. “Temperatures are rising because greenhouse gas emissions are rising, and that’s a great concern for everyone’s health – but especially the most vulnerable.”

Children fit into this category, wrote Dr. Perera and her coauthor, Kari Nadeau, MD, PhD, Naddisy Foundation Endowed Professor of Medicine and Pediatrics at Stanford (Calif.) University, because their ability to regulate temperature, known as thermoregulation, is not fully developed.

They are also more susceptible to heat-related stress because they’re smaller and need to drink and eat more frequently to stay healthy, said Dr. Perera. But because “young children are dependent on parents to provide, sometimes their needs go ignored,” she said.

The authors noted that heat-related illness is “a leading and increasing cause of death and illness among student athletes” in the United States. In addition, they cited studies suggesting that “the heat associated with climate change” takes a toll on the mental health of children and adolescents, as well as their ability to learn.

The review article pointed to previous research. that associated in utero exposure to heat waves with “increased risks of preterm birth or low birth weight; hyperthermia and death among infants; and heat stress, kidney disease, and other illnesses” among kids.

“Being pregnant is very physiologically demanding in itself, and then heat places additional stress on a pregnant woman,” said Dr. Robert Dubrow, a professor of epidemiology at Yale’s School of Public Health, New Haven, Conn., who was not associated with either study. “And the fetus can experience heat stress as well, which could result in adverse birth outcomes.”

And these heat-related risks are across-the-board greater for “low-income communities and communities of color,” wrote the authors of the new article.

Carbon dioxide emissions from burning fossil fuels have risen sharply in the past 70 years, according to the article. “Modeling indicates that some heat waves would be extraordinarily unlikely to occur in the absence of climate change,” it says.

The authors briefly outline solutions that they describe as “climate and environmental strategies” that “should also be seen as essential public health policy.” Beyond big-picture efforts to mitigate fossil fuel and greenhouse gas emissions, they offered various ways to protect children – steps they term “adaptation measures” – which included providing clean water to children and families facing drought or water contamination and creating shaded areas where children play, live, and go to school.

Separately, Austin-based research highlighted why this step could be meaningful.

Researchers tracked the physical activity levels and location of students ages 8 to 10 during recess at three elementary schools in 2019. They compared children’s activity at recess during two weeks in September, the hottest full month during the school year, to a cooler week in November. “We wanted to understand the impact of outdoor temperatures on children’s play in schoolyard environments,” said Dr. Kevin Lanza, the study’s lead investigator, to inform the design of “future school-based interventions for physical activity in the face of climate change.”

During the hotter periods, he said, “children engaged in less physical activity and sought shade.”

As temperatures continue to rise, he said, schools must be flexible in making sure students are getting the daily exercise they need. “Schools should consider adding shade, either by planting trees or installing artificial structures that cover spaces intended for physical activity,” said Dr. Lanza, an assistant professor at UTHealth School of Public Health, Austin, Tex. He also noted that school policies could be updated so that recesses are scheduled during cooler times of the day and moved inside during periods of extreme heat.

But the overall need to protect kids from scorching weather patterns requires action beyond such steps, Dr. Perera said, and more climate and clean air policies must be enacted.

“Governments have the responsibility to protect the population and especially those most vulnerable, which especially includes children,” Dr. Perera said. “Action must be done immediately because we’re absolutely heading in the wrong direction.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

Heat waves are getting hotter and becoming more frequent because of rising rates of air pollution, putting children’s health at risk, a wide-ranging new report finds.

An article in the New England Journal of Medicine reviews current research to take a sweeping inventory of how air pollution and climate change interact to adversely affect people’s health, especially that of kids. It examined the link between fossil fuel emissions and a variety of consequences of climate change – including extreme weather events; wildfires; vector-borne illnesses such as malaria, Zika, and Lyme disease; and heat waves, a topic at the forefront of many people’s minds.

This month, for example, record-high temperatures have been reported across the United States, affecting more than 100 million people and touching locations from the Gulf Coast to the Great Lakes, the Southwest, the mid-Atlantic, and the Midwest.

In Texas, Austin has already experienced an 8-day streak of temperatures above the 100° F mark in June, according to the Austin American-Statesman.

These patterns are an important reality to note, said Frederica Perera, DrPH, PhD, the article’s lead author. “My concern is that the threats are rising as temperature is rising,” Dr. Perera, a professor at Columbia University’s Mailman School of Public Health, New York, told KHN. “Temperatures are rising because greenhouse gas emissions are rising, and that’s a great concern for everyone’s health – but especially the most vulnerable.”

Children fit into this category, wrote Dr. Perera and her coauthor, Kari Nadeau, MD, PhD, Naddisy Foundation Endowed Professor of Medicine and Pediatrics at Stanford (Calif.) University, because their ability to regulate temperature, known as thermoregulation, is not fully developed.

They are also more susceptible to heat-related stress because they’re smaller and need to drink and eat more frequently to stay healthy, said Dr. Perera. But because “young children are dependent on parents to provide, sometimes their needs go ignored,” she said.

The authors noted that heat-related illness is “a leading and increasing cause of death and illness among student athletes” in the United States. In addition, they cited studies suggesting that “the heat associated with climate change” takes a toll on the mental health of children and adolescents, as well as their ability to learn.

The review article pointed to previous research. that associated in utero exposure to heat waves with “increased risks of preterm birth or low birth weight; hyperthermia and death among infants; and heat stress, kidney disease, and other illnesses” among kids.

“Being pregnant is very physiologically demanding in itself, and then heat places additional stress on a pregnant woman,” said Dr. Robert Dubrow, a professor of epidemiology at Yale’s School of Public Health, New Haven, Conn., who was not associated with either study. “And the fetus can experience heat stress as well, which could result in adverse birth outcomes.”

And these heat-related risks are across-the-board greater for “low-income communities and communities of color,” wrote the authors of the new article.

Carbon dioxide emissions from burning fossil fuels have risen sharply in the past 70 years, according to the article. “Modeling indicates that some heat waves would be extraordinarily unlikely to occur in the absence of climate change,” it says.

The authors briefly outline solutions that they describe as “climate and environmental strategies” that “should also be seen as essential public health policy.” Beyond big-picture efforts to mitigate fossil fuel and greenhouse gas emissions, they offered various ways to protect children – steps they term “adaptation measures” – which included providing clean water to children and families facing drought or water contamination and creating shaded areas where children play, live, and go to school.

Separately, Austin-based research highlighted why this step could be meaningful.

Researchers tracked the physical activity levels and location of students ages 8 to 10 during recess at three elementary schools in 2019. They compared children’s activity at recess during two weeks in September, the hottest full month during the school year, to a cooler week in November. “We wanted to understand the impact of outdoor temperatures on children’s play in schoolyard environments,” said Dr. Kevin Lanza, the study’s lead investigator, to inform the design of “future school-based interventions for physical activity in the face of climate change.”

During the hotter periods, he said, “children engaged in less physical activity and sought shade.”

As temperatures continue to rise, he said, schools must be flexible in making sure students are getting the daily exercise they need. “Schools should consider adding shade, either by planting trees or installing artificial structures that cover spaces intended for physical activity,” said Dr. Lanza, an assistant professor at UTHealth School of Public Health, Austin, Tex. He also noted that school policies could be updated so that recesses are scheduled during cooler times of the day and moved inside during periods of extreme heat.

But the overall need to protect kids from scorching weather patterns requires action beyond such steps, Dr. Perera said, and more climate and clean air policies must be enacted.

“Governments have the responsibility to protect the population and especially those most vulnerable, which especially includes children,” Dr. Perera said. “Action must be done immediately because we’re absolutely heading in the wrong direction.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

Heat waves are getting hotter and becoming more frequent because of rising rates of air pollution, putting children’s health at risk, a wide-ranging new report finds.

An article in the New England Journal of Medicine reviews current research to take a sweeping inventory of how air pollution and climate change interact to adversely affect people’s health, especially that of kids. It examined the link between fossil fuel emissions and a variety of consequences of climate change – including extreme weather events; wildfires; vector-borne illnesses such as malaria, Zika, and Lyme disease; and heat waves, a topic at the forefront of many people’s minds.

This month, for example, record-high temperatures have been reported across the United States, affecting more than 100 million people and touching locations from the Gulf Coast to the Great Lakes, the Southwest, the mid-Atlantic, and the Midwest.

In Texas, Austin has already experienced an 8-day streak of temperatures above the 100° F mark in June, according to the Austin American-Statesman.

These patterns are an important reality to note, said Frederica Perera, DrPH, PhD, the article’s lead author. “My concern is that the threats are rising as temperature is rising,” Dr. Perera, a professor at Columbia University’s Mailman School of Public Health, New York, told KHN. “Temperatures are rising because greenhouse gas emissions are rising, and that’s a great concern for everyone’s health – but especially the most vulnerable.”

Children fit into this category, wrote Dr. Perera and her coauthor, Kari Nadeau, MD, PhD, Naddisy Foundation Endowed Professor of Medicine and Pediatrics at Stanford (Calif.) University, because their ability to regulate temperature, known as thermoregulation, is not fully developed.

They are also more susceptible to heat-related stress because they’re smaller and need to drink and eat more frequently to stay healthy, said Dr. Perera. But because “young children are dependent on parents to provide, sometimes their needs go ignored,” she said.

The authors noted that heat-related illness is “a leading and increasing cause of death and illness among student athletes” in the United States. In addition, they cited studies suggesting that “the heat associated with climate change” takes a toll on the mental health of children and adolescents, as well as their ability to learn.

The review article pointed to previous research. that associated in utero exposure to heat waves with “increased risks of preterm birth or low birth weight; hyperthermia and death among infants; and heat stress, kidney disease, and other illnesses” among kids.

“Being pregnant is very physiologically demanding in itself, and then heat places additional stress on a pregnant woman,” said Dr. Robert Dubrow, a professor of epidemiology at Yale’s School of Public Health, New Haven, Conn., who was not associated with either study. “And the fetus can experience heat stress as well, which could result in adverse birth outcomes.”

And these heat-related risks are across-the-board greater for “low-income communities and communities of color,” wrote the authors of the new article.

Carbon dioxide emissions from burning fossil fuels have risen sharply in the past 70 years, according to the article. “Modeling indicates that some heat waves would be extraordinarily unlikely to occur in the absence of climate change,” it says.

The authors briefly outline solutions that they describe as “climate and environmental strategies” that “should also be seen as essential public health policy.” Beyond big-picture efforts to mitigate fossil fuel and greenhouse gas emissions, they offered various ways to protect children – steps they term “adaptation measures” – which included providing clean water to children and families facing drought or water contamination and creating shaded areas where children play, live, and go to school.

Separately, Austin-based research highlighted why this step could be meaningful.

Researchers tracked the physical activity levels and location of students ages 8 to 10 during recess at three elementary schools in 2019. They compared children’s activity at recess during two weeks in September, the hottest full month during the school year, to a cooler week in November. “We wanted to understand the impact of outdoor temperatures on children’s play in schoolyard environments,” said Dr. Kevin Lanza, the study’s lead investigator, to inform the design of “future school-based interventions for physical activity in the face of climate change.”

During the hotter periods, he said, “children engaged in less physical activity and sought shade.”

As temperatures continue to rise, he said, schools must be flexible in making sure students are getting the daily exercise they need. “Schools should consider adding shade, either by planting trees or installing artificial structures that cover spaces intended for physical activity,” said Dr. Lanza, an assistant professor at UTHealth School of Public Health, Austin, Tex. He also noted that school policies could be updated so that recesses are scheduled during cooler times of the day and moved inside during periods of extreme heat.

But the overall need to protect kids from scorching weather patterns requires action beyond such steps, Dr. Perera said, and more climate and clean air policies must be enacted.

“Governments have the responsibility to protect the population and especially those most vulnerable, which especially includes children,” Dr. Perera said. “Action must be done immediately because we’re absolutely heading in the wrong direction.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

Experts engaged in a contentious debate on the usefulness of the NOVA system, which divides foods into different categories based on how much they have been processed, during a session at a virtual conference sponsored by the American Society for Nutrition.

The NOVA system divides foods into “fresh or minimally processed,” such as strawberries or steel-cut oats; “processed culinary ingredients,” such as olive oil; “processed foods,” such as cheeses; and “ultra-processed foods.” UPFs are defined as “industrial formulations made by deconstructing natural food into its chemical constituents, modifying them and recombining them with additives into products liable to displace all other NOVA food groups.”

According to doctors who presented during the meeting, ultra-processed foods are drawing increased attention, because researchers have been examining them in National Institutes of Health–funded studies and journalists have been writing about them.

During the debate session at the meeting, some experts said that, with obesity and poor health skyrocketing, increased awareness and labeling of UPFs can only be a good thing. In contrast others noted at the meeting that the classification system that has come to be used for identifying UPFs – the NOVA Food Classification system – is too mushy, confusing, and, ultimately unhelpful.

Carlos Monteiro, MD, PhD, professor of nutrition and public health at the University of Sao Paolo, was part of the group favoring the NOVA system’s classifying certain foods as UPFs, during the debate. He drew attention to the extent to which the world’s population is getting its calories from UPFs.

Mexico and France get about 30% of calories from these foods. In Canada, it’s 48%. And in the United States, it’s 57%, Dr. Monteiro said.

Studies have found that UPFs, many of which are designed to be exceedingly flavorful and intended to replace consumption of unprocessed whole foods, lead to more overall energy intake, more added sugar in the diet, and less fiber and protein intake, he said.

To further support his arguments, Dr. Monteiro pointed to studies suggesting that it is not just the resulting change in the nutritional intake that is unhealthy, but the UPF manufacturing process itself. When adjusting for fat, sugar, and sodium intake, for example, health outcomes associated with UPFs remain poor, he explained.

“I’m sorry,” he said in the debate. “If you don’t reduce this, you don’t reduce your obesity, your diabetes prevalence.”

A study presented by Jacqueline Vernarelli, PhD, during a different session at the meeting suggested there may be other downsides to consuming UPFs. This research, which was based on the U.S. National Youth Fitness Survey, found that poorer locomotor skills among children aged 3-5 and poorer cardiovascular fitness among those aged 12-15 were associated with getting more calories from UPFs.

Those with lower cardiovascular fitness consumed 1,234 calories a day from UPFs, and those with higher cardiovascular fitness consumed 1,007 calories a day from UPFs (P = .002), according to the new research.

“It’s notable here that, although these differences are significant, both groups are consuming a pretty high proportion of their diet from ultra-processed foods,” said Dr. Vernarelli, associate professor of public health at Sacred Heart University, Fairfield, Conn., during her presentation.

In the debate session, Arne Astrup, MD, PhD, senior project director at the Healthy Weight Center at the Novo Nordisk Foundation, Hellerup, Denmark, presented an opposing view.

He said the definition of UPFs makes it too difficult to categorize many foods, pointing to a study from this year in which about 150 nutrition experts, doctors, and dietitians classified 120 foods. Only three marketed foods and one generic food were classified the same by all the evaluators.

Referring to the study Dr. Astrup cited, Dr. Monteiro said it was a mere “exercise,” and the experts involved in it had conflicts of interest.

Dr. Astrup touted this study’s size and its appearance in the peer-reviewed journal the European Journal of Clinical Nutrition.

Defending his point of view, Dr. Astrup said, “The definition and classification is so ambiguous, and the risk of misclassification is so extremely high, I think we really miss the basic requirement of science, namely that we know what we are talking about,” he said.

If you take an unprocessed food, and insert a “little additive … suddenly it’s an ultra-processed food,” he added.
 

UPF definition doesn’t flag some unhealthy foods

Susan Roberts, PhD, professor of nutrition at Tufts University, Boston, was a discussant at the debate and touched on the merits of both sides. She noted that the UPF definition doesn’t flag some “clearly unhealthy foods,” such as table sugar, but does flag some healthy ones, such as plant-based burgers – to which Dr. Monteiro said that the system was not a system meant to divide foods into healthy and unhealthy groups, during the debate session.

The inclusion of both healthy and unhealthy foods in NOVA’s definition of a UPF is a serious problem, Dr. Roberts said.

“It’s almost like it’s an emotional classification designed to get at the food industry rather than focusing on health – and I think that’s asking for trouble because it’s just going to be such a mess to tell consumers, ‘Well, this ultra-processed food is healthy and this one isn’t,’ ” she said. What’s happening is the term ultra-processed is being used interchangeably with unhealthy.

The discussion that the UPF classification has generated is useful, Dr. Roberts continued. “This definition grew out of that recognition that we’re engaged in an unprecedented experiment of how unhealthy can you make the world without having a major catastrophe.”

She added that the UPF concept deserves a more formalized and rigorous evaluation.

“This is an important topic for the future of public health, and I think it needs big committees to address it seriously,” she said. “I think we should not be dealing with this individually in different labs.”
 

Doctor’s take on usefulness of discussing UPF concept with patients

Mark Corkins, MD, who did not participate in the debate at the meeting, said he talks to parents and children about nutrition at every office visit in which he sees a child with an unhealthy weight.

“Persistence wears down resistance,” said the chair of the American Academy of Pediatrics nutrition committee, in an interview.“A consistent message – you say the same thing and you say it multiple times.”

The idea of “ultra-processed foods” plays a role in those conversations, but largely in the background. It’s a topic that’s important for pediatric health, Dr. Corkins said – but he doesn’t make it the focal point.

“It’s not a direct attack on ultra-processed foods that usually I take as my direction,” said Dr. Corkins, who is also chief of pediatric gastroenterology at Le Bonheur Children’s Hospital in Memphis, Tenn.. “What I try to focus on, and what I think the American Academy of Pediatrics would focus on, is that we need to focus on making the diet better.”

He added, “Parents are aware – they don’t call it ultra-processed food, they call it junk food.”

Dr. Corkins continued that he is reluctant to directly challenge parents on feeding their children unhealthy foods – ultra-processed or not – lest he shame them and harm the relationship.

“Guilt as a motivator isn’t really highly successful,” he said, in an interview.

Dr. Astrup reported advisory committee or board member involvement with Green Leaf Medical and RNPC, France. Dr. Roberts reported advisory committee or board member involvement with Danone, and an ownership interest in Instinct Health Science. Dr. Monteiro and Dr. Corkins reported no relevant disclosures.

Experts engaged in a contentious debate on the usefulness of the NOVA system, which divides foods into different categories based on how much they have been processed, during a session at a virtual conference sponsored by the American Society for Nutrition.

The NOVA system divides foods into “fresh or minimally processed,” such as strawberries or steel-cut oats; “processed culinary ingredients,” such as olive oil; “processed foods,” such as cheeses; and “ultra-processed foods.” UPFs are defined as “industrial formulations made by deconstructing natural food into its chemical constituents, modifying them and recombining them with additives into products liable to displace all other NOVA food groups.”

According to doctors who presented during the meeting, ultra-processed foods are drawing increased attention, because researchers have been examining them in National Institutes of Health–funded studies and journalists have been writing about them.

During the debate session at the meeting, some experts said that, with obesity and poor health skyrocketing, increased awareness and labeling of UPFs can only be a good thing. In contrast others noted at the meeting that the classification system that has come to be used for identifying UPFs – the NOVA Food Classification system – is too mushy, confusing, and, ultimately unhelpful.

Carlos Monteiro, MD, PhD, professor of nutrition and public health at the University of Sao Paolo, was part of the group favoring the NOVA system’s classifying certain foods as UPFs, during the debate. He drew attention to the extent to which the world’s population is getting its calories from UPFs.

Mexico and France get about 30% of calories from these foods. In Canada, it’s 48%. And in the United States, it’s 57%, Dr. Monteiro said.

Studies have found that UPFs, many of which are designed to be exceedingly flavorful and intended to replace consumption of unprocessed whole foods, lead to more overall energy intake, more added sugar in the diet, and less fiber and protein intake, he said.

To further support his arguments, Dr. Monteiro pointed to studies suggesting that it is not just the resulting change in the nutritional intake that is unhealthy, but the UPF manufacturing process itself. When adjusting for fat, sugar, and sodium intake, for example, health outcomes associated with UPFs remain poor, he explained.

“I’m sorry,” he said in the debate. “If you don’t reduce this, you don’t reduce your obesity, your diabetes prevalence.”

A study presented by Jacqueline Vernarelli, PhD, during a different session at the meeting suggested there may be other downsides to consuming UPFs. This research, which was based on the U.S. National Youth Fitness Survey, found that poorer locomotor skills among children aged 3-5 and poorer cardiovascular fitness among those aged 12-15 were associated with getting more calories from UPFs.

Those with lower cardiovascular fitness consumed 1,234 calories a day from UPFs, and those with higher cardiovascular fitness consumed 1,007 calories a day from UPFs (P = .002), according to the new research.

“It’s notable here that, although these differences are significant, both groups are consuming a pretty high proportion of their diet from ultra-processed foods,” said Dr. Vernarelli, associate professor of public health at Sacred Heart University, Fairfield, Conn., during her presentation.

In the debate session, Arne Astrup, MD, PhD, senior project director at the Healthy Weight Center at the Novo Nordisk Foundation, Hellerup, Denmark, presented an opposing view.

He said the definition of UPFs makes it too difficult to categorize many foods, pointing to a study from this year in which about 150 nutrition experts, doctors, and dietitians classified 120 foods. Only three marketed foods and one generic food were classified the same by all the evaluators.

Referring to the study Dr. Astrup cited, Dr. Monteiro said it was a mere “exercise,” and the experts involved in it had conflicts of interest.

Dr. Astrup touted this study’s size and its appearance in the peer-reviewed journal the European Journal of Clinical Nutrition.

Defending his point of view, Dr. Astrup said, “The definition and classification is so ambiguous, and the risk of misclassification is so extremely high, I think we really miss the basic requirement of science, namely that we know what we are talking about,” he said.

If you take an unprocessed food, and insert a “little additive … suddenly it’s an ultra-processed food,” he added.
 

UPF definition doesn’t flag some unhealthy foods

Susan Roberts, PhD, professor of nutrition at Tufts University, Boston, was a discussant at the debate and touched on the merits of both sides. She noted that the UPF definition doesn’t flag some “clearly unhealthy foods,” such as table sugar, but does flag some healthy ones, such as plant-based burgers – to which Dr. Monteiro said that the system was not a system meant to divide foods into healthy and unhealthy groups, during the debate session.

The inclusion of both healthy and unhealthy foods in NOVA’s definition of a UPF is a serious problem, Dr. Roberts said.

“It’s almost like it’s an emotional classification designed to get at the food industry rather than focusing on health – and I think that’s asking for trouble because it’s just going to be such a mess to tell consumers, ‘Well, this ultra-processed food is healthy and this one isn’t,’ ” she said. What’s happening is the term ultra-processed is being used interchangeably with unhealthy.

The discussion that the UPF classification has generated is useful, Dr. Roberts continued. “This definition grew out of that recognition that we’re engaged in an unprecedented experiment of how unhealthy can you make the world without having a major catastrophe.”

She added that the UPF concept deserves a more formalized and rigorous evaluation.

“This is an important topic for the future of public health, and I think it needs big committees to address it seriously,” she said. “I think we should not be dealing with this individually in different labs.”
 

Doctor’s take on usefulness of discussing UPF concept with patients

Mark Corkins, MD, who did not participate in the debate at the meeting, said he talks to parents and children about nutrition at every office visit in which he sees a child with an unhealthy weight.

“Persistence wears down resistance,” said the chair of the American Academy of Pediatrics nutrition committee, in an interview.“A consistent message – you say the same thing and you say it multiple times.”

The idea of “ultra-processed foods” plays a role in those conversations, but largely in the background. It’s a topic that’s important for pediatric health, Dr. Corkins said – but he doesn’t make it the focal point.

“It’s not a direct attack on ultra-processed foods that usually I take as my direction,” said Dr. Corkins, who is also chief of pediatric gastroenterology at Le Bonheur Children’s Hospital in Memphis, Tenn.. “What I try to focus on, and what I think the American Academy of Pediatrics would focus on, is that we need to focus on making the diet better.”

He added, “Parents are aware – they don’t call it ultra-processed food, they call it junk food.”

Dr. Corkins continued that he is reluctant to directly challenge parents on feeding their children unhealthy foods – ultra-processed or not – lest he shame them and harm the relationship.

“Guilt as a motivator isn’t really highly successful,” he said, in an interview.

Dr. Astrup reported advisory committee or board member involvement with Green Leaf Medical and RNPC, France. Dr. Roberts reported advisory committee or board member involvement with Danone, and an ownership interest in Instinct Health Science. Dr. Monteiro and Dr. Corkins reported no relevant disclosures.

Experts engaged in a contentious debate on the usefulness of the NOVA system, which divides foods into different categories based on how much they have been processed, during a session at a virtual conference sponsored by the American Society for Nutrition.

The NOVA system divides foods into “fresh or minimally processed,” such as strawberries or steel-cut oats; “processed culinary ingredients,” such as olive oil; “processed foods,” such as cheeses; and “ultra-processed foods.” UPFs are defined as “industrial formulations made by deconstructing natural food into its chemical constituents, modifying them and recombining them with additives into products liable to displace all other NOVA food groups.”

According to doctors who presented during the meeting, ultra-processed foods are drawing increased attention, because researchers have been examining them in National Institutes of Health–funded studies and journalists have been writing about them.

During the debate session at the meeting, some experts said that, with obesity and poor health skyrocketing, increased awareness and labeling of UPFs can only be a good thing. In contrast others noted at the meeting that the classification system that has come to be used for identifying UPFs – the NOVA Food Classification system – is too mushy, confusing, and, ultimately unhelpful.

Carlos Monteiro, MD, PhD, professor of nutrition and public health at the University of Sao Paolo, was part of the group favoring the NOVA system’s classifying certain foods as UPFs, during the debate. He drew attention to the extent to which the world’s population is getting its calories from UPFs.

Mexico and France get about 30% of calories from these foods. In Canada, it’s 48%. And in the United States, it’s 57%, Dr. Monteiro said.

Studies have found that UPFs, many of which are designed to be exceedingly flavorful and intended to replace consumption of unprocessed whole foods, lead to more overall energy intake, more added sugar in the diet, and less fiber and protein intake, he said.

To further support his arguments, Dr. Monteiro pointed to studies suggesting that it is not just the resulting change in the nutritional intake that is unhealthy, but the UPF manufacturing process itself. When adjusting for fat, sugar, and sodium intake, for example, health outcomes associated with UPFs remain poor, he explained.

“I’m sorry,” he said in the debate. “If you don’t reduce this, you don’t reduce your obesity, your diabetes prevalence.”

A study presented by Jacqueline Vernarelli, PhD, during a different session at the meeting suggested there may be other downsides to consuming UPFs. This research, which was based on the U.S. National Youth Fitness Survey, found that poorer locomotor skills among children aged 3-5 and poorer cardiovascular fitness among those aged 12-15 were associated with getting more calories from UPFs.

Those with lower cardiovascular fitness consumed 1,234 calories a day from UPFs, and those with higher cardiovascular fitness consumed 1,007 calories a day from UPFs (P = .002), according to the new research.

“It’s notable here that, although these differences are significant, both groups are consuming a pretty high proportion of their diet from ultra-processed foods,” said Dr. Vernarelli, associate professor of public health at Sacred Heart University, Fairfield, Conn., during her presentation.

In the debate session, Arne Astrup, MD, PhD, senior project director at the Healthy Weight Center at the Novo Nordisk Foundation, Hellerup, Denmark, presented an opposing view.

He said the definition of UPFs makes it too difficult to categorize many foods, pointing to a study from this year in which about 150 nutrition experts, doctors, and dietitians classified 120 foods. Only three marketed foods and one generic food were classified the same by all the evaluators.

Referring to the study Dr. Astrup cited, Dr. Monteiro said it was a mere “exercise,” and the experts involved in it had conflicts of interest.

Dr. Astrup touted this study’s size and its appearance in the peer-reviewed journal the European Journal of Clinical Nutrition.

Defending his point of view, Dr. Astrup said, “The definition and classification is so ambiguous, and the risk of misclassification is so extremely high, I think we really miss the basic requirement of science, namely that we know what we are talking about,” he said.

If you take an unprocessed food, and insert a “little additive … suddenly it’s an ultra-processed food,” he added.
 

UPF definition doesn’t flag some unhealthy foods

Susan Roberts, PhD, professor of nutrition at Tufts University, Boston, was a discussant at the debate and touched on the merits of both sides. She noted that the UPF definition doesn’t flag some “clearly unhealthy foods,” such as table sugar, but does flag some healthy ones, such as plant-based burgers – to which Dr. Monteiro said that the system was not a system meant to divide foods into healthy and unhealthy groups, during the debate session.

The inclusion of both healthy and unhealthy foods in NOVA’s definition of a UPF is a serious problem, Dr. Roberts said.

“It’s almost like it’s an emotional classification designed to get at the food industry rather than focusing on health – and I think that’s asking for trouble because it’s just going to be such a mess to tell consumers, ‘Well, this ultra-processed food is healthy and this one isn’t,’ ” she said. What’s happening is the term ultra-processed is being used interchangeably with unhealthy.

The discussion that the UPF classification has generated is useful, Dr. Roberts continued. “This definition grew out of that recognition that we’re engaged in an unprecedented experiment of how unhealthy can you make the world without having a major catastrophe.”

She added that the UPF concept deserves a more formalized and rigorous evaluation.

“This is an important topic for the future of public health, and I think it needs big committees to address it seriously,” she said. “I think we should not be dealing with this individually in different labs.”
 

Doctor’s take on usefulness of discussing UPF concept with patients

Mark Corkins, MD, who did not participate in the debate at the meeting, said he talks to parents and children about nutrition at every office visit in which he sees a child with an unhealthy weight.

“Persistence wears down resistance,” said the chair of the American Academy of Pediatrics nutrition committee, in an interview.“A consistent message – you say the same thing and you say it multiple times.”

The idea of “ultra-processed foods” plays a role in those conversations, but largely in the background. It’s a topic that’s important for pediatric health, Dr. Corkins said – but he doesn’t make it the focal point.

“It’s not a direct attack on ultra-processed foods that usually I take as my direction,” said Dr. Corkins, who is also chief of pediatric gastroenterology at Le Bonheur Children’s Hospital in Memphis, Tenn.. “What I try to focus on, and what I think the American Academy of Pediatrics would focus on, is that we need to focus on making the diet better.”

He added, “Parents are aware – they don’t call it ultra-processed food, they call it junk food.”

Dr. Corkins continued that he is reluctant to directly challenge parents on feeding their children unhealthy foods – ultra-processed or not – lest he shame them and harm the relationship.

“Guilt as a motivator isn’t really highly successful,” he said, in an interview.

Dr. Astrup reported advisory committee or board member involvement with Green Leaf Medical and RNPC, France. Dr. Roberts reported advisory committee or board member involvement with Danone, and an ownership interest in Instinct Health Science. Dr. Monteiro and Dr. Corkins reported no relevant disclosures.

Jack S. Resneck Jr., MD, is not usually the loudest voice in the room, but when he speaks, his words carry a heft and an appeal that is straightforward and undeniable.

That was on full display as the 51-year-old vice chair of dermatology at the University of California, San Francisco, addressed his colleagues in his inaugural speech as president of the American Medical Association (AMA) on June 14.

Courtesy Ted Grudzinski

He did not mince words when it came to describing the current landscape. “I doubt you imagined a divided country such as this, where physicians and public health officials often face antiscience aggression and threats of violence simply for doing our jobs,” he said. “You probably didn’t plan on insurers questioning every prescription and every procedure you asked for. Or government criminalizing routine and vital health care, enshrining discrimination against our LGBTQ patients or attacking a woman’s right to control health care decisions that should only be between her and her doctor,” said Dr. Resneck.

But, he added, all was not lost. “While it would be easy to get overwhelmed by despair as I begin this new role, I’ve never been prouder of my physician colleagues,” he said.

Dr. Resneck is the first dermatologist to lead the 175-year-old organization since 1925. Colleagues in the field speak of pride in having one of their own at the top, and they are even more complimentary about his depth of health policy knowledge, his communications skills, and his ability to find common ground.

“He loves looking at both sides,” said Marta J. Van Beek, MD, clinical professor of dermatology at the University of Iowa, Iowa City. “That’s how he builds consensus,” said Dr. Van Beek, who has known Dr. Resneck for more than 20 years, since they were chief dermatology residents – she at Iowa and he at UCSF.

Dr. Van Beek and Dr. Resneck have a deep interest in health policy and have long worked side by side on committees at both the American Academy of Dermatology (AAD) and the AMA. She looks back to the lead-up period before the 2010 passage of the Affordable Care Act as one of Dr. Resneck’s shining moments. “Those were contentious times in medicine,” Dr. Van Beek told this news organization. Dr. Resneck, as chair of the AAD’s Council on Government Affairs and Health Policy from 2008 to 2012, rallied the board to agree on a set of health care reform principles, she noted.

Dr. Resneck is “really very unifying,” agreed Bruce A. Brod, MD, clinical professor of dermatology at the University of Pennsylvania, Philadelphia. Dr. Brod has worked with Dr. Resneck for 2 decades on various committees at the AAD. They’ve also known each other through the AMA House of Delegates.

Now Dr. Brod is following in Dr. Resneck’s footsteps as chair of the AAD’s Council on Government Affairs and Health Policy. “Big shoes to fill there,” said Dr. Brod. He said he’s been inspired by Dr. Resneck’s always-positive approach, punctuated by his ever-constant belief that “there’s a lot more common ground than meets the eye here.”

“I really think he’s the perfect leader at this time,” he said.

Outgoing AMA President Gerald E. Harmon, MD, said that Dr. Resneck’s long experience as a teacher and a mentor, and what he describes as a “good, active listening talent,” have been integral to his success as a leader. He expects those qualities to make Dr. Resneck an effective advocate for all of medicine. “He identifies the problem, he identifies the gap, and then he establishes a workable, executable plan to close that gap,” Dr. Harmon told this news organization, adding that he’s seen this at work in AMA board meetings.

“He was a good teacher for me,” said Dr. Harmon, who had known Dr. Resneck through the House of Delegates and various AMA councils for at least a decade before they both joined the AMA board. “He can be such a mentor to all age groups, including senior physicians like myself,” said Dr. Harmon.

Dr. Resneck is excited, but also measured. “This has been a tumultuous couple of years in the country with the pandemic and with the fractured politics,” he said in an interview. Thinking about taking on the AMA presidency, he said, “I’ve had some moments of trepidation. I wanted to be sure that I was going to be able to make a difference.”
 

Long interest in health policy

Growing up in Shreveport, La., as the son of a dermatologist, Dr. Resneck said, “at first, I swore I was going to do something other than medicine.” It was not out of rebellion. He got along fine with his father. He wanted to pursue his own journey.

Dr. Resneck began his long love affair with health policy at Brown University, graduating magna cum laude with honors in public policy. A 1991 U.S. Department of Health & Human Services internship between his junior and senior years helped inform his honors thesis on health care financing policy.

Ultimately, Dr. Resneck did not stray far from his father’s career path. While still at Brown, he decided to go to medical school, entering UCSF in the fall of 1993. “At the end of the day, there was this undeniable influence that he loved his job,” Dr. Resneck said in the interview. His father was energized by the work and helping patients. “If burnout was in his vocabulary, I never heard it,” said Dr. Resneck.

Initially, he did a 1-year internal medicine residency at UCSF, but then switched to dermatology and became chief resident in 2000.

He was quickly pegged as a leader and an inspirational speaker. The AAD gave him its Young Physician Leadership Development Award in 2001, and the AMA gave Dr. Resneck its Excellence in Medicine National Award for Young Physician Leadership in 2004. He began giving talks at national meetings in 2002 and has been busy ever since, addressing the AMA, the AAD, state medical and dermatology societies, subspecialty groups such as the American College of Mohs Surgery and the Association of Professors of Dermatology, and other organizations such as the American Telemedicine Association.

He’s a sought-after speaker in part because of his ability to simply communicate health policy, said Dr. Brod. “He can connect the real-world issues really well to the policy needs and communicate it very well, and come in at just the right level,” he said.

Dr. Resneck has been immersed in policy and practice issues since the start of his career, serving on AAD and AMA committees addressing quality measures, data collection, access to care, workforce issues, and telemedicine. He started writing about dermatology workforce challenges in 2001 and has revisited that topic with regularity.

He has published often on the difficulties of patient access, looking at wait times for appointments, among other issues. In 2018, he expressed concern in a commentary in JAMA Dermatology that private equity purchases of dermatology practices might lead to an improper focus on profits over patients and that it could reduce the diversity of practice models.

At heart, Dr. Resneck is an institutionalist, someone who believes that the “collaborative, collective voice can make change,” said Dr. Brod. Dr. Resneck said as much in his inaugural speech. “I believe those who show up can use levers of power to confront our system’s flaws,” he said. “This is the nerdy policy part of my life, which my friends will force me to admit is most of my life,” said Dr. Resneck.


 

Prior authorization, telemedicine, equity

Beneath the reserved exterior lies an intense yearning to act on his passions, both at work and at play.

Dr. Resneck notes almost in passing that he likes to ski when he’s not practicing medicine or serving on a committee. Dr. Van Beek – whose family has vacationed with Dr. Resneck, his wife, Ellen Hufbauer, MD, a family medicine physician in Concord, Calif., and their two teenaged children Zachary and Amelia – said he’s “a very good skier.”

She noted that he and his children share the same enthusiasm for researching every aspect of wherever they travel, including the best places to eat. “He embraces work and life with an incredible amount of intellectual curiosity,” Dr. Van Beek said.

That curiosity – and the passion to make a difference – has driven his deep dives into what he sees as the corrosive practice of prior authorization and the promise of telemedicine, which he has explained and supported in testimony on Capitol Hill.

Dr. Brod said that Dr. Resneck was among those who helped convince the federal government to expand coverage for telemedicine during the COVID-19 pandemic. “He brought together his patient experience in dermatology and his policy experience,” and was able to deftly explain how it could increase access during the shutdown, said Dr. Brod.

Prior authorization gets him fired up. “We’ve reached a point where there’s almost not anything I will write a prescription for that doesn’t oftentimes require all of these hoops that we have to jump through,” he told this news organization. Prescriptions for generic topical cortisones that have been around for 50 years “now all of the sudden require a week of arguing,” said Dr. Resneck. In the meantime, patients aren’t getting treatment, he said.

Dr. Resneck’s passion for health equity is borne in part out of the racism witnessed by him and his family, including an uncle who started an antisegregationist newspaper and was kicked out of medical school for his views in the 1950s. Dr. Resneck said he had a rudimentary understanding of racism as a youngster. But he told the AMA delegates, “I knew enough at age 16 to write an op-ed in our city’s newspaper about the need to remove Confederate monuments from our courthouse lawn.” Added Dr. Resneck, “You can imagine how that went over in 1987.”

The pandemic shined a bright light on inequities and heightened awareness of “the institutionalized systems that have perpetuated racism and gender discrimination in medicine for as far back as we want to look,” Dr. Resneck said during his inaugural speech. Pointedly, he told his colleagues that “the AMA has not always been on the right side of history,” adding, “Each of us must do our part to eliminate health inequities by engaging in antiracist and antisexist work.”

That kind of talk is signature Resneck, said Dr. Brod. “He’s not afraid to exhibit very brave leadership,” especially “when there are issues that jeopardize the needs of patient access or patient safety,” he said.

“He’ll be a tremendous AMA president,” said Dr. Van Beek. “He’s present, he’s devoted, and he’s typically the expert in the room.”

Dr. Harmon said that Dr. Resneck is “cut from the same cloth that I am. He believes that if you get an opportunity to make things better, you take it.”

His advice to Dr. Resneck: “Rarely turn an opportunity down.” Dr. Harmon has little doubt that Dr. Resneck is up to the job but said, “I’m going to encourage him to keep that energy and enthusiasm up.”

Dr. Resneck told physician colleagues not to worry: “I will keep relentlessly showing up.”

A version of this article first appeared on Medscape.com.

Jack S. Resneck Jr., MD, is not usually the loudest voice in the room, but when he speaks, his words carry a heft and an appeal that is straightforward and undeniable.

That was on full display as the 51-year-old vice chair of dermatology at the University of California, San Francisco, addressed his colleagues in his inaugural speech as president of the American Medical Association (AMA) on June 14.

Courtesy Ted Grudzinski

He did not mince words when it came to describing the current landscape. “I doubt you imagined a divided country such as this, where physicians and public health officials often face antiscience aggression and threats of violence simply for doing our jobs,” he said. “You probably didn’t plan on insurers questioning every prescription and every procedure you asked for. Or government criminalizing routine and vital health care, enshrining discrimination against our LGBTQ patients or attacking a woman’s right to control health care decisions that should only be between her and her doctor,” said Dr. Resneck.

But, he added, all was not lost. “While it would be easy to get overwhelmed by despair as I begin this new role, I’ve never been prouder of my physician colleagues,” he said.

Dr. Resneck is the first dermatologist to lead the 175-year-old organization since 1925. Colleagues in the field speak of pride in having one of their own at the top, and they are even more complimentary about his depth of health policy knowledge, his communications skills, and his ability to find common ground.

“He loves looking at both sides,” said Marta J. Van Beek, MD, clinical professor of dermatology at the University of Iowa, Iowa City. “That’s how he builds consensus,” said Dr. Van Beek, who has known Dr. Resneck for more than 20 years, since they were chief dermatology residents – she at Iowa and he at UCSF.

Dr. Van Beek and Dr. Resneck have a deep interest in health policy and have long worked side by side on committees at both the American Academy of Dermatology (AAD) and the AMA. She looks back to the lead-up period before the 2010 passage of the Affordable Care Act as one of Dr. Resneck’s shining moments. “Those were contentious times in medicine,” Dr. Van Beek told this news organization. Dr. Resneck, as chair of the AAD’s Council on Government Affairs and Health Policy from 2008 to 2012, rallied the board to agree on a set of health care reform principles, she noted.

Dr. Resneck is “really very unifying,” agreed Bruce A. Brod, MD, clinical professor of dermatology at the University of Pennsylvania, Philadelphia. Dr. Brod has worked with Dr. Resneck for 2 decades on various committees at the AAD. They’ve also known each other through the AMA House of Delegates.

Now Dr. Brod is following in Dr. Resneck’s footsteps as chair of the AAD’s Council on Government Affairs and Health Policy. “Big shoes to fill there,” said Dr. Brod. He said he’s been inspired by Dr. Resneck’s always-positive approach, punctuated by his ever-constant belief that “there’s a lot more common ground than meets the eye here.”

“I really think he’s the perfect leader at this time,” he said.

Outgoing AMA President Gerald E. Harmon, MD, said that Dr. Resneck’s long experience as a teacher and a mentor, and what he describes as a “good, active listening talent,” have been integral to his success as a leader. He expects those qualities to make Dr. Resneck an effective advocate for all of medicine. “He identifies the problem, he identifies the gap, and then he establishes a workable, executable plan to close that gap,” Dr. Harmon told this news organization, adding that he’s seen this at work in AMA board meetings.

“He was a good teacher for me,” said Dr. Harmon, who had known Dr. Resneck through the House of Delegates and various AMA councils for at least a decade before they both joined the AMA board. “He can be such a mentor to all age groups, including senior physicians like myself,” said Dr. Harmon.

Dr. Resneck is excited, but also measured. “This has been a tumultuous couple of years in the country with the pandemic and with the fractured politics,” he said in an interview. Thinking about taking on the AMA presidency, he said, “I’ve had some moments of trepidation. I wanted to be sure that I was going to be able to make a difference.”
 

Long interest in health policy

Growing up in Shreveport, La., as the son of a dermatologist, Dr. Resneck said, “at first, I swore I was going to do something other than medicine.” It was not out of rebellion. He got along fine with his father. He wanted to pursue his own journey.

Dr. Resneck began his long love affair with health policy at Brown University, graduating magna cum laude with honors in public policy. A 1991 U.S. Department of Health & Human Services internship between his junior and senior years helped inform his honors thesis on health care financing policy.

Ultimately, Dr. Resneck did not stray far from his father’s career path. While still at Brown, he decided to go to medical school, entering UCSF in the fall of 1993. “At the end of the day, there was this undeniable influence that he loved his job,” Dr. Resneck said in the interview. His father was energized by the work and helping patients. “If burnout was in his vocabulary, I never heard it,” said Dr. Resneck.

Initially, he did a 1-year internal medicine residency at UCSF, but then switched to dermatology and became chief resident in 2000.

He was quickly pegged as a leader and an inspirational speaker. The AAD gave him its Young Physician Leadership Development Award in 2001, and the AMA gave Dr. Resneck its Excellence in Medicine National Award for Young Physician Leadership in 2004. He began giving talks at national meetings in 2002 and has been busy ever since, addressing the AMA, the AAD, state medical and dermatology societies, subspecialty groups such as the American College of Mohs Surgery and the Association of Professors of Dermatology, and other organizations such as the American Telemedicine Association.

He’s a sought-after speaker in part because of his ability to simply communicate health policy, said Dr. Brod. “He can connect the real-world issues really well to the policy needs and communicate it very well, and come in at just the right level,” he said.

Dr. Resneck has been immersed in policy and practice issues since the start of his career, serving on AAD and AMA committees addressing quality measures, data collection, access to care, workforce issues, and telemedicine. He started writing about dermatology workforce challenges in 2001 and has revisited that topic with regularity.

He has published often on the difficulties of patient access, looking at wait times for appointments, among other issues. In 2018, he expressed concern in a commentary in JAMA Dermatology that private equity purchases of dermatology practices might lead to an improper focus on profits over patients and that it could reduce the diversity of practice models.

At heart, Dr. Resneck is an institutionalist, someone who believes that the “collaborative, collective voice can make change,” said Dr. Brod. Dr. Resneck said as much in his inaugural speech. “I believe those who show up can use levers of power to confront our system’s flaws,” he said. “This is the nerdy policy part of my life, which my friends will force me to admit is most of my life,” said Dr. Resneck.


 

Prior authorization, telemedicine, equity

Beneath the reserved exterior lies an intense yearning to act on his passions, both at work and at play.

Dr. Resneck notes almost in passing that he likes to ski when he’s not practicing medicine or serving on a committee. Dr. Van Beek – whose family has vacationed with Dr. Resneck, his wife, Ellen Hufbauer, MD, a family medicine physician in Concord, Calif., and their two teenaged children Zachary and Amelia – said he’s “a very good skier.”

She noted that he and his children share the same enthusiasm for researching every aspect of wherever they travel, including the best places to eat. “He embraces work and life with an incredible amount of intellectual curiosity,” Dr. Van Beek said.

That curiosity – and the passion to make a difference – has driven his deep dives into what he sees as the corrosive practice of prior authorization and the promise of telemedicine, which he has explained and supported in testimony on Capitol Hill.

Dr. Brod said that Dr. Resneck was among those who helped convince the federal government to expand coverage for telemedicine during the COVID-19 pandemic. “He brought together his patient experience in dermatology and his policy experience,” and was able to deftly explain how it could increase access during the shutdown, said Dr. Brod.

Prior authorization gets him fired up. “We’ve reached a point where there’s almost not anything I will write a prescription for that doesn’t oftentimes require all of these hoops that we have to jump through,” he told this news organization. Prescriptions for generic topical cortisones that have been around for 50 years “now all of the sudden require a week of arguing,” said Dr. Resneck. In the meantime, patients aren’t getting treatment, he said.

Dr. Resneck’s passion for health equity is borne in part out of the racism witnessed by him and his family, including an uncle who started an antisegregationist newspaper and was kicked out of medical school for his views in the 1950s. Dr. Resneck said he had a rudimentary understanding of racism as a youngster. But he told the AMA delegates, “I knew enough at age 16 to write an op-ed in our city’s newspaper about the need to remove Confederate monuments from our courthouse lawn.” Added Dr. Resneck, “You can imagine how that went over in 1987.”

The pandemic shined a bright light on inequities and heightened awareness of “the institutionalized systems that have perpetuated racism and gender discrimination in medicine for as far back as we want to look,” Dr. Resneck said during his inaugural speech. Pointedly, he told his colleagues that “the AMA has not always been on the right side of history,” adding, “Each of us must do our part to eliminate health inequities by engaging in antiracist and antisexist work.”

That kind of talk is signature Resneck, said Dr. Brod. “He’s not afraid to exhibit very brave leadership,” especially “when there are issues that jeopardize the needs of patient access or patient safety,” he said.

“He’ll be a tremendous AMA president,” said Dr. Van Beek. “He’s present, he’s devoted, and he’s typically the expert in the room.”

Dr. Harmon said that Dr. Resneck is “cut from the same cloth that I am. He believes that if you get an opportunity to make things better, you take it.”

His advice to Dr. Resneck: “Rarely turn an opportunity down.” Dr. Harmon has little doubt that Dr. Resneck is up to the job but said, “I’m going to encourage him to keep that energy and enthusiasm up.”

Dr. Resneck told physician colleagues not to worry: “I will keep relentlessly showing up.”

A version of this article first appeared on Medscape.com.

Jack S. Resneck Jr., MD, is not usually the loudest voice in the room, but when he speaks, his words carry a heft and an appeal that is straightforward and undeniable.

That was on full display as the 51-year-old vice chair of dermatology at the University of California, San Francisco, addressed his colleagues in his inaugural speech as president of the American Medical Association (AMA) on June 14.

Courtesy Ted Grudzinski

He did not mince words when it came to describing the current landscape. “I doubt you imagined a divided country such as this, where physicians and public health officials often face antiscience aggression and threats of violence simply for doing our jobs,” he said. “You probably didn’t plan on insurers questioning every prescription and every procedure you asked for. Or government criminalizing routine and vital health care, enshrining discrimination against our LGBTQ patients or attacking a woman’s right to control health care decisions that should only be between her and her doctor,” said Dr. Resneck.

But, he added, all was not lost. “While it would be easy to get overwhelmed by despair as I begin this new role, I’ve never been prouder of my physician colleagues,” he said.

Dr. Resneck is the first dermatologist to lead the 175-year-old organization since 1925. Colleagues in the field speak of pride in having one of their own at the top, and they are even more complimentary about his depth of health policy knowledge, his communications skills, and his ability to find common ground.

“He loves looking at both sides,” said Marta J. Van Beek, MD, clinical professor of dermatology at the University of Iowa, Iowa City. “That’s how he builds consensus,” said Dr. Van Beek, who has known Dr. Resneck for more than 20 years, since they were chief dermatology residents – she at Iowa and he at UCSF.

Dr. Van Beek and Dr. Resneck have a deep interest in health policy and have long worked side by side on committees at both the American Academy of Dermatology (AAD) and the AMA. She looks back to the lead-up period before the 2010 passage of the Affordable Care Act as one of Dr. Resneck’s shining moments. “Those were contentious times in medicine,” Dr. Van Beek told this news organization. Dr. Resneck, as chair of the AAD’s Council on Government Affairs and Health Policy from 2008 to 2012, rallied the board to agree on a set of health care reform principles, she noted.

Dr. Resneck is “really very unifying,” agreed Bruce A. Brod, MD, clinical professor of dermatology at the University of Pennsylvania, Philadelphia. Dr. Brod has worked with Dr. Resneck for 2 decades on various committees at the AAD. They’ve also known each other through the AMA House of Delegates.

Now Dr. Brod is following in Dr. Resneck’s footsteps as chair of the AAD’s Council on Government Affairs and Health Policy. “Big shoes to fill there,” said Dr. Brod. He said he’s been inspired by Dr. Resneck’s always-positive approach, punctuated by his ever-constant belief that “there’s a lot more common ground than meets the eye here.”

“I really think he’s the perfect leader at this time,” he said.

Outgoing AMA President Gerald E. Harmon, MD, said that Dr. Resneck’s long experience as a teacher and a mentor, and what he describes as a “good, active listening talent,” have been integral to his success as a leader. He expects those qualities to make Dr. Resneck an effective advocate for all of medicine. “He identifies the problem, he identifies the gap, and then he establishes a workable, executable plan to close that gap,” Dr. Harmon told this news organization, adding that he’s seen this at work in AMA board meetings.

“He was a good teacher for me,” said Dr. Harmon, who had known Dr. Resneck through the House of Delegates and various AMA councils for at least a decade before they both joined the AMA board. “He can be such a mentor to all age groups, including senior physicians like myself,” said Dr. Harmon.

Dr. Resneck is excited, but also measured. “This has been a tumultuous couple of years in the country with the pandemic and with the fractured politics,” he said in an interview. Thinking about taking on the AMA presidency, he said, “I’ve had some moments of trepidation. I wanted to be sure that I was going to be able to make a difference.”
 

Long interest in health policy

Growing up in Shreveport, La., as the son of a dermatologist, Dr. Resneck said, “at first, I swore I was going to do something other than medicine.” It was not out of rebellion. He got along fine with his father. He wanted to pursue his own journey.

Dr. Resneck began his long love affair with health policy at Brown University, graduating magna cum laude with honors in public policy. A 1991 U.S. Department of Health & Human Services internship between his junior and senior years helped inform his honors thesis on health care financing policy.

Ultimately, Dr. Resneck did not stray far from his father’s career path. While still at Brown, he decided to go to medical school, entering UCSF in the fall of 1993. “At the end of the day, there was this undeniable influence that he loved his job,” Dr. Resneck said in the interview. His father was energized by the work and helping patients. “If burnout was in his vocabulary, I never heard it,” said Dr. Resneck.

Initially, he did a 1-year internal medicine residency at UCSF, but then switched to dermatology and became chief resident in 2000.

He was quickly pegged as a leader and an inspirational speaker. The AAD gave him its Young Physician Leadership Development Award in 2001, and the AMA gave Dr. Resneck its Excellence in Medicine National Award for Young Physician Leadership in 2004. He began giving talks at national meetings in 2002 and has been busy ever since, addressing the AMA, the AAD, state medical and dermatology societies, subspecialty groups such as the American College of Mohs Surgery and the Association of Professors of Dermatology, and other organizations such as the American Telemedicine Association.

He’s a sought-after speaker in part because of his ability to simply communicate health policy, said Dr. Brod. “He can connect the real-world issues really well to the policy needs and communicate it very well, and come in at just the right level,” he said.

Dr. Resneck has been immersed in policy and practice issues since the start of his career, serving on AAD and AMA committees addressing quality measures, data collection, access to care, workforce issues, and telemedicine. He started writing about dermatology workforce challenges in 2001 and has revisited that topic with regularity.

He has published often on the difficulties of patient access, looking at wait times for appointments, among other issues. In 2018, he expressed concern in a commentary in JAMA Dermatology that private equity purchases of dermatology practices might lead to an improper focus on profits over patients and that it could reduce the diversity of practice models.

At heart, Dr. Resneck is an institutionalist, someone who believes that the “collaborative, collective voice can make change,” said Dr. Brod. Dr. Resneck said as much in his inaugural speech. “I believe those who show up can use levers of power to confront our system’s flaws,” he said. “This is the nerdy policy part of my life, which my friends will force me to admit is most of my life,” said Dr. Resneck.


 

Prior authorization, telemedicine, equity

Beneath the reserved exterior lies an intense yearning to act on his passions, both at work and at play.

Dr. Resneck notes almost in passing that he likes to ski when he’s not practicing medicine or serving on a committee. Dr. Van Beek – whose family has vacationed with Dr. Resneck, his wife, Ellen Hufbauer, MD, a family medicine physician in Concord, Calif., and their two teenaged children Zachary and Amelia – said he’s “a very good skier.”

She noted that he and his children share the same enthusiasm for researching every aspect of wherever they travel, including the best places to eat. “He embraces work and life with an incredible amount of intellectual curiosity,” Dr. Van Beek said.

That curiosity – and the passion to make a difference – has driven his deep dives into what he sees as the corrosive practice of prior authorization and the promise of telemedicine, which he has explained and supported in testimony on Capitol Hill.

Dr. Brod said that Dr. Resneck was among those who helped convince the federal government to expand coverage for telemedicine during the COVID-19 pandemic. “He brought together his patient experience in dermatology and his policy experience,” and was able to deftly explain how it could increase access during the shutdown, said Dr. Brod.

Prior authorization gets him fired up. “We’ve reached a point where there’s almost not anything I will write a prescription for that doesn’t oftentimes require all of these hoops that we have to jump through,” he told this news organization. Prescriptions for generic topical cortisones that have been around for 50 years “now all of the sudden require a week of arguing,” said Dr. Resneck. In the meantime, patients aren’t getting treatment, he said.

Dr. Resneck’s passion for health equity is borne in part out of the racism witnessed by him and his family, including an uncle who started an antisegregationist newspaper and was kicked out of medical school for his views in the 1950s. Dr. Resneck said he had a rudimentary understanding of racism as a youngster. But he told the AMA delegates, “I knew enough at age 16 to write an op-ed in our city’s newspaper about the need to remove Confederate monuments from our courthouse lawn.” Added Dr. Resneck, “You can imagine how that went over in 1987.”

The pandemic shined a bright light on inequities and heightened awareness of “the institutionalized systems that have perpetuated racism and gender discrimination in medicine for as far back as we want to look,” Dr. Resneck said during his inaugural speech. Pointedly, he told his colleagues that “the AMA has not always been on the right side of history,” adding, “Each of us must do our part to eliminate health inequities by engaging in antiracist and antisexist work.”

That kind of talk is signature Resneck, said Dr. Brod. “He’s not afraid to exhibit very brave leadership,” especially “when there are issues that jeopardize the needs of patient access or patient safety,” he said.

“He’ll be a tremendous AMA president,” said Dr. Van Beek. “He’s present, he’s devoted, and he’s typically the expert in the room.”

Dr. Harmon said that Dr. Resneck is “cut from the same cloth that I am. He believes that if you get an opportunity to make things better, you take it.”

His advice to Dr. Resneck: “Rarely turn an opportunity down.” Dr. Harmon has little doubt that Dr. Resneck is up to the job but said, “I’m going to encourage him to keep that energy and enthusiasm up.”

Dr. Resneck told physician colleagues not to worry: “I will keep relentlessly showing up.”

A version of this article first appeared on Medscape.com.

The cupboard in Dr. Nicolás Rascovan’s microbial paleogenomics lab at Institut Pasteur in Paris is filled up with cardboard boxes that look as if they were shipped from an office supply store. Yet, instead of pencils and Post-it notes, the boxes are filled with ancient human remains from South America – several-thousand-year-old vertebrae, petrus bones (which protect inner ear structures), and teeth – all neatly packed in plastic bags. From these artifacts Dr. Rascovan hopes to retrieve DNA of ancient pathogens – which could help us better understand how microbes emerge and evolve and how pandemics spread. It could even, perhaps, rewrite history. “It’s a story of a continent in a closet,” Dr. Rascovan says.

Over the past decade, technologic advances in DNA recovery and sequencing have made it possible for scientists such as Dr. Rascovan, an Argentinian molecular biologist, to analyze ancient specimens relatively quickly and affordably. They’ve been hunting for – and finding – DNA of centuries-old microbes in various archeological samples: from smallpox variola virus and Mycobacterium tuberculosis in mummified tissues, to the Black Death bacteria, Yesinia pestis, in neolithic teeth, to Plasmodium falciparum preserved in historical blood stains.

The ultramodern Parisian offices of the microbial paleogenomics group, a team of five scientists led by Dr. Rascovan, clash with the logo they half-jokingly chose for themselves and plastered all over the lab’s walls: a Jurassic Park–inspired dinosaur baring its giant, ancient teeth, made to look like an image seen under a microscope. Ancient teeth are certainly central to the group’s work, because it’s there where ancient pathogens’ DNA is most likely to be preserved – after death, teeth act like tiny, sealed-up boxes for microbes. “If you have a pathogen that is circulating in the blood, it will sometimes get into the teeth, and when you die, the DNA will stay there,” Dr. Rascovan says.

To process ancient teeth, Dr. Rascovan enters a lab clad head to toe in protective gear. That’s not so much to save himself from potentially deadly disease as to save the samples from contamination, he says. According to Sebastian Duchene Garzon, a microbiologist at the University of Melbourne, “the likelihood of ancient pathogen DNA leading to infections at present is remote, although certainly not impossible, because of how degraded the DNA usually is and because it would still need all the molecular machinery to infect a modern host.”

To process ancient teeth in his lab, Dr. Rascovan starts with a thorough cleaning that involves bleach to remove any modern DNA contamination. Next, he cuts the tooth with a Dremel rotary tool to open it up and get into its pulp – which is not only very durable but also naturally sterile – a perfect place to find ancient pathogens. He then scrapes the pulp into a powder that can be poured into a tube for DNA extraction.

So far, Dr. Rascovan’s biggest breakthrough didn’t come from the teeth he cut up himself, though. It came from analyzing publicly available DNA data from studies of ancient human genomes. When such genomes are sequenced from fossil teeth or bones, scientists pick out the material they need for study of our ancestors’ evolutionary history. However, among the double helixes coding hominid genetic instructions often hide scraps of microbial DNA, which in the past were frequently simply discarded.

Dr. Rascovan downloaded data from published articles on ancient human DNA that had been found in teeth and reanalyzed them, searching for bacteria. One night, when he was alone in his office going through lines and lines of data, he spotted it: DNA of the plague-causing bacteria, Y. pestis. When Dr. Rascovan cross-checked to determine in which samples the bacteria’s DNA was found, his heart raced. “It was not supposed to be there,” he says. He had just discovered the most ancient case of plague in humans – which occurred 4,900 years ago in Sweden.

Scientists used to believe that plague pandemics came to Europe from the Eurasian Steppe. Yet here was the DNA of Y. pestis lodged in the teeth of two farmers, a woman and a man, who died in Scandinavia before the plague’s supposed arrival from the East. Their bodies were buried in an unusually large common grave – of itself a possible indication of an epidemic.

When Dr. Rascovan and his colleagues applied molecular-clock analyses of the phylogenetic tree of the plague bacteria and compared various strains to see which one was the most ancestral, they confirmed that the Swedish strain of Y. pestis, named Gok2, was indeed the oldest – the origin of the Steppe strains rather than its distant cousin. Plague, it seemed, wasn’t brought to Europe during mass migrations from the East. Instead, it might have originated there.

Such work is not simply about rewriting history. By updating our knowledge of ancient pandemics, we can learn how different factors influence each other in fostering outbreaks. For Dr. Rascovan, the Swedish plague story underscores the importance of our lifestyle and environment for the emergence and spread of dangerous pathogens. The Gok2 strain didn’t contain a gene that makes plague particularly virulent, called ymt, yet it might have played an important role in Bronze Age Europe. At that time, mega-settlements of 10,000 to 20,000 people existed in what is now Ukraine, Romania, and Moldova, yet those settlements were frequently burned to the ground and abandoned. According to Dr. Rascovan and his colleagues, that could fit with the plague pandemic story (although this remains very much a hypothesis).

In Mexico, environmental factors might have played an important role in the severity of the 16th century “cocoliztli” epidemic (the word means “pestilence” in a local language), considered one of the most devastating epidemics in New World history. The disease, which caused vomiting, red spots on the skin, and bleeding from various body orifices, didn’t have a known cause. Some hypothesized the bug might have been smallpox, judging by the severity of the outbreak. A 2018 study of a victim’s DNA showed it contained the genome of Salmonella enterica, a bacterium that causes enteric fever – a microbe generally milder than smallpox. The study’s authors argued that specific conditions may have been necessary at the onset of the epidemic for the S. enterica microbe to cause such devastating outcomes. A mix of severe draught, forced relocations of the local population by their Spanish rulers, and new subsistence farming practices all negatively affected hygienic conditions in the local settlements. According to Dr. Rascovan, such research can “place pandemics into their broader context” – with potential lessons for the future.

One of the microbes Dr. Rascovan and his team are hoping to find in the ancient teeth stocked in their lab’s closet is tuberculosis – a pathogen that kills 1.5 million people a year, yet whose evolutionary history remains largely a mystery. The focus of Dr. Rascovan and his colleagues remains on fossils shipped from South America, since we still know very little about microbes that were associated with pre-Columbian populations. South Americans have been isolated from the rest of the world for 20,000 years, making them particularly interesting candidates for the study of emergence, evolution, and spread of pathogens.

Dr. Rascovan believes that ancient microbial genomic data can help scientists better understand antibiotic resistance through comparisons of bacterial evolution before and after the discovery of antibiotics. In general, he says, by studying only current pathogens and the modern outbreaks they cause, we see only a narrow sample of something that is much more diverse and much larger. “We are missing an important part of information. Ancient samples can bring us a perspective,” he says.

A version of this article first appeared on Medscape.com.

The cupboard in Dr. Nicolás Rascovan’s microbial paleogenomics lab at Institut Pasteur in Paris is filled up with cardboard boxes that look as if they were shipped from an office supply store. Yet, instead of pencils and Post-it notes, the boxes are filled with ancient human remains from South America – several-thousand-year-old vertebrae, petrus bones (which protect inner ear structures), and teeth – all neatly packed in plastic bags. From these artifacts Dr. Rascovan hopes to retrieve DNA of ancient pathogens – which could help us better understand how microbes emerge and evolve and how pandemics spread. It could even, perhaps, rewrite history. “It’s a story of a continent in a closet,” Dr. Rascovan says.

Over the past decade, technologic advances in DNA recovery and sequencing have made it possible for scientists such as Dr. Rascovan, an Argentinian molecular biologist, to analyze ancient specimens relatively quickly and affordably. They’ve been hunting for – and finding – DNA of centuries-old microbes in various archeological samples: from smallpox variola virus and Mycobacterium tuberculosis in mummified tissues, to the Black Death bacteria, Yesinia pestis, in neolithic teeth, to Plasmodium falciparum preserved in historical blood stains.

The ultramodern Parisian offices of the microbial paleogenomics group, a team of five scientists led by Dr. Rascovan, clash with the logo they half-jokingly chose for themselves and plastered all over the lab’s walls: a Jurassic Park–inspired dinosaur baring its giant, ancient teeth, made to look like an image seen under a microscope. Ancient teeth are certainly central to the group’s work, because it’s there where ancient pathogens’ DNA is most likely to be preserved – after death, teeth act like tiny, sealed-up boxes for microbes. “If you have a pathogen that is circulating in the blood, it will sometimes get into the teeth, and when you die, the DNA will stay there,” Dr. Rascovan says.

To process ancient teeth, Dr. Rascovan enters a lab clad head to toe in protective gear. That’s not so much to save himself from potentially deadly disease as to save the samples from contamination, he says. According to Sebastian Duchene Garzon, a microbiologist at the University of Melbourne, “the likelihood of ancient pathogen DNA leading to infections at present is remote, although certainly not impossible, because of how degraded the DNA usually is and because it would still need all the molecular machinery to infect a modern host.”

To process ancient teeth in his lab, Dr. Rascovan starts with a thorough cleaning that involves bleach to remove any modern DNA contamination. Next, he cuts the tooth with a Dremel rotary tool to open it up and get into its pulp – which is not only very durable but also naturally sterile – a perfect place to find ancient pathogens. He then scrapes the pulp into a powder that can be poured into a tube for DNA extraction.

So far, Dr. Rascovan’s biggest breakthrough didn’t come from the teeth he cut up himself, though. It came from analyzing publicly available DNA data from studies of ancient human genomes. When such genomes are sequenced from fossil teeth or bones, scientists pick out the material they need for study of our ancestors’ evolutionary history. However, among the double helixes coding hominid genetic instructions often hide scraps of microbial DNA, which in the past were frequently simply discarded.

Dr. Rascovan downloaded data from published articles on ancient human DNA that had been found in teeth and reanalyzed them, searching for bacteria. One night, when he was alone in his office going through lines and lines of data, he spotted it: DNA of the plague-causing bacteria, Y. pestis. When Dr. Rascovan cross-checked to determine in which samples the bacteria’s DNA was found, his heart raced. “It was not supposed to be there,” he says. He had just discovered the most ancient case of plague in humans – which occurred 4,900 years ago in Sweden.

Scientists used to believe that plague pandemics came to Europe from the Eurasian Steppe. Yet here was the DNA of Y. pestis lodged in the teeth of two farmers, a woman and a man, who died in Scandinavia before the plague’s supposed arrival from the East. Their bodies were buried in an unusually large common grave – of itself a possible indication of an epidemic.

When Dr. Rascovan and his colleagues applied molecular-clock analyses of the phylogenetic tree of the plague bacteria and compared various strains to see which one was the most ancestral, they confirmed that the Swedish strain of Y. pestis, named Gok2, was indeed the oldest – the origin of the Steppe strains rather than its distant cousin. Plague, it seemed, wasn’t brought to Europe during mass migrations from the East. Instead, it might have originated there.

Such work is not simply about rewriting history. By updating our knowledge of ancient pandemics, we can learn how different factors influence each other in fostering outbreaks. For Dr. Rascovan, the Swedish plague story underscores the importance of our lifestyle and environment for the emergence and spread of dangerous pathogens. The Gok2 strain didn’t contain a gene that makes plague particularly virulent, called ymt, yet it might have played an important role in Bronze Age Europe. At that time, mega-settlements of 10,000 to 20,000 people existed in what is now Ukraine, Romania, and Moldova, yet those settlements were frequently burned to the ground and abandoned. According to Dr. Rascovan and his colleagues, that could fit with the plague pandemic story (although this remains very much a hypothesis).

In Mexico, environmental factors might have played an important role in the severity of the 16th century “cocoliztli” epidemic (the word means “pestilence” in a local language), considered one of the most devastating epidemics in New World history. The disease, which caused vomiting, red spots on the skin, and bleeding from various body orifices, didn’t have a known cause. Some hypothesized the bug might have been smallpox, judging by the severity of the outbreak. A 2018 study of a victim’s DNA showed it contained the genome of Salmonella enterica, a bacterium that causes enteric fever – a microbe generally milder than smallpox. The study’s authors argued that specific conditions may have been necessary at the onset of the epidemic for the S. enterica microbe to cause such devastating outcomes. A mix of severe draught, forced relocations of the local population by their Spanish rulers, and new subsistence farming practices all negatively affected hygienic conditions in the local settlements. According to Dr. Rascovan, such research can “place pandemics into their broader context” – with potential lessons for the future.

One of the microbes Dr. Rascovan and his team are hoping to find in the ancient teeth stocked in their lab’s closet is tuberculosis – a pathogen that kills 1.5 million people a year, yet whose evolutionary history remains largely a mystery. The focus of Dr. Rascovan and his colleagues remains on fossils shipped from South America, since we still know very little about microbes that were associated with pre-Columbian populations. South Americans have been isolated from the rest of the world for 20,000 years, making them particularly interesting candidates for the study of emergence, evolution, and spread of pathogens.

Dr. Rascovan believes that ancient microbial genomic data can help scientists better understand antibiotic resistance through comparisons of bacterial evolution before and after the discovery of antibiotics. In general, he says, by studying only current pathogens and the modern outbreaks they cause, we see only a narrow sample of something that is much more diverse and much larger. “We are missing an important part of information. Ancient samples can bring us a perspective,” he says.

A version of this article first appeared on Medscape.com.

The cupboard in Dr. Nicolás Rascovan’s microbial paleogenomics lab at Institut Pasteur in Paris is filled up with cardboard boxes that look as if they were shipped from an office supply store. Yet, instead of pencils and Post-it notes, the boxes are filled with ancient human remains from South America – several-thousand-year-old vertebrae, petrus bones (which protect inner ear structures), and teeth – all neatly packed in plastic bags. From these artifacts Dr. Rascovan hopes to retrieve DNA of ancient pathogens – which could help us better understand how microbes emerge and evolve and how pandemics spread. It could even, perhaps, rewrite history. “It’s a story of a continent in a closet,” Dr. Rascovan says.

Over the past decade, technologic advances in DNA recovery and sequencing have made it possible for scientists such as Dr. Rascovan, an Argentinian molecular biologist, to analyze ancient specimens relatively quickly and affordably. They’ve been hunting for – and finding – DNA of centuries-old microbes in various archeological samples: from smallpox variola virus and Mycobacterium tuberculosis in mummified tissues, to the Black Death bacteria, Yesinia pestis, in neolithic teeth, to Plasmodium falciparum preserved in historical blood stains.

The ultramodern Parisian offices of the microbial paleogenomics group, a team of five scientists led by Dr. Rascovan, clash with the logo they half-jokingly chose for themselves and plastered all over the lab’s walls: a Jurassic Park–inspired dinosaur baring its giant, ancient teeth, made to look like an image seen under a microscope. Ancient teeth are certainly central to the group’s work, because it’s there where ancient pathogens’ DNA is most likely to be preserved – after death, teeth act like tiny, sealed-up boxes for microbes. “If you have a pathogen that is circulating in the blood, it will sometimes get into the teeth, and when you die, the DNA will stay there,” Dr. Rascovan says.

To process ancient teeth, Dr. Rascovan enters a lab clad head to toe in protective gear. That’s not so much to save himself from potentially deadly disease as to save the samples from contamination, he says. According to Sebastian Duchene Garzon, a microbiologist at the University of Melbourne, “the likelihood of ancient pathogen DNA leading to infections at present is remote, although certainly not impossible, because of how degraded the DNA usually is and because it would still need all the molecular machinery to infect a modern host.”

To process ancient teeth in his lab, Dr. Rascovan starts with a thorough cleaning that involves bleach to remove any modern DNA contamination. Next, he cuts the tooth with a Dremel rotary tool to open it up and get into its pulp – which is not only very durable but also naturally sterile – a perfect place to find ancient pathogens. He then scrapes the pulp into a powder that can be poured into a tube for DNA extraction.

So far, Dr. Rascovan’s biggest breakthrough didn’t come from the teeth he cut up himself, though. It came from analyzing publicly available DNA data from studies of ancient human genomes. When such genomes are sequenced from fossil teeth or bones, scientists pick out the material they need for study of our ancestors’ evolutionary history. However, among the double helixes coding hominid genetic instructions often hide scraps of microbial DNA, which in the past were frequently simply discarded.

Dr. Rascovan downloaded data from published articles on ancient human DNA that had been found in teeth and reanalyzed them, searching for bacteria. One night, when he was alone in his office going through lines and lines of data, he spotted it: DNA of the plague-causing bacteria, Y. pestis. When Dr. Rascovan cross-checked to determine in which samples the bacteria’s DNA was found, his heart raced. “It was not supposed to be there,” he says. He had just discovered the most ancient case of plague in humans – which occurred 4,900 years ago in Sweden.

Scientists used to believe that plague pandemics came to Europe from the Eurasian Steppe. Yet here was the DNA of Y. pestis lodged in the teeth of two farmers, a woman and a man, who died in Scandinavia before the plague’s supposed arrival from the East. Their bodies were buried in an unusually large common grave – of itself a possible indication of an epidemic.

When Dr. Rascovan and his colleagues applied molecular-clock analyses of the phylogenetic tree of the plague bacteria and compared various strains to see which one was the most ancestral, they confirmed that the Swedish strain of Y. pestis, named Gok2, was indeed the oldest – the origin of the Steppe strains rather than its distant cousin. Plague, it seemed, wasn’t brought to Europe during mass migrations from the East. Instead, it might have originated there.

Such work is not simply about rewriting history. By updating our knowledge of ancient pandemics, we can learn how different factors influence each other in fostering outbreaks. For Dr. Rascovan, the Swedish plague story underscores the importance of our lifestyle and environment for the emergence and spread of dangerous pathogens. The Gok2 strain didn’t contain a gene that makes plague particularly virulent, called ymt, yet it might have played an important role in Bronze Age Europe. At that time, mega-settlements of 10,000 to 20,000 people existed in what is now Ukraine, Romania, and Moldova, yet those settlements were frequently burned to the ground and abandoned. According to Dr. Rascovan and his colleagues, that could fit with the plague pandemic story (although this remains very much a hypothesis).

In Mexico, environmental factors might have played an important role in the severity of the 16th century “cocoliztli” epidemic (the word means “pestilence” in a local language), considered one of the most devastating epidemics in New World history. The disease, which caused vomiting, red spots on the skin, and bleeding from various body orifices, didn’t have a known cause. Some hypothesized the bug might have been smallpox, judging by the severity of the outbreak. A 2018 study of a victim’s DNA showed it contained the genome of Salmonella enterica, a bacterium that causes enteric fever – a microbe generally milder than smallpox. The study’s authors argued that specific conditions may have been necessary at the onset of the epidemic for the S. enterica microbe to cause such devastating outcomes. A mix of severe draught, forced relocations of the local population by their Spanish rulers, and new subsistence farming practices all negatively affected hygienic conditions in the local settlements. According to Dr. Rascovan, such research can “place pandemics into their broader context” – with potential lessons for the future.

One of the microbes Dr. Rascovan and his team are hoping to find in the ancient teeth stocked in their lab’s closet is tuberculosis – a pathogen that kills 1.5 million people a year, yet whose evolutionary history remains largely a mystery. The focus of Dr. Rascovan and his colleagues remains on fossils shipped from South America, since we still know very little about microbes that were associated with pre-Columbian populations. South Americans have been isolated from the rest of the world for 20,000 years, making them particularly interesting candidates for the study of emergence, evolution, and spread of pathogens.

Dr. Rascovan believes that ancient microbial genomic data can help scientists better understand antibiotic resistance through comparisons of bacterial evolution before and after the discovery of antibiotics. In general, he says, by studying only current pathogens and the modern outbreaks they cause, we see only a narrow sample of something that is much more diverse and much larger. “We are missing an important part of information. Ancient samples can bring us a perspective,” he says.

A version of this article first appeared on Medscape.com.

Your gut microbiome will thank you later

A healthy gut seems like the new catch-all to better overall health these days. Nutrition and diet culture has us drinking kombucha and ginger tea and coffee, but what if we told you that going to happy hour might also help?

In a recent double-blind study published in the Journal of Agricultural and Food Chemistry, 19 men were divided into two groups and asked to drink 11 ounces of alcoholic lager (5.2% by volume) or nonalcoholic lager with dinner for 4 weeks.

Beer? Yes. Beer.

Engin Akyurt/Pixabay

We humans have trillions of microorganisms running rampant through our digestive tracts. When they’re happy, we have a lower chance of developing heart disease and diabetes. You know what else has millions of happy microorganisms from fermentation? Beer. It also has polyphenols that can help the body’s tissues fight cancers, as well as heart disease and inflammation. So beer is looking a little more healthy now, isn’t it?

In the study, the researchers found that both the alcoholic- and nonalcoholic-lager groups had a boost in bacterial diversity in the gut and higher fecal alkaline phosphatase levels, which showed improved intestinal health. They acknowledged, however, that the nonalcoholic route would be safer and healthier for overall health.

So add a lager to the list of gut-healthy foods that you should be consuming. It may give the phrase “beer gut” a whole new meaning.
 

We’ve lost our minds, but at least we know how fast they’re going

The phrase “quantum consciousness” sounds like something out of a particularly cheesy episode of Star Trek: “Oh no, Captain, the quantum consciousness has invaded our computer, and the only way to drive it out is to reverse the polarity of a focused tachyon beam.”

Massimiliano De Deo, LNGS-INFN

When it comes to understanding such basic existential issues as the origin of consciousness, however, quantum mechanics wasn’t off the table. The theory of the quantum origin of consciousness dates back to the 1990s (thanks in part to noted physician Roger Penrose), and goes something like this: There are microtubules within neurons in the brain that are small enough and isolated enough from the warm, wet, and chaotic brain environment where quantum effects can briefly come into play. We’re talking miniscule fractions of a second here, but still, long enough for quantum calculations to take place in the form of system wavefunction collapse, courtesy of gravity.

To plunge even deeper into the rabbit hole of quantum mechanics, the reason Schrödinger’s cat doesn’t occur in real life is wavefunction collapse; the more massive a quantum system is, the more likely it is to collapse into one state or another (alive or dead, in the cat’s case). The quantum origin of consciousness, or Orch OR theory, holds that human consciousness arises from electrical oscillations within the neuronal microtubules caused by the computations stemming from the collapse of small quantum systems.

That is an awful lot of overly simplified explanation, especially considering the study that just came out essentially disproved it. Oops. The research, published in Physics of Life Reviews, is pretty simple. The researchers went to a lab deep underground to avoid interference from cosmic rays, and sat around for months, observing a chunk of germanium for signs of spontaneous radiation, attributable to the same sort of wavefunction collapse that is supposedly occurring in our brains. They found nothing out of the ordinary, pretty definitively disproving most of Orch OR theory.

The researchers were unwilling to completely dismiss the idea (this is quantum mechanics, after all, uncertainty kind of goes with the territory), but it does seem like we’ll have to search elsewhere for sources of human consciousness. Personally, we’re big fans of the cymbal-playing monkey.
 

Missing links: A real fish story

Dear LOTME:

Ear’s a question that’s been keeping me up at night. Is the human middle ear the result of top-secret government experiments involving alien technology, Abraham Lincoln, and the Illuminati?

Restless in Roswell

Dear Restless:

The paleoanthropologic community has been sorting through this mystery for decades, and fossils discovered in China over the past 20 years finally provide a much less conspiratorially satisfying answer.

IVPP

For some time now, experts in the field have believed that the bones of the human middle ear evolved from the spiracular gill of a fish. The spiracle is a small hole behind each eye that opens to the mouth in some fishes and was used to breathe air in the earliest, most primitive species. But how did we get from spiracle to ear?

The missing links come in the form of the cranial anatomy of Shuyu, a 438-million-year-old, fingernail-sized skull of a jawless fish, and the 419-million-year-old fossil of a completely preserved fish with gill filaments in the first branchial chamber.

“These fossils provided the first anatomical and fossil evidence for a vertebrate spiracle originating from fish gills,” senior author Gai Zhikun, PhD, of the Institute of Vertebrate Paleontology and Paleoanthropology, Beijing, said in a written statement.

In many ways, it seems, we are fish: “Many important structures of human beings can be traced back to our fish ancestors, such as our teeth, jaws, middle ears, etc,” added Zhu Min, PhD, also of the institute.

So, Restless, the next time you hear the soothing sounds of an angry mob storming the Capitol or you chew on a slab, slice, or chunk of mutant, laboratory-produced chicken in your favorite fast-food restaurant, be sure to thank Shuyu.
 

Can you lend me an ear?

If you thought locusts were only a nuisance, think again. They have their uses. If you take a locust’s ear and put it inside a robot, the robot will be able to hear and receive signals. Who knew?

850977/Pixabay

Researchers from Tel Aviv University in Israel showed the robot’s hearing abilities by giving clap signals that told the robot what to do: One clap means go forward, two claps mean move back. What do you think the robot would do if it heard the clap break from Cha Cha Slide?

“Our task was to replace the robot’s electronic microphone with a dead insect’s ear, use the ear’s ability to detect the electrical signals from the environment, in this case vibrations in the air, and, using a special chip, convert the insect input to that of the robot,” Ben M. Maoz, PhD, said in a statement from the university.

And how does a dead locust ear work in a robot? Well, Dr. Maoz explained: “My laboratory has developed a special device – Ear-on-a-Chip – that allows the ear to be kept alive throughout the experiment by supplying oxygen and food to the organ while allowing the electrical signals to be taken out of the locust’s ear and amplified and transmitted to the robot.”

The research won’t stop at hearing, he said, as the other four senses also will be taken into consideration. This could help us sense dangers in the future, such as earthquakes or diseases. We said it before and we’ll say it again: We’re rooting for you, science!

Your gut microbiome will thank you later

A healthy gut seems like the new catch-all to better overall health these days. Nutrition and diet culture has us drinking kombucha and ginger tea and coffee, but what if we told you that going to happy hour might also help?

In a recent double-blind study published in the Journal of Agricultural and Food Chemistry, 19 men were divided into two groups and asked to drink 11 ounces of alcoholic lager (5.2% by volume) or nonalcoholic lager with dinner for 4 weeks.

Beer? Yes. Beer.

Engin Akyurt/Pixabay

We humans have trillions of microorganisms running rampant through our digestive tracts. When they’re happy, we have a lower chance of developing heart disease and diabetes. You know what else has millions of happy microorganisms from fermentation? Beer. It also has polyphenols that can help the body’s tissues fight cancers, as well as heart disease and inflammation. So beer is looking a little more healthy now, isn’t it?

In the study, the researchers found that both the alcoholic- and nonalcoholic-lager groups had a boost in bacterial diversity in the gut and higher fecal alkaline phosphatase levels, which showed improved intestinal health. They acknowledged, however, that the nonalcoholic route would be safer and healthier for overall health.

So add a lager to the list of gut-healthy foods that you should be consuming. It may give the phrase “beer gut” a whole new meaning.
 

We’ve lost our minds, but at least we know how fast they’re going

The phrase “quantum consciousness” sounds like something out of a particularly cheesy episode of Star Trek: “Oh no, Captain, the quantum consciousness has invaded our computer, and the only way to drive it out is to reverse the polarity of a focused tachyon beam.”

Massimiliano De Deo, LNGS-INFN

When it comes to understanding such basic existential issues as the origin of consciousness, however, quantum mechanics wasn’t off the table. The theory of the quantum origin of consciousness dates back to the 1990s (thanks in part to noted physician Roger Penrose), and goes something like this: There are microtubules within neurons in the brain that are small enough and isolated enough from the warm, wet, and chaotic brain environment where quantum effects can briefly come into play. We’re talking miniscule fractions of a second here, but still, long enough for quantum calculations to take place in the form of system wavefunction collapse, courtesy of gravity.

To plunge even deeper into the rabbit hole of quantum mechanics, the reason Schrödinger’s cat doesn’t occur in real life is wavefunction collapse; the more massive a quantum system is, the more likely it is to collapse into one state or another (alive or dead, in the cat’s case). The quantum origin of consciousness, or Orch OR theory, holds that human consciousness arises from electrical oscillations within the neuronal microtubules caused by the computations stemming from the collapse of small quantum systems.

That is an awful lot of overly simplified explanation, especially considering the study that just came out essentially disproved it. Oops. The research, published in Physics of Life Reviews, is pretty simple. The researchers went to a lab deep underground to avoid interference from cosmic rays, and sat around for months, observing a chunk of germanium for signs of spontaneous radiation, attributable to the same sort of wavefunction collapse that is supposedly occurring in our brains. They found nothing out of the ordinary, pretty definitively disproving most of Orch OR theory.

The researchers were unwilling to completely dismiss the idea (this is quantum mechanics, after all, uncertainty kind of goes with the territory), but it does seem like we’ll have to search elsewhere for sources of human consciousness. Personally, we’re big fans of the cymbal-playing monkey.
 

Missing links: A real fish story

Dear LOTME:

Ear’s a question that’s been keeping me up at night. Is the human middle ear the result of top-secret government experiments involving alien technology, Abraham Lincoln, and the Illuminati?

Restless in Roswell

Dear Restless:

The paleoanthropologic community has been sorting through this mystery for decades, and fossils discovered in China over the past 20 years finally provide a much less conspiratorially satisfying answer.

IVPP

For some time now, experts in the field have believed that the bones of the human middle ear evolved from the spiracular gill of a fish. The spiracle is a small hole behind each eye that opens to the mouth in some fishes and was used to breathe air in the earliest, most primitive species. But how did we get from spiracle to ear?

The missing links come in the form of the cranial anatomy of Shuyu, a 438-million-year-old, fingernail-sized skull of a jawless fish, and the 419-million-year-old fossil of a completely preserved fish with gill filaments in the first branchial chamber.

“These fossils provided the first anatomical and fossil evidence for a vertebrate spiracle originating from fish gills,” senior author Gai Zhikun, PhD, of the Institute of Vertebrate Paleontology and Paleoanthropology, Beijing, said in a written statement.

In many ways, it seems, we are fish: “Many important structures of human beings can be traced back to our fish ancestors, such as our teeth, jaws, middle ears, etc,” added Zhu Min, PhD, also of the institute.

So, Restless, the next time you hear the soothing sounds of an angry mob storming the Capitol or you chew on a slab, slice, or chunk of mutant, laboratory-produced chicken in your favorite fast-food restaurant, be sure to thank Shuyu.
 

Can you lend me an ear?

If you thought locusts were only a nuisance, think again. They have their uses. If you take a locust’s ear and put it inside a robot, the robot will be able to hear and receive signals. Who knew?

850977/Pixabay

Researchers from Tel Aviv University in Israel showed the robot’s hearing abilities by giving clap signals that told the robot what to do: One clap means go forward, two claps mean move back. What do you think the robot would do if it heard the clap break from Cha Cha Slide?

“Our task was to replace the robot’s electronic microphone with a dead insect’s ear, use the ear’s ability to detect the electrical signals from the environment, in this case vibrations in the air, and, using a special chip, convert the insect input to that of the robot,” Ben M. Maoz, PhD, said in a statement from the university.

And how does a dead locust ear work in a robot? Well, Dr. Maoz explained: “My laboratory has developed a special device – Ear-on-a-Chip – that allows the ear to be kept alive throughout the experiment by supplying oxygen and food to the organ while allowing the electrical signals to be taken out of the locust’s ear and amplified and transmitted to the robot.”

The research won’t stop at hearing, he said, as the other four senses also will be taken into consideration. This could help us sense dangers in the future, such as earthquakes or diseases. We said it before and we’ll say it again: We’re rooting for you, science!

Your gut microbiome will thank you later

A healthy gut seems like the new catch-all to better overall health these days. Nutrition and diet culture has us drinking kombucha and ginger tea and coffee, but what if we told you that going to happy hour might also help?

In a recent double-blind study published in the Journal of Agricultural and Food Chemistry, 19 men were divided into two groups and asked to drink 11 ounces of alcoholic lager (5.2% by volume) or nonalcoholic lager with dinner for 4 weeks.

Beer? Yes. Beer.

Engin Akyurt/Pixabay

We humans have trillions of microorganisms running rampant through our digestive tracts. When they’re happy, we have a lower chance of developing heart disease and diabetes. You know what else has millions of happy microorganisms from fermentation? Beer. It also has polyphenols that can help the body’s tissues fight cancers, as well as heart disease and inflammation. So beer is looking a little more healthy now, isn’t it?

In the study, the researchers found that both the alcoholic- and nonalcoholic-lager groups had a boost in bacterial diversity in the gut and higher fecal alkaline phosphatase levels, which showed improved intestinal health. They acknowledged, however, that the nonalcoholic route would be safer and healthier for overall health.

So add a lager to the list of gut-healthy foods that you should be consuming. It may give the phrase “beer gut” a whole new meaning.
 

We’ve lost our minds, but at least we know how fast they’re going

The phrase “quantum consciousness” sounds like something out of a particularly cheesy episode of Star Trek: “Oh no, Captain, the quantum consciousness has invaded our computer, and the only way to drive it out is to reverse the polarity of a focused tachyon beam.”

Massimiliano De Deo, LNGS-INFN

When it comes to understanding such basic existential issues as the origin of consciousness, however, quantum mechanics wasn’t off the table. The theory of the quantum origin of consciousness dates back to the 1990s (thanks in part to noted physician Roger Penrose), and goes something like this: There are microtubules within neurons in the brain that are small enough and isolated enough from the warm, wet, and chaotic brain environment where quantum effects can briefly come into play. We’re talking miniscule fractions of a second here, but still, long enough for quantum calculations to take place in the form of system wavefunction collapse, courtesy of gravity.

To plunge even deeper into the rabbit hole of quantum mechanics, the reason Schrödinger’s cat doesn’t occur in real life is wavefunction collapse; the more massive a quantum system is, the more likely it is to collapse into one state or another (alive or dead, in the cat’s case). The quantum origin of consciousness, or Orch OR theory, holds that human consciousness arises from electrical oscillations within the neuronal microtubules caused by the computations stemming from the collapse of small quantum systems.

That is an awful lot of overly simplified explanation, especially considering the study that just came out essentially disproved it. Oops. The research, published in Physics of Life Reviews, is pretty simple. The researchers went to a lab deep underground to avoid interference from cosmic rays, and sat around for months, observing a chunk of germanium for signs of spontaneous radiation, attributable to the same sort of wavefunction collapse that is supposedly occurring in our brains. They found nothing out of the ordinary, pretty definitively disproving most of Orch OR theory.

The researchers were unwilling to completely dismiss the idea (this is quantum mechanics, after all, uncertainty kind of goes with the territory), but it does seem like we’ll have to search elsewhere for sources of human consciousness. Personally, we’re big fans of the cymbal-playing monkey.
 

Missing links: A real fish story

Dear LOTME:

Ear’s a question that’s been keeping me up at night. Is the human middle ear the result of top-secret government experiments involving alien technology, Abraham Lincoln, and the Illuminati?

Restless in Roswell

Dear Restless:

The paleoanthropologic community has been sorting through this mystery for decades, and fossils discovered in China over the past 20 years finally provide a much less conspiratorially satisfying answer.

IVPP

For some time now, experts in the field have believed that the bones of the human middle ear evolved from the spiracular gill of a fish. The spiracle is a small hole behind each eye that opens to the mouth in some fishes and was used to breathe air in the earliest, most primitive species. But how did we get from spiracle to ear?

The missing links come in the form of the cranial anatomy of Shuyu, a 438-million-year-old, fingernail-sized skull of a jawless fish, and the 419-million-year-old fossil of a completely preserved fish with gill filaments in the first branchial chamber.

“These fossils provided the first anatomical and fossil evidence for a vertebrate spiracle originating from fish gills,” senior author Gai Zhikun, PhD, of the Institute of Vertebrate Paleontology and Paleoanthropology, Beijing, said in a written statement.

In many ways, it seems, we are fish: “Many important structures of human beings can be traced back to our fish ancestors, such as our teeth, jaws, middle ears, etc,” added Zhu Min, PhD, also of the institute.

So, Restless, the next time you hear the soothing sounds of an angry mob storming the Capitol or you chew on a slab, slice, or chunk of mutant, laboratory-produced chicken in your favorite fast-food restaurant, be sure to thank Shuyu.
 

Can you lend me an ear?

If you thought locusts were only a nuisance, think again. They have their uses. If you take a locust’s ear and put it inside a robot, the robot will be able to hear and receive signals. Who knew?

850977/Pixabay

Researchers from Tel Aviv University in Israel showed the robot’s hearing abilities by giving clap signals that told the robot what to do: One clap means go forward, two claps mean move back. What do you think the robot would do if it heard the clap break from Cha Cha Slide?

“Our task was to replace the robot’s electronic microphone with a dead insect’s ear, use the ear’s ability to detect the electrical signals from the environment, in this case vibrations in the air, and, using a special chip, convert the insect input to that of the robot,” Ben M. Maoz, PhD, said in a statement from the university.

And how does a dead locust ear work in a robot? Well, Dr. Maoz explained: “My laboratory has developed a special device – Ear-on-a-Chip – that allows the ear to be kept alive throughout the experiment by supplying oxygen and food to the organ while allowing the electrical signals to be taken out of the locust’s ear and amplified and transmitted to the robot.”

The research won’t stop at hearing, he said, as the other four senses also will be taken into consideration. This could help us sense dangers in the future, such as earthquakes or diseases. We said it before and we’ll say it again: We’re rooting for you, science!

Children who attend center-based childcare are more likely to maintain a healthier body weight than children who receive nonparental, non–center-based care – especially if they come from lower-income families – a new study finds.

The findings of the prospective Canadian study suggest that professional childcare centers that engage in standard practices are having a positive and lasting impact on children’s health, reported lead author Michaela Kucab, RD, MHSc, of the University of Toronto and colleagues.

“Attending center-based childcare in early childhood may influence important health behaviors including nutrition, physical activity, and routines related to child growth and weight status,” the investigators wrote in their abstract, which Ms. Kucab presented at the virtual conference sponsored by the American Society for Nutrition.

Their study involved 3,503 children who attended childcare in Canada during early childhood (mean age at baseline was 2.7 years) with follow-up from ages 4-10.
 

Overweight/obesity risk reduced

Children who received full-time, center-based care had a 22% lower risk of overweight/obesity and a mean body mass index z score (zBMI) that was 0.11 points lower at age 4 and 7 years than those who received non–center-based care. The benefits of center-based care were even more pronounced among children from lower-income families, who, at age 10, had a 48% lower risk of overweight/obesity and a mean zBMI that was 0.32 points lower with center-based versus non–center-based care.

In a written comment, Ms. Kucab and principal author Jonathon Maguire, MD, MSc, of the University of Toronto, explained that the former difference in zBMI translates to approximately half a pound of bodyweight in an average child, whereas the larger difference in zBMI among children from lower-income families would amount to approximately three pounds. They emphasized that these are rough estimations.

Ms. Kucab and Dr. Maguire noted that body weight differences correlated with the amount of time spent in center-based care.

“There was an observed trend, whereby the estimated mean difference [in zBMI] became slightly larger (or stronger) with a higher intensity of center-based childcare compared to non–center-based childcare,” they said.

To learn more about the earliest impacts of center-based care, the investigators are conducting a clinical trial, The Nutrition Recommendation Intervention Trials in Children’s Health Care (NuRISH), which will involve 600 children aged younger than 2 years.
 

Center-based childcare may reduce disadvantages of low-income children

“Although more research is needed, our findings suggest that center-based childcare may help” reduce disadvantages children from low-income families experience related to their heath,” Ms. Kucab said in a press release.

Laurent Legault, MD, an associate professor specializing in endocrinology in the department of pediatrics at McGill University, Montreal, highlighted the “quite significant” sample size of more than 3,000 participants, noting that “it’s quite tough to have numerous children” involved in a study, especially with several years of follow-up.

Dr. Legault also praised the investigators for considering socioeconomic status, “which is absolutely paramount, because, unfortunately, it’s not necessarily an even playing field for these families.”

He said the findings deserve to be promoted, as they highlight the benefits of center-based care, including ones with room for physical activity, opportunities for social interaction with other children, and a structured routine.

Still, Dr. Legault said it’s “very difficult to pinpoint specifically” what led to healthier body weights. “The problem, of course, is that obesity is very multifactorial in nature,” although “early intervention is more likely to be efficient.”

Center-based care appears to be one such intervention, he said, which should “push people to make centered care more affordable and easy to access for everyone.”The investigators and Dr. Legault reported no conflicts of interest.

Children who attend center-based childcare are more likely to maintain a healthier body weight than children who receive nonparental, non–center-based care – especially if they come from lower-income families – a new study finds.

The findings of the prospective Canadian study suggest that professional childcare centers that engage in standard practices are having a positive and lasting impact on children’s health, reported lead author Michaela Kucab, RD, MHSc, of the University of Toronto and colleagues.

“Attending center-based childcare in early childhood may influence important health behaviors including nutrition, physical activity, and routines related to child growth and weight status,” the investigators wrote in their abstract, which Ms. Kucab presented at the virtual conference sponsored by the American Society for Nutrition.

Their study involved 3,503 children who attended childcare in Canada during early childhood (mean age at baseline was 2.7 years) with follow-up from ages 4-10.
 

Overweight/obesity risk reduced

Children who received full-time, center-based care had a 22% lower risk of overweight/obesity and a mean body mass index z score (zBMI) that was 0.11 points lower at age 4 and 7 years than those who received non–center-based care. The benefits of center-based care were even more pronounced among children from lower-income families, who, at age 10, had a 48% lower risk of overweight/obesity and a mean zBMI that was 0.32 points lower with center-based versus non–center-based care.

In a written comment, Ms. Kucab and principal author Jonathon Maguire, MD, MSc, of the University of Toronto, explained that the former difference in zBMI translates to approximately half a pound of bodyweight in an average child, whereas the larger difference in zBMI among children from lower-income families would amount to approximately three pounds. They emphasized that these are rough estimations.

Ms. Kucab and Dr. Maguire noted that body weight differences correlated with the amount of time spent in center-based care.

“There was an observed trend, whereby the estimated mean difference [in zBMI] became slightly larger (or stronger) with a higher intensity of center-based childcare compared to non–center-based childcare,” they said.

To learn more about the earliest impacts of center-based care, the investigators are conducting a clinical trial, The Nutrition Recommendation Intervention Trials in Children’s Health Care (NuRISH), which will involve 600 children aged younger than 2 years.
 

Center-based childcare may reduce disadvantages of low-income children

“Although more research is needed, our findings suggest that center-based childcare may help” reduce disadvantages children from low-income families experience related to their heath,” Ms. Kucab said in a press release.

Laurent Legault, MD, an associate professor specializing in endocrinology in the department of pediatrics at McGill University, Montreal, highlighted the “quite significant” sample size of more than 3,000 participants, noting that “it’s quite tough to have numerous children” involved in a study, especially with several years of follow-up.

Dr. Legault also praised the investigators for considering socioeconomic status, “which is absolutely paramount, because, unfortunately, it’s not necessarily an even playing field for these families.”

He said the findings deserve to be promoted, as they highlight the benefits of center-based care, including ones with room for physical activity, opportunities for social interaction with other children, and a structured routine.

Still, Dr. Legault said it’s “very difficult to pinpoint specifically” what led to healthier body weights. “The problem, of course, is that obesity is very multifactorial in nature,” although “early intervention is more likely to be efficient.”

Center-based care appears to be one such intervention, he said, which should “push people to make centered care more affordable and easy to access for everyone.”The investigators and Dr. Legault reported no conflicts of interest.

Children who attend center-based childcare are more likely to maintain a healthier body weight than children who receive nonparental, non–center-based care – especially if they come from lower-income families – a new study finds.

The findings of the prospective Canadian study suggest that professional childcare centers that engage in standard practices are having a positive and lasting impact on children’s health, reported lead author Michaela Kucab, RD, MHSc, of the University of Toronto and colleagues.

“Attending center-based childcare in early childhood may influence important health behaviors including nutrition, physical activity, and routines related to child growth and weight status,” the investigators wrote in their abstract, which Ms. Kucab presented at the virtual conference sponsored by the American Society for Nutrition.

Their study involved 3,503 children who attended childcare in Canada during early childhood (mean age at baseline was 2.7 years) with follow-up from ages 4-10.
 

Overweight/obesity risk reduced

Children who received full-time, center-based care had a 22% lower risk of overweight/obesity and a mean body mass index z score (zBMI) that was 0.11 points lower at age 4 and 7 years than those who received non–center-based care. The benefits of center-based care were even more pronounced among children from lower-income families, who, at age 10, had a 48% lower risk of overweight/obesity and a mean zBMI that was 0.32 points lower with center-based versus non–center-based care.

In a written comment, Ms. Kucab and principal author Jonathon Maguire, MD, MSc, of the University of Toronto, explained that the former difference in zBMI translates to approximately half a pound of bodyweight in an average child, whereas the larger difference in zBMI among children from lower-income families would amount to approximately three pounds. They emphasized that these are rough estimations.

Ms. Kucab and Dr. Maguire noted that body weight differences correlated with the amount of time spent in center-based care.

“There was an observed trend, whereby the estimated mean difference [in zBMI] became slightly larger (or stronger) with a higher intensity of center-based childcare compared to non–center-based childcare,” they said.

To learn more about the earliest impacts of center-based care, the investigators are conducting a clinical trial, The Nutrition Recommendation Intervention Trials in Children’s Health Care (NuRISH), which will involve 600 children aged younger than 2 years.
 

Center-based childcare may reduce disadvantages of low-income children

“Although more research is needed, our findings suggest that center-based childcare may help” reduce disadvantages children from low-income families experience related to their heath,” Ms. Kucab said in a press release.

Laurent Legault, MD, an associate professor specializing in endocrinology in the department of pediatrics at McGill University, Montreal, highlighted the “quite significant” sample size of more than 3,000 participants, noting that “it’s quite tough to have numerous children” involved in a study, especially with several years of follow-up.

Dr. Legault also praised the investigators for considering socioeconomic status, “which is absolutely paramount, because, unfortunately, it’s not necessarily an even playing field for these families.”

He said the findings deserve to be promoted, as they highlight the benefits of center-based care, including ones with room for physical activity, opportunities for social interaction with other children, and a structured routine.

Still, Dr. Legault said it’s “very difficult to pinpoint specifically” what led to healthier body weights. “The problem, of course, is that obesity is very multifactorial in nature,” although “early intervention is more likely to be efficient.”

Center-based care appears to be one such intervention, he said, which should “push people to make centered care more affordable and easy to access for everyone.”The investigators and Dr. Legault reported no conflicts of interest.