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Women undergo less aggressive open heart surgery, experience worse outcomes than men

Women are significantly less likely than men to undergo coronary artery bypass grafting (CABG) using guideline-recommended approaches, which may result in worse outcomes after surgery, according to a scientific presentation at the 57th Annual Meeting of The Society of Thoracic Surgeons.

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Women are significantly less likely than men to undergo coronary artery bypass grafting (CABG) using guideline-recommended approaches, which may result in worse outcomes after surgery, according to a scientific presentation at the 57th Annual Meeting of The Society of Thoracic Surgeons.

“This study highlights key differences between women and men in surgical techniques used for CABG and reveals opportunities to improve outcomes in women,” said Oliver K. Jawitz, MD, from Duke University in Durham, North Carolina.

Using the STS Adult Cardiac Surgery Database–which contains records of nearly all CABG procedures performed in the US–Dr. Jawitz and colleagues from Duke and The Johns Hopkins University School of Medicine in Baltimore, Maryland, identified adult patients who underwent first-time isolated CABG from 2011 to 2019. Researchers analyzed detailed demographic, clinical, and procedural data from more than 1.2 million patients.

The correlation between female sex and three different CABG surgical techniques that are recommended in official US and European guidelines was examined closely. According to Dr. Jawitz, all of these surgical approaches–grafting of the left internal mammary artery (LIMA) to the left anterior descending (LAD) artery, complete revascularization, and multiarterial grafting–have been associated with improved short and/or long-term outcomes. However, the results showed that women were 14%-22% less likely than men to undergo CABG procedures with these revascularization strategies.

“With these findings, we did in fact see less aggressive treatment strategies with women,” said Dr. Jawitz. “It is clear that sex disparities exist in all aspects of care for patients with coronary artery disease (CAD), including diagnosis, referral for treatment, and now, in surgical approaches to CABG. We must ensure that female patients undergoing CABG are receiving evidence-based, guideline-concordant techniques.”

A cardiac surgeon who was not affiliated with the study said that the sheer volume of patient records analyzed is meaningful. “This was an important study, especially since it utilized the world’s largest cardiac surgical database to document a difference in surgical strategies between men and women who underwent coronary bypass surgery, said Robbin G. Cohen, MD, MMM, from Keck School of Medicine of the University of Southern California in Los Angeles. “Now we need to understand the reasons for this disparity and the implications for both short- and long-term results.”

While multifactorial, the undertreatment of CAD in women largely stems from a failure to recognize key differences in cardiovascular risk factors and symptoms in females compared with males, explained Dr. Jawitz.

Women are much more likely to experience atypical, subtler symptoms of heart disease such as fatigue, abdominal pain, nausea, vomiting, indigestion, and back pain. Sometimes, women do not even feel the obvious chest pain and pressure that are characteristic of CAD. As far as risk factors, women have their own unique set, including relatively high testosterone levels prior to menopause, increased hypertension during menopause, and higher levels of stress and depression.

Another challenge has been that women’s health historically has been focused largely on mother and child issues, as well as early diagnosis and treatment of breast cancer. These conversations need to include a stronger emphasis on cardiovascular risk factors and interventions, which is vital to successfully tackling the leading cause of death for women in the US–heart disease, according to Dr. Jawitz.

In addition, women tend to have a longer time from symptom onset to diagnosis and from diagnosis to medical intervention. Each of these delays allows the disease to worsen over time, increasing the risk for poor surgical outcomes. And when women finally are referred for bypass surgery, they continue to be disadvantaged, since they often do not receive CABG with LIMA to LAD, complete revascularization, or multiarterial grafting–all of which are associated with improved outcomes.

“Delayed diagnosis of CAD in women leads to late initiation of key behavioral and pharmacologic interventions for minimizing heart disease risk, as well as delayed referral for invasive diagnostic and therapeutic procedures, including surgical revascularization with CABG,” said Dr. Jawitz. “This often means that by the time female patients undergo these procedures, they have more severe disease than males, as well as a greater number of comorbidities, which leads to worse outcomes.”

In some clinical trials, women remain grossly underrepresented. According to an unrelated analysis of research data, less than 40% of all people enrolled in cardiovascular clinical trials from 2010 to 2017 were women. Lack of knowledge often is cited as a reason for these persistent disparities.

“The evidence available for various therapies and interventions is disproportionally based on male cardiovascular biology,” said Dr. Jawitz. “But as research in this area becomes more robust, data will continue to emerge showing that cardiovascular disease manifests differently by sex. Raising awareness will go a long way toward minimizing sex differences in CAD outcomes.”

Moving forward, guidelines must be developed that reflect the important differences between men and women in CAD manifestation, which certainly will require increased representation of female patients in clinical trials of cardiovascular therapies, explained Dr. Jawitz.

“Now that we have identified specific differences in surgical approaches to CABG between females and males, we must further elucidate how these differences result in disparate outcomes such as increased mortality, readmissions, and complications,” he said. “These findings will help inform the development of sex-specific guidelines for the diagnosis and management of cardiovascular disease.”

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AXA PH volunteers join forces for good

In the Philippines, the volunteer activities kicked off with two simultaneous events: a meal packing session for the benefit of Rise Against Hunger Philippines, and solar light building in partnership with Liter of Light.

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Annually, insurance company AXA organizes one full week dedicated to sustainability. The AXA Week for Good, the highlight of the purpose-led company’s year-long corporate responsibility activities, aims to celebrate the ability of AXA employees to take positive action by offering their time and skills to support our two sustainability pillars: climate change & biodiversity and inclusive protection.

In the Philippines, the volunteer activities kicked off with two simultaneous events: a meal packing session for the benefit of Rise Against Hunger Philippines, and solar light building in partnership with Liter of Light. Rise Against Hunger is an organization committed to ending hunger and malnutrition, while Liter of Light is a global non-profit organization that provides sustainable and affordable lights to people with limited or no access to electricity.

Employees also volunteered for Rise Against Hunger’s mobile soup kitchen activity in communities around Taguig. These soup kitchens serve Filipinos that are especially in need of nutrition, including pregnant mothers, the elderly, and children.

Through the combined efforts of these activities, volunteers were able to pack a total of 5,400 meals, assemble 250 solar lamps, and feed 1,500 children.

The company also organized a blood donation drive, which served as their response to the current blood shortage in the country due to the ongoing pandemic. A total of 44 bags of blood were collected from this initiative.

AXA Philippines employees also participated in mangrove planting activities held in Batangas and La Union, with volunteers working together to plant a total of 550 mangrove seedlings to help maintain the ecological health of the area.

In addition to the multitude of activities arranged by AXA entities locally, the Paris-based AXA Group also organizes a ‘Global Challenge’ with all members of its volunteer program, AXA Hearts in Action.

AXA entities worldwide celebrated Week for Good via special activities in partnership with The Good Planet Foundation. These include climate- and biodiversity-themed workshops that help raise employees’ awareness on climate change issues.

In the Philippines, employees volunteered at the Rise Against Hunger Good Food Farm to learn about sustainable agriculture practices and help harvest produce from vegetable and fruit gardens. Volunteers harvested 35kg worth of vegetables with the local farmers, which will be used in meals for the adopted communities of AXA Philippines and Rise Against Hunger.

“AXA has always been committed towards leaving a positive impact on the planet, which is why we are glad that we are able to once again gather together as a team to participate in our sustainability efforts as we celebrate Week for Good. We take pride in our employees’ passion and enthusiasm in dedicating their time and skills to do good for society and for the environment,” said Gael Lapie, CEO In-Charge and Chief Financial Officer of AXA Philippines.

To know more about AXA Week for Good, visit https://www.axa.com/en/about-us/community-corporate-responsibility-week.

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Down on Vitamin D? It could be the cause of chronic inflammation

Lead researcher, UniSA’s Dr Ang Zhou, says the findings suggest that boosting vitamin D in people with a deficiency may reduce chronic inflammation.

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Inflammation is an essential part of the body’s healing process. But when it persists, it can contribute to a wide range of complex diseases including type 2 diabetes, heart disease, and autoimmune diseases.

Now, world-first genetic research from the University of South Australia shows a direct link between low levels of vitamin D and high levels of inflammation, providing an important biomarker to identify people at higher risk of or severity of chronic illnesses with an inflammatory component.

The study examined the genetic data of 294 ,970 participants in the UK Biobank, using Mendelian randomization to show the association between vitamin D and C-reactive protein levels, an indicator of inflammation.

Lead researcher, UniSA’s Dr Ang Zhou, says the findings suggest that boosting vitamin D in people with a deficiency may reduce chronic inflammation.

“Inflammation is your body’s way of protecting your tissues if you’ve been injured or have an infection,” Dr Zhou says. “High levels of C-reactive protein are generated by the liver in response to inflammation, so when your body is experiencing chronic inflammation, it also shows higher levels of C-reactive protein. This study examined vitamin D and C-reactive proteins and found a one-way relationship between low levels of vitamin D and high levels of C-reactive protein, expressed as inflammation. Boosting vitamin D in people with deficiencies may reduce chronic inflammation, helping them avoid a number of related diseases.”

Supported by the National Health and Medical Research Council and published in the International Journal of Epidemiology the study also raises the possibility that having adequate vitamin D concentrations may mitigate complications arising from obesity and reduce the risk or severity of chronic illnesses with an inflammatory component, such as CVDs, diabetes, and autoimmune diseases.

Senior investigator and Director of UniSA’s Australian Centre for Precision Health, Professor Elina Hyppönen, says these results are important and provide an explanation for some of the controversies in reported associations with vitamin D.

“We have repeatedly seen evidence for health benefits for increasing vitamin D concentrations in individuals with very low levels, while for others, there appears to be little to no benefit.” Prof Hyppönen says.  “These findings highlight the importance of avoiding clinical vitamin D deficiency, and provide further evidence for the wide-ranging effects of hormonal vitamin D.”

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Fatigue, headache among top lingering symptoms months after COVID

Fatigue and headache were the most common symptoms reported by individuals an average of more than four months out from having COVID-19, investigators report.

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Fatigue and headache were the most common symptoms reported by individuals an average of more than four months out from having COVID-19, investigators report.

Muscle aches, cough, changes in smell and taste, fever, chills and nasal congestion were next in the long line of lingering symptoms.

“Our results support the growing evidence that there are chronic neuropsychiatric symptoms following COVID-19 infections,” Medical College of Georgia investigators write in the journal ScienceDirect

“There are a lot of symptoms that we did not know early on in the pandemic what to make of them, but now it’s clear there is a long COVID syndrome and that a lot of people are affected,” says Dr. Elizabeth Rutkowski, MCG neurologist and the study’s corresponding author.

The published study reports on preliminary findings from the first visit of the first 200 patients enrolled in the COVID-19 Neurological and Molecular Prospective Cohort Study in Georgia, or CONGA, who were recruited on average about 125 days after testing positive for the COVID-19 virus.

CONGA was established at MCG early in the pandemic in 2020 to examine the severity and longevity of neurological problems and began enrolling participants in March 2020 with the ultimate goal of recruiting 500 over five years.

Eighty percent of the first 200 participants reported neurological symptoms with fatigue, the most common symptom, reported by 68.5%, and headache close behind at 66.5%. Just over half reported changes in smell (54.5%) and taste (54%) and nearly half the participants (47%) met the criteria for mild cognitive impairment, with 30% demonstrating impaired vocabulary and 32% having impaired working memory.

Twenty-one percent reported confusion, and hypertension was the most common medical condition reported by participants in addition to their bout with COVID-19.

No participants reported having a stroke, weakness or inability to control muscles involved with speaking, and coordination problems were some of the less frequently reported symptoms.

Twenty-five percent met the criteria for depression, and diabetes, obesity, sleep apnea and a history of depression were associated with those who met the criteria. Anemia and a history of depression were associated with the 18% who met the objective criteria for anxiety.

While the findings to date are not surprising and are consistent with what other investigators are finding, Rutkowski says the fact that symptoms reported by participants often didn’t match what objective testing indicated, was surprising. And, it was bidirectional.

For example, the majority of participants reported taste and smell changes, but objective testing of both these senses did not always line up with what they reported. In fact, a higher percentage of those who did not report the changes actually had evidence of impaired function based on objective measures, the investigators write. While the reasons are not certain, part of the discrepancy may be a change in the quality of their taste and smell rather than pure impaired ability, Rutkowski says.

“They eat a chicken sandwich and it tastes like smoke or candles or some weird other thing but our taste strips are trying to depict specific tastes like salty and sweet,” Rutkowski says. Others, for example, may rely on these senses more, even when they are preparing the food, and may be apt to notice even a slight change, she says.

Either way, their data and others suggest a persistent loss of taste and smell following COVID-19, Rutkowski and her colleagues write.

Many earlier reports have been based on these kinds of self-reports, and the discrepancies they are finding indicate that approach may not reflect objective dysfunction, the investigators write.

On the other hand, cognitive testing may overestimate impairment in disadvantaged populations, they report.

The first enrollees were largely female, 35.5% were male. They were an average of 44.6 years old, nearly 40% were Black and 7% had been hospitalized because of COVID-19. Black participants were generally disproportionately affected, the investigators say.

Seventy-five percent of Black participants and 23.4% of white participants met criteria for mild cognitive impairment. The findings likely indicate that cognitive tests assess different ethnic groups differently. And, socioeconomic, psychosocial (issues like family problems, depression and sexual abuse) and physical health factors generally may disproportionately affect Black individuals, the investigators write. It also could mean that cognitive testing may overestimate clinical impairment in disadvantaged populations, they write.

Black and Hispanic individuals are considered twice as likely to be hospitalized by COVID-19 and ethnic and racial minorities are more likely to live in areas with higher rates of infection. Genetics also is a likely factor for their increased risk for increased impact from COVID, much like being at higher risk for hypertension and heart disease early and more severely in life.

A focus of CONGA is to try to better understand how increased risk and effects from COVID-19 impact Blacks, who comprise about 33% of the state’s population.

A reason fatigue appears to be such a major factor among those who had COVID-19 is potentially because of levels of inflammation, the body’s natural response to an infection, remain elevated in some individuals. For example, blood samples taken at the initial visit and again on follow up showed some inflammatory markers were up and stayed up in some individuals.

These findings and others indicate that even though the antibodies to the virus itself may wain, persistent inflammation is contributing to some of the symptoms like fatigue, she says. She notes patients with conditions like multiple sclerosis and rheumatoid arthritis, both considered autoimmune conditions that consequently also have high levels of inflammation, also include fatigue as a top symptom.

“They have body fatigue where they feel short of breath, they go to get the dishes done and they are feeling palpitations, they immediately have to sit down and they feel muscle soreness like they just ran a mile or more,” Rutkowski says.

“There is probably some degree of neurologic fatigue as well because patients also have brain fog, they say it hurts to think, to read even a single email and that their brain is just wiped out,” she says. Some studies have even shown shrinkage of brain volume as a result of even mild to moderate disease. 

These multisystem, ongoing concerns are why some health care facilities have established long COVID clinics where physicians with expertise in the myriad of problems they are experiencing gather to see each patient.

CONGA participants who reported more symptoms and problems tended to have depression and anxiety. Problems like these as well as mild cognitive impairment and even impaired vocabulary may also reflect the long-term isolation COVID-19 produced for many individuals, Rutkowski says.

“You are not doing what you would normally do, like hanging out with your friends, the things that bring most people joy,” Rutkowski says. “On top of that, you may be dealing with physical ailments, lost friends and family members and loss of your job.”

For CONGA, participants self-report symptoms and answer questions about their general state of health like whether they smoked, drank alcohol, exercised, and any known preexisting medical conditions. But they also receive an extensive neurological exam that looks at fundamentals like mental status, reflexes and motor function. They also take established tests to assess cognitive function with results being age adjusted. They also do at-home extensive testing where they are asked to identify odors and the ability to taste sweet, sour, bitter, salty, brothy or no taste. They also have blood analysis done to look for indicators of lingering infection like those inflammatory markers and oxidative stress.

Neuropsychiatric symptoms are observed in the acute phase of infection, but there is a need for accurate characterization of how symptoms evolve over time, the investigators write.

And particularly for some individuals, symptoms definitely linger. Even some previously high-functioning individuals, who normally worked 80 hours a week and exercised daily, may find themselves only able to function about an hour a day and be in the bed the remainder, Rutkowski says.

The investigators are searching for answers to why and how, and while Rutkowski says she cannot yet answer all their questions, she can tell them with certainty that they are not alone or “crazy.”  

One of the best things everyone can do moving forward is to remain diligent about avoiding infection, including getting vaccinated or boosted to help protect your brain and body from long COVID symptoms and help protect others from infection, Rutkowski says. There is evidence that the more times you are infected, the higher the risk of ongoing problems.

Rutkowski notes that their study findings may be somewhat biased toward high percentages of ongoing symptoms because the study likely is attracting a high percentage of individuals with concerns about ongoing problems.

SARS-CoV-2 is thought to have first infected people in late 2019 and is a member of the larger group of coronaviruses, which have been a source of upper respiratory tract infections, like the common cold, in people for years.

At least part of the reason SARS-CoV-2 is believed to have such a wide-ranging impact is that the virus is known to attach to angiotensin-converting enzyme-2, or ACE2, which is pervasive in the body. ACE2 has a key role in functions like regulating blood pressure and inflammation. It’s found on neurons, cells lining the nose, mouth, lungs and blood vessels, as well as the heart, kidneys and gastrointestinal tract. The virus attaches directly to the ACE2 receptor on the surface of cells, which functions much like a door to let the virus inside.

Experience and study since COVID-19 started both indicate immediate neurological impact can include loss of taste and smell, brain infection, headaches and, less commonly, seizures, stroke and damage or death of nerves. As time has passed, there is increasing evidence that problems like loss of taste and smell, can become chronic, as well as problems like brain fog, extreme fatigue, depression, anxiety and insomnia, the investigators write. Persistent conditions including these and others are now referenced as “long Covid.”

The research was supported by funding from the National Institute of Neurological Disorders and Stroke and philanthropic support from the TR Reddy Family Fund.

Read the full study.

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