Culture

A study by researchers at Kaiser Permanente in Denver, Colorado evaluated the stability of thyroid stimulating hormone (TSH) in patients using synthetic medication versus those using desiccated thyroid products to treat hypothyroidism. The results showed no difference in TSH stability over a three-year period between patients taking desiccated thyroid products and those on synthetic levothyroxine, an unanticipated finding given concerns about variability among batches of desiccated thyroid, which is prescribed much less frequently than synthetic levothyroxine.

In an accompanying editorial, Jill Schneiderhan and Suzanna Zick argue in favor of a patient-centered approach as opposed to relying primarily on laboratory results when determining the best way to manage hyperthyroidism. Emerging evidence shows that for many patients taking levothyroxine, symptoms persist despite lab results indicating normal TSH values. Further, these patients may feel invalidated and not in control of their treatment decisions. Schneiderhan and Zick conclude, "[k]eeping desiccated thyroid medications as an option in our tool kit will allow for improved shared decision making, while allowing for patient preference, and offer an option for those patients who remain symptomatic on levothyroxine monotherapy."

Telehealth Supports Collaborative Care Model in Addressing Mental Health Needs of Rural Patients

Traditionally, primary care clinics connect patients who have mental health care needs to specialists like psychiatrists in a collaborative care model. However, rural clinics often lack the workforce capacity to provide collaborative behavioral health services. In a new qualitative study, rural Washington primary care clinics adopted telehealth methods to connect remotely with specialists. The study found that telepsychiatric collaboration prepared primary care physicians and rural clinic staff to deliver high quality mental health care in underserved areas.

Study authors interviewed 17 clinical, support and administrative staff members of three rural primary care clinics. They found that through telepsychiatric consultation, all members of the clinic learned how to better serve the needs of mental health patients. Primary care doctors learned to work proficiently with these patients. Care managers learned to appreciate how medical issues affect mental health and how to diagnose and assess mental health issues, and consulting psychiatrists learned how to coach a primary care team, serve as educators and lead program implementation. The collaborative care model provides important benefits that other rural primary care clinics should consider adopting to help meet the needs of patients with mental health disorders.

Telepsychiatric Consultation as a Training and Workforce Development Strategy for Rural Primary Care
Morhaf Al Achkar, MD, PhD, et al
Department of Family Medicine, University of Washington, Seattle
https://www.annfammed.org/content/18/5/438

Vaping marijuana and vaping nicotine rose sharply in the past three years among college-age (19-22 years old) adults, according to 2019 survey results from the Monitoring the Future (MTF) study. The percentage of college students who said they vaped marijuana in the past 30 days rose from 5.2% in 2017 to 14% in 2019. The corresponding percentages for their non-college-attending peers increased from 7.8% in 2017 to 17% in 2019.

MTF, an ongoing study of the trends in substance use by adolescents and adults in the United States, is funded by the National Institute on Drug Abuse (NIDA), part of the National Institutes of Health. The survey is conducted by scientists at the University of Michigan's Institute for Social Research, Ann Arbor.

The percentage of college-age adults aged 19 to 22 who vaped nicotine also rose dramatically between 2017 and 2019. In 2017, 6.1% of college students and 7.9% of those not in college said they vaped nicotine in the past month, rising to 22% and 18%, respectively, in 2019. These increases in vaping marijuana and nicotine are among the largest increases in use for any substance reported by the study in its 45-year history.

"We are seeing an increasingly concerning trend," said Nora D. Volkow, M.D., director of NIDA. "Many young people may view vaping and cannabis use as 'safer', but the reality is that nicotine is highly addictive, and cannabis can also be addictive, particularly in younger adults for whom the brain is still developing."

The MTF study has been annually tracking substance use among college students and non-college adults since 1980. Results are based on data from college students one to four years beyond high school graduation who are enrolled full-time in a two- or four-year college in March of the given year, compared with same-age high school graduates not enrolled full-time in college. These 2019 survey results are now online.

The 2019 data also revealed a continued high prevalence of marijuana use among young adults, who are 19 to 22 years old. In 2018, 43% of this group--regardless of college attendance--reported using marijuana in the past year, and this percentage was unchanged in 2019. Particularly notable is the prevalence of daily, or near-daily, use of marijuana among those not attending college in 2019--at 15%, it is at the highest level since the survey began. This compares to 5.9% of college students who reported daily, or near-daily, use of marijuana.

The 2019 MTF survey data reflect drug use patterns prior to the outbreak of the COVID-19 pandemic. The pandemic's impact on substance use and related behaviors and attitudes among the nation's young adults may be reflected in future MTF survey results. The 2020 MTF middle and high school student findings are due to be released later in 2020.

Other highlights from the 2019 survey results on college-age adults include:

Cigarette smoking continued a downward trend, with 7.9% of college students reporting having smoked in the past month. Among their peers who are not in college, 16% reported having smoked in the past month, an all-time low.

Binge drinking (five or more drinks in a row in the past two weeks), which has been declining gradually over the past few decades, showed no significant changes for young adults attending or not attending college. In 2019, 33% of college students and 22% of same-age adults not in college reported binge drinking. High-intensity drinking (10 or more drinks in a row in the past two weeks) has stayed level at about 11% since 2015 for people between the ages of 19 and 22, regardless of college attendance.

Prescription opioid misuse continued to decline, with 1.5% of college students and 3.3% of those not attending college reporting non-medical use of opioids (narcotic drugs other than heroin) in the past year. This represents a significant five-year decline from rates of 4.8% and 7.7%, respectively, in 2014.

Amphetamine use continued to decline, with 8.1% of college students and 5.9% of noncollege respondents reporting non-medical use of amphetamines in the past year.

Information on previous years' MTF survey findings and other resources, including an infographic, can be found on NIDA's College-Age & Young Adults webpage.

Canada is the first country to facilitate provision of medical abortion in primary care settings through evidence-based deregulation of mifepristone, which is considered the 'gold standard' for medical abortion. A Canadian study investigated the factors that influence successful initiation and ongoing provision of medical abortion services among Canadian health professionals and how these factors relate to abortion policies, systems and service access throughout the country.

Results suggest that Health Canada's initial restrictions discouraged physicians from prescribing mifepristone and were inconsistent with provincial licensing standards, thereby limiting patient access. During, and after removal of, these restrictions, researchers identified four barriers to utilizing/prescribing the drug, including the initial federal restrictions which made mifepristone "more complicated than it needs to be"; navigating the "huge bureaucratic process" of organizational implementation; challenges with diffusion and dissemination of policy information; and adoption by physicians as "a process rather than an event."

This study, the authors write, is relevant to other nations experiencing challenges to accessing family planning services. Amidst the COVID-19 pandemic, U.S. policies restricting access to mifepristone have reached the Supreme Court after a federal district court judge temporarily suspended strict FDA regulations that require patients to visit a hospital or clinic in-person to obtain mifepristone. In Canada, ongoing implementation of mifepristone will require organizations to create tailored solutions to barriers, which may include creating new medical billing codes, provincial policy advocacy efforts, specifically in Quebec, which added its own restriction requiring accredited training in surgical abortion for any mifepristone provider, and conducting physician engagement to raise awareness to access barriers.

This study found an association between improved physician-patient relationships and improved patient-reported health status. Researchers at Case Western Reserve University found over a one-year period that while consistent access to a provider is important, the quality of each clinical encounter is equally as important in shaping a patient's reported overall health outcomes, as measured by the SF-12 quality of life questionnaire.

The authors also found some evidence that adults with five or more diagnosed conditions experience physician-patient relationships that are significantly lower in quality than those reported by adults without multimorbidity. This discrepancy may reflect unmet physician-patient relationship needs among adults bearing multimorbidity burdens and indicate another opportunity for intervention. The study findings can potentially inform health care strategies and health policy aimed at improving patient-centered health outcomes.

Processes Supportive of Patient Engagement are Boosted by Full Staffing, Daily Huddles, Responsible Leadership and Performance Improvement Discussions

VA researchers whose aim was to identify organizational and contextual factors associated with greater use of patient engagement processes found that high performing clinics were more likely to have fully-staffed primary care teams, clearly defined roles for team members, leadership responsible for implementing team-based care, and team meetings to discuss performance improvement, compared to clinics that performed poorly with regard to use of patient engagement processes.

Previous research has found that patients who are actively engaged in their own care are more likely to adhere to treatment, perform regular self-monitoring, have better intermediate health outcomes, and report better mental health and physical functioning. for engaging patients in self-management include involving patients in long-term planning and goal setting, training providers in motivational interviewing, and promoting the use of shared medical appointments, group visits, peer support, and home telehealth. Improving organizational functioning of primary care teams may enhance patient engagement in care.

Care Practices to Promote Patient Engagement in VA Primary Care: Factors Associated With High Performance
David A. Katz, MD, MSc, et al
Iowa City VA Medical Center and the University of Iowa, Departments of Medicine and Epidemiology, Iowa City
https://www.annfammed.org/content/18/5/397

New research from UBC finds that after a night of shorter sleep, people react more emotionally to stressful events the next day--and they don't find as much joy in the good things. The study, led by health psychologist Nancy Sin, looks at how sleep affects our reaction to both stressful and positive events in daily life.

"When people experience something positive, such as getting a hug or spending time in nature, they typically feel happier that day," says Nancy Sin, assistant professor in UBC's department of psychology. "But we found that when a person sleeps less than their usual amount, they don't have as much of a boost in positive emotions from their positive events."

People also reported a number of stressful events in their daily lives, including arguments, social tensions, work and family stress, and being discriminated against. When people slept less than usual, they responded to these stressful events with a greater loss of positive emotions. This has important health implications: previous research by Sin and others shows that being unable to maintain positive emotions in the face of stress puts people at risk of inflammation and even an earlier death.

Using daily diary data from a national U.S. sample of almost 2,000 people, Sin analyzed sleep duration and how people responded to negative and positive situations the next day. The participants reported on their experiences and the amount of sleep they had the previous night in daily telephone interviews over eight days.

"The recommended guideline for a good night's sleep is at least seven hours, yet one in three adults don't meet this standard," says Sin. "A large body of research has shown that inadequate sleep increases the risk for mental disorders, chronic health conditions, and premature death. My study adds to this evidence by showing that even minor night-to-night fluctuations in sleep duration can have consequences in how people respond to events in their daily lives."

Chronic health conditions--such as heart disease, diabetes, and cancer--are prevalent among adults, especially as we grow older. Past research suggests that people with health conditions are more reactive when faced with stressful situations, possibly due to wear-and-tear of the physiological stress systems.

"We were also interested in whether adults with chronic health conditions might gain an even larger benefit from sleep than healthy adults," says Sin. "For those with chronic health conditions, we found that longer sleep--compared to one's usual sleep duration--led to better responses to positive experiences on the following day."

Sin hopes that by making sleep a priority, people can have a better quality of life and protect their long-term health.

Human white blood cells, known as leukocytes, swim using a newly described mechanism called molecular paddling, researchers report in the September 15th issue of Biophysical Journal. This microswimming mechanism could explain how both immune cells and cancer cells migrate in various fluid-filled niches in the body, for good or for harm.

"The capacity of living cells to move autonomously is fascinating and crucial for many biological functions, but mechanisms of cell migration remain partially understood," says co-senior study author Olivier Theodoly of Aix-Marseille University in France. "Our findings shed new light on the migration mechanisms of amoeboid cells, which is a crucial topic in immunology and cancer research."

Cells have evolved different strategies to migrate and explore their environment. For example, sperm cells, microalgae, and bacteria can swim through shape deformations or by using a whip-like appendage called a flagellum. By contrast, somatic mammalian cells are known to migrate by attaching to surfaces and crawling. It is widely accepted that leukocytes cannot migrate on 2D surfaces without adhering to them.

A prior study reported that certain human white blood cells called neutrophils could swim, but no mechanism was demonstrated. Another study showed that mouse leukocytes could be artificially provoked to swim. It is widely thought that cell swimming without a flagellum requires changes in cell shape, but the precise mechanisms underlying leukocyte migration have been debated.

In contrast to previous studies, Theodoly, co-senior study author Chaouqi Misbah of Grenoble Alpes University, and their collaborators provide experimental and computational evidence in the new study that human leukocytes can migrate on 2D surfaces without sticking to them and can swim using a mechanism that does not rely on changes in cell shape. "Looking at cell motion gives the illusion that cells deform their body like a swimmer," Misbah says. "Although leukocytes display highly dynamic shapes and seem to swim with a breast-stroke mode, our quantitative analysis suggests that these movements are inefficient to propel cells."

Instead, the cells paddle using transmembrane proteins, which span the cell membrane and protrude outside the cell. The researchers show that membrane treadmilling--rearward movement of the cell surface--propels leukocyte migration in solid or liquid environments, with and without adhesion.

However, the cell membrane does not move like a homogenous treadmill. Some transmembrane proteins are linked to actin microfilaments, which form part of the cytoskeleton and contract to allow cells to move. The actin cytoskeleton is widely accepted as the molecular engine propelling cell crawling. The new findings demonstrate that actin-bound transmembrane proteins paddle and propel the cell forward, whereas freely diffusing transmembrane proteins hinder swimming.

The researchers propose that continuous paddling is enabled by a combination of actin-driven external treadmilling and inner recycling of actin-bound transmembrane proteins through vesicular transport. Specifically, the paddling proteins at the rear of the cell are enclosed inside a vesicle that pinches off from the cell membrane and transported to the front of the cell. By contrast, the non-paddling transmembrane proteins are sorted out and do not undergo this process of internal recycling through vesicular transport.

"This recycling of the cell membrane is studied intensively by the community working on intracellular vesicular traffic, but its role in motility was hardly considered," Theodoly says. "These functions of protein sorting and trafficking seemed highly sophisticated for swimming. Our investigations, to our own surprise, bridge such distant domains as the physics of microswimmers and the biology of vesicular traffic."

The authors say that molecular paddling could allow immune cells to thoroughly explore all locations in the body as they migrate in liquid-filled niches such as swollen body parts, infected bladders, cerebrospinal fluid, or amniotic fluid. Moving forward, the researchers plan to investigate the functions of molecular paddling in various environments and assess whether other types of cells use this mode of migration.

Sacramento, CA-- In 2018, Lin Tian and her team at UC Davis Health developed dLight1, a single fluorescent protein-based biosensor. This family of highly specific sensors detects dopamine, a hormone released by neurons to send signals to other nerve cells. When combined with advanced microscopy, dLight1 provides high resolution, real-time imaging of the spatial and temporal release of dopamine in live animals.

Recently, Tian and her team succeeded in expanding the color spectrum of the dLight1 sensor. In an article published Sept. 7 in Nature Methods, they introduced two new spectral variants of dLight1: the yellow YdLight1 and the red RdLight1.

"The new sensors will help researchers to detect and monitor different information processing activities in the brain," said Lin Tian, associate professor of biochemistry and molecular medicine and the lead author on the study. "With the different colors, we will be able to see multiple neurochemical release and neural activities at the same time."

The RdLight1 permits the simultaneous assessment of dopamine, pre- or post-synaptic neuronal activity and the glutamate release in specific types of cells and neuronal projections in animals. Its increased light penetration and imaging depth provide enhanced dopamine signal quality. This allows researchers to optically dissect dopamine's release and model its effects on neural circuits.

As a neurotransmitter, dopamine plays an important role in movement, attention, learning and the brain's pleasure and reward system.

"These exciting new tools opened a new door to developing color-shifted neurochemical indicators. Together with other tools, they have great potential to unlock the mysteries of brain chemistry in health and disease," Tian said. "The knowledge we gain from these sensors will facilitate the development of safer next-generation therapies to neuropsychiatric disorders such as depression, anxiety, schizophrenia and addiction."

September 15, 2020 - Digital phenotyping approaches that collect and analyze Smartphone-user data on locations, activities, and even feelings - combined with machine learning to recognize patterns and make predictions from the data - have emerged as promising tools for monitoring patients with psychosis spectrum illnesses, according to a report in the September/October issue of Harvard Review of Psychiatry. The journal is published in the Lippincott portfolio by Wolters Kluwer.

John Tourous, MD, MBI, of Harvard Medical School and colleagues reviewed available evidence on digital phenotyping and machine learning to improve care for people living with schizophrenia, bipolar disorder, and related illnesses. "Digital phenotyping provides a much-needed bridge between patients' symptomatology and the behaviors that can be used to assess and monitor psychiatric disorders," the researchers write.

Digital Phenotyping in Schizophrenia and Bipolar Disorder - The Evidence So Far

"Digital phenotyping is the use of data from smartphones and wearables collected in situ for capturing a digital expression of human behaviors," according to the authors. Psychiatry researchers think that collecting and analyzing this kind of behavioral information might be useful in understanding how patients with severe mental illness are functioning in everyday life outside of the clinic or lab - in particular, to assess symptoms and predict clinical relapses.

Dr. Tourous and colleagues identified 51 studies of digital phenotyping in patients with schizophrenia or bipolar disorder. The review focused on studies using "passively" collected data - for example, accelerometer readings (step counters) and GPS signals. Other digital phenotyping approaches use "actively" collected data - for example, surveys to ask patients to report their mood.

The studies varied in terms of the digital phenotyping features used, data handling, analytical techniques, algorithms tested, and outcome measures reported. Nearly all studies included patients with bipolar disorder or schizophrenia. The studies included an average of 31 participants and monitored them for about four months.

Most studies used passive data collected by accelerometers and GPS; other measures included voice call and text message logs. The studies used a wide range of different apps, as well as different clinical tools/questionnaires for assessing patients' mental health status.

The studies presented higher variability in reporting of basic data such as smartphone model and operating system, patient age and race/ethnicity, and whether patients had received training in use of the technology. The authors make suggestions for a standardized reporting format that would improve the comparability of future studies.

Sixteen of the studies used machine learning-based approaches to analyze the passively collected data. As Dr. Tourous and coauthors note, the studies used various different algorithms, and for different purposes. The most commonly used algorithm type was "random forests," which work by combining many small, weak decisions to make a single strong prediction. For example, one study used passively tracked behavioral data to predict mental health scores in patients with schizophrenia.

Other studies used machine-learning approaches such as support vector machine/support vector regression or neural nets. These algorithms work in different ways to use behavioral data - where patients are going, whether they're returning calls, even their tone of voice - to assess patients' current mental health status, predict their risk of relapse, and so forth.

"Digital phenotyping provides a much-needed bridge between patients' symptomatology and the behaviors that can be used to assess and monitor psychotic disorders," Dr. Tourous and colleagues write. They call for larger studies with higher-quality data - along with "expanded efforts to apply machine learning to passive digital phenotyping data in early diagnosis and treatment of psychosis, including in clinical high risk and early-course psychosis patients."

A molecule known as ACE2 sits like a doorknob on the outer surfaces of the cells that line the lungs. Since January 2020, researchers have known that SARS-CoV-2, the novel coronavirus that causes COVID-19, primarily uses ACE2 to enter these cells and establish respiratory infections. Finding a way to lock out that interaction between virus and doorknob, as a means to treat the infection, has become the goal of many research studies.

University of California San Diego School of Medicine researchers have discovered that SARS-CoV-2 can't grab onto ACE2 without a carbohydrate called heparan sulfate, which is also found on lung cell surfaces and acts as a co-receptor for viral entry.

"ACE2 is only part of the story," said Jeffrey Esko, PhD, Distinguished Professor of Cellular and Molecular Medicine at UC San Diego School of Medicine and co-director of the Glycobiology Research and Training Center. "It isn't the whole picture."

Esko's study, published September 14, 2020 in Cell, introduces a potential new approach for preventing and treating COVID-19.

The team demonstrated two approaches that can reduce the ability of SARS-CoV-2 to infect human cells cultured in the lab by approximately 80 to 90 percent: 1) removing heparan sulfate with enzymes or 2) using heparin as bait to lure and bind the coronavirus away from human cells. Heparin, a form of heparan sulfate, is already a widely used medication to prevent and treat blood clots, suggesting that a Food and Drug Administration-approved drug might be repurposed to reduce virus infection.

Esko's team has long studied heparan sulfate and the role it plays in health and disease. He led this study with visiting scholar Thomas Mandel Clausen, PhD, and postdoctoral researcher Daniel Sandoval, PhD. While Esko's lab doesn't necessarily focus on viruses, Clausen had previously studied how the malaria parasite interacts with a related carbohydrate on human cells and Sandoval had been interested in viruses since he was an undergraduate student -- he still keeps up with the latest virology research for fun.

Late one Friday afternoon in March 2020, Clausen was tired and, he admits, putting off his experiments. Instead, he perused the latest research coming out about SARS-CoV-2. That's when he came across a preliminary study that suggested an interaction between the coronavirus's spike protein -- the "hand" the virus uses to grab the ACE2 doorknob -- and another carbohydrate related to heparan sulfate.

"I ran down to Daniel to tell him to look at the study -- and of course, he was already thinking the same thing," said Clausen, who is also an associate professor at University of Copenhagen in Denmark.

Within a week, the team was testing their theories in the lab. They discovered that the SARS-CoV-2 spike protein binds to heparin. The team also drilled down to uncover the exact part of the SARS-CoV-2 spike protein that interacts with heparin -- the receptor binding domain. When heparin is bound, the receptor binding domain opens up and increases binding to ACE2. The virus, they found, must bind both heparan sulfate on the cell surface and ACE2 in order to get inside human lung cells grown in a laboratory dish.

With this viral entry mechanism established, the researchers next set about trying to disrupt it. They found that enzymes that remove heparan sulfate from cell surfaces prevent SARS-CoV-2 from gaining entry into cells. Likewise, treatment with heparin also blocked infection. The heparin treatment worked as an anti-viral at doses currently given to patients, even when the researchers removed the anticoagulant region of the protein -- the part responsible for preventing blood clots.

The findings are still far from translating into a COVID-19 treatment for people, said Esko. Researchers will need to test heparin and heparan sulfate inhibitors in animal models of SARS-CoV-2 infection. In a related study, UC San Diego scientists are also exploring the role human microbiomes, including the bacteria that live in and on the body, play in altering heparan sulfate and thus influencing a person's susceptibility to COVID-19.

"This is one of the most exciting periods of my career -- all of the things we've learned about heparan sulfate and the resources we've developed over the years have come together with a variety of experts across multiple institutions who were quick to collaborate and share ideas," Esko said. "If there's a silver lining to this pandemic, I hope it's that the scientific community will continue to work rapidly together like this to address other problems."

Boulder, Colo., USA: When early humans began to travel out of Africa and spread into Eurasia over a hundred thousand years ago, a fertile region around the eastern Mediterranean Sea called the Levant served as a critical gateway between northern Africa and Eurasia. A new study, published in Geology, shows that the existence of that oasis depended almost entirely on something we almost never think about: dust.

Dr. Rivka Amit, at the Geological Survey of Israel, and her team initially set out with a simple question: why are some soils around the Mediterranean thin and why are some thick? Their investigation led them to discover not only that dust deposition played a critical role in forming thick soils in the Levant, but also that had the source of dust not changed 200,000 years ago, early humans might have had a much tougher time leaving Africa, and parts of the Fertile Crescent wouldn't have been so hospitable for civilization to take root.

Thick soils tend to form in areas with wet, humid climates, and thin soils form in arid environments with lower weathering rates. But in the Mediterranean, where much of the bedrock is dissolvable carbonate, the opposite is true: wetter northern regions have thin, unproductive soils, and more arid southeastern regions have thick, productive soils. Some scientists have attributed these patterns to differences in the rates of erosion, driven by human activity. But for Amit, who has been studying the area for years, a high erosion rate alone didn't make sense. She challenged the existing hypotheses, reasoning that another factor--dust input--likely plays a critical role when weathering rates are too slow to form soils from bedrock.

To assess the influence of dust on Mediterranean soils, Amit and her team needed to trace the dust back to its original source. They collected dust samples from soils in the region, as well as nearby and far-flung dust sources, and compared the samples' grain size distribution. The team identified a key difference between areas with thin and thick soils: thin soils comprised only the finest grain sizes sourced from distant deserts like the Sahara, whereas the thicker, more productive soils had coarser dust called loess, sourced from the nearby Negev desert and its massive dune fields. The thick soils in the eastern Mediterranean formed 200,000 years ago when glaciers covered large swaths of land, grinding up bedrock and creating an abundance of fine-grained sediments. "The whole planet was a lot dustier," Amit said, which allowed extensive dune fields like those in the Negev to build up, creating new sources of dust and ultimately, thicker soils in places like the Levant.

Amit, then, had her answer: regions with thin soils simply hadn't received enough loess to form thick, agriculturally productive soils, whereas the southeastern Mediterranean had. "Erosion here is less important," she said. "What's important is whether you get an influx of coarse [dust] fractions. [Without that], you get thin, unproductive soils."

Amit didn't stop there. She now knew that the thickest soils had received a large flux of coarse dust, leading to the area's designation as the "land of milk and honey" for its agricultural productivity. Her next question was, had it always been like this?

She was surprised at what they found. Looking below the loess in the soil profile, they found a dearth of fine-grained sediments. "What was [deposited] before the loess were very thin soils," she said. "It was a big surprise... The landscape was totally different, so I'm not sure that people would [have chosen] this area to live in because it was a harsh environment and [an] almost bare landscape, without much soil." Without the changing winds and formation of the Negev dune field, then, the fertile area that served as a passage for early humans may have been too difficult to pass through and survive.

In the modern Mediterranean, the soils aren't accumulating any more. "The dust source is cut off," Amit explained, since the glaciers retreated in the Holocene, "now we're only reworking the old loess." Even if there were a dust source, it would take tens of thousands of years to rebuild a soil there. That leaves these mountainous soils in a fragile state, and people living there must balance conservation and agricultural use. Employing responsible agricultural practices in the region, as terracing has been used for thousands of years, is critical for soil preservation if agriculture is to continue.

Below please find a summary and link(s) of new coronavirus-related content published today in Annals of Internal Medicine. The summary below is not intended to substitute for the full article as a source of information. A collection of coronavirus-related content is free to the public at http://go.annals.org/coronavirus.

1. Active surveillance and routine on-site testing could prevent spread of COVID-19 in homeless shelters

Passive sentinel surveillance for COVID-19 in homeless shelters and other congregate living situations may only detect symptomatic cases while missing milder ones. Active testing is needed to identify cases and potentially prevent outbreaks and further viral spread. Findings from a community-based surveillance study are published in Annals of Internal Medicine.

Researchers from University of Washington School of Medicine conducted COVID-19 case counts across several adult and family homeless shelters in King County, Washington between January and April 2020 to demonstrate how active surveillance and surge testing could identify asymptomatic or mild cases. Routine surveillance involved self-selected participation at staffed kiosks in shelters during standardized days and times. Surge testing was initiated on 30 March 2020 (and continued through 24 April) in collaboration with Public Health--Seattle & King County's Communicable Disease Epidemiology Team to conduct contact tracing at 6 shelters where cases of COVID-19 were previously detected. During these 1-day events, the researchers offered testing to all residents and staff. Among 1434 encounters, 29 cases of SARS-CoV-2 infection were detected across 5 shelters. Most of those cases were detected during surge testing events rather than routine surveillance, and of those, most were asymptomatic at the time of sample collection. Eighty-six percent of persons with positive test results slept in a communal space rather than in a private or shared room.

According to the authors, their findings provide key insights into detection strategies for SARS-CoV-2 in a vulnerable, hard-to-reach population. Read the full text: https://www.acpjournals.org/doi/10.7326/M20-3799.

Media contacts: A PDF for this article is not yet available. Please click the link to read full text. To reach the lead author, Helen Y. Chu, MD, MPH, please contact Leila Gray at leilag@uw.edu.

2. Researchers discuss research needs for developing guidelines in the era of COVID-19

The sudden emergence and scale of the COVID-19 pandemic have led to substantial pressure and heightened expectations for accelerated systematic reviews and rapid guidelines. Researchers, systematic reviewers, and guideline developers have been tasked with resolving uncertainty in much shorter time frames, in an emerging field, and with types of evidence that they may not have used previously. The evidence base for COVID-19 is characterized by many studies and systematic reviews that are poorly designed and conducted, presenting numerous complications for guideline developers. In addition to presenting the challenges, authors from the Guidelines International Network, Pitlochry, Scotland, and Joanna Briggs Institute, University of Adelaide, Adelaide, Australia discuss several solutions for those developing guidelines and recommendations related to COVID-19. Read the full text: https://www.acpjournals.org/doi/10.7326/M20-4907.

The COVID-NMA Project

In an accompanying article, authors from the Université de Paris, Centre of Research Epidemiology and Statistics (CRESS), Inserm, Cochrane France and international colleagues describe a large collaborative project called the COVID-NMA project. Researchers proposed and implemented an "evidence ecosystem" for COVID-19-related studies that minimizes multiple low-quality reviews and helps connect evidence generation, synthesis, and decision making. The ecosystem consists of living mapping of all trials and a comprehensive living synthesis of all available trial evidence evaluating the effect of interventions for the prevention or treatment of COVID-19. There is a master protocol and subprotocols dedicated to specific questions, which are discussed and agreed on by a steering committee. A search to identify eligible RCTs is performed daily. As soon any trial with results is identified, data are collected, risk of bias fully assessed and forest plots of appropriately pooled data produced. All data are made available on a website (https://covid-nma.com). This ecosystem, called the COVID-NMA Project, is intended to change and improve primary research, evidence synthesis and the guideline development process. Read the full text: https://www.acpjournals.org/doi/10.7326/M20-5261.

Media contacts: A PDF for this article is not yet available. Please click the link to read full text. To reach the lead author for the COVID-NMA Project, Isabelle Boutron, MD, PhD, contact her directly at isabelle.boutron@aphp.fr.

A new study, co-led by University of Cincinnati researchers, describes the development of a refining process that scientists deem a superior method to help produce better dietary omega-3 health and dietary supplements containing fish oil.

Fish oil is widely known to be an excellent dietary source of omega-3 polyunsaturated fatty acids (PUFAs) having positive effects on human health including heart and eye health, inflammation and bone density.

The novel process uses a new tool called a vortex fluidic device (VFD) developed by research collaborators at Flinders University of Australia. The process is successful in lifting the quality of active ingredients of the PUFAs in fish oil, says Harshita Kumari, the study's co-author and associate professor of pharmaceutical sciences at UC's James L. Winkle College of Pharmacy.

The study now appears in Nature Papers Journals Science of Food.

Researchers applied the VFD-mediated encapsulated fish oil to enrich the omega-3 fatty acid content of apple juice.

"This novel process enriches the omega-3 fatty acid content of apple juice remarkably without changing its taste," says Kumari, adding that two common consumer complaints regarding fish oil supplements is the taste and odor. Liquid omega-3 oils can also break down over time when exposed to oxygen which leads to degradation.

Compared to regular homogenization processing, Kumari says the device can raise PUFA levels and purity by lowering oxidation and dramatically improving shelf life. Natural bioactive molecules, also used in processing, reveal that the fish oil medium can absorb flavonoids and other health supplements.

Roughly 1 in 10 patients diagnosed with COVID-19 needed to return to the hospital within a week of discharge from an emergency department visit, according to data from the first three months of the COVID-19 outbreak in the Philadelphia region--March, April and May 2020. Researchers in the Perelman School of Medicine at the University of Pennsylvania also found that factors like lower pulse oximetry levels and fever were some of the most telling symptoms that resulted in return trips that resulted in admission. This information, published in Academic Emergency Medicine, could prove invaluable to clinicians working to fight a disease.

"We hope this study helps emergency clinicians have more informed conversations with patients suspected to have COVID-19," said the study's lead author Austin Kilaru, MD, an Emergency Medicine physician at Penn Medicine. "It can be difficult to make this diagnosis and send patients home without knowing if they will get sick in the coming days. This study gives clinicians a few signposts to know how often and when patients may need to return, and what risk factors to pay attention to."

The study looked at 1,419 patients who went to an emergency department (ED) between March 1 and May 28, 2020, were discharged, and tested positive for COVID-19 in the seven days surrounding that visit. Data showed that 4.7 percent of the patients returned to the hospital and were admitted within just three days for their initial ED visit, and an additional 3.9 percent were hospitalized within a week. In total, that meant that 8.6 percent of patients were coming back to the hospital after their first ED visit due to COVID-19.

"We were surprised with the overall rate that patients return and need admission, which is twice that of other illnesses," Kilaru explained. "The concern is not that emergency physicians are making wrong decisions, but rather that COVID can be unpredictable and turn severe rather quickly."

A population that the study showed was particularly vulnerable were patients over 60 years old. Compared to patients in the 18 to 39 years of age range, those over 60 were more than five times as likely to require hospitalization after being discharged from their initial emergency department visit. Those in the 40 to 59 age range were found to be three times as likely to require hospitalization than the younger group.

When it came to individual symptoms, the study showed that patients of any age with low pulse oximetry readings were about four times as likely to require hospitalization upon return as compared to those with higher readings, while patients with fevers were more than three times as likely as compared to those without.

"If the patient had other factors such as an abnormal chest x-ray, the likelihood of needing to come back to be hospitalized goes up even more," said the study's senior author, M. Kit Delgado, MD, an assistant professor of Emergency Medicine and Epidemiology.

The study collected demographic data for patients, which showed no signs of differences along racial or gender lines.

"This further contributes to the evidence that the known racial disparities in COVID mortality are not related to differences in care and outcomes among patients once treated in the same hospital system. Rather, the disparities are structural related to the higher rates of infection and access to care in low-income communities, which are disproportionately Black and Hispanic."

With the hope that their findings can better inform doctors on who is most appropriate for home recovery, the researchers called out remote monitoring as a useful tool for looking after COVID-19 patients.

An example of this is Penn Medicine's COVID Watch system, a text-message-based system that sends daily check-ups on known COVID-19 patients recuperating at home to make sure their symptoms aren't worsening. To date, more than 5,500 patients have been enrolled in the system, which is the subject of a new Patient-Centered Outcomes Research Institute (PCORI) study for which Delgado, Kilaru amd the other researchers on this study are also serving as investigators.

"We are eagerly awaiting the result of this study, which focuses specifically on pulse oximetry," Delgado said.

Other authors on the completed hospital readmission study included Kathleen Lee, MD; Christopher K. Snider; Zachary F. Meisel, MD; David A. Asch, MD; and Nandita Mitra, PhD; all of Penn.