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With enough training, pigeons can distinguish between the http://scoalaromaneasca.ca/lowest-levitra-price/ works of Picasso and best price for levitra 20mg Monet. Ravens can identify themselves in a mirror. And on a university campus in Japan, crows best price for levitra 20mg are known to intentionally leave walnuts in a crosswalk and let passing traffic do their nut cracking. Many bird species are incredibly smart.

Yet among intelligent animals, the âbird brainâ often doesnât get much respect. Two papers published today in Science find birds actually have a brain best price for levitra 20mg that is much more similar to our complex primate organ than previously thought. For years it was assumed that the avian brain was limited in function because it lacked a neocortex. In mammals, the neocortex is the hulking, evolutionarily modern outer layer of the brain that allows for complex cognition and creativity and that makes up most of what, in vertebrates as a whole, is called the pallium.

The new findings show that birdsâ do, in fact, have a best price for levitra 20mg brain structure that is comparable to the neocortex despite taking a different shape. It turns out that at a cellular level, the brain region is laid out much like the mammal cortex, explaining why many birds exhibit advanced behaviors and abilities that have long befuddled scientists. The new work even suggests that certain birds demonstrate some degree of best price for levitra 20mg consciousness. The mammalian cortex is organized into six layers containing vertical columns of neurons that communicate with one another both horizontally and vertically.

The avian brain, on the other hand, was thought to be arranged into discrete collections of neurons called nuclei, including a region called the dorsal ventricular ridge, or DVR, and a single nucleus named the wulst. In one of the new papers, senior author Onur GÃ¼ntÃ¼rkÃ¼n, a neuroscientist at Ruhr University Bochum in Germany, and his colleagues analyzed regions of best price for levitra 20mg the DVR and wulst involved in sound and vision processing. To do so, they used a technology called three-dimensional polarized light imaging, or 3D-PLIâa light-based microscopy technique that can be employed to visualize nerve fibers in brain samples. The researchers found that in both pigeons and barn owls, these brain regions are constructed much like our neocortex, with both layerlike and columnar organizationâand with both horizontal and vertical circuitry.

They confirmed best price for levitra 20mg the 3D-PLI findings using biocytin tracing, a technique for staining nerve cells. [In a Scientific American article, GÃ¼ntÃ¼rkÃ¼n describes how the avian brain demonstrates surprising cognitive abilities.] âWe can now claim that this layered, corticallike organization is indeed a feature of the whole sensory forebrain in most, if not all, birds,â says Martin Stacho, co-lead author of the study and GÃ¼ntÃ¼rkÃ¼nâs colleague at Ruhr University Bochum. ÂItâs not best price for levitra 20mg that the DVR is the neocortex,â says Vanderbilt University neuroscientist Suzana Herculano-Houzel, who wrote a commentary accompanying the two new papers and was not involved in either of them, âbut rather that the whole of the pallium in mammals and in birds has similar developmental origins and connectivity, and therefore [the pallia of both classes] should be considered equivalent structures. Stacho shows that settling for what the naked eye sees can be misleading.â The idea that the DVR was somehow related to the neocortex was proposed in the 1960s by neuroscientist Harvey Karten.

Yet it didnât stick. Others subsequently claimed the DVR actually corresponded with other best price for levitra 20mg mammalian brain regions, including the amygdala, which, among other tasks, carries out the processing of emotion. ÂThe theory about a DVR [correlation] has been possibly one of the biggest disputes in the field of comparative neurobiology,â Stacho says. But his new work lends credibility to Kartenâs original hypothesis.

Stacho and best price for levitra 20mg his colleagues think the findings also represent a glimpse into ancient animal brain evolution. The last common ancestor of birds and mammals was a reptile that roamed the earth around 320 million years ago. And its brain, the team believes, was probably a precursor to that of the two best price for levitra 20mg lineages that diverged through evolution. ÂNobody knows how exactly the brain of the last common ancestor looked like,â Stacho says.

ÂMost likely, it wasnât like the neocortex or the DVR. It was best price for levitra 20mg probably something in between that, in mammals, developed to a six-layered neocortex and, in birds, to the wulst and DVR.â The other new paper, by a group at the University of TÃ¼bingen in Germany, lends still more insight into the avian brain, suggesting that birds have some ability for sensory consciousnessâsubjective experiences in which they recall sensory experiences. Consciousness has long been thought to be localized in the cerebral cortex of smart primatesânamely, chimps, bonobos and us humans. Yet crows appear to have at least a rudimentary form of sensory consciousness.

In the TÃ¼bingen groupâs experiment, two carrion crows were trained to recall best price for levitra 20mg a previous experience to guide their behavior. When their training was completed, they went through a testing phase in which a gray square might appear followed by either a red or blue square 2.5 seconds later. In this exercise, the crows were trained to move their head if they saw a gray square and then a red one. And they learned to keep their head still if they saw a gray square and best price for levitra 20mg then a blue one.

When the birds saw no stimulus followed by the appearance of a colored square, the sequence was reversed. Blue signaled them to move their head, and red told them not best price for levitra 20mg to. So to correctly respond to the colored squares, the crows had to recall whether or not they had seen a gray one firstâequating to a past subjective experience. It was crucial to the experiment to present the gray square in six different intensities, including at the threshold of the birdsâ perception.

This way, lead author and neurobiologist Andreas Nieder and his colleagues could confirm that the crows were not simply carrying out best price for levitra 20mg conditioned responses to stimuli but instead drawing on a subjective experience. Further, by implanting electrodes in an avian brain region called the nidopallium caudolaterale (NCL), the researchers were able to monitor activity of individual neurons in response to the stimuli. When the crows viewed a dim gray square at their perceptual threshold, NCL neurons became active in the period between that stimulus and the presentation of a colored squareâbut only if the crows reported seeing the gray one. If they could not detect that square, the neurons remained best price for levitra 20mg silent.

This result suggests a unique subjective experience was being manifested through neuronal activity. Nieder does not claim crows have the self-conscious existence and self-awareness of apes but simply that the birds can partake in a unique, multipart sensory experience in best price for levitra 20mg response to a stimulus. ÂI am generally not a big fan of ascribing complex humanlike cognitive states to animals and prefer to maintain a conservative attitude,â he says. ÂHumans easily start to project their own mental states to other living (or even nonliving) beings.

But in terms of sensory consciousness in other species, it is probably fair to assume that advanced vertebrates, such as mammals and birds, possess it.â Niederâs teamâs findings suggest that the neural underpinnings of sensory consciousness either were in place before mammals evolved or developed independently in both lineagesâwith the avian line showing that being conscious does not necessarily best price for levitra 20mg depend on a bulky cerebral cortex. Work by Herculano-Houzel demonstrates that the brains of corvidsâmembers of a family of so-called âsmart birdsâ such as crows, ravens and magpiesâare very densely populated with interconnected neurons. Her studies jibe with the new Science papers. ÂWith GÃ¼ntÃ¼rkÃ¼nâs findings that pallium connectivity is indeed very similar between birds and mammals..., it all comes together very nicely,â she says, pointing out that the corvid pallium holds about as many neurons as best price for levitra 20mg youâd find in primates with a much larger brain.

This latest research also undercuts primate exceptionalism. ÂI hope that more people will be tempted to drop the notion that there is something very unique and exclusive about the human brain,â Herculano-Houzel says..

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We have created a list of all medications currently known to contain nitrosamine impurities. We will continue to update it, as needed, as more information becomes available. As we continue to hold companies accountable for determining the root causes, weâre learning more about how nitrosamine impurities may best price for levitra 20mg have formed or be present in medications. In the meantime, we will continue to take action to address and prevent the presence of unacceptable levels of these impurities. These actions may include.

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Food and Drug Administration European Medicines Agency Australiaâs Therapeutic Goods Administration Japanâs Ministry of Health, Labour and Welfare and Pharmaceuticals and Medical Devices Agency Switzerlandâs Swissmedic Singaporeâs Health Sciences AuthorityWe continue to work with companies and our international regulatory partners to. Determine the root causes best price for levitra 20mg of the issue verify that appropriate actions are taken to minimize or avoid the presence of nitrosamine impurities We regularly communicate information on health risks, test results, recalls and other actions taken. Some of these key actions and communications include. Letter to all manufacturers (October 2, 2019). Health Canada issued a key communication to all companies marketing human prescription and non-prescription medications requesting them to best price for levitra 20mg conduct detailed evaluations of their manufacturing procedures and controls for the potential presence of nitrosamines.

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Today, the Centers for where can you buy levitra over the counter Medicare &. Medicaid Services (CMS) issued guidance to state health officials designed to drive the adoption of strategies that address the social determinants of health (SDOH) in Medicaid and the Childrenâs Health Insurance Program (CHIP) so states can further improve beneficiary health outcomes, reduce health disparities, and lower overall costs in Medicaid and CHIP. SDOH describe the range of social, environmental, and economic factors that can influence health statusâconditions that can often have a greater where can you buy levitra over the counter impact on health outcomes than the actual delivery of health services. The new guidance describes how states can leverage existing flexibilities under federal law to tackle adverse health outcomes that can be impacted by SDOH and supports states with designing programs, benefits, and services that can more effectively improve population health and reduce the cost of caring for our nationâs most vulnerable and high-risk populations.

The United States spends more on health care than almost any other country yet often underperforms on key health indicators including life expectancy, reducing chronic heart disease, and maternal and infant mortality rates. According to the CMS Office where can you buy levitra over the counter of the Actuary, national health spending is projected to grow rapidly and reach $6.2 trillion by 2028. For its part, in 1985, Medicaid spending consumed less than 10% of state budgets and totaled just over $33 billion dollars. In 2019 that number had grown to consume 29% of total state spending at a total cost of $604 billion dollars.

To address the contradiction between rising costs and low health outcomes, CMS has committed to accelerating the industryâs shift away from traditional fee-for-service payment where can you buy levitra over the counter models to value-based models that hold clinicians accountable for cost and quality. As part of its continued efforts to advance value-based care, CMS recently issued guidance to state Medicaid directors to encourage the incorporation of value-based strategies across their healthcare systems allowing states to provide Medicaid beneficiaries with efficient, high quality care, while lowering cost and improving health outcomes. The guidance also noted that the adoption of value-based care arrangements could better provide opportunities for states to address SDOH as well as disparities across the health care system. ÂThe evidence is where can you buy levitra over the counter clear.

Social determinants of health, such as access to stable housing or gainful employment, may not be strictly medical, but they nevertheless have a profound impact on peopleâs wellbeing,â said CMS Administrator Seema Verma. ÂUnfortunately, our fee-for-service system inherently limits the doctor-patient relationship to what where can you buy levitra over the counter can be accomplished inside the four walls of a clinicianâs office. Todayâs letter to state health officials highlights strategies by which states can promote a value-based system that fosters treatment of the whole person and lowers healthcare costs. Patients are more than a bundle of medical diagnoses, and itâs time our healthcare system treated them as such.â With the release of todayâs SDOH guidance, CMS acknowledges that an understanding of the social, economic, and environmental factors that affect the health outcomes of Medicaid and CHIP populations can be an integral component of statesâ efforts to realign incentives, reduce costs, and advance value-based care in their health systems.

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Https://www.medicaid.gov/federal-policy-guidance/downloads/sho21001.pdf ### Get CMS news at cms.gov/newsroom, sign up for CMS news via email and follow CMS on Twitter CMS Administrator @SeemaCMS and @CMSgov.

Today, the Centers for best price for levitra 20mg Medicare &. Medicaid Services (CMS) issued guidance to state health officials designed to drive the adoption of strategies that address the social determinants of health (SDOH) in Medicaid and the Childrenâs Health Insurance Program (CHIP) so states can further improve beneficiary health outcomes, reduce health disparities, and lower overall costs in Medicaid and CHIP. SDOH describe the range of social, environmental, and economic factors that can influence health statusâconditions that can often have a greater impact on health outcomes than the best price for levitra 20mg actual delivery of health services. The new guidance describes how states can leverage existing flexibilities under federal law to tackle adverse health outcomes that can be impacted by SDOH and supports states with designing programs, benefits, and services that can more effectively improve population health and reduce the cost of caring for our nationâs most vulnerable and high-risk populations. The United States spends more on health care than almost any other country yet often underperforms on key health indicators including life expectancy, reducing chronic heart disease, and maternal and infant mortality rates.

According to the CMS Office of the Actuary, national health spending is projected to grow rapidly and reach $6.2 trillion by best price for levitra 20mg 2028. For its part, in 1985, Medicaid spending consumed less than 10% of state budgets and totaled just over $33 billion dollars. In 2019 that number had grown to consume 29% of total state spending at a total cost of $604 billion dollars. To address the contradiction between rising costs and low health outcomes, CMS has committed to accelerating the best price for levitra 20mg industryâs shift away from traditional fee-for-service payment models to value-based models that hold clinicians accountable for cost and quality. As part of its continued efforts to advance value-based care, CMS recently issued guidance to state Medicaid directors to encourage the incorporation of value-based strategies across their healthcare systems allowing states to provide Medicaid beneficiaries with efficient, high quality care, while lowering cost and improving health outcomes.

The guidance also noted that the adoption of value-based care arrangements could better provide opportunities for states to address SDOH as well as disparities across the health care system. ÂThe evidence is clear best price for levitra 20mg. Social determinants of health, such as access to stable housing or gainful employment, may not be strictly medical, but they nevertheless have a profound impact on peopleâs wellbeing,â said CMS Administrator Seema Verma. ÂUnfortunately, our fee-for-service system inherently limits the doctor-patient relationship best price for levitra 20mg to what can be accomplished inside the four walls of a clinicianâs office. Todayâs letter to state health officials highlights strategies by which states can promote a value-based system that fosters treatment of the whole person and lowers healthcare costs.

Patients are more than a bundle of medical diagnoses, and itâs time our healthcare system treated them as such.â With the release of todayâs SDOH guidance, CMS acknowledges that an understanding of the social, economic, and environmental factors that affect the health outcomes of Medicaid and CHIP populations can be an integral component of statesâ efforts to realign incentives, reduce costs, and advance value-based care in their health systems. The guidance recognizes that Medicaid and CHIP beneficiaries face best price for levitra 20mg challenges related to SDOH, including but not limited to access to nutritious food, affordable and accessible housing, quality education, and opportunities for meaningful employment. Growing evidence indicates that these challenges can lead to poorer health outcomes for beneficiaries and higher health care costs for Medicaid and CHIP programs and can exacerbate health disparities for a broad range of populations, including individuals with disabilities, older adults, pregnant women, children and youth, individuals with mental health and/or substance use disorders, and individuals living in rural communities. SDOH can affect health care utilization and cost, health outcomes, and health disparities. For example, the on-going erectile dysfunction treatment levitra has exacerbated long-understood disparities in health outcomes best price for levitra 20mg among low-income populations, particularly children.

Recent Centers for Disease Control and Prevention data indicate that counties with greater social vulnerability, including high poverty rates and crowded housing units were more likely to become erectile dysfunction treatment hotspots, potentially putting those who experience economic and housing constraints at a higher risk of contracting the levitra. Additionally, with many schools closed for in-person learning due to erectile dysfunction treatment restrictions, some low-income children have less access to free non-academic supports that affect their health and well-being, including food assistance, counseling services, and homelessness and maltreatment interventions. According to CMSâs own data, some children are also forgoing key services they might receive such as child screens and vaccinations prior best price for levitra 20mg to the start of the school year or in-school services such as speech therapy, physical therapy, and occupational therapy, demonstrating the influence that social networks and physical environment can have on childrenâs health. Current research indicates that some social interventions targeted at Medicaid and CHIP beneficiaries can result in improved health outcomes and significant savings to the health care sector. These investments can also prevent or delay beneficiaries needing nursing facility care by offering services to facilitate community integration and participation and help keep children on normative developmental trajectories in education and best price for levitra 20mg social skills.

The SDOH guidance details how state Medicaid and CHIP programs can utilize a variety of delivery approaches, benefits, and reimbursement methodologies to improve beneficiary outcomes. States can use different federal authorities that can provide them with flexibility to design an array of services to address SDOH and that can be tailored, within the constraints of certain federal rules, to address state-specific policy goals and priorities, including the movement from volume-based payments to value-based care, and the specific needs of statesâ Medicaid and CHIP beneficiaries. While states have flexibility to design a number of different services to address SDOH, the guidance focuses on a set of services and supports that states can best price for levitra 20mg cover under current law, including housing-related services and supports, non-medical transportation, home-delivered meals, educational services, and employment supports. CMS remains committed to partnering with states to address beneficiariesâ SDOH. When used in accordance with statutory and regulatory requirements, the Medicaid and CHIP programs are uniquely positioned to help states lower health care costs, improve health outcomes, and increase the cost-effectiveness of health care services and interventions for its beneficiaries.

CMS has placed an emphasis on addressing SDOH across all of its programs in its continued efforts to move toward a value-based model of care delivery. To view the Opportunities in Medicaid and CHIP to Address Social Determinants of Health letter, please visit. Https://www.medicaid.gov/federal-policy-guidance/downloads/sho21001.pdf ### Get CMS news at cms.gov/newsroom, sign up for CMS news via email and follow CMS on Twitter CMS Administrator @SeemaCMS and @CMSgov.

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Credit click for more info levitra rash. IStock Share Fast Facts New @HopkinsMedicine study finds African-American women with common form of hair loss at increased risk of uterine fibroids - Click to Tweet New study in @JAMADerm shows most common form of alopecia (hair loss) in African-American women associated with higher risks of uterine fibroids - Click to Tweet In a study of medical records gathered on hundreds of thousands of African-American women, Johns Hopkins researchers say they have evidence that women with a common form of hair loss have an increased chance of developing uterine leiomyomas, or fibroids.In a report on the research, published in the December 27 issue of JAMA Dermatology, the researchers call on physicians who treat women with central centrifugal cicatricial alopecia (CCCA) to make patients aware that they may be at increased risk for fibroids and should be screened for the condition, particularly if they have symptoms such as heavy bleeding and pain. CCCA predominantly affects black women and is the most common levitra rash form of permanent alopecia in this population. The excess scar tissue that forms as a result of this type of hair loss may also explain the higher risk for uterine fibroids, which are characterized by fibrous growths in the lining of the womb.

Crystal Aguh, M.D., assistant professor of dermatology at the Johns Hopkins University School of Medicine, says the scarring associated with CCCA is similar to the scarring associated with excess fibrous tissue elsewhere in the body, a situation that may levitra rash explain why women with this type of hair loss are at a higher risk for fibroids.People of African descent, she notes, are more prone to develop other disorders of abnormal scarring, termed fibroproliferative disorders, such as keloids (a type of raised scar after trauma), scleroderma (an autoimmune disorder marked by thickening of the skin as well as internal organs), some types of lupus and clogged arteries. During a four-year period from 2013-2017, the researchers analyzed patient data from the Johns Hopkins electronic medical record system (Epic) of 487,104 black women ages 18 and over. The prevalence of those with fibroids was compared in patients levitra rash with and without CCCA. Overall, the researchers found that 13.9 percent of women with CCCA also had a history of uterine fibroids compared to only 3.3 percent of black women without the condition.

In absolute numbers, out of the 486,000 women who were reviewed, 16,212 had fibroids.Within that population, 447 had CCCA, of which 62 had fibroids. The findings translate to a fivefold increased risk of uterine fibroids in women with levitra rash CCCA, compared to age, sex and race matched controls. Aguh cautions that their study does not suggest any cause and effect relationship, or prove a common cause for both conditions. ÂThe cause of the link between levitra rash the two conditions remains unclear,â she says.

However, the association was strong enough, she adds, to recommend that physicians and patients be made aware of it. Women with this type of scarring alopecia should be screened not only for fibroids, but also for other disorders associated with excess levitra rash fibrous tissue, Aguh says. An estimated 70 percent of white women and between 80 and 90 percent of African-American women will develop fibroids by age 50, according to the NIH, and while CCCA is likely underdiagnosed, some estimates report a prevalence of rates as high as 17 percent of black women having this condition. The other authors on this paper were levitra rash Ginette A.

Okoye, M.D. Of Johns Hopkins and Yemisi Dina of Meharry Medical College.Credit. The New England Journal of Medicine Share Fast Facts This study clears up how big levitra rash an effect the mutational burden has on outcomes to immune checkpoint inhibitors across many different cancer types. - Click to Tweet The number of mutations in a tumorâs DNA is a good predictor of whether it will respond to a class of cancer immunotherapy drugs known as checkpoint inhibitors.

- Click to Tweet The âmutational burden,â or the number of levitra rash mutations present in a tumorâs DNA, is a good predictor of whether that cancer type will respond to a class of cancer immunotherapy drugs known as checkpoint inhibitors, a new study led by Johns Hopkins Kimmel Cancer Center researchers shows. The finding, published in the Dec. 21 New England Journal of Medicine, could be used to guide levitra rash future clinical trials for these drugs. Checkpoint inhibitors are a relatively new class of drug that helps the immune system recognize cancer by interfering with mechanisms cancer cells use to hide from immune cells.

As a result, the drugs cause the immune system to fight cancer in the same way that it would fight an . These medicines have had remarkable success in treating some types of cancers that historically have had poor prognoses, such as advanced melanoma and levitra rash lung cancer. However, these therapies have had little effect on other deadly cancer types, such as pancreatic cancer and glioblastoma. The mutational burden of certain tumor types has previously been proposed as an explanation for why certain levitra rash cancers respond better than others to immune checkpoint inhibitors says study leader Mark Yarchoan, M.D., chief medical oncology fellow.

Work by Dung Le, M.D., associate professor of oncology, and other researchers at the Johns Hopkins Kimmel Cancer Center and its Bloomberg~Kimmel Cancer Institute for Cancer Immunotherapy showed that colon cancers that carry a high number of mutations are more likely to respond to checkpoint inhibitors than those that have fewer mutations. However, exactly how big an effect the mutational burden has on outcomes to levitra rash immune checkpoint inhibitors across many different cancer types was unclear. To investigate this question, Yarchoan and colleagues Alexander Hopkins, Ph.D., research fellow, and Elizabeth Jaffee, M.D., co-director of the Skip Viragh Center for Pancreas Cancer Clinical Research and Patient Care and associate director of the Bloomberg~Kimmel Institute, combed the medical literature for the results of clinical trials using checkpoint inhibitors on various different types of cancer. They combined these findings with data on the mutational burden of thousands of tumor samples from patients with levitra rash different tumor types.

Analyzing 27 different cancer types for which both pieces of information were available, the researchers found a strong correlation. The higher a cancer typeâs mutational burden tends to be, the more likely it is to respond to checkpoint inhibitors. More than half of the differences in how well cancers responded to immune checkpoint inhibitors could be explained by the mutational burden levitra rash of that cancer. ÂThe idea that a tumor type with more mutations might be easier to treat than one with fewer sounds a little counterintuitive.

Itâs one of those levitra rash things that doesnât sound right when you hear it,â says Hopkins. ÂBut with immunotherapy, the more mutations you have, the more chances the immune system has to recognize the tumor.â Although this finding held true for the vast majority of cancer types they studied, there were some outliers in their analysis, says Yarchoan. For example, Merkel cell levitra rash cancer, a rare and highly aggressive skin cancer, tends to have a moderate number of mutations yet responds extremely well to checkpoint inhibitors. However, he explains, this cancer type is often caused by a levitra, which seems to encourage a strong immune response despite the cancerâs lower mutational burden.

In contrast, the most common type of colorectal cancer has moderate mutational burden, yet responds poorly to checkpoint inhibitors for reasons that are still unclear. Yarchoan notes that these findings could help guide levitra rash clinical trials to test checkpoint inhibitors on cancer types for which these drugs havenât yet been tried. Future studies might also focus on finding ways to prompt cancers with low mutational burdens to behave like those with higher mutational burdens so that they will respond better to these therapies. He and his colleagues plan to extend this line of research by investigating whether mutational burden might be a good predictor of whether levitra rash cancers in individual patients might respond well to this class of immunotherapy drugs.

ÂThe end goal is precision medicineâmoving beyond whatâs true for big groups of patients to see whether we can use this information to help any given patient,â he says. Yarchoan receives funding levitra rash from the Norman &. Ruth Rales Foundation and the Conquer Cancer Foundation. Through a licensing agreement with Aduro Biotech, Jaffee has the potential to receive royalties in the future..

Credit. IStock Share Fast Facts New @HopkinsMedicine study finds African-American women with common form of hair loss at increased risk of uterine fibroids - Click to Tweet New study in @JAMADerm shows most common form of alopecia (hair loss) in African-American women associated with higher risks of uterine fibroids - Click to Tweet In a study of medical records gathered on hundreds of thousands of African-American women, Johns Hopkins researchers say they have evidence that women with a common form of hair loss have an increased chance of developing uterine leiomyomas, or fibroids.In a report on the research, published in the December 27 issue of JAMA Dermatology, the researchers call on physicians who treat women with central centrifugal cicatricial alopecia (CCCA) to make patients aware that they may be at increased risk for fibroids and should be screened for the condition, particularly if they have symptoms such as heavy bleeding and pain. CCCA predominantly affects black women and is the most common form of permanent alopecia in this population.

The excess scar tissue that forms as a result of this type of hair loss may also explain the higher risk for uterine fibroids, which are characterized by fibrous growths in the lining of the womb. Crystal Aguh, M.D., assistant professor of dermatology at the Johns Hopkins University School of Medicine, says the scarring associated with CCCA is similar to the scarring associated with excess fibrous tissue elsewhere in the body, a situation that may explain why women with this type of hair loss are at a higher risk for fibroids.People of African descent, she notes, are more prone to develop other disorders of abnormal scarring, termed fibroproliferative disorders, such as keloids (a type of raised scar after trauma), scleroderma (an autoimmune disorder marked by thickening of the skin as well as internal organs), some types of lupus and clogged arteries. During a four-year period from 2013-2017, the researchers analyzed patient data from the Johns Hopkins electronic medical record system (Epic) of 487,104 black women ages 18 and over.

The prevalence of those with fibroids was compared in patients with and without CCCA. Overall, the researchers found that 13.9 percent of women with CCCA also had a history of uterine fibroids compared to only 3.3 percent of black women without the condition. In absolute numbers, out of the 486,000 women who were reviewed, 16,212 had fibroids.Within that population, 447 had CCCA, of which 62 had fibroids.

The findings translate to a fivefold increased risk of uterine fibroids in women with CCCA, compared to age, sex and race matched controls. Aguh cautions that their study does not suggest any cause and effect relationship, or prove a common cause for both conditions. ÂThe cause of the link between the two conditions remains unclear,â she says.

However, the association was strong enough, she adds, to recommend that physicians and patients be made aware of it. Women with this type of scarring alopecia should be screened not only for fibroids, but also for other disorders associated with excess fibrous tissue, Aguh says. An estimated 70 percent of white women and between 80 and 90 percent of African-American women will develop fibroids by age 50, according to the NIH, and while CCCA is likely underdiagnosed, some estimates report a prevalence of rates as high as 17 percent of black women having this condition.

The other authors on this paper were Ginette A. Okoye, M.D. Of Johns Hopkins and Yemisi Dina of Meharry Medical College.Credit.

The New England Journal of Medicine Share Fast Facts This study clears up how big an effect the mutational burden has on outcomes to immune checkpoint inhibitors across many different cancer types. - Click to Tweet The number of mutations in a tumorâs DNA is a good predictor of whether it will respond to a class of cancer immunotherapy drugs known as checkpoint inhibitors. - Click to Tweet The âmutational burden,â or the number of mutations present in a tumorâs DNA, is a good predictor of whether that cancer type will respond to a class of cancer immunotherapy drugs known as checkpoint inhibitors, a new study led by Johns Hopkins Kimmel Cancer Center researchers shows.

The finding, published in the Dec. 21 New England Journal of Medicine, could be used to guide future clinical trials for these drugs. Checkpoint inhibitors are a relatively new class of drug that helps the immune system recognize cancer by interfering with mechanisms cancer cells use to hide from immune cells.

The mutational burden of certain tumor types has previously been proposed as an explanation for why certain cancers respond better than others to immune checkpoint inhibitors says study leader Mark Yarchoan, M.D., chief medical oncology fellow. Work by Dung Le, M.D., associate professor of oncology, and other researchers at the Johns Hopkins Kimmel Cancer Center and its Bloomberg~Kimmel Cancer Institute for Cancer Immunotherapy showed that colon cancers that carry a high number of mutations are more likely to respond to checkpoint inhibitors than those that have fewer mutations. However, exactly how big an effect the mutational burden has on outcomes to immune checkpoint inhibitors across many different cancer types was unclear.

To investigate this question, Yarchoan and colleagues Alexander Hopkins, Ph.D., research fellow, and Elizabeth Jaffee, M.D., co-director of the Skip Viragh Center for Pancreas Cancer Clinical Research and Patient Care and associate director of the Bloomberg~Kimmel Institute, combed the medical literature for the results of clinical trials using checkpoint inhibitors on various different types of cancer. They combined these findings with data on the mutational burden of thousands of tumor samples from patients with different tumor types. Analyzing 27 different cancer types for which both pieces of information were available, the researchers found a strong correlation.

The higher a cancer typeâs mutational burden tends to be, the more likely it is to respond to checkpoint inhibitors. More than half of the differences in how well cancers responded to immune checkpoint inhibitors could be explained by the mutational burden of that cancer. ÂThe idea that a tumor type with more mutations might be easier to treat than one with fewer sounds a little counterintuitive.

Itâs one of those things that doesnât sound right when you hear it,â says Hopkins. ÂBut with immunotherapy, the more mutations you have, the more chances the immune system has to recognize the tumor.â Although this finding held true for the vast majority of cancer types they studied, there were some outliers in their analysis, says Yarchoan. For example, Merkel cell cancer, a rare and highly aggressive skin cancer, tends to have a moderate number of mutations yet responds extremely well to checkpoint inhibitors.

However, he explains, this cancer type is often caused by a levitra, which seems to encourage a strong immune response despite the cancerâs lower mutational burden. In contrast, the most common type of colorectal cancer has moderate mutational burden, yet responds poorly to checkpoint inhibitors for reasons that are still unclear. Yarchoan notes that these findings could help guide clinical trials to test checkpoint inhibitors on cancer types for which these drugs havenât yet been tried.

Future studies might also focus on finding ways to prompt cancers with low mutational burdens to behave like those with higher mutational burdens so that they will respond better to these therapies. He and his colleagues plan to extend this line of research by investigating whether mutational burden might be a good predictor of whether cancers in individual patients might respond well to this class of immunotherapy drugs. ÂThe end goal is precision medicineâmoving beyond whatâs true for big groups of patients to see whether we can use this information to help any given patient,â he says.

Yarchoan receives funding from the Norman &. Ruth Rales Foundation and the Conquer Cancer Foundation. Through a licensing agreement with Aduro Biotech, Jaffee has the potential to receive royalties in the future..