Medical Bulletin 25/ September/ 2024

Nearly 74% of adolescents and 50% of adults are not physically active, World Health Organization recently stated asking the South-East Asia Region to strengthen policies to promote healthy diets and physical activity to combat the rising levels of overweight, obesity, and noncommunicable diseases which is a leading cause of deaths in the Region.

“The burden of overweight, obesity, and associated metabolic disorders has been steadily rising in the World Health Organization South-East Asia Region, affecting both children and adults. These trends have fueled a surge in noncommunicable diseases such as cardiovascular disease, diabetes, and cancer, which are now responsible for nearly two-thirds of all deaths in our Region” said Saima Wazed, Regional Director, World Health Organization South-East Asia, speaking at the inaugural of a regional meeting to ‘Promote healthy diets and food environments, and physical activity through policies and enabling environments.’

The Region is experiencing rapid demographic transition with rapid urbanization, and economic growth further driving unhealthy diets, reduced physical activity, and more sedentary lifestyles stated World Health Organization.

“Healthy diets and regular physical activity are fundamental to achieving this target. However, this requires more than knowledge and behavior change it calls for creating enabling environments that support and encourage healthier choices,” said the Regional Director.

Strong regulatory frameworks and policies are crucial for creating healthier food environments at home, school, retail, and digital spaces, as well as safe recreational areas and walkways, especially in urban settings. Fiscal policies should also incentivize healthy diets.

To address these challenges, World Health Organization has outlined evidence-based 'best buy' recommendations. World Health Organization’s Global Action Plan for Physical Activity (GAPPA) provides additional guidance for making populations and societies more active, while recognizing the cultural constraints that often limit participation, especially for girls and women.

Several countries in the Region have already made significant progress by introducing food labeling regulations, banning trans fats in food, and implementing taxes on sugar-sweetened beverages, but further action is necessary.

“We must confront the challenges that stand in our way. The lack of multisectoral coordination, lobbying to protect the strong commercial interests of industry, and capacity gaps of stakeholders, are major obstacles,” the Regional Director said, adding, “By collaborating across sectors, we can strengthen national coordination efforts, build government capacity, and foster support from civil society. Together, we can drive meaningful progress towards healthier communities.”

Reference: World Health Organization. (2024, September 18). Promote healthy diets, physical activity: WHO. https://www.who.int/southeastasia/news/detail/18-09-2024-promote-healthy-diets-physical-activity-who

People who initiate a premature or “before medically advised” (BMA) hospital discharge have a 10-fold increase in the risk of drug overdose in the following month, according to new research in Canadian Medical Association Journal.

Hospital patients who initiate a before medically advised discharge are up to 3 times more likely to die in the following year than people who undergo routine physician-advised discharge.

“For a long time, front-line doctors and nurses have wondered if before medically advised discharge increases subsequent overdose risk,” says Dr. John Staples, study senior author and a clinical associate professor at the University of British Columbia in Vancouver, BC. “For patients with substance use disorder, a long hospital stay can sometimes be a period of drug abstinence, potentially reducing opioid tolerance and interrupting access to [addiction] treatments. After these patients leave hospital, persistent pain and untreated addiction might prompt heavier-than-usual drug use. All these factors can increase the risk of subsequent overdose.”

To understand the link between before medically advised discharge and drug overdose, researchers conducted a study that examined health data on 189 808 hospital admissions occurring between 2015 and 2019 in British Columbia, Canada. A total of 6440 (3.4%) of these admissions ended with patients leaving hospital against medical advice. They found that patients with a before medically advised discharge were more likely to be younger males with psychiatric illness, substance use disorder, or a history of illicit drug use. The rate of fatal or nonfatal illicit drug overdose in the first 30 days after departure from hospital was 10 times higher after before medically advised discharge than after physician-advised discharge. “Before medically advised” discharge was associated with subsequent overdose even after accounting for other risk factors for overdose.

“These findings indicate that patients initiating a before medically advised discharge are at high risk of overdose, that before medically advised discharge may be a causal contributor to subsequent overdose, and that patients initiating a Before medically advised discharge, especially those with a history of substance use disorder, should be offered urgent clinical and social supports to reduce overdose-related harms,” write the authors.

Reference: Khan, M., Xiao, N., Crabtree, A., Moe, J., Nasmith, T., Daly-Grafstein, D., Brubacher, J. R., Slaunwhite, A. K., & Staples, J. A. (2024). Before medically advised departure from hospital and subsequent drug overdose: A population-based cohort study. CMAJ, 196(31), E1066-E1075. https://doi.org/10.1503/cmaj.240364

Researchers have found that Selective Serotonin Reuptake Inhibitors antidepressants have the potential to improve certain cognitive functions, such as verbal memory. They measured brain function in patients before and after taking the Selective Serotonin Reuptake Inhibitors escitalopram and correlated this to a drop in the level of one of the serotonin receptors in the brain and to cognitive improvements during treatment. The findings were published in journal Biological Psychiatry.

The researchers began by scanning the brains of 90 depressed patients, to measure the quantity of 5HT4 receptor which serotonin binds to. At the same time, patients were given a series of tests to measure mood and cognitive abilities.

Patients were given daily doses of escitalopram, and at the end of an 8-week period, 40 patients were rescanned to measure the quantity of 5HT4 receptor in the brain. The mood of the patients had improved, but the team also found that the levels of 5HT4 receptor had dropped by around 9% possibly due to adaptations to increased levels of serotonin. When they asked these patients to undertake more cognitive tests, they found that their performance had improved, so that the less the 5HT4 receptor had changed the better the cognitive outcome. This phenomenon was particularly prominent for the ability to recall words.

“This is potentially significant” said researcher Vibeke Dam (Copenhagen University Hospital, Rigshospitalet, Denmark), “It seems that the Selective Serotonin Reuptake Inhibitors medication contributes to an improvement on cognitive function, at the same time as helping improve mood. Our work ties the improvement in cognitive function to the specific 5HT4 receptor and suggest that direct serotonin 4 receptor stimulation may be in important pro-cognitive target to consider in optimizing outcomes of antidepressant treatment. It also reinforces the idea that serotonin is crucial to mood improvement.

Co-researcher Vibe Froekjaer (Copenhagen University Hospital, Rigshospitalet, Denmark), added, “This is a first result, so we need to do a lot more work to look at the implications. Poor cognitive function is very hard to treat efficiently and may require extra treatment. This work points to the possibility of stimulating this specific receptor so that we can treat cognitive problems, even aside from whether or not the patient is has overcome the core symptoms of depression”.

Reference: Dam, V. H., Köhler-Forsberg, K., Ozenne, B., Larsen, S. V., Ip, C. T., Jorgensen, A., ... & Frokjaer, V. G. (2024). Effect of antidepressant treatment on 5-HT4 receptor binding and associations with clinical outcomes and verbal memory in major depressive disorder. Biological Psychiatry.

Fungal infections are also adapting beyond the means of our medicine, causing a Silent Pandemic that needs to be addressed urgently, according to a new Lancet Study.

"The threat of fungal pathogens and antifungal resistance, even though it is a growing global issue, is being left out of the debate,” explains molecular biologist Norman van Rhijn from the University of Manchester in the UK.

Fungal infections, they write in a correspondence for The Lancet, are left out too many initiatives to tackle antimicrobial resistance.

Without urgent attention and action, some particularly nasty fungal infections, which already infect 6.5 million a year and claim 3.8 million lives annually, could become even more dangerous.

"The disproportionate focus on bacteria is concerning because many drug resistance problems over the past decades were the result of invasive fungal diseases, which are largely under-recognized by the community and governments alike," write van Rhijn and his colleagues.

"To treat deep or invasive fungal infections, only four systemic antifungal classes are available and resistance is now the rule rather than the exception for those currently available classes," write the authors of the correspondence.

“Even before the newer drugs reach the market after years of development and clinical trials fungicides with similar modes of action are developed by the agrochemical industry resulting in cross-resistance for critical priority pathogens," explain the researchers in their correspondence.

"Antifungal protection is required for food security. The question is, how do we balance food security with the ability to treat current and future resistant fungal pathogens?"

It's a conundrum that has been discussed at length for antibiotics but not so much for antifungals. Van Rhijn and his team recommend a global agreement to limit certain antifungal drugs to specific purposes, as well as collaborative regulations to balance food security with health.

The UN's meeting this September "must serve as a starting point" for an orchestrated and diverse approach to antimicrobial resistance, the researchers conclude.

Reference: van Rhijn, N., Arikan-Akdagli, S., Beardsley, J., Bongomin, F., Chakrabarti, A., Chen, S. C., ... & Hagen, F. (2024). Beyond bacteria: the growing threat of antifungal resistance. The Lancet, 404(10457), 1017-1018.