Jacinda Abdul-Mutakabbir, PharmD, MPH, assistant professor of Clinical Pharmacy and antimicrobial resistance researcher at the University of California San Diego, was reviewing HIV manuscripts when she first became aware of the use of syndemics. It was there that she began to think about multidrug resistant (MDR) infections and if she could apply this synergistic approach.
“One thing that the syndemic approach states is that there has to be evidence of a synergistic and bidirectional relationship between the diseases,” Abdul-Mutakabbir said. “And then it made me think about the fact that so often we have patients that have antimicrobial resistant infections, and more often than not, they have a noncommunicable disease (NCD).”
In her further examination, working alongside her PhD candidate, found clinical data for isolates that were carbapenem resistant. When they studied the clinical characteristics, all of the patients had at least 1 comorbid disease, with diabetes being the most prevalent. Additionally, she saw that people with multidrug resistant tuberculosis were more susceptible to COPD.
The further she delved into the subject, the more she discovered that other researchers and clinicians were finding syndemic relationships between NCD and MDR infections. This became the basis for her study, which was recently published in the journal Infectious Diseases and Therapy.
Abdul-Mutakabbir explains the direct and indirect impacts and how noncommunicable diseases can impact MDR infections and vice versa.
“When I think about diabetes and just the hyperglycemic disease state, hyperglycemia can decrease our innate immunity…So when we think about diabetes, a macrovascular complication of diabetes is neuropathy that individuals can experience and can lead to diabetic foot infections. MRSA is often characterized in diabetic foot infections, and we’re starting to see coinfections with other multidrug resistant organisms. And when we think about these complications and when they worsen or they get really bad, especially with cancer, we see patients are immunocompromised, which can lead to a hospitalization. So now, we have exposure to hospital-acquired resistant organisms.”
On the indirect side, she uses the example of patients with gram-negative infections and how lipopolysaccharide (LPS) can affects glycemic levels.
“When we think about these infections, and we have pathways like gram-negative bacteria that have LPS, that LPS can then impact our glycemic stores and how hyperglycemia presents itself,” she said.
This is part 1 of a 2-part interview. In the next episode, Abdul-Mutakabbir explains how social determinants of health contribute to the syndemic relationship between NCDs and multidrug resistant infections as well as what clinicians and public health officials can consider in this area when thinking about patient management.
Manchester City have been dealt a huge blow just days before the Manchester derby after Omar Marmoush was spotted in a leg brace and on crutches following a knee injury sustained on international duty. The 25-year-old forward, a January signing who has quickly become a favourite under Pep Guardiola, suffered the problem in Egypt’s World Cup qualifier against Burkina Faso on Tuesday.
Those were the words of a Baghdad-based director named Hasan Hadi when asked how he was able to corral not just a host of non-actor children for his new movie but a particular kind of junglefowl.
Hadi – his The President’s Cake will come out this fall from Sony Pictures Classics and was just chosen as the official Iraqi Oscar submission – made the comment to a pair of reporters at a dinner at the Toronto International Film Festival. While among the more colorful – and barnyardy – of the remarks uttered at the important early-September gathering, it was far from the only one emphasizing the uniquely human qualities of filmmaking.
Across the Canadian city, directors made statements that, as the algorithm rises, almost take on a political cast. Richard Linklater and Ethan Hawke stood in front of an audience and described the painstaking rehearsal for their movie about Lorenz Hart. (“Ethan and I have done our share of dialogue-intensive movies,” Linklater said, “but this was something else.”) Nia DaCosta talked about how her feelings on Ibsen animated her need to redo Hedda Gabler. Paul Greengrass left audiences breathless with his latest neo-verite adventure that has Matthew McConaughey as an embattled bus driver saving children in the 2018 Paradise wildfires. None of them mentioned AI explicitly. They didn’t have to. Their pro-human vehemence was evident in every quote and frame.
One filmmaker who did mention AI did so with stridency. Guillermo del Toro, whose Pinocchio was conceived as an ode to the human over the machine, was emphatic on the subject. “[We live in] a world that now wants to tell us loud and clear that art is not important; they want to insist it can be done by an app, that it can be done by anyone,” he said at the TIFF gala, where he received an award. “We cannot allow that to happen.”
But a different, more computer-enabled vision of Hollywood was also playing out at the industry’s big convocation, as tech entrepreneurs pitched their own vision to the entertainment decisionmakers. People from Largo, which builds models to test movies using virtual audiences. Gennie, which uses Google’s VEO-3 to help documentarians create re-enactment footage with the push of a button. And Luma AI, whose executives believe studios can deploy their video-generation tool to ramp up production (and ramp down sets); its chief executive laid out a vision at THR’s Access Canada Summit in which studios could survive only by producing 1,000 movies every year with a massive assist from AI.
All of them were at TIFF too, trying to enact their own vision of the entertainment future. And while they rarely crossed paths with the humanists, they clashed with them ideologically just the same. Hollywood may only be big enough for one them.
Pull the camera back and you’ll suddenly see the same battle playing out everywhere, in boardrooms and courtrooms. Warner Bros. has just sued Midjourney, making similar allegations as Disney and Universal before it against the image-generation startup. Anthropic has just agreed to settle with three authors who sued the AI company for training its models on their books. If the settlement is approved, it could result in the company paying a total of $1.5 billion to hundreds of thousands of authors – but the judge in the case also cleared the way for tech companies to engage in such training without permission so long as they bought retail copies of the books.
Seeking to convey the stakes, two activists, Guido Reichstadter and Michael Trazzi, have gone on hunger strikes outside the San Francisco office of Anthropic and London office of Google’s DeepMind respectively. They say they won’t eat any food until the companies stop developing all new AI models, giving both a visual and historical dimension to the conflict.
Meanwhile, the startup Showrunner, with investment from Amazon, made waves when it said it would use AI for an internal experiment to restore some 43 minutes of lost footage from Orson Welles’ The Magnificent Ambersons. The announcement generated a backlash from the company managing Welles’ estate, which an official there calling the move a “purely mechanical exercise” that lacked “uniquely innovative thinking.”
And of course The Sphere just opened an AI-enabled re-formatted The Wizard of Oz, aided by Google and $80 million (a budget $15 million higher than the original’s in 2025 dollars). While eliciting rave reviews, the project also added in cameos for the CEOs David Zaslav and James Dolan who were not, according to most film historians, present on the 1939 MGM set.
After years of companies building tech and raising money, the introduction of AI into the house of storytelling is finally here. And media players need to decide whether they want to make up the guest bedroom.
It would also be a mistake to think AI will only be used on classic films – on films with few stakeholders. The tools pitched and implemented would be used to create what was once done by hand on sets and in marketing departments, automating the analogue, with all the labor and cultural consequences to go with it.
At a hearing for the Anthropic settlement, one of the author plaintiffs, Kirk Wallace Johnson, said he saw the proceeding as the “beginning of a fight on behalf of humans that don’t believe we have to sacrifice everything on the altar of AI.” Johnson is the author of The Feather Thief, a critically acclaimed 2018 true-crime book about a heist that made off with scores of centuries-old historical bird skins. You could say that he, too, knows the rooster.
This story appeared in the Sept. 10 issue of The Hollywood Reporter magazine. Click here to subscribe.
Full case: A preterm infant presents with neonatal respiratory distress | Image credit: Contemporary Pediatrics
A 32 weeks and 6/7 days, 1970 g infant was born via meconium-stained vaginal delivery to a 37-year-old G2P1 mother who recently immigrated from India. The mother presented with preterm premature rupture of membranes (PPROM) for 11 hours prior to eventual vaginal delivery. Maternal history was otherwise notable for rubella nonimmune, advanced maternal age, and a prior history of intrauterine fetal demise 4 years prior. Prior to delivery, the mother received 1 dose of ampicillin given unknown Group B streptococcus (GBS) status, and a single dose of betamethasone to accelerate fetal lung maturity. After delivery, the infant was vigorous with delayed cord clamping of 1 minute. The Apgar scores were 8 and 8 at 1 and 5 minutes of life, respectively. There was mildly increased respiratory effort in the delivery room for which CPAP respiratory support was begun. The child was brought to the NICU on CPAP 5, 30% FiO2.
Initial vital signs included a temperature of 98.9F, heart rate of 165, respirations of 58, blood pressure of 47/18 with a mean of 28 and oxygen saturation of 97% on CPAP 5, 30% FiO2. Her physical exam was unremarkable except for mild intermittent tachypnea and subcostal retractions. Umbilical venous and umbilical arterial catheters were placed, a NS bolus was administered, and the child was begun on empiric ampicillin and gentamicin given preterm labor and PPROM. The admission chest x-ray was notable for moderate diffuse haziness bilaterally without focal infiltrates and no pneumothorax. Initial arterial blood gas at 1 hour of life was consistent with a respiratory acidosis with a pH of 7.08, CO2 of 85, and base of -6. Interval blood gases were monitored with rapid improvement of respiratory acidosis on CPAP6 respiratory support which was weaned to CPAP6 21% by 12 hours of life. A CBC obtained after birth was within normal limits including a white blood cell count of 12, hematocrit of 42, and platelet count of 312,000 with a differential that included 52% Neutrophils, 2% Bands, 26% Lymphocytes, 18% Monocytes, and 2% Eosinophils.
Within 18 hours of life, the initial blood culture was positive for gram negative rods with suggestion of extended spectrum beta-lactamase (ESBL).
The initial presentation was most notable for preterm birth of unclear etiology, mild respiratory distress, and an initial blood culture that returned positive within the first 24 hours of life suggestive of early onset sepsis. The differential diagnosis for this infant’s initial presentation included respiratory distress syndrome/surfactant deficiency, meconium aspiration, transient tachypnea of the newborn, pneumonia/sepsis and more as listed in Table 1.
Typical bacterial pathogens for early-onset sepsis, defined by blood or cerebrospinal fluid (CSF) culture bacterial growth in the first 72 hours of life, include Group B streptococcus (GBS), Escherichia coli, coagulase-negative Staphylococcus, Haemophilus influenza, and Listeria monocytogenes.1 Among these bacteria, E Coli is the most common pathogen isolated and accounts for approximately half of reported cases nationally.
Actual diagnosis
Sensitivity analysis for this infant’s initial positive blood culture confirmed E. coli with ESBL profile including resistance to ampicillin, ampicillin/sulbactam, cephalosporins, and gentamicin.
The condition
Extended-spectrum beta-lactamase producing Enterobacteriaceae (ESBL) strains have been implicated in severe and often lethal neonatal sepsis cases. A 2018 study from Alabama noted 3 cases of ESBL E. coli sepsis in neonates born to mothers originating from South Asia and Southeast Asia.2 In all 3 cases, the patients became critically ill including respiratory failure that required intubation and disseminated intravascular coagulation with pulmonary hemorrhage. All 3 cases were managed with β-lactams and aminoglycosides. Two deteriorated rapidly and passed away despite vigorous resuscitative efforts. However, early use of meropenem in the third patient led to a favorable outcome.
ESBL enzymes are characterized by the ability to hydrolyze third-generation cephalosporins (such as ceftriaxone and cefixime) and aztreonam.3 Resistance rates to ampicillin are as high as 66% to 78% in invasive neonatal E. coli isolates.4 Less data still exists worldwide regarding ESBL resistance towards aminoglycosides but the overall increasing rate of resistance to gentamicin now surpasses 10% in the United States and Europe.5 ESBL colonization exceeds just over 10% worldwide though approaches at least double that figure in certain parts of the world such as India, Southeast Asia, and Africa.6
Analysis of neonatal E. coli bacteremia isolates in the United States from 2006 to 2016 found 67% resistance to ampicillin, 14% to gentamicin, 2% to ceftriaxone, and 0% to amikacin and carbapenems.7
Management
The combination of ampicillin and gentamicin is the first choice for empirical antibiotic therapy when early onset sepsis is suspected. This targeted combination of gram positive and gram negative coverage addresses the most common bacterial pathogens in early onset neonatal sepsis. Broader spectrum antibiotics are reserved for rarer cases such as the one presented here. When selecting or adjusting appropriate antibiotic coverage, clinical context must be taken into account including demographics, clinical course, and available susceptibility patterns.
Patient course
Pediatric infectious disease was consulted and antibiotic coverage was changed from ampicillin and gentamicin to meropenem with the first dose administered by 24 hours of life. Repeat blood culture at 48 hours of life remained positive with a first negative blood culture at 72 hours of life. A lumbar puncture was performed on day of life number 4. Cerebrospinal fluid (CSF) culture pretreated with meropenem was negative, but concerning for elevated white blood cells of 97/mm3 with protein of 296 mg/dL. A 21 day course of meropenem was therefore completed. The infant remained on noninvasive respiratory support throughout the NICU course and was eventually weaned to room air by 5 weeks of life. The remainder of the NICU hospital course was remarkable for mild hyperbilirubinemia, anemia of prematurity, immature retinal exam in zones 2 and 3, and an occlusive thrombus in the right great saphenous vein likely secondary to a right lower extremity PICC. At the time of discharge at 46 days of life and 39 weeks corrected gestational age, the patient’s weight was 2775 grams. She was stable on room air and tolerating ad lib feeds of maternal milk fortified to 22kcal per ounce.
Discussion
Neonatal sepsis is the leading cause of death in preterm newborns worldwide, with an estimated annual mortality rate of 203,000.8 A systematic review in 2017 comparing 23 global studies, with a total of 3,381 laboratory-confirmed bloodstream infection cases, found the prevalence of extended-spectrum ß-lactamase producing Escherichia coli (ESBL-PE) infections to be 11% among neonates.7 These cases were pooled from Africa, South America, India, Asia, and Europe in order of descending prevalence. Surprisingly there were no North American cases in this review. However, between 1990 to 2011 the number of ESBL cases tripled in the United States.9
Early onset sepsis with ESBL has historically demonstrated relatively high mortality rates especially among the preterm neonatal population. These alarming statistics highlight the dangers and increasing frequency of ESBL infections in the vulnerable newborn population. Clinicians should have a high index of suspicion for ESBL E. coli sepsis in infants whose clinical status does not improve on typical empiric antibiotic coverage and/or in the context of infants born to mothers from high-risk regions. We believe that in our case early initiation of meropenem was life saving for this infant.
Dolma K, Summerlin TL, Wongprasert H, Lal CV, Philips Iii JB, Winter L. Early-Onset Neonatal Sepsis with Extended Spectrum Beta-Lactamase Producing Escherichia Coli in Infants Born to South and South East Asian Immigrants: A Case Series. AJP Rep. 2018;8(4):e277-e279. doi:10.1055/s-0038-1675336
Pana ZD, Zaoutis T. Treatment of extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBLs) infections: what have we learned until now?. F1000Res. 2018;7:F1000 Faculty Rev-1347. Published 2018 Aug 29. doi:10.12688/f1000research.14822.1
Schrag SJ, Farley MM, Petit S, et al. Epidemiology of Invasive Early-Onset Neonatal Sepsis, 2005 to 2014. Pediatrics. 2016;138(6):e20162013. doi:10.1542/peds.2016-2013
Sader HS, Farrell DJ, Flamm RK, Jones RN. Antimicrobial susceptibility of Gram-negative organisms isolated from patients hospitalised with pneumonia in US and European hospitals: results from the SENTRY Antimicrobial Surveillance Program, 2009-2012. Int J Antimicrob Agents. 2014;43(4):328-334. doi:10.1016/j.ijantimicag.2014.01.007
Flokas ME, Karanika S, Alevizakos M, Mylonakis E. Prevalence of ESBL-Producing Enterobacteriaceae in Pediatric Bloodstream Infections: A Systematic Review and Meta-Analysis. PLoS One. 2017;12(1):e0171216. Published 2017 Jan 31. doi:10.1371/journal.pone.0171216
Cole BK, Ilikj M, McCloskey CB, Chavez-Bueno S. Antibiotic resistance and molecular characterization of bacteremia Escherichia coli isolates from newborns in the United States. PLoS One. 2019;14(7):e0219352. Published 2019 Jul 5. doi:10.1371/journal.pone.0219352
Fleischmann C, Reichert F, Cassini A, et al. Global incidence and mortality of neonatal sepsis: a systematic review and meta-analysis. Arch Dis Child. 2021;106(8):745-752. Published 2021 Jul 19. doi:10.1136/archdischild-2020-320217
Logan LK, Braykov NP, Weinstein RA, Laxminarayan R; CDC Epicenters Prevention Program. Extended-Spectrum β-Lactamase-Producing and Third-Generation Cephalosporin-Resistant Enterobacteriaceae in Children: Trends in the United States, 1999-2011. J Pediatric Infect Dis Soc. 2014;3(4):320-328. doi:10.1093/jpids/piu010
A Mediterranean-style diet, rich in fiber, vegetable proteins and healthy fats, benefits maternal health during pregnancy and breastfeeding. In addition to improving intestinal function and mucosal immunity, it also prevents fat accumulation and optimizes the composition of the microbiota in the digestive system. In babies, this maternal dietary pattern helps to reduce the incidence and severity of infections.
These conclusions come from two studies published in the journal eBioMedicine, carried out with the support of La Marató de TV3 (2017). The research was jointly led by Francisco José Pérez-Cano, professor at the Faculty of Pharmacy and Food Sciences of the University of Barcelona and director of the Nutrition and Food Safety Research Institute (INSA-UB), based at the UB’s Torribera Food Campus, and the expert M. Carmen Collado, from the Institute of Agrochemistry and Food Technology (IATA-CSIC).
Led by researcher Karla Rio Aige (INSA-UB) as first author, the studies, coordinated globally by the UB, used data from the MAMI (Maternal Microbiome) cohort to identify relevant observations. Researchers also developed a preclinical model with animal models using the diets detected in the cohort with the aim of understanding the mechanisms of action involved.
Nutrition and mother-child health: many open questions
A balanced diet and a healthy lifestyle and habits are important for good health in pregnancy. Therefore, establishing optimal nutritional habits during pregnancy, lactation and early life is crucial for the health and well-being of mother and baby. However, the associated mechanisms linking maternal diet to maternal and infant health outcomes are still poorly understood.
María José Rodríguez Lagunas, a member of the project’s research team and of the UB’s Department of Biochemistry and Physiology, notes that understanding how maternal diet influences mother and infant physiology “is crucial, as its effects extend to short- and long-term outcomes for both mother and child.” However, she adds that “there is a notable lack of research on the underlying mechanisms, particularly those that could improve the physiological recovery of the mother after childbirth”.
The first study, at the preclinical level, compared the effects of two different diets during gestation and lactation on microbiota composition, immunity and lipid metabolism: the Mediterranean-like D1 diet, rich in fiber and vegetable protein, and a Western D2 diet, richer in animal protein and fats. During the nutritional intervention, various biological samples were analysed to see the effects of each diet on the epithelial barrier, lipid metabolism, microbiota composition, metabolites and immunity.
The results reveal that a diet similar to the Mediterranean diet and enriched with fish oil, soya protein and inulin has beneficial effects on lipid metabolism, the composition of the microbiota and the immune response during pregnancy and breastfeeding, and improves maternal health.”
Professor Francisco J. Pérez-Cano
“Furthermore, if this diet is maintained during breastfeeding, it seems to more effectively reverse the physiological changes that occur during pregnancy, supporting immune function and limiting fat accumulation,” adds the expert.
Improving child health through maternal diet
The second study shows that a maternal diet rich in plant protein, fibre and polyunsaturated fatty acids reduces the severity and frequency of infections in infants through the modulating effect of gut microbiota on the immune system.
The study, conducted on infants and animal models, analyses the effect of maternal diet on the health of offspring and reinforces the importance of maternal nutrition during pregnancy and lactation to strengthen infant health. The synergy of the INSA-UB and IATA-CSIC teams — institutions recognized with the María de Maeztu and Severo Ochoa seals of excellence, respectively — was key to obtaining the results.
In this context, the influence of the maternal diet emerges as a key factor in the composition of the defensive elements of milk during lactation. As essential elements, immunoglobulin A (IgA) in human milk and the diversity of the microbiota demonstrate their protective role against infections in infants.
These studies provide new insights that may lead to more precise dietary guidelines for pregnant and breastfeeding women. On the one hand, they would help to strengthen the health of mothers and support their physiological recovery, and on the other hand, they would protect infant development in the early stages of life by reducing the risk of infections, thus supporting the wellbeing of babies.
“The study may also help to better understand the relationship between maternal diet, bioactive components of breast milk, infant microbiota and infant immunity. In the future, further research will be necessary to obtain more solid conclusions and better understand the mechanisms involved,” conclude experts M. Carmen Collado and Francisco José Pérez-Cano.
Source:
Journal reference:
Rio-Aige, K., et al. (2025). A diet rich in fibre and vegetable protein during gestation and lactation shapes maternal immunity, intestinal microbiota and lipid metabolism. eBioMedicine. doi.org/10.1016/j.ebiom.2025.105784
Italy’s Giulio Pellizzari won stage 17 of the Vuelta a Espana, with Britain’s Tom Pidcock in second as Jonas Vingegaard extended his overall race lead.
Pellizzari, 21, launched an attack 3.5km from the end of the 143.2km route on the punishing slopes of the summit finish on the Alto de El Morredero.
Pidcock was next to cross the line from a small group of general classification favourites that had gone clear on the climb, with Pellizzari’s Red Bull-Bora-hansgrohe team-mate Jai Hindley in third.
Vingegaard was fourth, two seconds ahead of his main rival Joao Almeida, who is now 50 seconds adrift of the Dane in the GC race.
Earlier on Wednesday, riders in the peloton had voted to neutralise the stage in the event of a disruption, rather than race to an undefined finish, which has been a feature on days disrupted by pro-Palestine supporters on the Grand Tour this year.
Vuelta organisers announced later on Wednesday the individual time trial in Valladolid on Thursday’s 18th stage will be reduced from 27.2km to a 12.2km route, with the same start and finish as originally planned, to ensure “greater protection” for the stage.
In an interview with news agency Reuters, the vice president of the rider’s union Pascal Chanteur said they could decide to quit the race altogether if there are further incidents due to safety concerns.
“The riders voted by a majority to stop in case of a new problem. They will then decide whether to continue or to end the event,” said Chanteur.
Bahrain Victorious rider Jack Haig, added: “Unfortunately we’re being caught in the middle of something that maybe doesn’t even really involve us.
“At the moment we are kind of just the pawns in a very large chess game that unfortunately is affecting us.”
An individual clutching a Palestine flag caused a crash on stage 15. The team time trial on stage five was also disrupted when the Israel-Premier Tech team, owned by Israeli-Canadian businessman Sylvan Adams, were stopped on the road by a group of protesters holding Palestinian flags.
Tuesday’s stage 16 ended eight kilometres before the scheduled finish, while several other stages of this year’s race including stage 11 – which was shortened without a winner – have suffered the same issues.
Research suggests that initiation of ECMO within 24 hours of when the patient meets ECMO criteria leads to improved survival rates and enhanced functional status, particularly for individuals suffering from ARDS or cardiogenic shock.
“For a while, some have viewed ECMO as something of an expensive and risky last resort, and so they would wait until the lungs or heart were too far gone to benefit from ECMO,” explained Dr. Scott. “But because the benefit of ECMO is its ability to rest the lung or support a failing heart, you should be thinking about initiating ECMO as soon as your patient meets criteria. The sooner that ECMO gets involved, the more likely you are to see organ recovery.”
Timely execution of ECMO—specifically after cardiopulmonary resuscitation (CPR) has failed to restore oxygenation and circulation—also is essential. “If the indications for ECMO are after CPR, which has failed for a prolonged period of time, say 30 to 40 minutes, those patients are not likely to have a good outcome,” said Dr. Aziz. “On the other hand, if you look at a select group of patients where ECMO was performed earlier, specifically before the cardiac arrest has happened, they generally have better outcomes. I think if patients who are extremely sick have a bad outcome, it’s not because of ECMO, it’s because of the time point when ECMO was started.”
Successful ECMO programs typically engage in a multidisciplinary approach that can include surgeons, intensivists, perfusionists, ECMO specialist nurses, palliative care services, and other consulting specialists that play an essential role in the decision to administer this rescue therapy as early as possible for properly vetted patients.
A retrospective review of adult ECMO patient charts at Massachusetts General Hospital in Boston examined mortality rates before and after 2014, when a multidisciplinary approach to ECMO was launched. Prior to that year, patients were treated independently by intensivists with specific training for this intervention.
A total of 279 charts was reviewed, and survival to discharge for patients before the team-based approach was formalized at this institution was 37.7% compared to a survival to discharge of 52.3% between 2014 and 2017.2
“I am very proud of the highly collaborative approach that we take at Harborview Medical Center. Every time we consider putting a patient on ECMO, we discuss the case briefly on a just-in-time group call with all of our ECMO faculty. Because there’s always some nuance and there’s always intricacies, it would take decades to acquire all of the necessary expertise for these highly complex patients,” said Dr. Scott. “But our system means that we can quickly, in one call, determine if the patient meets the criteria for ECMO, talk through any patient-specific details, and get things going for a rapid and smooth cannulation.”
Emerging Role of ECMO in Trauma Care
ECMO is a rescue therapy that provides temporary support for select trauma patients, particularly for individuals with severe lung injuries, ARDS, or those suffering from severe trauma-related cardiopulmonary failure (e.g., massive pulmonary embolism).
However, some view the use of this modality in the trauma setting as somewhat controversial, largely due to high costs and limited resources, and the potential for complications related to anticoagulation.
“The science is there. Current evidence supports that trauma centers should offer ECMO to appropriate patients—it is often a lifesaving intervention,” said Dr. Scott, a trauma surgeon. “It doesn’t matter if the patients are suffering from traumatic brain injury (TBI) or if they are at risk of hemorrhaging; these no longer qualify as absolute contraindication. While patient selection remains important, essentially all injured patients with ECMO indications can benefit significantly from this intervention.”
One of the main barriers to ECMO use in trauma, according to Dr. Scott, is the perceived lack of data. He cited a systemic review published in 2023, that examined 36 observational studies with 1,822 patients, including studies with a focus on TBI patients.3
“The overall survival rate for trauma patients with TBI who went on ECMO was 66%, and that is right in line with ECMO survival rates for non-trauma patients,” Dr. Scott said. “I think it’s key for people to realize that trauma patients on ECMO are not at an increased risk for poor outcomes.”
The authors of the systemic review also noted the benefits of this modality for this cohort, asserting that, “ECMO is now considered beneficial for severely traumatized patients, improving prognosis, and serving as a valuable tool in managing trauma-related severe cardiorespiratory failure, hemorrhagic shock, and cardiac arrest.”3
Another barrier to ECMO use in trauma patients is the increased risk of bleeding associated with anticoagulation, although innovations in ECMO technology and anticoagulation have made this approach more feasible for these individuals.
“The reasons most people don’t want to put a trauma patient on ECMO tend to focus on bleeding risks, and yet, the data show that a trauma patient who gets ECMO does better than a trauma patient who needs ECMO and doesn’t get it. Just as an injured patient with a pulmonary embolism may need anticoagulation, most trauma patients tolerate lower-dose anticoagulation with ECMO. And for those who cannot be anticoagulated, there is increasing experience that shows it is safe to run VV ECMO without anticoagulation as long as the flow rates aren’t too low,” Dr. Scott said.
Portable Devices as Bridge to Critical Care Support
While traditional ECMO systems can be cumbersome and unwieldy, typically occupying a large footprint at the patient’s bedside, portable systems allow enhanced ambulation with a single cannulation site. One of the most transformative benefits of these smaller circuits is the ability for well-trained staff to administer this therapy in the field or in resource-challenged settings.
“I think ECMO portability is a big game changer because it fits in the helicopter, it fits in the ambulance, and now patients who were ‘too sick to travel’ can get the care they need,” explained Dr. Scott. “We have all of our cannulation equipment and our pump in a backpack and a wagon, and we can quickly drive down the road to another hospital to cannulate the patient, and then we take the ambulance back to our hospital once they are on VV ECMO.”
Interfacility transport is a primary advantage of mobile ECMO therapy because it enhances timely access to centers with advanced capabilities and expertise.
“As surgeons, we cannot live in an isolated world. We have to keep ourselves updated, especially with advancements like portable ECMO,” urged Dr. Aziz. “The traditional ECMO machines are huge, with big tubes attached to big machines, which makes transporting a patient a nightmare—especially if you are putting someone in a helicopter. If something disconnects, especially when you are in the air, it could be fatal. While portable ECMO is not ideal, it certainly makes the transport process easier and safer.”
It also is pertinent to note that, while mobile ECMO services enhance interfacility transport, they also increase access within the center itself by providing cardiac and respiratory support outside the ICU, allowing some patients to receive a computed tomography scan or magnetic resonance imaging services.
Currently, limited data exist on patient outcomes related to portable ECMO therapy; however, more programs across the US are investing in this mobile rescue intervention.
In a survey published in 2024, researchers examined US programs registered with ELSO. According to the survey, it is estimated that 63 out of 274 adult ECMO centers offer mobile ECMO services. The following are two examples of centers that have provided yearslong portable ECMO therapy with promising results.4
The Penn Lung Rescue Program in Philadelphia, which includes portable ECMO services, has transported more than 700 patients since its inception in 2014.5 The program is managed by Penn Medicine, an academic medical center that comprises the University of Pennsylvania Health System and the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. The survival rate for patients who received mobile VV ECMO has exceeded the ELSO average since the program began, according to Penn Medicine administrators.
The University of Utah Health in Salt Lake City, one of the only academic medical centers in the state, also has an ECMO program that includes portable ECMO systems. In an article published in 2022 in the Journal of Clinical Medicine, study authors affiliated with the university concluded the following: “Developing an in-hospital, primed, and portable VA ECMO program resulted in increased clinical volume with equivalent patient survival despite a sicker cohort of patients. We conclude that more rapid deployment of VA ECMO may extend the treatment eligibility to more patients and improve patient outcomes.”6
Insights for Achieving Sustainable ECMO Program Success
The provision of ECMO services can cost as much as $73,000 per patient, according to a recent survey, although those expenditures can vary by institution and the care required to treat individual cases.7 Expensive equipment and a specialized team of physicians, surgeons, nurses, and perfusionists are the primary factors driving these costs.
“I think the biggest issue, in terms of getting buy-in from hospital administrators to start an ECMO program, is the budget,” said Dr. Aziz. “How do we justify starting this program? Do we have enough resources? One important thing to consider is that hospital billing typically goes up when the case mix index (CMI) goes up. When patients are on ECMO, it generally adds to the CMI. You may need to acquire more resources in the beginning as you launch the program, but once it is place it has the potential to increase hospital reimbursements.”
In other words, implementing an ECMO program can be a financially sustainable endeavor, not to mention its potential to generate a halo effect through referrals and transfers to billable critical care services such as cardiovascular services, trauma, and neonatology.8
“All the things it takes to build a successful ECMO program are the same things needed to build a successful trauma program,” added Dr. Scott. “Trauma programs are so well-suited to develop ECMO programs because multidisciplinary collaboration across the entire hospital and using data to drive quality improvement are in a trauma program’s DNA. The same patient-centered, team-based, and data-driven approach that underlies successful trauma programs is a perfect platform upon which to build an ECMO program.”
Further research regarding the development of standardized guidelines for ECMO treatment, and strategies to optimize cost effectiveness are essential for achieving hospital leadership support and expanding these programs across the US.
“If you are taking care of patients who are sick enough to have indications for ECMO, then I hope you’re part of a program that is able to get this lifesaving intervention to them when they need it,” Dr. Scott said. “There are a lot of creative ways to do this, but it starts with people opening their minds and looking past some of the outdated beliefs about this treatment that aren’t actually backed by data. Don’t let a failure of imagination hold you back from giving your patients the lifesaving care that they need.”
Five of the top 10 performers in history will be in Tokyo
World leader Sander Skotheim has already won two major titles this year and is looking for a third
Strong North American presence from US champion Kyle Garland and Canadian duo Damian Warner and Pierce LePage
For the second year in a row, a global decathlon gold medal could be making its way back to Norway. But this time, it could be a different athlete standing on top of the podium.
One year on from Markus Rooth winning the Olympic decathlon title, his Norwegian teammate Sander Skotheim heads to the World Athletics Championships Tokyo 25 as the favourite for the gold medal.
The 23-year-old has already won two major titles this year, having earned heptathlon gold at the European Indoor Championships and World Indoor Championships, setting a European indoor record of 6558 at the former.
His incredible form continued outdoors and he won at the Hypo Meeting in Gotzis with a world-leading 8909 to move to seventh on the world all-time list. That also broke the Norwegian record set by Rooth in Paris last year, continuing the ongoing exchange of national records between the pair.
The domestic rivalry between the duo has elevated them both to considerable international success in recent years. Rooth and Skotheim took gold and silver respectively at the European U23 Championships in 2023, then both finished in the top 10 at the World Championships later that year.
In 2024, Skotheim took European silver while Rooth failed to finish. The tables were turned at the Olympic Games as Skotheim failed to register a height in the pole vault, but he still lined up for the 1500m to help motivate Rooth in his run for glory.
Rooth won’t be in Tokyo, but there’s no shortage of opponents for Skotheim as he targets his first major outdoor title.
Kyle Garland finished second to Skotheim in Gotzis with 8626, then went on to smash his PB to win the US title with 8869, putting him just 40 points shy of the Norwegian on this year’s world list and elevating him to ninth on the world all-time list.
In fact, five of the world all-time top 10 will be in Tokyo, including Canada’s Damian Warner who won Olympic gold in the Japanese capital four years ago. Now 35, Warner is one of just four men to have surpassed 9000 points in the decathlon. He is also one of the most consistent performers in the history of the event; he has competed at every outdoor global championships over the past 14 years and has won medals at six of them.
He had a rare off day at the Olympics last year and failed to register a height in the pole vault, the memories of which will motivate him in Tokyo. He finished sixth in Gotzis this year with 8527.
Compatriot Pierce LePage, winner of the world title in 2023, will defend his crown. He withdrew from the decathlon in Gotzis in May with three disciplines to go and has competed sparingly since then.
Olympic silver medallist Leo Neugebauer is sandwiched between the Canadian duo on the world all-time list with his 8961 German record from last year’s NCAA Championships. He has completed just one decathlon this year, scoring 8555 to finish fifth in Gotzis.
That mark put him just one place behind compatriot Niklas Kaul, who tied for third place in Gotzis with Simon Ehammer, both scoring 8575. For Kaul, that represented the second-best score of his career behind the 8691 PB he set when winning the 2019 world title. Ehammer, meanwhile, broke the Swiss record with that performance.
Puerto Rico’s Ayden Owens-Delerme should also be in the medal hunt. He finished one place shy of the podium at the 2022 World Championships with 8532, then improved on that mark in 2024 with a national record of 8732. This year he placed seventh in Gotzis with 8486 then almost replicated that mark to win in Talence with 8478.
Lindon Victor hasn’t completed a decathlon this year, but the 32-year-old from Grenada took bronze medals at the 2024 Olympics and 2023 World Championships so undoubtedly has the potential to contend for a podium place.
Decathlon powerhouse Estonia, meanwhile, will be well represented in the form of European champion Johannes Erm, 2023 World Championships fourth-place finisher Karel Tilga and 2022 European bronze medallist Janek Oiglane.
Others to keep an eye on include Olympic fourth-place finisher Sven Roosen of the Netherlands and US duo Heath Baldwin and Harrison Williams.
Deep beneath the Earth’s surface, in a layer called the mantle, heat builds up and pulses, causing rock to slowly rise toward the crust. This movement is known as a mantle upwelling, and it plays a major role in forming volcanoes, breaking continents apart, and even creating new ocean basins.
In East Africa, the Afar Depression is famous among geologists because it’s one of the few places on the planet where three divergent plate boundaries meet – the Main Ethiopian Rift, the Red Sea Rift, and the Gulf of Aden Rift.
Scientists have long suspected the presence of one of these upwellings. But its exact shape, composition, and how it interacts with the shifting plates above remained unclear.
While the region’s volcanic activity and frequent earthquakes have long hinted at a hot mantle plume pulsing up from deep below, new research provides the clearest picture yet of its structure and behavior.
Mantle pulses from deep Earth
To learn more, researchers led by the University of Southampton collected lava samples from over 130 relatively young volcanoes across the region.
By analyzing the chemistry of these rocks and combining their findings with existing geological data, they discovered that the upwelling beneath Afar isn’t simple or uniform.
It’s asymmetrical and made up of plumes and various types of hot mantle material – almost like a patchwork, rather than a single stream.
Emma Watts, the study’s lead author, began the project at Southampton and now conducts research at Swansea University.
“We found that the mantle beneath Afar is not uniform or stationary – it pulses, and these pulses carry distinct chemical signatures,” she said. “These ascending pulses of partially molten mantle are channeled by the rifting plates above.”
Because those plates are stretching and thinning, the hot material can creep upward more easily, weakening the crust further and accelerating the birth of a new ocean basin.
Mantle pulses like a heart
Co-author Tom Gernon, a professor at Southampton, likens the chemical striping to a cardiovascular rhythm.
“The chemical striping suggests the plume is pulsing, like a heartbeat,” Gernon said. “These pulses appear to behave differently depending on the thickness of the plate and how fast it’s pulling apart.”
What’s particularly interesting is how this upwelling behaves differently depending on what’s happening above it.
In places where the Earth’s crust is pulling apart quickly – like the Red Sea Rift – the mantle flow is faster and more focused. In slower-moving areas, the upwelling spreads out more gradually.
The rifts across Afar and the mantle upwelling being channelized by the rift. The lines of section X–Y–Z are those shown in panel c. Volcanic segments are shown and labelled. b, The Afar upwelling showing the dimensions of channelized flow along the three rifts (dashed lines). c, Cross sections along the RSR (line section X–Y) and MER (Y–Z) showing the distribution of chemical heterogeneities within the upwelling and how those map to the clusters shown in Fig. 5. Note that the depths of distinct features, including the lithosphere–asthenosphere boundary (LAB), are not shown to scale. Click image to enlarge. Credit: Nature Geoscience
Tectonics drive mantle flow
By tying mantle chemistry to plate dynamics, the study reshapes thinking about how continents fracture.
“We have found that the evolution of deep mantle upwellings is intimately tied to the motion of the plates above,” said co-author Derek Keir, affiliated with both Southampton and the University of Florence.
That coupling, he adds, influences “surface volcanism, earthquake activity, and the process of continental breakup.”
The observed plume is eroding the lithosphere – Earth’s rigid outer shell – from below, thinning it to as little as 15 kilometers in places. When combined with stretching from plate motion, that thinning triggers periodic volcanic episodes.
Active lava flows spilling out of the Erta Ale volcano in Afar, Ethiopia. Click image to enlarge. Credit: Dr Derek Keir, University of Southampton/ University of Florence
Lava flows blanket wide swaths of Ethiopia, while seismic swarms mark places where new crust is forming. Eventually, researchers say, seawater will flood in.
The Horn of Africa will split from the mainland, like the Atlantic did from Europe and North America.
Forecasting Earth’s deep forces
Large igneous provinces, like the North Atlantic Igneous Province, formed Northern Ireland’s Giant’s Causeway 60 million years ago.
Scientists blame them for climatic upheavals due to the vast volumes of CO2 and SO2 they release. Some may have even triggered mass extinctions.
Understanding the tempo of the Afar plume, therefore, has ramifications that reach beyond regional geology.
Mantle “heartbeats” elsewhere could explain past volcanic bursts and sudden environmental changes in Earth’s history.
A succession of volcanic deposits at Boset Volcano in the Main Ethiopian Rift. Click image to enlarge. Credit: Prof Thomas Gernon, University of Southampton
Researchers plan to map mantle flow beneath thin plates and how it directs volcanic vents in future studies.
“The work shows that deep mantle upwellings can flow beneath the base of tectonic plates and help to focus volcanic activity to where the tectonic plate is thinnest,” Keir explained.
“Follow-on research includes understanding how and at what rate mantle flow occurs beneath plates.”
Solving Earth’s deep puzzle
“Working with researchers with different expertise across institutions, as we did for this project, is essential to unraveling the processes that happen under Earth’s surface and relate it to recent volcanism,” Watts concluded.
“Without using a variety of techniques, it is hard to see the full picture, like putting a puzzle together when you don’t have all the pieces.”
In short, the study shows that mantle upwellings aren’t just deep Earth features operating in isolation. They’re actively shaped and guided by the movement of tectonic plates above, creating a dynamic connection between the deep Earth and the surface we live on.
For now, scientists can at least hear the planet’s mantle pulses beneath Ethiopia – a rhythmic signal of forces playing out deep below Earth’s surface, slowly ripping apart a massive continent and sketching the outlines of an ocean yet to be born.
The study is published in the journal Nature Geoscience.
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Despite evidence suggesting the safety of hormone therapy for patients with a history of low-grade endometrial or epithelial ovarian cancer, a new survey shows that many gynecologists and some gynecologic oncologists are still uncomfortable prescribing the therapy for this patient population. This indicates a need for more clinician education to help overcome lingering misconceptions. Results of the survey are published online today in Menopause, the journal of The Menopause Society.
Although most patients with gynecologic cancers are postmenopausal, it is estimated that 40% of these patients are premenopausal or perimenopausal at the time of diagnosis. Many patients undergoing surgery for a gynecologic malignancy will require a bilateral oophorectomy as part of their treatment. In addition, both chemotherapy and radiotherapy put women at risk of decreased ovarian function.
Thanks to improvements in cancer therapies, it is important to consider the long-term effects of primary ovarian insufficiency and hormone deprivation in premenopausal patients with gynecologic cancer. Estrogen therapy, however, has historically been underused in this population because of provider concerns primarily regarding cancer recurrence.
In 2020, the Society of Gynecologic Oncology (SGO) released a statement that was affirmed by The Menopause Society to help guide the use of hormone therapy in patients with gynecologic cancer. Since that time, there is no known publication of statistics relative to the effect on the frequency of practitioners prescribing hormones for this population.
That’s why this new web-based survey of 293 members of the SGO and the American College of Obstetricians and Gynecologists was undertaken to explore and define the use of estrogen therapy in women with a history of gynecologic cancer. Some of the highlighted results of the survey include
63.82% of respondents prescribe estrogen therapy to patients with endometrial cancer
65.19% of respondents feel comfortable prescribing estrogen to patients with epithelial ovarian cancer
96.8% of respondents are comfortable prescribing estrogen for patients with cervical cancer
Prescribing patterns differed significantly based on sex, job title, and years in practice. The data suggest that benign gynecology care professionals and those with less clinical experience are more likely to hold misconceptions around hormone safety.
The respondents were also asked about their preferred estrogen therapy alternatives. Selective serotonin reuptake inhibitors were the most frequently selected (88.4%), followed by gabapentin (58%), and neurokinin-3 antagonists (46.4%).
Studies demonstrate that hormone therapy is a highly effective and safe (for most women) treatment to manage bothersome menopause symptoms that can greatly affect a woman’s quality of life. The most common reason for not prescribing estrogen therapy in patients with a history of gynecologic cancer was the belief that the risks outweighed the benefits. Although this may be true for certain cancers, it is not for all.
Survey results are published in the article “Estrogen therapy in patients with gynecologic cancer: a survey of gynecologists and oncologists in the United States.”
Treatment for gynecologic cancers often accelerates the onset of menopause and contributes to more severe symptoms in this population. Hormone therapy is the most effective treatment for the management of vasomotor symptoms and genitourinary syndrome of menopause. Recognizing when hormone therapy can be safely used will have a beneficial effect on overall well-being and health.”
Dr. Monica Christmas, associate medical director for The Menopause Society
