Results of a small pilot study showed that impaired cognition was common in adults with hypothyroidism and linked to lower serum calcium levels and higher serum phosphate levels.
Despite patients with hypoparathyroidism describing cognitive deficits, data are limited regarding objective assessment of cognitive function, Mishaela R. Rubin, MD, MS, an associate professor of medicine in the metabolic bone disease unit at the Vagelos College of Physicians & Surgeons at Columbia University Irving Medical Center, and colleagues wrote. The researchers sought to determine objective cognition in adults with hypoparathyroidism using the NIH Toolbox Cognitive Battery (NIHTB-CB) and aimed to assess whether cognition is linked to emotion, quality of life and hypoparathyroidism-related biochemistries.
Rubin is an associate professor of medicine in the metabolic bone disease unit at the Vagelos College of Physicians & Surgeons at Columbia University Irving Medical Center.
The researchers defined impairment as fully demographically adjusted T-score less than 1.5 standard deviation in at least one cognitive domain or less than 1 standard deviation in two or more domains.
The study included 19 participants (median age, 49 years; 84% white) with hypoparathyroidism, of whom 17 were women and 18 had postsurgical hypoparathyroidism. All participants had at least a high school degree, while most worked in professional settings and three were on medications known to affect cognitive function or emotion.
Researchers reported impaired demographically adjusted NIHTB-CB cognition scores for 13 participants and noted that cognition scores were connected to self-reported perception of general health.
Processing speed was the most commonly impaired cognitive domain, with T-scores that were below or equal to 2 standard deviations among 32% of participants. Moreover, processing speed corresponded with serum calcium levels (P = .023) and inversely with serum phosphate levels (P = .042).
“This small pilot study suggests that impaired cognition might be present in hypoparathyroid subjects and may be associated with lower serum calcium and higher serum phosphate levels,” Rubin and colleagues concluded. “These preliminary data are hypothesis-generating and lay the groundwork for further investigation in a larger sample size involving comprehensive neuropsychological evaluation in hypoparathyroid patients and matched controls.”
The researchers further noted that a future direction is to assess whether duration of hypocalcemia and/or hyperphosphatemia correlate with more impaired cognitive function. “Identification of possible impairment could help with institution of targeted cognitive interventions to reduce symptom burden in this rare but debilitating disease,” they wrote.
Adults with thyroid eye disease and diabetes have a higher prevalence of diplopia, strabismus and sight-threatening disease compared with those without diabetes, according to study findings published in Endocrine Practice.
Lissa Padnick-Silver
“This study provides further evidence that thyroid eye disease is more severe in patients with diabetes. More frequent severity manifested in higher rates of optic neuropathy, perhaps because of greater optic nerve vulnerability stemming from diabetes-related vasculopathies,” Lissa Padnick-Silver, PhD, senior manager of medical affairs, publications and data management for Horizon Therapeutics, told Healio. “Further, thyroid eye disease patients with diabetes were noted to have less proptosis and more extraocular muscle involvement than patients without diabetes. To the best of our knowledge, this finding has not been previously reported and further study is warranted.”
Patients with thyroid eye disease and diabetes have a higher prevalence of diplopia than those with thyroid eye disease and no diabetes. Data were derived from Patel VK, et al. Endocr Pract. 2021;doi:10.1016/j.eprac.2021.11.080.
Researchers analyzed data from the Symphony insurance claims database on medical claims for 51,220 adults with Graves’ disease or thyroid eye disease from 2010 to 2015. Patients with a diagnosis of Graves’ disease or thyroid eye disease with data in Symphony for at least 2 years after diagnosis were included. Diabetes status was obtained from the database. Sight-threatening thyroid eye disease included those with optic neuropathy or exposure keratopathy.
Of the study cohort, 5.1% had type 1 diabetes, and 25.1% had type 2 diabetes. Adults with type 1 diabetes and type 2 diabetes had a higher prevalence of strabismus (type 1 diabetes, 25.4% vs. type 2 diabetes, 22.6% vs. no diabetes, 19.9%; P < .001) and diplopia (38.6% vs. 37.9% vs. 29.9%, respectively; P < .001) and a lower prevalence of proptosis (42.3% vs. 46.3% vs. 58.5%, respectively; P < .001) compared with those without diabetes.
Sight-threatening thyroid eye disease was reported in 11.7% of the study cohort. Patients with type 1 diabetes and type 2 diabetes had higher prevalence of sight-threatening thyroid eye disease compared with those without diabetes (13.3% vs. 12.8% vs. 11.2%, respectively; P < .001). In all diabetes subgroups, women were more likely to have sight-threatening thyroid eye disease than men.
Of the study cohort, 13.5% had at least one thyroid eye disease-related surgery. Patients without diabetes had a higher surgical rate compared with those with type 2 diabetes (14% vs. 12.3%; P < .001). Patients with type 2 diabetes had a higher rate of full-thickness keratoplasty compared with those without diabetes (1.9% vs. 0.7%; P < .001), whereas eyelid surgery rates were higher among those without diabetes compared with the type 2 diabetes group (58.8% vs. 54.9%; P = .007). Neither group had any significantly different surgery rates compared with those with type 1 diabetes.
“Knowing that thyroid eye disease patients with diabetes may be at an increased risk for optic nerve injury is important and may warrant closer monitoring and earlier referral to a thyroid eye disease specialist,” Padnick-Silver said. “Further, the finding that proptosis may be less common and muscle involvement more common indicates that patients with diabetes and Graves’ disease may require special attention and monitoring for visual and ocular muscle abnormalities characteristic of thyroid eye disease, particularly eye misalignment and double vision.”
Padnick-Silver said the next step in research could be a retrospective chart review with a larger population of people with thyroid eye disease both with and without diabetes.
“This would allow us to have more clinical details on these patients to better understand important factors about both the impact and interplay of diabetes and thyroid eye disease,” Padnick-Silver said.
Most children who undergo image-guided radiofrequency ablation for treatment of benign nonfunctional thyroid nodules have at least a 50% reduction in nodule volume 4 years after treatment, according to study data published in Thyroid.
“Radiofrequency ablation was effective in reducing the volume of benign nonfunctional thyroid nodules in children, providing significant symptomatic relief with a good safety profile during short- and long-term follow-up,” Xinguang Qiu, MD,of thedepartment of thyroid surgery at The First Affiliated Hospital of Zhengzhou University in China, and colleagues wrote. “Radiofrequency ablation should be considered as a beneficial, minimally invasive treatment modality for selected pediatric patients.”
Children undergoing radiofrequency ablation for the treatment of benign thyroid nodules had a mean volume reduction ratio of 65% or more at 3 months, 6 months and 1 year of follow up. Data were derived from Li L, et al. Thyroid. 2022;doi:10.1089/thy.2021.0454.
Researchers reviewed data from 62 patients aged 18 years or younger with benign thyroid nodules treated with radiofrequency ablation at The First Affiliated Hospital of Zhengzhou University from July 2014 to August 2017 (75.8% girls; mean age, 14.4 years). Participants underwent an ultrasonography prior to the procedure to evaluate thyroid nodule composition and symptoms and had follow-up 3, 6 and 12 months after treatment. After 1 year, follow-up visits were performed annually. Ultrasonography and laboratory tests were repeated at each follow-up visit. Volume reduction ratio was calculated to assess the extent of nodule volume reduction.
Of the study cohort, 54 children had one thyroid nodule requiring treatment, and eight had two thyroid nodules. At 3 months, the mean volume reduction ratio was 65.1%, and increased to 74.7% at 6 months and to 77.5% at 1 year. The mean volume reduction ratio was 60.3% at 2 years, 68.5% at 3 years and 55.1% at 4 years. Thirty-six nodules had strong echogenicity or hyperechogenicity at 3 months, and six retained these characteristics at 6 months.
Sixteen of the 70 nodules began to regrow after initial treatment. Of the regrowing nodules, 56.3% had a volume reduction ratio below 50%, indicating a loss in treatment efficacy. Of those that lost treatment efficacy, 66.7% became larger than before treatment. Three nodules underwent a second radiofrequency ablation and surgery was performed on two other nodules.
Children requiring treatment of bilateral nodules had a lower volume reduction rate (13.6% vs. 74.1%; P < .001), lower technical efficacy (56.3% vs. 90.7%; P = .001) and higher regrowth rate (68.8% vs. 9.3%; P < .001) compared with unilateral nodules.
“We found that bilateral nodules requiring treatment had lower volume reduction rates, lower therapeutic efficacy and higher rates of regrowth, and the presence of bilateral nodules was an independent factor related to efficacy and regrowth,” the researchers wrote. “The specific reason for these associations is unclear. In addition, such results have not been reported in adult studies. Thus, radiofrequency ablation may not be appropriate for the treatment of bilateral thyroid nodules in children.”
Nodules with a higher cystic component had a higher volume reduction ratio than those with a lower cystic component (72.4% vs. 46.7%; P = .001). Nodules with higher vascularity had a lower regrowth rate than those with low vascularity (12.1% vs. 32.4%; P = .043). In all, 4.8% of patients had complications from the procedure.
The researchers wrote that radiofrequency ablation provides benefits for many patients, but those who undergo the procedure require long-term follow-up and the lack of a pathological exam means providers can not rule out malignancy.
“This treatment requires specialized treatment centers, specialized equipment, and highly skilled and experienced physicians, so access to radiofrequency ablation may also be a barrier to its use,” the researchers wrote. “Therefore, we believe that radiofrequency ablation is more likely to be a complementary treatment modality to surgical treatment.”
During the past 2 decades, Endocrine Today has reported on the latest developments in treating thyroid cancer. For its 20thyear, the publication is taking a look back.
Twenty years ago, the options for treating differentiated thyroid cancer were much more limited than they are today.
Risk stratification, ultrasound neck mapping and molecular testing have paved the way for more precise management of thyroid cancer over the past 20 years.
When differentiated thyroid cancer was diagnosed 2 decades ago, most patients underwent a total thyroidectomy followed by radioactive iodine, regardless of the characteristics of the thyroid tumor or the patient.
Elizabeth H. Holt
“In the past, pretty routinely once we had a biopsy that came back indicative of cancer or looking like it could be a cancer, very often those patients would get the entire thyroid taken out,” Elizabeth H. Holt, MD, PhD, associate professor of endocrinology at Yale School of Medicine, told Healio.
Today, the treatment of thyroid cancer has been significantly altered. Advances in ultrasound neck mapping and molecular testing, in addition to updated risk stratification guidelines published by the American Thyroid Association in 2015, allow providers to take a more individual approach to managing thyroid cancer. This has led to less aggressive treatment for people with low-risk cancers.
“In the past, we sent every patient for total thyroidectomy plus radioactive iodine,” Arti Bhan, MD, FACE, division head of endocrinology at Henry Ford Health System, told Healio. “Risk stratification in differentiated thyroid cancer has changed and we now use information at the time of diagnosis and dynamic risk assessment during follow up, to determine extent of treatment.”
Other advances, such as molecular testing, have allowed even more individualized care in recent years. Elizabeth N. Pearce, MD, MSc, professor of medicine in the section of endocrinology, diabetes and nutrition at Boston University School of Medicine and an Endocrine Today Editorial Board Member, said providers better understand molecular drivers now than they did 20 years ago and can use this knowledge to prescribe treatment targeting specific mutations, particularly for people with more advanced cancer.
Despite these advancements, disparities exist in thyroid cancer treatment. Multiple studies have noted that Black adults have significantly fewer age-adjusted cases of thyroid cancer compared with white adults, but study results published in World Journal of Surgical Oncology in 2018 found that Black Americans had a 12% worse thyroid cancer survival rate compared with white Americans. Geography is also an issue, as a higher proportion of people treated by a low-volume surgeon have worse postoperative outcomes, according to study findings published in JAMA Otolaryngology – Head & Neck Surgery in 2016.
“Having access to a high-volume, experienced thyroid surgeon is critically important for the care of thyroid cancer patients,” Pearce told Healio.
Risk stratification changes treatment paradigm
In 2015, the ATA’s updated its guideline on thyroid cancer treatment outlined steps for risk stratification of patients with differentiated thyroid cancer and gave providers an important new tool when planning treatment. Although total thyroidectomy and radioactive iodine were commonplace for all patients with malignant thyroid cancer at the turn of the 21st century, the 2015 update, which were an update of the ATA’s original risk stratification guidelines published in 2009, advised health care professionals to categorize patients into low-, intermediate- or high-risk categories to construct a better treatment plan.
“By and large, low-risk patients don’t get recommended for radioactive iodine, even in cases where there may be small metastases in the lymph node of the central neck,” Holt, who is also and an Endocrine Today Editorial Board Member, said. “Triaging patients into those groups and using that information to inform whether to recommend radioactive iodine has been better standardized since 2015.”
Some people categorized with low-risk cancer may not have surgery or treatment immediately after risk stratification. Bhan noted that the guideline pushed providers more often toward monitoring low-risk patients.
Arti Bhan
“There’s a big movement toward active surveillance,” Bhan, who is also and an Endocrine Today Editorial Board Member, said. “In the peri-diagnostic period, if the cancer is categorized as very low risk, the choices range from careful monitoring or minimalistic surgical intervention. If the size of the tumor hasn’t changed, let’s watch these people over time.”
For those who undergo surgery, a total thyroidectomy is not necessarily a given. Neck mapping ultrasound gives providers a better idea of any local thyroid cancer progression and helps determine the extent of surgery needed.
“This helps us to know if there’s any disease in the lymph nodes in the lateral neck,” Holt said. “In the past, it wasn’t routine that everyone would get that screening. That helps to plan the surgery and tells us whether they need more extensive surgery.”
Fine-needle aspiration is used to determine malignancy of thyroid nodules for most adults. However, about 15% of nodules are found to be cytologically indeterminate after the procedure. In the past, those with indeterminate nodules would have undergone diagnostic thyroid lobectomy to determine malignancy. The need for that has been greatly reduced with the advent of molecular testing, a process that identifies genomic or gene expression changes in thyroid biopsy samples.
“Using a combination of mutations and RNA expression changes, they are able to identify the risk of the patient based on a molecular profile,” Holt said. “They can tell you that this is a 3% risk for cancer, which is comparable to the risk you would get with a benign biopsy on cytopathology, or they might tell you there’s a 70% to 80% risk this is a cancer. That helps to determine who needs to go to surgery and who can be monitored with serial ultrasound.”
Using molecular testing to determine malignancy risk has helped to reduce the number of patients undergoing surgery. Holt noted that before molecular testing, most patients with cytologically indeterminate nodules who underwent diagnostic lobectomy ultimately were found to have benign surgical pathology and therefore had not needed surgery.
Molecular testing also plays a role in monitoring some patients after thyroidectomy, according to Bhan.
“If the patient has a high-risk mutational profile, particularly mutational combinations associated with higher risk of recurrence, then it is reasonable to consider more careful follow-up or more aggressive therapy,” Bhan said. “Molecular testing can also be used for patients with radioactive iodine refractory cancer metastatic disease, to guide choice of therapy.”
Understanding cancer mutations has also improved the prognosis for those with anaplastic thyroid cancer, a rarer but much more aggressive form of cancer compared with differentiated thyroid cancer. According to study data published in JAMA Oncology in 2020, the median overall survival rate of anaplastic thyroid cancer for those diagnosed from 2000 to 2013 was 35% 1 year after diagnosis. That rate increased to 47% for those diagnosed from 2014 to 2016 and to 59% for those diagnosed from 2017 to 2019.
Elizabeth N. Pearce
“Very recently, with the advent of some of these targeted therapies for specific mutations, knowing the mutation that drives the anaplastic cancer has allowed for at least some patients to receive systemic therapies to provide a meaningful prolongation of life,” Pearce said. “That is, in itself, huge.”
Disparities in access to care
With these advancements in management, mortality rates for thyroid cancer have remained flat to very modestly elevated in recent years even as incidences of thyroid cancer continue to increase globally. However, some populations remain vulnerable, particularly those without access to an experienced surgeon.
“People who get their surgery from a non-high-volume surgeon tend to not do as well,” Holt said. “If they live outside of a major center, they may get their surgery from somebody who doesn’t operate for thyroid cancer often. If the preop evaluation or surgery are incomplete the patient may have a higher likelihood of recurrence and need for more and riskier surgery down the road.”
The lack of access is not only a geographical issue, according to Pearce.
“There are pretty good data, unfortunately, that Hispanic and Black patients in the U.S. are more likely to see the low-volume surgeons, who do one to nine cases a year, as opposed to the high-volume surgeons, who do more than 100,” Pearce said. “That manifests as worse outcomes for the thyroid cancer, and also in the acute setting, longer hospital stays and higher risk of complications and mortality from the surgery itself.”
Future movement in care should focus on improving access, according to Holt. She said providers need to identify which patients should be referred to a larger center with a high-volume surgeon based on their cancer severity. Additionally, providers should explore ways to assist patients who may struggle to find transportation to a high-volume surgeon a long distance from their home.
From 2000 to 2018, use of radioactive iodine therapy in papillary thyroid cancer treatment greatly declined in favor of total thyroidectomy alone without radioactive iodine or lobectomy, according to study data.
Cari M. Kitahara
“Since we now know that many low-risk thyroid cancers can be managed effectively with less aggressive approaches, often with the same or better outcomes, the American Thyroid Association guidelines strongly recommend less or no radioactive iodine and lobectomy instead of total thyroidectomy for thyroid cancers without aggressive features,” Cari M. Kitahara, PhD, senior investigator in the division of cancer epidemiology and genetics at the National Cancer Institute, told Healio. “For the first time, the 2015 guidelines listed active surveillance as a viable option for some very low-risk thyroid cancers. Our results showed that physicians have been quick to adapt to these changing practice guidelines. In particular, we saw a clear shift away from radioactive iodine therapy for smaller papillary thyroid cancers.”
The use of radioactive iodine therapy with a total thyroidectomy in the treatment of papillary thyroid cancer in the U.S. greatly declined from 2000 to 2018, reflecting changes in ATA guidelines. Data were derived from Pasqual E, et al. Thyroid. 2022;doi:10.1089/thy.2021.0557.
Kitahara and colleagues analyzed data from 18 Surveillance, Epidemiology and End Results (SEER) cancer registries. People diagnosed with primary papillary thyroid cancer between 2000 and 2018 were included in the analysis. The cohort was classified by treatment type: total thyroidectomy followed by radioactive iodine, total thyroidectomy alone, lobectomy, no surgery or other/unknow therapy. Trends by tumor size were analyzed, and for those with a tumor smaller than 4 cm, cases were stratified by age, sex, race and ethnicity, the patient’s residence at diagnosis and insurance status.
The findings were published in Thyroid.
There were 105,483 patients diagnosed with papillary thyroid cancer during the study period, with 98% having a tumor of less than 4 cm and 50% having a tumor of less than 1 cm.
For those with a tumor smaller than 4 cm, the use of radioactive iodine after a total thyroidectomy increased from 35% in 2000 to 38% in 2006 before dropping to 18% in 2018. The percentage of participants having a total thyroidectomy alone increased from 35% in 2000 to 54% in 2018. Lobectomy increased from 17% in 2015 to 24% in 2018. No measurable changes in treatment were observed for those with a tumor 4 cm or larger.
Kitahara said it was surprising to see lobectomy use increase only slightly with the changes in ATA recommendations. Additionally, the use of nonsurgical management remained at less than 1% during the entire study period.
“There may be some hesitation on behalf of both physicians and patients to use less aggressive therapeutic approaches,” Kitahara said. “Some physicians may not be convinced of their overall safety and waiting for more evidence, and some patients may prefer more aggressive therapies because they are worried about recurrence or metastasis. Also, active surveillance is a fairly new approach in thyroid cancer management, and so it may take some time before we see more widespread acceptance. There are still some practical issues with active surveillance, including uncertainty about the cost-effectiveness, and the need for long-term monitoring.”
Before 2010, radioactive iodine after total thyroidectomy was more common for younger people than older adults, peaking at 60% in 2009 for adolescents younger than 20 years. By 2018, radioactive iodine use was below 20% in all age groups and lowest for adolescents at 11%. Radioactive iodine use was highest among Asians/Pacific Islanders and Hispanic patients and lowest for non-Hispanic Black patients.
With the ATA developing another update to its thyroid cancer treatment guidelines, it will be important to continue monitoring trends to see what impact on clinical practice the updates will have, Kitahara said.
“More research is also needed to understand reasons for departures from the treatment guidelines, including physician and patient preferences and other barriers to less aggressive therapeutic options,” Kitahara said.
Low levels of bombardment reveal that the TRAPPIST-1 system probably grew quickly
Like many planets, bombardment from space rocks and other debris influenced the formation of the planets of the Trappist-1 system. Credit: Dimitar Todorov / Alamy Stock Photo
Some of the best movies are origin stories. When we know where a superhero is coming from, then we can understand why they do what they do. The same goes for planets: knowing how they formed is key in understanding their internal structure, geology and climates. We know a lot about how Earth formed from decades of analyzing meteorites and lunar rocks. We think the final phases of Earth’s growth involved titanic collisions, the last of which spun out a disk of vaporized rock that coalesced into the moon.
But what about the thousands of planets we’ve found around other stars; did they form like Earth? Answering this question may seem hopeless because we’ll never have rocks from those planets to analyze. But there may be another way, and this way is important because it gives us the rare opportunity to compare our planet’s origins story with those of rocky exoplanets.
In a recent study published in Nature Astronomy, we used the orbital architecture of a system of exoplanets to figure out how planets might form, using the TRAPPIST-1 system as an example. This system is iconic among exoplanets: it contains seven known planets, each close to Earth’s size and three of which receive a similar amount of energy from their tiny red star as Earth does from the Sun.ADVERTISEMENT
For the purpose of our analysis, a key feature of TRAPPIST-1 is orbital resonance. After a specific number of orbits, each pair of neighboring planets realigns. For example, among the outer pair of planets, called g and h, orbital alignment repeats every three orbits of planet g and two orbits of planet h; this is a 3:2 resonance. Each adjacent pair is in a similar resonance. Together, all seven planets participate in this orbital dance, forming a resonant chain.
In paintball, each time a person is hit, the impact leaves behind a blob of paint, so you can tell at a glance how often any player gets shot. Likewise, the surfaces of planets and moons retain the signs of impacts; when an object from space crashes down, it explodes and leaves behind a crater. You can see the biggest craters on the Moon by eye; Tycho is one of the most dramatic.
We wanted to figure out how much space junk—meaning, leftover asteroids and comets—could have bombarded the TRAPPIST-1 planets. A key piece of our study was to calculate exactly how fragile the system’s orbital resonances are. It turns out the resonances are extremely easy to break. When an asteroid or comet collides with a planet, or even just passes close by, the planet’s orbit shifts a little. Add up a few of these shifts and the orbits of neighboring planets are spread apart enough far enough to lose their resonance. From that point onward, they can never realign again.
Using orbital simulations, we determined how much space junk would have collided with each TRAPPIST-1 planet if the system’s resonances had been lost. Of course, TRAPPIST-1’s resonances were not lost; they have survived for billions of years since the planets formed, and we observe them today. TRAPPIST-1 is like a paintball player wearing an outfit that’s still almost perfectly clean. Our simulations show us the “worst-case scenario”; the maximum amount of material that could have impacted any of the TRAPPIST-1 planets since they formed is tiny (in cosmic terms), less than 1 percent of Earth’s mass. Any more than that would have permanently disrupted the resonances we see today.
Because there were so few impacts, the TRAPPIST-1 planets must have grown much faster than Earth. Resonances like TRAPPIST-1’s form by orbital migration, as the growing planets’ orbits slowly shrink by interacting with the gaseous planet-forming disk. Once the disk is gone, resonances can break but they cannot re-form. So, the TRAPPIST-1 system must have been fully formed within the lifetime of its star’s disk—just a few million years. There was at most a gentle bombardment over the ensuing billions of years.ADVERTISEMENT
In contrast, analysis of Earth and moon rocks indicates that the planet-sized collision that formed the moon took place about 100 million years after the start of solar system formation. The TRAPPIST-1 planets may well have experienced such giant collisions, but only very early in their histories, before the resonant chain was set in stone. We don’t fully understand how these different formation pathways affect the internal evolution, geology and climate of the TRAPPIST-1 planets as compared with Earth, but it’s an active area of study. For instance, it’s possible that their rapid growth would greatly increase the amount of water that could be stored within rocks in the planets’ interior, but decrease the amount that could remain as surface oceans.
Our study borders the controversy-ridden waters of what objects should be called “planets.” Following the International Astronomical Union’s definition, the factor that was used to demote Pluto to the status of “dwarf planet” was that it has not cleared the neighborhood around its orbit of space junk. Rather, Pluto orbits within the Kuiper belt of ice-rich cometlike objects. Our simulations show that no substantial population of space junk can remain in the TRAPPIST-1 system. Each of these seven objects therefore deserves to be called a planet.
For now, we can only apply our new technique to the handful of other systems, the resonant chains with nearly clean paintball jerseys. Yet these are some of the most interesting systems that we know from both an orbital point of view and because one theory proposes that almost all planetary systems spend some time as a resonant chain (although very few resonant chains survive). Understanding the bombardment histories of planets in these systems is a first step toward telling the origins stories of other worlds.
There are no individual saviors for Tonga’s Internet infrastructure
Massive mushroom cloud blasts volcanic ash from the violent eruption of the underwater Hunga Tonga–Hunga Haʻapai volcano in Tonga captured by the GOES-West satellite over the South Pacific Ocean on January 15, 2022. Credit: NOAA/Alamy Stock Photo
The undersea cable connecting Tonga to the global Internet and phone systems was finally restored in late February. The archipelagic nation’s access had been cut off since January 15, when the largely submerged Hunga Tonga–Hunga Ha‘apai volcano unleashed a gargantuan blast and tsunami. Powerful underwater currents, perhaps triggered by the volcano’s partial collapse, severely damaged a 50-mile stretch of the 510-mile-long undersea cable that linked Tonga to the rest of the world.
Parts of the government-owned cable were cut into pieces, while other sections were blasted several miles away or buried in silt. This left most of Tonga’s 105,000 residents isolated (aside from a handful of satellite-linked devices called “Chatty Beetles” that could transmit text-based alerts and messages). When it became clear this would last more than a month, a controversial figure stepped in: In late January Elon Musk, billionaire CEO of Tesla and SpaceX, tweeted, “Could people from Tonga let us know if it is important for SpaceX to send over Starlink terminals?” Musk’s offer of this satellite Internet connectivity equipment appeared to be well-received by Tongans reeling from the disaster. Almost immediately, the company flew a team of its engineers to the remote Pacific islands.
At a glance, providing the stricken country with another way to access the Internet in the longer term—aside from a vulnerable undersea cable—seems like a helpful development. And it is not the only occasion when Starlink has offered its service in the wake of disaster or disruption. In 2020 the company also sent Washington State seven terminals, small dish antennas that communicate with Starlink satellites in orbit, to use during wildfire season for free. This gave besieged residents and emergency responders vital Internet access, says Steven Friederich, a public information officer at the Washington Military Department. And on February 26 Musk said on Twitter that Starlink service is now active in war-torn Ukraine. (Specific details about the company’s work in the region remain somewhat scarce, but Starlink terminals have been delivered to the nation, and civilians on the ground are reporting that the Internet service is operational.)
Like SpaceX’s other interventions, the offer of Starlink services to postdisaster Tonga certainly has an altruistic element to it. But as other coverage has noted, providing Starlink Internet access to Ukraine is not as straightforward as it seems, and doing so will not end the country’s connectivity issues in the middle of a fight for its survival. For different reasons, SpaceX’s offer to Tonga is also not without complications. Adding another way to access the Internet in the event of a future disaster is obviously welcome. But the decision also benefits the company by helping it move into a new (and vulnerable) market, all while giving Starlink—whose highly reflective satellites have angered many astronomers, among others—a decent public relations boost.
When it comes to Tonga, the awkward mixture of Starlink pros and cons has made some observers wary. “They’re not a charity. They’re not doing this out of the goodness of their hearts,” says Samantha Lawler, an astronomer at University of Regina in Saskatchewan, who has spent the past few years closely monitoring Starlink’s proliferation. “They’re doing this for profit.” (At press time, SpaceX has not responded to requests for comment.)
Given the historical vulnerability of Tonga’s undersea cable (in 2019 a ship’s anchor damaged it and briefly cut off Internet access), a dedicated connection using satellites sounds like a great fit. And Starlink is not the only satellite Internet provider moving into the region. About two weeks after the eruption damaged the undersea cable, Tongan authorities cleared Kacific, a Singapore-based broadband satellite operator, to offer its own services to the country, and it is now starting to roll them out to customers. This type of system works a little differently than Starlink: A customer’s small dish antenna listens to and talks with the geostationary Kacific1 satellite. Kacific1, in turn, communicates with one of three ground stations, or “teleports”—larger dishes located in Australia, Indonesia and the Philippines. A customer’s Internet connection works so long as the Kacific1 satellite can “see” one of these three ground stations and the customer’s own dish. As this satellite hangs out at a very high altitude (about 22,400 miles), pretty much anyone with a dish in the Asia-Pacific region is within range.
Geostationary satellites such as Kacific’s generally offer a slowerInternet connection, compared with the low-altitude orbits used by Starlink, however. The latter’s system relies on a ground station called a “gateway,” which is physically wired into the nearest data center or router connected to the global Internet via underground fiber-optic cables. This gateway then beams Internet data from the rest of the world to Starlink satellites, which send the information to small individual dishes, or terminals, on people’s properties. After the recent eruption damaged Tonga’s undersea cable, the country lost its ground-based Internet access—so a gateway could not be set up in Tonga itself. Instead SpaceX chose nearby Fiji as the spot to build a temporary gateway, says Ulrich Speidel, a computer science and data communications specialist at the University of Auckland in New Zealand. Last month Fiji’s communications minister Aiyaz Sayed-Khaiyum announced on Twitter that a “SpaceX team is now in Fiji establishing a Starlink Gateway station to reconnect Tonga to the world.” But little else seems to be known about SpaceX’s efforts. “We had received information from Starlink a few weeks ago regarding their attempt to provide Internet connectivity to the country via Fiji, but so far there’s no development on that. Starlink has been silent since then, and I don’t know why,” says an engineer at Tonga Cable, who wishes to remain anonymous. (At the time of this writing, Sayed-Khaiyum’s office has not responded to requests for comment.)
Fiji may not be an ideal location for the gateway serving Tonga because Starlink satellites in lower orbits cannot receive Internet data from a very distant ground station, Speidel explains, only from one within their relatively restricted view. It has previously been reported that to use Starlink, one’s antenna must be within 500 miles of a ground station. But Speidel says people usually have to be closer—within 180 to 250 miles—to get a high-quality Internet connection. And the new gateway in Fiji is about 500 miles away from Tonga. Speidel notes that future Starlink satellites will use lasers to relay Internet data among one another, meaning they will not all need connections to nearby ground stations in the years to come. But for now, because of this gateway’s distance from Tonga, it remains unclear how effective the Fiji gateway will be for Tonga’s people. As Musk tweeted on February 25, “Starlink is a little patchy to Tonga right now, but will improve dramatically as laser inter-satellite links activate.”
More generally, various satellite Internet systems share similar vulnerabilities. For example, volcanic ash—a layer of which blanketed parts of Tonga following the latest eruption—can cover up and damage satellite dishes. Solar activity can knock outsatellites in orbit. “Even if we got every household in Tonga a Starlink terminal, we still have to plan for outages,” says Ilan Kelman, a researcher at the Institute for Risk and Disaster Reduction at University College London.
Satellite access is also slower and often more expensive than cable Internet, notes Nicole Starosielski, an associate professor of media, culture and communication at New York University. “Most places in the world wouldn’t use satellites if they had access to a cable,” she says. Cables may be vulnerable to damage but can usually be repaired relatively quickly. (In Tonga’s case, a fix was delayed because the nearest cable repair ship was moored in Papua New Guinea’s Port Moresby, nearly 2,500 miles away, when disaster struck.) Regardless, “once they fix the cable, it will be as good as new. They do a really good job with repairing cables,” Starosielski says. Instead of backing up the original cable with Starlink, she recommends supporting it with another undersea cable laid down along a different route, which is “the norm for most parts of the world.”
But a second undersea cable would be a costly option for Tonga—and could still be disrupted. “Even with the backup cable, I’m in no doubt that satellite-based Internet is a must-have at all times, given our geographical position is highly vulnerable to volcanic activities,” says the Tonga Cable engineer. Of all the satellite options, he thinks Starlink would be best, “if they’re willing to help with the costs of expensive satellite capacity and subscription.”
Things are off to a generous start—regional news has reported that 50 Starlink satellite terminals have been donated to Tonga, and other news suggests that, for now, Starlink services will be offered for free. But this situation will only last until another damaged submarine cable—a system that funnels the Internet between Tongatapu (the main island of the archipelagic nation) and the outlying islands—is also replaced. This task may take until the year’s end to complete, and after that, it appears that Starlink will begin charging for its services. And they are not cheap: subscriptions are $99 per month, and setting up the mountable satellite dish and router costs $499. If the standard pricing system does not change in this instance, then it may not be affordable for many in Tonga, a nation in disaster recovery mode.
That members of the private sector, including SpaceX, have been able to get a foot in the door in stricken Tonga in the wake of troubles with its state-run undersea Internet cable is not an entirely unexpected development. Nor is it inherently concerning. “But since they’re profit-making, there’s no reliability,” Kelman says. “If they’re suddenly not making a profit from Tonga, they will pull out. If they suddenly decide they’re changing from $99 a month to $300 a month, they will do it.”
High prices are not the only consideration regarding satellite Internet. The unintentionally reflective nature of SpaceX’s 2,000 or so Starlink satellites—a number that, if no legal restrictions are introduced, is set to increase exponentially in the coming years—has not only disrupted ground-basedastronomy efforts. It has also added a prominent source of light pollution for certain cultures, including some of Polynesian descent, for whom stargazing plays a key role. Some consider this a desecration of a communal space. “In addressing one natural disaster on Earth, we don’t want to create another in space,” says Aparna Venkatesan, a cosmologist at the University of San Francisco, who assesses the cultural impact of satellite “megaconstellations” like Starlink.
Ultimately Tonga’s Internet connectivity troubles cannot be resolved by choosing between a state-owned undersea cable and satelliteInternet from the private sector. “You do need both,” says Jacques-Samuel Prolon, executive vice president of Kacific. A diversity of Internet options may be needed. Future-proofing places like Tonga will likely require a team effort, involving an array of partners both domestic and international, public and private. There are no individual saviors in this story.
Did you know that traumatic brain injury (TBI) can cause epilepsy and seizures? Learn the signs and how to protect your health.
A traumatic brain injury (TBI) happens when someone gets a bump, blow, or jolt to the head, or a penetrating injury to the head (such as a gunshot).1 TBIs can range from mild (such as concussions) to severe, life-threatening injuries. They can cause changes in:
Thinking and remembering. Vision and balance. Emotions, such as anxiety, irritability, or sadness. Sleep.2 TBIs can happen to anyone, but some groups are at greater risk of dying or having long-term health problems after the injury.1 These groups include racial and ethnic minorities, service members and veterans, people experiencing homelessness, people in correctional and detention facilities, survivors of intimate partner violence, and people living in rural areas.1
TBIs can also cause epilepsy and seizures Epilepsy is a broad term used for a brain disorder that causes repeated seizures. There are many types of epilepsy and there are also many different kinds of seizures. TBIs can cause a seizure right after the injury happens or even months or years later. Researchers agree that the more severe the TBI, the greater the chance the person may develop epilepsy.3 Age and other medical conditions may also play a role in whether or not a person may develop epilepsy after a TBI.
The terms post-traumatic epilepsy (PTE) and post-traumatic seizures (PTS) are both used to describe seizures that happen because of a TBI.4 In 2018, there were about 223,050 hospitalizations for TBI in the United States.5 A CDC-funded study found that among people aged 15 years and older hospitalized for TBI, about 1 out of 10 developed epilepsy in the following 3 years.3
Everyone can: Learn the signs and symptoms of TBI and when to seek medical care. Take the CDC’s HEADS UP training to learn how to recognize, respond to, and minimize the risk of concussion or TBI – especially if you’re a parent, coach, child care provider, or school professional. If you or someone you care for has a head injury, here’s what you need to know: Seek medical attention and share information about TBI signs and symptoms. Talk to the doctor about the risk for having seizures or developing epilepsy after a TBI. Learn to recognize the signs of a seizure. Sometimes it can be hard to tell. Some seizures cause a person to fall, cry out, shake or jerk, and become unaware of what’s going on around them. Other seizures can make a person appear confused, make it hard for them to answer questions, twitch, or cause the person to feel like they taste, see, or smell something unusual. Learn first aid so you are prepared if someone has a seizure. To prevent TBIs that may cause epilepsy, protect your brain from injury. For example: Use seat belts and properly installed car safety seats every time you drive or ride in a motor vehicle. Never drive while under the influence of alcohol or drugs. Wear a helmet when playing certain sports and riding bikes, horses, motorcycles, or all-terrain vehicles. Prevent falls, especially in older adults and young children. An older woman is sitting on the ground, holding her head, and looking distressed.
Always wear a helmet when riding a bike to prevent head injuries!
A boy and his dad smile while wearing helmets and sitting on their bikes.
If you or someone you care for has had a head injury, talk to a doctor about the risk of seizures and epilepsy.
More Information CDC Epilepsy Program CDC Traumatic Brain Injury & Concussion References Centers for Disease Control and Prevention. Get the Facts About TBI website. Accessed January 31, 2022. https://www.cdc.gov/traumaticbraininjury/get_the_facts.html Centers for Disease Control and Prevention. Symptoms of Mild TBI and Concussion website. Accessed January 31, 2022. https://www.cdc.gov/traumaticbraininjury/concussion/symptoms.html Ferguson PL, Smith GM, Wannamaker BB, Thurman DJ, Pickelsimer EE, Selassie AW. A population-based study of risk of epilepsy after hospitalization for traumatic brain injury. Epilepsia. 2010;51(5):891–898. doi: 10.1111/j.1528-1167.2009.02384.x Frey LC. Epidemiology of posttraumatic epilepsy: a critical review. Epilepsia. 2003;44(10):11–17. doi:10.1046/j.1528-1157.44.s10.4.x Centers for Disease Control and Prevention. TBI Data website. Accessed January 31, 2022. https://www.cdc.gov/traumaticbraininjury/data/index.html
March is National Nutrition Month, and the U.S. Food and Drug Administration is shining a spotlight on the importance of good nutrition and the big impact it has on improving people’s lives and lowering the enormous costs of diet-related chronic diseases. Each year, more than a million Americans die from diet-related diseases like cardiovascular disease, diabetes and certain forms of cancers. In 2020 alone, an estimated 800,000 people died from cardiovascular disease, an even greater number than the horrific toll of COVID-19 during that same year. And obesity, which is both a disease and a condition that increases the risk for other diet-related chronic diseases, has increased to historic levels in children and adults during the COVID-19 pandemic.
Susan T. Mayne, Ph.D.
The FDA also knows that racial and ethnic minority groups as well as those living at a lower socioeconomic level are disproportionately affected by diet-related chronic diseases. For example, more than 4 in 10 American adults have high blood pressure, but that number increases to about 6 in 10 for non-Hispanic Black adults. Additionally, American Indians and Alaska Natives are diagnosed with diabetes, primarily Type 2, at higher rates than other race-ethnicity groups.
Improving nutrition can turn the tide on the unacceptably high rates of diet-related diseases and deaths in the U.S., saving lives, improving quality of life, and reducing health care costs. We recommend that consumers eat more fruits, vegetables, low-fat dairy products, whole grains, and healthy oils. They also should consume less sodium, saturated fat and added sugars. To help consumers make better food choices, the FDA is ramping up its food labeling and broader nutrition education efforts. We are also redoubling our work on a healthier food supply, working with key partners and stakeholders to improve the food environment so consumers have more healthy food choices.
Sodium Reduction Targets and Food Labeling
The FDA took a very big step in supporting a healthier food supply in October 2021 when we established voluntary short-term sodium reduction targets for commercially processed, packaged, and prepared foods. Consumers typically take in far more sodium than is healthy, and excess sodium consumption is directly linked to hypertension, a leading risk factor for heart attacks and stroke. Most of the sodium comes from processed, packaged, and prepared food, and encouraging sodium reduction across the food supply will make it easier for consumers to access lower-sodium options. The FDA is also looking at our standards of identity – which are like recipes with criteria that certain foods must meet – to see what changes could lead to a healthier food supply.
Food labeling is another tool in the agency’s toolbox that we are employing to create a healthier food supply and empower consumers with information. After the FDA required trans fat to be declared on the Nutrition Facts label, there was an 80% reduction in trans fat in the food supply. Experts have said that this led to prevention of tens of thousands of cases of cardiovascular disease and saved numerous lives. This powerful example underscores the impact of food labeling and how it can lead to enormous public health benefits. The agency has updated the Nutrition Facts label requirements to be more consistent with current nutrition advice. For example, one change that was made requires companies to declare added sugars, which we believe will encourage some companies to reformulate existing food products or create healthier ones. We also now require calories to be listed on certain menus and menu boards to help consumer know what they are consuming away from home.
Our immediate priority in labeling is to make it easier for consumers to identify foods that are part of a healthy eating pattern. The FDA has several initiatives underway to do this. We are updating the nutrient content claim definition for when “healthy” can be used on a food package. Nutrition science has evolved since we first established the claim in the early 1990’s. Along with helping consumers better identify foods that help them build a healthy dietary pattern, the updated definition could also provide an incentive to industry to reformulate so their products can bear the “healthy” claim.
The FDA is also conducting consumer research on a potential “healthy” symbol that would act as a quick signal for busy consumers. In addition, we are working on draft guidance on dietary guidance statements, for example statements about whole grains in a product. The guidance will give best practices for the use of such statements on food labels to describe the role a food or food group plays in a nutritious dietary pattern.
Healthier Diets for Young Children and Addressing Toxic Elements
The FDA is expanding our work to help establish the healthiest diets in young children. Focusing on younger populations is critical because healthy dietary patterns early in life can influence the trajectory of eating habits and health behaviors throughout life. We are taking a holistic approach that encompasses some of our work on reducing toxic elements in infant and toddler food set out in our Closer to Zero Action Plan.
There is great value in addressing toxic elements and nutrition together in young children because many foods that can be higher in toxic elements, such as fruits and vegetables, are also the very foundation of life-long healthy eating patterns. There is much we can do to mitigate exposure to these elements – to as close to zero as possible – for example, by setting action levels. We intend to publish guidance documents this year on action levels in foods commonly consumed by babies and young children.
We also published, in coordination with the U.S. Environmental Protection Agency, updated advice to help those who might become pregnant, are pregnant or breastfeeding, and parents and caregivers who are feeding children, make informed choices about fish that are nutritious and safe to eat. Seafood provides beneficial fatty acids and other nutrients that can help children’s growth and development. The FDA continues to develop a variety of educational materials to enhance the ability of consumers to be aware of the advice and to encourage the consumption of seafood that is lower in mercury.
This is just a snapshot of our nutrition work. The FDA continues to work with our federal partners to create a healthier food supply, empower consumers to choose healthier diets and establish healthy eating habits early. We’re excited about the work we are doing now and the opportunities ahead to help turn the tide on diet-related chronic disease and improve health equity.
Removal of obstructive jaundice in metastatic pancreatic cancer is an important part of palliative therapy. However, it is not known whether invasive procedures reduce cancer-related mortality. In this study, the effect of palliative biliary drainage on survival outcomes in pancreatic cancer patients was evaluated.
Methods
Patients diagnosed with pancreatic cancer and undergoing biliary drainage in two different centers between 2010 and 2019 were evaluated retrospectively.
Results
Biliary drainage was applied to 73 patients, constituting 20.6% of 355 patients included in the study. The median progression-free survival (PFS) of patients with biliary stent was 5 months, while the median PFS of patients without stenting was 5.5 months and the median overall survival (OS) was 11.1 and 11.5 months, respectively (p: 0.424, p: 0.802).
Conclusions
A positive effect of palliative biliary drainage on median PFS and OS could not be demonstrated in our study group. In pancreatic cancer, predictive markers are needed to select patients who can derive a survival benefit from biliary drainage.
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