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Foot OA: Forgotten no longer
TORONTO – Foot osteoarthritis has been a relatively neglected topic by researchers – but that’s finally changing, Michelle Marshall, PhD, observed at the OARSI 2019 World Congress.
She was a coinvestigator in the groundbreaking Clinical Assessment of the Foot (CASF), a large prospective study that has brought new insights into the prevalence of foot osteoarthritis (OA), its risk factors, the sizable disease burden, and foot OA’s diverse phenotypes. She shared study highlights at the meeting, which was sponsored by the Osteoarthritis Research Society International.
Elsewhere at OARSI 2019, Lucy S. Gates, PhD, presented the eagerly awaited results of the Chingford 1000 Women Study of the progression pattern of symptomatic radiographic OA of the first metatarsophalangeal joint (MTPJ). With 19 years of follow-up, Chingford is far and away the largest and longest longitudinal study of first MTP joint OA.
The prospective, population-based, observational cohort CASF study was carried out by Dr. Marshall and her coinvestigators at Keele University in Staffordshire, England. They surveyed Staffordshire residents aged 50 and older regarding whether they had experienced foot pain within the last 12 months. Those who answered affirmatively were invited to come in for a more detailed assessment and get weight-bearing x-rays of both feet. Among the 557 symptomatic participants with foot x-rays, the prevalence of radiographic OA of the foot was 16.7%, or roughly one in six – underscoring that it’s a common condition. The first MTP joint was the most commonly affected site, with a prevalence of 7.8%, followed by the second cuneometatarsal joint (CMJ) at 6.8%, the talonavicular joint (TNJ) at 5.2%, the navicular first cuneiform joint (NCJ) at 5.2%, and the first CMJ at 3.9%. Three-quarters of those who had symptomatic radiographic foot OA reported disabling symptoms, an established risk factor for falls (Ann Rheum Dis. 2015 Jan;74[1]:156-63).
With an eye toward identification of potential distinct phenotypes of foot OA, the CASF investigators conducted a separate analysis of those study participants with symptomatic radiographic midfoot OA – that is, OA of the TNJ, NCJ, and/or first or second CMJs, but not the first MTP joint. The prevalence in the Staffordshire population over age 50 with a history of foot pain was 12%. Independent risk factors for midfoot OA included obesity, with an adjusted odds ratio of 2.0; pain in other weight-bearing lower limb joints, with an adjusted odds ratio of 8.5; diabetes, odds ratio of 1.9; and previous foot injury, with an associated 1.6-fold increased risk. Midfoot OA was most prevalent in women older than 75 years; however, contrary to the conventional wisdom, a history of frequently wearing high-heeled shoes posed no increased risk.
The burden associated with midfoot OA was reflected in affected individuals’ frequent use of health care resources: During the past year, 46% of them had consulted their primary care physicians about their foot pain, 48% had been to a podiatrist, and 19% had seen a physical therapist (Arthritis Res Ther. 2015 Jul 13;17:178. doi: 10.1186/s13075-015-0693-3).
In a separate analysis, the investigators compiled additional evidence from CASF pointing to the existence of two phenotypes of foot OA: isolated first MTP OA and polyarticular foot OA, with distinct risk factors and symptom profiles (Arthritis Care Res [Hoboken]. 2016 Feb;68[2]:217-27).
“We found that OA affected both feet significantly more than was expected by chance, and we identified strong symmetrical patterns. This mirrors findings in hand OA and implies involvement of systemic components within a foot,” Dr. Marshall said.
The course of foot OA
During 18 months of prospective follow-up in CASF, subjects with isolated first MTP joint or polyarticular foot OA showed no clinically meaningful change in symptoms (Arthritis Care Res [Hoboken]. 2018 Jul;70[7]:1107-12).
But that finding may have been a function of the relatively brief follow-up, as the Chingford 1000 Women Study, with its 19 years of prospective follow-up, told a different story. Dr. Gates, of the University of Southampton (England), reported that among the 193 patients with foot x-rays at both baseline and follow-up, by which point they averaged nearly 76 years in age, 33.2% had OA of the first MTP joint of either foot at baseline as defined by at least a grade 2 score on the LaTrobe foot atlas, and 13% had prevalent involvement of both feet. During 19 years of follow-up of the women from Chingford, an area in northeast London, the incidence of new-onset radiographic first MTP joint OA was 7% in the left foot and 17% in the right. Meanwhile, progression to grade 3 radiographic OA occurred in the left foot of 28% of those with grade 2 disease at baseline and in 35% of those with baseline first MTP joint OA of the right foot. Twenty-eight percent of patients with unilateral first MTP joint OA at baseline progressed to bilateral involvement within 19 years.
Dr. Gates reported having no financial conflicts regarding the Chingford study, funded primarily by Arthritis Research UK, which merged with Arthritis Care in 2018 to form Versus Arthritis.
Similarly, Dr. Marshall reported no financial conflicts regarding CASF, also funded by Arthritis Research UK.
SOURCES: Marshall M. Osteoarthritis Cartilage. 2019 Apr;27[suppl 1]:S16, Abstract I-8 and Magnusson K et al. Osteoarthritis Cartilage. 2019 Apr;27[suppl 1]:S260-S261, Abstract 367.
TORONTO – Foot osteoarthritis has been a relatively neglected topic by researchers – but that’s finally changing, Michelle Marshall, PhD, observed at the OARSI 2019 World Congress.
She was a coinvestigator in the groundbreaking Clinical Assessment of the Foot (CASF), a large prospective study that has brought new insights into the prevalence of foot osteoarthritis (OA), its risk factors, the sizable disease burden, and foot OA’s diverse phenotypes. She shared study highlights at the meeting, which was sponsored by the Osteoarthritis Research Society International.
Elsewhere at OARSI 2019, Lucy S. Gates, PhD, presented the eagerly awaited results of the Chingford 1000 Women Study of the progression pattern of symptomatic radiographic OA of the first metatarsophalangeal joint (MTPJ). With 19 years of follow-up, Chingford is far and away the largest and longest longitudinal study of first MTP joint OA.
The prospective, population-based, observational cohort CASF study was carried out by Dr. Marshall and her coinvestigators at Keele University in Staffordshire, England. They surveyed Staffordshire residents aged 50 and older regarding whether they had experienced foot pain within the last 12 months. Those who answered affirmatively were invited to come in for a more detailed assessment and get weight-bearing x-rays of both feet. Among the 557 symptomatic participants with foot x-rays, the prevalence of radiographic OA of the foot was 16.7%, or roughly one in six – underscoring that it’s a common condition. The first MTP joint was the most commonly affected site, with a prevalence of 7.8%, followed by the second cuneometatarsal joint (CMJ) at 6.8%, the talonavicular joint (TNJ) at 5.2%, the navicular first cuneiform joint (NCJ) at 5.2%, and the first CMJ at 3.9%. Three-quarters of those who had symptomatic radiographic foot OA reported disabling symptoms, an established risk factor for falls (Ann Rheum Dis. 2015 Jan;74[1]:156-63).
With an eye toward identification of potential distinct phenotypes of foot OA, the CASF investigators conducted a separate analysis of those study participants with symptomatic radiographic midfoot OA – that is, OA of the TNJ, NCJ, and/or first or second CMJs, but not the first MTP joint. The prevalence in the Staffordshire population over age 50 with a history of foot pain was 12%. Independent risk factors for midfoot OA included obesity, with an adjusted odds ratio of 2.0; pain in other weight-bearing lower limb joints, with an adjusted odds ratio of 8.5; diabetes, odds ratio of 1.9; and previous foot injury, with an associated 1.6-fold increased risk. Midfoot OA was most prevalent in women older than 75 years; however, contrary to the conventional wisdom, a history of frequently wearing high-heeled shoes posed no increased risk.
The burden associated with midfoot OA was reflected in affected individuals’ frequent use of health care resources: During the past year, 46% of them had consulted their primary care physicians about their foot pain, 48% had been to a podiatrist, and 19% had seen a physical therapist (Arthritis Res Ther. 2015 Jul 13;17:178. doi: 10.1186/s13075-015-0693-3).
In a separate analysis, the investigators compiled additional evidence from CASF pointing to the existence of two phenotypes of foot OA: isolated first MTP OA and polyarticular foot OA, with distinct risk factors and symptom profiles (Arthritis Care Res [Hoboken]. 2016 Feb;68[2]:217-27).
“We found that OA affected both feet significantly more than was expected by chance, and we identified strong symmetrical patterns. This mirrors findings in hand OA and implies involvement of systemic components within a foot,” Dr. Marshall said.
The course of foot OA
During 18 months of prospective follow-up in CASF, subjects with isolated first MTP joint or polyarticular foot OA showed no clinically meaningful change in symptoms (Arthritis Care Res [Hoboken]. 2018 Jul;70[7]:1107-12).
But that finding may have been a function of the relatively brief follow-up, as the Chingford 1000 Women Study, with its 19 years of prospective follow-up, told a different story. Dr. Gates, of the University of Southampton (England), reported that among the 193 patients with foot x-rays at both baseline and follow-up, by which point they averaged nearly 76 years in age, 33.2% had OA of the first MTP joint of either foot at baseline as defined by at least a grade 2 score on the LaTrobe foot atlas, and 13% had prevalent involvement of both feet. During 19 years of follow-up of the women from Chingford, an area in northeast London, the incidence of new-onset radiographic first MTP joint OA was 7% in the left foot and 17% in the right. Meanwhile, progression to grade 3 radiographic OA occurred in the left foot of 28% of those with grade 2 disease at baseline and in 35% of those with baseline first MTP joint OA of the right foot. Twenty-eight percent of patients with unilateral first MTP joint OA at baseline progressed to bilateral involvement within 19 years.
Dr. Gates reported having no financial conflicts regarding the Chingford study, funded primarily by Arthritis Research UK, which merged with Arthritis Care in 2018 to form Versus Arthritis.
Similarly, Dr. Marshall reported no financial conflicts regarding CASF, also funded by Arthritis Research UK.
SOURCES: Marshall M. Osteoarthritis Cartilage. 2019 Apr;27[suppl 1]:S16, Abstract I-8 and Magnusson K et al. Osteoarthritis Cartilage. 2019 Apr;27[suppl 1]:S260-S261, Abstract 367.
TORONTO – Foot osteoarthritis has been a relatively neglected topic by researchers – but that’s finally changing, Michelle Marshall, PhD, observed at the OARSI 2019 World Congress.
She was a coinvestigator in the groundbreaking Clinical Assessment of the Foot (CASF), a large prospective study that has brought new insights into the prevalence of foot osteoarthritis (OA), its risk factors, the sizable disease burden, and foot OA’s diverse phenotypes. She shared study highlights at the meeting, which was sponsored by the Osteoarthritis Research Society International.
Elsewhere at OARSI 2019, Lucy S. Gates, PhD, presented the eagerly awaited results of the Chingford 1000 Women Study of the progression pattern of symptomatic radiographic OA of the first metatarsophalangeal joint (MTPJ). With 19 years of follow-up, Chingford is far and away the largest and longest longitudinal study of first MTP joint OA.
The prospective, population-based, observational cohort CASF study was carried out by Dr. Marshall and her coinvestigators at Keele University in Staffordshire, England. They surveyed Staffordshire residents aged 50 and older regarding whether they had experienced foot pain within the last 12 months. Those who answered affirmatively were invited to come in for a more detailed assessment and get weight-bearing x-rays of both feet. Among the 557 symptomatic participants with foot x-rays, the prevalence of radiographic OA of the foot was 16.7%, or roughly one in six – underscoring that it’s a common condition. The first MTP joint was the most commonly affected site, with a prevalence of 7.8%, followed by the second cuneometatarsal joint (CMJ) at 6.8%, the talonavicular joint (TNJ) at 5.2%, the navicular first cuneiform joint (NCJ) at 5.2%, and the first CMJ at 3.9%. Three-quarters of those who had symptomatic radiographic foot OA reported disabling symptoms, an established risk factor for falls (Ann Rheum Dis. 2015 Jan;74[1]:156-63).
With an eye toward identification of potential distinct phenotypes of foot OA, the CASF investigators conducted a separate analysis of those study participants with symptomatic radiographic midfoot OA – that is, OA of the TNJ, NCJ, and/or first or second CMJs, but not the first MTP joint. The prevalence in the Staffordshire population over age 50 with a history of foot pain was 12%. Independent risk factors for midfoot OA included obesity, with an adjusted odds ratio of 2.0; pain in other weight-bearing lower limb joints, with an adjusted odds ratio of 8.5; diabetes, odds ratio of 1.9; and previous foot injury, with an associated 1.6-fold increased risk. Midfoot OA was most prevalent in women older than 75 years; however, contrary to the conventional wisdom, a history of frequently wearing high-heeled shoes posed no increased risk.
The burden associated with midfoot OA was reflected in affected individuals’ frequent use of health care resources: During the past year, 46% of them had consulted their primary care physicians about their foot pain, 48% had been to a podiatrist, and 19% had seen a physical therapist (Arthritis Res Ther. 2015 Jul 13;17:178. doi: 10.1186/s13075-015-0693-3).
In a separate analysis, the investigators compiled additional evidence from CASF pointing to the existence of two phenotypes of foot OA: isolated first MTP OA and polyarticular foot OA, with distinct risk factors and symptom profiles (Arthritis Care Res [Hoboken]. 2016 Feb;68[2]:217-27).
“We found that OA affected both feet significantly more than was expected by chance, and we identified strong symmetrical patterns. This mirrors findings in hand OA and implies involvement of systemic components within a foot,” Dr. Marshall said.
The course of foot OA
During 18 months of prospective follow-up in CASF, subjects with isolated first MTP joint or polyarticular foot OA showed no clinically meaningful change in symptoms (Arthritis Care Res [Hoboken]. 2018 Jul;70[7]:1107-12).
But that finding may have been a function of the relatively brief follow-up, as the Chingford 1000 Women Study, with its 19 years of prospective follow-up, told a different story. Dr. Gates, of the University of Southampton (England), reported that among the 193 patients with foot x-rays at both baseline and follow-up, by which point they averaged nearly 76 years in age, 33.2% had OA of the first MTP joint of either foot at baseline as defined by at least a grade 2 score on the LaTrobe foot atlas, and 13% had prevalent involvement of both feet. During 19 years of follow-up of the women from Chingford, an area in northeast London, the incidence of new-onset radiographic first MTP joint OA was 7% in the left foot and 17% in the right. Meanwhile, progression to grade 3 radiographic OA occurred in the left foot of 28% of those with grade 2 disease at baseline and in 35% of those with baseline first MTP joint OA of the right foot. Twenty-eight percent of patients with unilateral first MTP joint OA at baseline progressed to bilateral involvement within 19 years.
Dr. Gates reported having no financial conflicts regarding the Chingford study, funded primarily by Arthritis Research UK, which merged with Arthritis Care in 2018 to form Versus Arthritis.
Similarly, Dr. Marshall reported no financial conflicts regarding CASF, also funded by Arthritis Research UK.
SOURCES: Marshall M. Osteoarthritis Cartilage. 2019 Apr;27[suppl 1]:S16, Abstract I-8 and Magnusson K et al. Osteoarthritis Cartilage. 2019 Apr;27[suppl 1]:S260-S261, Abstract 367.
REPORTING FROM OARSI 2019
Sequential dermoscopy imaging helps find melanomas early
WAIKOLOA, HAWAII – Sequential dermoscopy imaging (SDI) is a valuable strategy for diagnosing melanomas early and with better sensitivity and specificity, compared with biopsy decisions based solely on the ugly duckling sign, the ABCDs of melanoma, or other aspects of lesion morphology, Michael A. Marchetti, MD, said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.
SDI entails obtaining repeated dermoscopy images over time in order to detect subtle changes. It is typically done short term, over the course of 3-4 months, or longer term, over a period of 6 months to years, with long-term SDI being reserved for monitoring of less suspicious lesions, often in patients with an atypical mole syndrome.
SDI improves diagnostic specificity by dramatically reducing excision of benign pigmented lesions: in one large Belgian study, by up to 75% (Br J Dermatol. 2012 Oct;167[4]:778-86).
Short-term SDI also improves diagnostic sensitivity. That’s because it enables early identification of clinically featureless melanomas that are detected solely based upon change over a 3-month follow-up period. The operative principle here is that 93%-96% of melanomas will show change on dermoscopy within 3 months, while 99% of unchanged melanocytic lesions are benign. Since 16% of benign nevi will change within 3 months, that means 10%-30% of changed lesions are melanomas.
“If there is any change – it doesn’t matter what the change is, but the two images look different – that should lead to a biopsy,” explained Dr. Marchetti, a dermatologist at Memorial Sloan Kettering Cancer Center, New York.
As a result of this improved sensitivity and specificity, SDI has been shown to reduce the cost per melanoma diagnosis by about 40% (PLoS One. 2014 Oct 14;9[10]:e109339. doi: 10.1371/journal.pone.0109339).
Dr. Marchetti considers SDI a second-level diagnostic test for individual equivocal lesions. His first-level diagnostic tool is total-body photography.
SDI needs to be done by scrupulous examination of digital photographic images side-by-side on a computer monitor. A basic rule of SDI is that it should never be used to monitor raised or palpable lesions.
“The only thing you can monitor is something that’s flat,” he stressed.
Nor should SDI be used to monitor lesions with a peripheral globular pattern. And very slow-growing melanomas could potentially be missed by short-term SDI, so suspected lentigo maligna should be monitored for a minimum of 12 months, according to Dr. Marchetti.
Not every patient with an equivocal melanocytic lesion is a good candidate for SDI. It’s a monitoring strategy that should be reserved for reliable patients who will come back in 3 months. “If a patient doesn’t come back I take that very seriously. We call or send a letter,” Dr. Marchetti said.
Moreover, even in a patient who is a good candidate for SDI, he always offers the option of biopsy today rather than short-term monitoring.
SDI employed in conjunction with total-body photography is an extremely effective means of monitoring patients at very high risk for melanoma, Dr. Marchetti said. The power of this combination was illustrated in a prospective Australian study of 311 patients with a history of invasive melanoma plus either a high-risk genetic mutation or a strong family history. During a median follow-up of 3.5 years, 75 melanomas were detected, 14 of them at the baseline visit. The median thickness of melanomas detected post baseline was in situ. Thirty-nine percent of melanomas were detected using SDI and 38% via total body photography. Roughly one in five biopsied melanocytic lesions proved to be melanoma. Of note, five of the melanomas were more than 1 mm in Breslow thickness: Three of them were histologically desmoplastic, and the other two had nodular components (JAMA Dermatol. 2014 Aug;150(8):819-27).
For dermatologists who need to brush up on their dermoscopy skills, Dr. Marchetti recommended dermoscopedia as a useful, free resource.
Legal implications of monitoring via photography
“People often get worked up about this, but I’m not aware of a lawsuit alleging missed melanoma using baseline photography as evidence. And patients, in my experience, are universally appreciative of the use of imaging, although admittedly my experience is biased because people generally come to me for imaging,” Dr. Marchetti said.
He makes a point of telling every patient who opts for short-term SDI that, although the lesion has no features of concern now, it’s important to return promptly for reexamination should any changes occur.
Dr. Marchetti reported having no financial conflicts regarding his presentation.
SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
WAIKOLOA, HAWAII – Sequential dermoscopy imaging (SDI) is a valuable strategy for diagnosing melanomas early and with better sensitivity and specificity, compared with biopsy decisions based solely on the ugly duckling sign, the ABCDs of melanoma, or other aspects of lesion morphology, Michael A. Marchetti, MD, said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.
SDI entails obtaining repeated dermoscopy images over time in order to detect subtle changes. It is typically done short term, over the course of 3-4 months, or longer term, over a period of 6 months to years, with long-term SDI being reserved for monitoring of less suspicious lesions, often in patients with an atypical mole syndrome.
SDI improves diagnostic specificity by dramatically reducing excision of benign pigmented lesions: in one large Belgian study, by up to 75% (Br J Dermatol. 2012 Oct;167[4]:778-86).
Short-term SDI also improves diagnostic sensitivity. That’s because it enables early identification of clinically featureless melanomas that are detected solely based upon change over a 3-month follow-up period. The operative principle here is that 93%-96% of melanomas will show change on dermoscopy within 3 months, while 99% of unchanged melanocytic lesions are benign. Since 16% of benign nevi will change within 3 months, that means 10%-30% of changed lesions are melanomas.
“If there is any change – it doesn’t matter what the change is, but the two images look different – that should lead to a biopsy,” explained Dr. Marchetti, a dermatologist at Memorial Sloan Kettering Cancer Center, New York.
As a result of this improved sensitivity and specificity, SDI has been shown to reduce the cost per melanoma diagnosis by about 40% (PLoS One. 2014 Oct 14;9[10]:e109339. doi: 10.1371/journal.pone.0109339).
Dr. Marchetti considers SDI a second-level diagnostic test for individual equivocal lesions. His first-level diagnostic tool is total-body photography.
SDI needs to be done by scrupulous examination of digital photographic images side-by-side on a computer monitor. A basic rule of SDI is that it should never be used to monitor raised or palpable lesions.
“The only thing you can monitor is something that’s flat,” he stressed.
Nor should SDI be used to monitor lesions with a peripheral globular pattern. And very slow-growing melanomas could potentially be missed by short-term SDI, so suspected lentigo maligna should be monitored for a minimum of 12 months, according to Dr. Marchetti.
Not every patient with an equivocal melanocytic lesion is a good candidate for SDI. It’s a monitoring strategy that should be reserved for reliable patients who will come back in 3 months. “If a patient doesn’t come back I take that very seriously. We call or send a letter,” Dr. Marchetti said.
Moreover, even in a patient who is a good candidate for SDI, he always offers the option of biopsy today rather than short-term monitoring.
SDI employed in conjunction with total-body photography is an extremely effective means of monitoring patients at very high risk for melanoma, Dr. Marchetti said. The power of this combination was illustrated in a prospective Australian study of 311 patients with a history of invasive melanoma plus either a high-risk genetic mutation or a strong family history. During a median follow-up of 3.5 years, 75 melanomas were detected, 14 of them at the baseline visit. The median thickness of melanomas detected post baseline was in situ. Thirty-nine percent of melanomas were detected using SDI and 38% via total body photography. Roughly one in five biopsied melanocytic lesions proved to be melanoma. Of note, five of the melanomas were more than 1 mm in Breslow thickness: Three of them were histologically desmoplastic, and the other two had nodular components (JAMA Dermatol. 2014 Aug;150(8):819-27).
For dermatologists who need to brush up on their dermoscopy skills, Dr. Marchetti recommended dermoscopedia as a useful, free resource.
Legal implications of monitoring via photography
“People often get worked up about this, but I’m not aware of a lawsuit alleging missed melanoma using baseline photography as evidence. And patients, in my experience, are universally appreciative of the use of imaging, although admittedly my experience is biased because people generally come to me for imaging,” Dr. Marchetti said.
He makes a point of telling every patient who opts for short-term SDI that, although the lesion has no features of concern now, it’s important to return promptly for reexamination should any changes occur.
Dr. Marchetti reported having no financial conflicts regarding his presentation.
SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
WAIKOLOA, HAWAII – Sequential dermoscopy imaging (SDI) is a valuable strategy for diagnosing melanomas early and with better sensitivity and specificity, compared with biopsy decisions based solely on the ugly duckling sign, the ABCDs of melanoma, or other aspects of lesion morphology, Michael A. Marchetti, MD, said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.
SDI entails obtaining repeated dermoscopy images over time in order to detect subtle changes. It is typically done short term, over the course of 3-4 months, or longer term, over a period of 6 months to years, with long-term SDI being reserved for monitoring of less suspicious lesions, often in patients with an atypical mole syndrome.
SDI improves diagnostic specificity by dramatically reducing excision of benign pigmented lesions: in one large Belgian study, by up to 75% (Br J Dermatol. 2012 Oct;167[4]:778-86).
Short-term SDI also improves diagnostic sensitivity. That’s because it enables early identification of clinically featureless melanomas that are detected solely based upon change over a 3-month follow-up period. The operative principle here is that 93%-96% of melanomas will show change on dermoscopy within 3 months, while 99% of unchanged melanocytic lesions are benign. Since 16% of benign nevi will change within 3 months, that means 10%-30% of changed lesions are melanomas.
“If there is any change – it doesn’t matter what the change is, but the two images look different – that should lead to a biopsy,” explained Dr. Marchetti, a dermatologist at Memorial Sloan Kettering Cancer Center, New York.
As a result of this improved sensitivity and specificity, SDI has been shown to reduce the cost per melanoma diagnosis by about 40% (PLoS One. 2014 Oct 14;9[10]:e109339. doi: 10.1371/journal.pone.0109339).
Dr. Marchetti considers SDI a second-level diagnostic test for individual equivocal lesions. His first-level diagnostic tool is total-body photography.
SDI needs to be done by scrupulous examination of digital photographic images side-by-side on a computer monitor. A basic rule of SDI is that it should never be used to monitor raised or palpable lesions.
“The only thing you can monitor is something that’s flat,” he stressed.
Nor should SDI be used to monitor lesions with a peripheral globular pattern. And very slow-growing melanomas could potentially be missed by short-term SDI, so suspected lentigo maligna should be monitored for a minimum of 12 months, according to Dr. Marchetti.
Not every patient with an equivocal melanocytic lesion is a good candidate for SDI. It’s a monitoring strategy that should be reserved for reliable patients who will come back in 3 months. “If a patient doesn’t come back I take that very seriously. We call or send a letter,” Dr. Marchetti said.
Moreover, even in a patient who is a good candidate for SDI, he always offers the option of biopsy today rather than short-term monitoring.
SDI employed in conjunction with total-body photography is an extremely effective means of monitoring patients at very high risk for melanoma, Dr. Marchetti said. The power of this combination was illustrated in a prospective Australian study of 311 patients with a history of invasive melanoma plus either a high-risk genetic mutation or a strong family history. During a median follow-up of 3.5 years, 75 melanomas were detected, 14 of them at the baseline visit. The median thickness of melanomas detected post baseline was in situ. Thirty-nine percent of melanomas were detected using SDI and 38% via total body photography. Roughly one in five biopsied melanocytic lesions proved to be melanoma. Of note, five of the melanomas were more than 1 mm in Breslow thickness: Three of them were histologically desmoplastic, and the other two had nodular components (JAMA Dermatol. 2014 Aug;150(8):819-27).
For dermatologists who need to brush up on their dermoscopy skills, Dr. Marchetti recommended dermoscopedia as a useful, free resource.
Legal implications of monitoring via photography
“People often get worked up about this, but I’m not aware of a lawsuit alleging missed melanoma using baseline photography as evidence. And patients, in my experience, are universally appreciative of the use of imaging, although admittedly my experience is biased because people generally come to me for imaging,” Dr. Marchetti said.
He makes a point of telling every patient who opts for short-term SDI that, although the lesion has no features of concern now, it’s important to return promptly for reexamination should any changes occur.
Dr. Marchetti reported having no financial conflicts regarding his presentation.
SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
REPORTING FROM SDEF HAWAII DERMATOLOGY SEMINAR
Rapid assay distinguishes viral from bacterial infection
LJUBLJANA, SLOVENIA – assessing RNA expression of a single patient gene, according to a proof-of-concept study presented by Ruth Barral-Arca at the annual meeting of the European Society for Paediatric Infectious Diseases.
The gene of interest – IFI44L – is entwined in a child’s response to infection. It’s upregulated in the presence of viral infection and suppressed in bacterial infection, explained Ms. Barral-Arca, a PhD student at the University of Santiago de Compostela (Spain).
This investigational real-time PCR assay could provide a major advance over current routine practice, which is to admit a sick febrile child to the hospital, order bacterial cultures, and start parenteral antibiotics presumptively while awaiting the culture results, which usually don’t come back for more than 24 hours. This practice is a step backwards in terms of antibiotic stewardship, because the majority of febrile children have a self-resolving viral infection.
“This is a big problem because a lot of children with viral infections are inappropriately given antibiotics, leading to antimicrobial resistance,” she noted.
Also, misleadingly false-negative bacterial cultures can occur if the causative pathogen wasn’t included in the test, the infection is in a nonaccessible site, or the child has recently been on antibiotics.
All of these shortcomings have led to a new diagnostic strategy based upon measuring the pattern of key host genes upregulated or suppressed during the inflammatory response.
“We’ve seen that, instead of analyzing the bugs, analyzing the host transcriptome response during infection is proving to be a promising tool for disease biomarker identification. And it’s faster. An early differentiation between viral and bacterial patients will help improve triage in emergency departments, decrease the misuse of antibiotics, and guide clinics to a more precise diagnosis. A lot of big hospitals are already doing PCR. They could quickly adopt this kind of analysis,” Ms. Barral-Arca continued.
She presented a pilot study in which the assay was put to the test using multiple blood samples from 14 febrile infants and children up to 6 years of age with microbiologically confirmed bacterial infection, 11 febrile children with confirmed viral infection, and 10 healthy controls.
“I know the numbers seem small, but we did a sample-size power calculation and it’s just fine,” according to the researcher.
The initial study goal was to confirm earlier promising findings from a study of 370 febrile children in the United Kingdom, Spain, and the United States, conducted by the Immunopathology of Respiratory, Inflammatory and Infectious Disease Study (IRIS) Consortium, a study in which several of Ms. Barral-Arca’s senior coinvestigators participated. The IRIS investigators demonstrated that the combined expression pattern of two genes – IFI44L and FAM89A – distinguished the bacterial from viral infections with impressive sensitivity and specificity (JAMA. 2016 Aug 23-30;316[8]:835-45).
The two-gene signature performed similarly well in Ms. Barral-Arca’s study. However, when she and her coinvestigators tested the discriminatory power of the two genes individually, they got a surprise: The real-time PCR analysis assessing expression of IFI44L alone performed even better than the two-gene combination, discriminating viral from bacterial infections with 91% sensitivity, 93% specificity, and an area under the curve of 94%. In contrast, the two-gene signature based upon IFI44L and FAM89A had a sensitivity of 91%, a specificity of 86%, and an area under the curve of 92%. While those differences in performance are small, a single-gene assay saves time, work, and cost, according to Ms. Barral-Arca.
Her group then validated their findings regarding the performance of the IFI44L single-gene signature in two independent cohorts: stored blood samples from the children in the earlier IRIS study, and a group of children with diarrhea of viral or bacterial etiology.
“One gene seems to be enough,” she said. “We have demonstrated in a real-life scenario that host gene expression microarray data can be successfully translated into a fast, highly accurate, and relatively inexpensive in vitro assay that could be implemented in the clinical routine.”
Planned future work includes investigation of how the gene expression evolves over time from fever onset, the possible utility of the assay in noninfectious febrile illnesses such as rheumatoid arthritis, and whether the test discriminates viral from bacterial infection in adults.
Ms. Barral-Arca reported having no financial conflicts regarding her study, supported by institutional funding.
LJUBLJANA, SLOVENIA – assessing RNA expression of a single patient gene, according to a proof-of-concept study presented by Ruth Barral-Arca at the annual meeting of the European Society for Paediatric Infectious Diseases.
The gene of interest – IFI44L – is entwined in a child’s response to infection. It’s upregulated in the presence of viral infection and suppressed in bacterial infection, explained Ms. Barral-Arca, a PhD student at the University of Santiago de Compostela (Spain).
This investigational real-time PCR assay could provide a major advance over current routine practice, which is to admit a sick febrile child to the hospital, order bacterial cultures, and start parenteral antibiotics presumptively while awaiting the culture results, which usually don’t come back for more than 24 hours. This practice is a step backwards in terms of antibiotic stewardship, because the majority of febrile children have a self-resolving viral infection.
“This is a big problem because a lot of children with viral infections are inappropriately given antibiotics, leading to antimicrobial resistance,” she noted.
Also, misleadingly false-negative bacterial cultures can occur if the causative pathogen wasn’t included in the test, the infection is in a nonaccessible site, or the child has recently been on antibiotics.
All of these shortcomings have led to a new diagnostic strategy based upon measuring the pattern of key host genes upregulated or suppressed during the inflammatory response.
“We’ve seen that, instead of analyzing the bugs, analyzing the host transcriptome response during infection is proving to be a promising tool for disease biomarker identification. And it’s faster. An early differentiation between viral and bacterial patients will help improve triage in emergency departments, decrease the misuse of antibiotics, and guide clinics to a more precise diagnosis. A lot of big hospitals are already doing PCR. They could quickly adopt this kind of analysis,” Ms. Barral-Arca continued.
She presented a pilot study in which the assay was put to the test using multiple blood samples from 14 febrile infants and children up to 6 years of age with microbiologically confirmed bacterial infection, 11 febrile children with confirmed viral infection, and 10 healthy controls.
“I know the numbers seem small, but we did a sample-size power calculation and it’s just fine,” according to the researcher.
The initial study goal was to confirm earlier promising findings from a study of 370 febrile children in the United Kingdom, Spain, and the United States, conducted by the Immunopathology of Respiratory, Inflammatory and Infectious Disease Study (IRIS) Consortium, a study in which several of Ms. Barral-Arca’s senior coinvestigators participated. The IRIS investigators demonstrated that the combined expression pattern of two genes – IFI44L and FAM89A – distinguished the bacterial from viral infections with impressive sensitivity and specificity (JAMA. 2016 Aug 23-30;316[8]:835-45).
The two-gene signature performed similarly well in Ms. Barral-Arca’s study. However, when she and her coinvestigators tested the discriminatory power of the two genes individually, they got a surprise: The real-time PCR analysis assessing expression of IFI44L alone performed even better than the two-gene combination, discriminating viral from bacterial infections with 91% sensitivity, 93% specificity, and an area under the curve of 94%. In contrast, the two-gene signature based upon IFI44L and FAM89A had a sensitivity of 91%, a specificity of 86%, and an area under the curve of 92%. While those differences in performance are small, a single-gene assay saves time, work, and cost, according to Ms. Barral-Arca.
Her group then validated their findings regarding the performance of the IFI44L single-gene signature in two independent cohorts: stored blood samples from the children in the earlier IRIS study, and a group of children with diarrhea of viral or bacterial etiology.
“One gene seems to be enough,” she said. “We have demonstrated in a real-life scenario that host gene expression microarray data can be successfully translated into a fast, highly accurate, and relatively inexpensive in vitro assay that could be implemented in the clinical routine.”
Planned future work includes investigation of how the gene expression evolves over time from fever onset, the possible utility of the assay in noninfectious febrile illnesses such as rheumatoid arthritis, and whether the test discriminates viral from bacterial infection in adults.
Ms. Barral-Arca reported having no financial conflicts regarding her study, supported by institutional funding.
LJUBLJANA, SLOVENIA – assessing RNA expression of a single patient gene, according to a proof-of-concept study presented by Ruth Barral-Arca at the annual meeting of the European Society for Paediatric Infectious Diseases.
The gene of interest – IFI44L – is entwined in a child’s response to infection. It’s upregulated in the presence of viral infection and suppressed in bacterial infection, explained Ms. Barral-Arca, a PhD student at the University of Santiago de Compostela (Spain).
This investigational real-time PCR assay could provide a major advance over current routine practice, which is to admit a sick febrile child to the hospital, order bacterial cultures, and start parenteral antibiotics presumptively while awaiting the culture results, which usually don’t come back for more than 24 hours. This practice is a step backwards in terms of antibiotic stewardship, because the majority of febrile children have a self-resolving viral infection.
“This is a big problem because a lot of children with viral infections are inappropriately given antibiotics, leading to antimicrobial resistance,” she noted.
Also, misleadingly false-negative bacterial cultures can occur if the causative pathogen wasn’t included in the test, the infection is in a nonaccessible site, or the child has recently been on antibiotics.
All of these shortcomings have led to a new diagnostic strategy based upon measuring the pattern of key host genes upregulated or suppressed during the inflammatory response.
“We’ve seen that, instead of analyzing the bugs, analyzing the host transcriptome response during infection is proving to be a promising tool for disease biomarker identification. And it’s faster. An early differentiation between viral and bacterial patients will help improve triage in emergency departments, decrease the misuse of antibiotics, and guide clinics to a more precise diagnosis. A lot of big hospitals are already doing PCR. They could quickly adopt this kind of analysis,” Ms. Barral-Arca continued.
She presented a pilot study in which the assay was put to the test using multiple blood samples from 14 febrile infants and children up to 6 years of age with microbiologically confirmed bacterial infection, 11 febrile children with confirmed viral infection, and 10 healthy controls.
“I know the numbers seem small, but we did a sample-size power calculation and it’s just fine,” according to the researcher.
The initial study goal was to confirm earlier promising findings from a study of 370 febrile children in the United Kingdom, Spain, and the United States, conducted by the Immunopathology of Respiratory, Inflammatory and Infectious Disease Study (IRIS) Consortium, a study in which several of Ms. Barral-Arca’s senior coinvestigators participated. The IRIS investigators demonstrated that the combined expression pattern of two genes – IFI44L and FAM89A – distinguished the bacterial from viral infections with impressive sensitivity and specificity (JAMA. 2016 Aug 23-30;316[8]:835-45).
The two-gene signature performed similarly well in Ms. Barral-Arca’s study. However, when she and her coinvestigators tested the discriminatory power of the two genes individually, they got a surprise: The real-time PCR analysis assessing expression of IFI44L alone performed even better than the two-gene combination, discriminating viral from bacterial infections with 91% sensitivity, 93% specificity, and an area under the curve of 94%. In contrast, the two-gene signature based upon IFI44L and FAM89A had a sensitivity of 91%, a specificity of 86%, and an area under the curve of 92%. While those differences in performance are small, a single-gene assay saves time, work, and cost, according to Ms. Barral-Arca.
Her group then validated their findings regarding the performance of the IFI44L single-gene signature in two independent cohorts: stored blood samples from the children in the earlier IRIS study, and a group of children with diarrhea of viral or bacterial etiology.
“One gene seems to be enough,” she said. “We have demonstrated in a real-life scenario that host gene expression microarray data can be successfully translated into a fast, highly accurate, and relatively inexpensive in vitro assay that could be implemented in the clinical routine.”
Planned future work includes investigation of how the gene expression evolves over time from fever onset, the possible utility of the assay in noninfectious febrile illnesses such as rheumatoid arthritis, and whether the test discriminates viral from bacterial infection in adults.
Ms. Barral-Arca reported having no financial conflicts regarding her study, supported by institutional funding.
REPORTING FROM ESPID 2019
Key clinical point: A novel real-time single-gene–expression PCR test quickly distinguishes viral from bacterial infection in febrile children.
Major finding: The expression signature of the IFI44L gene rapidly distinguished bacterial from viral infection in febrile children with 91% sensitivity and 93% specificity.
Study details: This translational study included 25 febrile children with definite bacterial or viral infections and 10 healthy controls.
Disclosures: The presenter reported having no financial conflicts regarding her study, supported by institutional funding.
Pap screen gaps abound in SLE population
SAN FRANCISCO – Ann Igoe, MD, said at an international congress on systemic lupus erythematosus.
Why is this of relevance to rheumatologists?
“The rheumatologist is probably the main physician that lupus patients see. They may see their rheumatologist every couple of months. The question is, how often do rheumatologists say, ‘Hey, you need your Pap smear!’ I don’t think many of them address it,” said Dr. Igoe, a rheumatology fellow at Case Western Reserve University in Cleveland.
She presented a retrospective, cross-sectional, single-center study utilizing the EHRs of 604 women with SLE and 3,337 female controls who had asthma but not SLE. Sixty percent of the SLE patients were overdue for a Pap smear, compared with 51% of controls.
“We also looked at race,” Dr. Igoe said in an interview. “We were able to show that, at our institution, racial disparities do exist, that the black lupus patients had a much higher rate of HPV [human papillomavirus] positivity, compared to the white lupus patients, and they also were more behind on their Pap screening.”
Indeed, 56% of the black lupus patients were overdue for a Pap test, compared with 43% of the white SLE patients, and 46% of black women without SLE. Among the subgroup composed of black HPV-positive SLE patients, the overdue status rate soared to 70%, versus 30% in white HPV-positive SLE patients.
Dr. Igoe noted that in October 2018, the Food and Drug Administration approved an expanded indication for the quadrivalent HPV vaccine known as Gardasil 9 for women through 45 years of age. The prior upper age limit was age 26. This is an especially important development for unvaccinated women with SLE. Women with SLE have been shown to have higher rates of cervical neoplasia than in the general population, and being on potent immunosuppressive agents such as mycophenolate mofetil, azathioprine, and methotrexate further boosts that risk.
“We and others have shown that women with lupus who receive the vaccine mount a good response. So regardless of whether you’ve had HPV in the past, that doesn’t preclude you from getting the vaccine,” she noted.
The Advisory Committee on Immunization Practices and Centers for Disease Control and Prevention have yet to adopt the expanded age limit recommendation. That needs to happen, Dr. Igoe stressed.
“I’d like to see this study as a little stepping stone towards having women get their Pap screen addressed and making the Gardasil vaccine available to women who are not vaccinated,” she said.
She reported having no financial conflicts regarding her study, conducted free of commercial support.
SAN FRANCISCO – Ann Igoe, MD, said at an international congress on systemic lupus erythematosus.
Why is this of relevance to rheumatologists?
“The rheumatologist is probably the main physician that lupus patients see. They may see their rheumatologist every couple of months. The question is, how often do rheumatologists say, ‘Hey, you need your Pap smear!’ I don’t think many of them address it,” said Dr. Igoe, a rheumatology fellow at Case Western Reserve University in Cleveland.
She presented a retrospective, cross-sectional, single-center study utilizing the EHRs of 604 women with SLE and 3,337 female controls who had asthma but not SLE. Sixty percent of the SLE patients were overdue for a Pap smear, compared with 51% of controls.
“We also looked at race,” Dr. Igoe said in an interview. “We were able to show that, at our institution, racial disparities do exist, that the black lupus patients had a much higher rate of HPV [human papillomavirus] positivity, compared to the white lupus patients, and they also were more behind on their Pap screening.”
Indeed, 56% of the black lupus patients were overdue for a Pap test, compared with 43% of the white SLE patients, and 46% of black women without SLE. Among the subgroup composed of black HPV-positive SLE patients, the overdue status rate soared to 70%, versus 30% in white HPV-positive SLE patients.
Dr. Igoe noted that in October 2018, the Food and Drug Administration approved an expanded indication for the quadrivalent HPV vaccine known as Gardasil 9 for women through 45 years of age. The prior upper age limit was age 26. This is an especially important development for unvaccinated women with SLE. Women with SLE have been shown to have higher rates of cervical neoplasia than in the general population, and being on potent immunosuppressive agents such as mycophenolate mofetil, azathioprine, and methotrexate further boosts that risk.
“We and others have shown that women with lupus who receive the vaccine mount a good response. So regardless of whether you’ve had HPV in the past, that doesn’t preclude you from getting the vaccine,” she noted.
The Advisory Committee on Immunization Practices and Centers for Disease Control and Prevention have yet to adopt the expanded age limit recommendation. That needs to happen, Dr. Igoe stressed.
“I’d like to see this study as a little stepping stone towards having women get their Pap screen addressed and making the Gardasil vaccine available to women who are not vaccinated,” she said.
She reported having no financial conflicts regarding her study, conducted free of commercial support.
SAN FRANCISCO – Ann Igoe, MD, said at an international congress on systemic lupus erythematosus.
Why is this of relevance to rheumatologists?
“The rheumatologist is probably the main physician that lupus patients see. They may see their rheumatologist every couple of months. The question is, how often do rheumatologists say, ‘Hey, you need your Pap smear!’ I don’t think many of them address it,” said Dr. Igoe, a rheumatology fellow at Case Western Reserve University in Cleveland.
She presented a retrospective, cross-sectional, single-center study utilizing the EHRs of 604 women with SLE and 3,337 female controls who had asthma but not SLE. Sixty percent of the SLE patients were overdue for a Pap smear, compared with 51% of controls.
“We also looked at race,” Dr. Igoe said in an interview. “We were able to show that, at our institution, racial disparities do exist, that the black lupus patients had a much higher rate of HPV [human papillomavirus] positivity, compared to the white lupus patients, and they also were more behind on their Pap screening.”
Indeed, 56% of the black lupus patients were overdue for a Pap test, compared with 43% of the white SLE patients, and 46% of black women without SLE. Among the subgroup composed of black HPV-positive SLE patients, the overdue status rate soared to 70%, versus 30% in white HPV-positive SLE patients.
Dr. Igoe noted that in October 2018, the Food and Drug Administration approved an expanded indication for the quadrivalent HPV vaccine known as Gardasil 9 for women through 45 years of age. The prior upper age limit was age 26. This is an especially important development for unvaccinated women with SLE. Women with SLE have been shown to have higher rates of cervical neoplasia than in the general population, and being on potent immunosuppressive agents such as mycophenolate mofetil, azathioprine, and methotrexate further boosts that risk.
“We and others have shown that women with lupus who receive the vaccine mount a good response. So regardless of whether you’ve had HPV in the past, that doesn’t preclude you from getting the vaccine,” she noted.
The Advisory Committee on Immunization Practices and Centers for Disease Control and Prevention have yet to adopt the expanded age limit recommendation. That needs to happen, Dr. Igoe stressed.
“I’d like to see this study as a little stepping stone towards having women get their Pap screen addressed and making the Gardasil vaccine available to women who are not vaccinated,” she said.
She reported having no financial conflicts regarding her study, conducted free of commercial support.
REPORTING FROM LUPUS 2019
How to have ‘the talk’ with vaccine skeptics
LJUBLJANA, SLOVENIA – An effective strategy in helping vaccine skeptics to come around to accepting immunizations for their children is to pivot the conversation away from vaccine safety and focus instead on the disease itself and its potential consequences, Saad B. Omer, MBBS, PhD, asserted at the annual meeting of the European Society for Paediatric Infectious Diseases.
“Why do we cede ground by focusing too much on the vaccine itself? I call it the disease salience approach,” said Dr. Omer, professor of global health, epidemiology, and pediatrics at Emory University in Atlanta.
It’s a strategy guided by developments in social psychology, persuasion theory, and communication theory. But if applied incorrectly, the disease salience approach can backfire, causing behavioral paralysis and an inability to act, he cautioned.
Dr. Omer explained that it’s a matter of framing.
“Always include a solution to promote self-efficacy and response-efficacy. After you inform parents of disease risks, provide them with actions they can take. Now readdress the vaccine, pointing out that this is the single best way to protect yourself and your baby,” he said. “The lesson is that since vaccines are a social norm, reframe nonvaccination as an active act, rather than vaccination as an active act.”
Don’t attempt to wow parents with statistics on how vaccine complication rates are dwarfed by the disease risk if left unvaccinated, he advised. Studies have shown that‘s generally not effective. What actually works is to provide narratives of disease severity.
“We are excellent linguists, but really, really poor statisticians,” Dr. Omer observed.
Is it ethical to talk to parents about disease risks to influence their behavior? Absolutely, in his view.
“We’re not selling toothpaste. We are in the business of life-saving vaccines. And I would submit that if it’s done correctly it’s entirely ethical to talk about the disease, and sometimes even the severe risks of the disease, instead of the vaccine,” said Dr. Omer.
If parents cite a myth about vaccines, it’s necessary to address it head on without lingering on it. But debunking a myth is tricky because people tend to remember negative information they received earlier.
“If you’re going to debunk a myth, clearly label it as a myth in the headline as you introduce it. State why it’s not true. Replace the myth with the best alternative explanation. Think of it like a blank space where the myth used to reside. That space needs to be filled with an alternative explanation or the myth will come back,” Dr. Omer said.
He is a coauthor of a book titled, ‘The Clinician’s Vaccine Safety Resource Guide: Optimizing Prevention of Vaccine-Preventable Diseases Across the Lifespan.’
LJUBLJANA, SLOVENIA – An effective strategy in helping vaccine skeptics to come around to accepting immunizations for their children is to pivot the conversation away from vaccine safety and focus instead on the disease itself and its potential consequences, Saad B. Omer, MBBS, PhD, asserted at the annual meeting of the European Society for Paediatric Infectious Diseases.
“Why do we cede ground by focusing too much on the vaccine itself? I call it the disease salience approach,” said Dr. Omer, professor of global health, epidemiology, and pediatrics at Emory University in Atlanta.
It’s a strategy guided by developments in social psychology, persuasion theory, and communication theory. But if applied incorrectly, the disease salience approach can backfire, causing behavioral paralysis and an inability to act, he cautioned.
Dr. Omer explained that it’s a matter of framing.
“Always include a solution to promote self-efficacy and response-efficacy. After you inform parents of disease risks, provide them with actions they can take. Now readdress the vaccine, pointing out that this is the single best way to protect yourself and your baby,” he said. “The lesson is that since vaccines are a social norm, reframe nonvaccination as an active act, rather than vaccination as an active act.”
Don’t attempt to wow parents with statistics on how vaccine complication rates are dwarfed by the disease risk if left unvaccinated, he advised. Studies have shown that‘s generally not effective. What actually works is to provide narratives of disease severity.
“We are excellent linguists, but really, really poor statisticians,” Dr. Omer observed.
Is it ethical to talk to parents about disease risks to influence their behavior? Absolutely, in his view.
“We’re not selling toothpaste. We are in the business of life-saving vaccines. And I would submit that if it’s done correctly it’s entirely ethical to talk about the disease, and sometimes even the severe risks of the disease, instead of the vaccine,” said Dr. Omer.
If parents cite a myth about vaccines, it’s necessary to address it head on without lingering on it. But debunking a myth is tricky because people tend to remember negative information they received earlier.
“If you’re going to debunk a myth, clearly label it as a myth in the headline as you introduce it. State why it’s not true. Replace the myth with the best alternative explanation. Think of it like a blank space where the myth used to reside. That space needs to be filled with an alternative explanation or the myth will come back,” Dr. Omer said.
He is a coauthor of a book titled, ‘The Clinician’s Vaccine Safety Resource Guide: Optimizing Prevention of Vaccine-Preventable Diseases Across the Lifespan.’
LJUBLJANA, SLOVENIA – An effective strategy in helping vaccine skeptics to come around to accepting immunizations for their children is to pivot the conversation away from vaccine safety and focus instead on the disease itself and its potential consequences, Saad B. Omer, MBBS, PhD, asserted at the annual meeting of the European Society for Paediatric Infectious Diseases.
“Why do we cede ground by focusing too much on the vaccine itself? I call it the disease salience approach,” said Dr. Omer, professor of global health, epidemiology, and pediatrics at Emory University in Atlanta.
It’s a strategy guided by developments in social psychology, persuasion theory, and communication theory. But if applied incorrectly, the disease salience approach can backfire, causing behavioral paralysis and an inability to act, he cautioned.
Dr. Omer explained that it’s a matter of framing.
“Always include a solution to promote self-efficacy and response-efficacy. After you inform parents of disease risks, provide them with actions they can take. Now readdress the vaccine, pointing out that this is the single best way to protect yourself and your baby,” he said. “The lesson is that since vaccines are a social norm, reframe nonvaccination as an active act, rather than vaccination as an active act.”
Don’t attempt to wow parents with statistics on how vaccine complication rates are dwarfed by the disease risk if left unvaccinated, he advised. Studies have shown that‘s generally not effective. What actually works is to provide narratives of disease severity.
“We are excellent linguists, but really, really poor statisticians,” Dr. Omer observed.
Is it ethical to talk to parents about disease risks to influence their behavior? Absolutely, in his view.
“We’re not selling toothpaste. We are in the business of life-saving vaccines. And I would submit that if it’s done correctly it’s entirely ethical to talk about the disease, and sometimes even the severe risks of the disease, instead of the vaccine,” said Dr. Omer.
If parents cite a myth about vaccines, it’s necessary to address it head on without lingering on it. But debunking a myth is tricky because people tend to remember negative information they received earlier.
“If you’re going to debunk a myth, clearly label it as a myth in the headline as you introduce it. State why it’s not true. Replace the myth with the best alternative explanation. Think of it like a blank space where the myth used to reside. That space needs to be filled with an alternative explanation or the myth will come back,” Dr. Omer said.
He is a coauthor of a book titled, ‘The Clinician’s Vaccine Safety Resource Guide: Optimizing Prevention of Vaccine-Preventable Diseases Across the Lifespan.’
EXPERT ANALYSIS FROM ESPID 2019
Reducing pediatric RSV burden is top priority
LJUBLJANA, SLOVENIA – Prevention or early effective treatment of respiratory syncytial virus (RSV) infection in infants and small children holds the promise of sharply reduced burdens of both acute otitis media (AOM) and pneumonia, Terho Heikkinen, MD, PhD, predicted in the Bill Marshall Award Lecture presented at the annual meeting of the European Society for Paediatric Infectious Diseases (ESPID).
RSV is by far the hottest virus in the world,” declared Dr. Heikkinen, professor of pediatrics at the University of Turku (Finland).
“A lot of progress is being made with respect to RSV. This increased understanding holds great promise for new interventions,” he explained. “Lots of different types of vaccines are being developed, monoclonal antibodies, antivirals. So
Today influenza is the only respiratory viral infection that’s preventable via vaccine or effectively treatable using antiviral drugs. That situation has to change, as Dr. Heikkinen demonstrated early in his career; RSV is the respiratory virus that’s most likely to invade the middle ear during AOM. It’s much more ototropic than influenza, parainfluenza, enteroviruses, or adenoviruses (N Engl J Med. 1999 Jan 28;340[4]:260-4), he noted.
The Bill Marshall Award and Lecture, ESPID’s most prestigious award, is given annually to an individual recognized as having significantly advanced the field of pediatric infectious diseases. Dr. Heikkinen was singled out for his decades of work establishing that viruses, including RSV, play a key role in AOM, which had traditionally been regarded as a bacterial infection. He and his coinvestigators demonstrated that in about two-thirds of cases, AOM is actually caused by a combination of bacteria and viruses, which explains why patients’ clinical response to antibiotic therapy for AOM often is poor. They also described the chain of events whereby viral infection of the upper airway epithelium triggers an inflammatory response in the nasopharynx, with resultant Eustachian tube dysfunction and negative middle ear pressure, which in turn encourages microbial invasion of the middle ear. Moreover, they showed that the peak incidence of AOM isn’t on day 1 after onset of upper respiratory infection symptoms, but on day 3 or 4.
“What this tells us is that, once a child has a viral respiratory infection, there is a certain window of opportunity to try to prevent the development of the complication if we have the right tools in place,” Dr. Heikkinen said.
He and his colleagues put this lesson to good use nearly a decade ago in a randomized, double-blind trial in which they showed that giving oseltamivir (Tamiflu) within 12 hours after onset of influenza symptoms in children aged 1-3 years reduced the subsequent incidence of AOM by 85%, compared with placebo (Clin Infect Dis. 2010 Oct 15;51[8]:887-94).
These observations paved the way for the ongoing intensive research effort exploring ways of preventing AOM through interventions at two different levels: by developing viral vaccines to prevent a healthy child from contracting the viral upper respiratory infection that precedes AOM and by coming up with antiviral drugs or bacterial vaccines to prevent a upper respiratory infection from evolving into AOM.
The same applies to pneumonia. Other investigators showed years ago that both respiratory viruses and bacteria were present in two-thirds of sputum samples obtained from children with community-acquired pneumonia (Clin Microbiol Infect. 2012 Mar;18[3]:300-7).
RSV is the top cause of hospitalization for acute respiratory infection – pneumonia and bronchiolitis – in infants. Worldwide, it’s estimated that RSV accounts for more than 33 million episodes of pneumonia annually, with 3.2 million hospitalizations and 118,200 deaths.
Beyond the hospital, however, Dr. Heikkinen and colleagues conducted a prospective cohort study in Turku over the course of two consecutive respiratory infection seasons in which they captured the huge burden of RSV as an outpatient illness. It hit hardest in children younger than 3 years, in whom the average annual incidence of RSV infection was 275 cases per 1,000 children. In that youngest age population, RSV upper respiratory infection was followed by AOM 58% of the time, with antibiotics prescribed in 66% of the cases of this complication of RSV illness. The mean duration of RSV illness was greatest in this young age group, at 13 days, and it was associated with parental absenteeism from work at a rate of 136 days per 100 children with RSV illness.
Moreover, while AOM occurred less frequently in children aged 3-6 years, 46% of the cases were attributed to a preceding RSV infection, which led to antibiotic treatment nearly half of the time (J Infect Dis. 2017 Jan 1;215[1]:17-23). This documentation has spurred further efforts to develop RSV vaccines and antivirals.
He reported serving as a consultant to a half-dozen pharmaceutical companies, as well as having received research funding from Janssen, GlaxoSmithKline, and Novavax.
LJUBLJANA, SLOVENIA – Prevention or early effective treatment of respiratory syncytial virus (RSV) infection in infants and small children holds the promise of sharply reduced burdens of both acute otitis media (AOM) and pneumonia, Terho Heikkinen, MD, PhD, predicted in the Bill Marshall Award Lecture presented at the annual meeting of the European Society for Paediatric Infectious Diseases (ESPID).
RSV is by far the hottest virus in the world,” declared Dr. Heikkinen, professor of pediatrics at the University of Turku (Finland).
“A lot of progress is being made with respect to RSV. This increased understanding holds great promise for new interventions,” he explained. “Lots of different types of vaccines are being developed, monoclonal antibodies, antivirals. So
Today influenza is the only respiratory viral infection that’s preventable via vaccine or effectively treatable using antiviral drugs. That situation has to change, as Dr. Heikkinen demonstrated early in his career; RSV is the respiratory virus that’s most likely to invade the middle ear during AOM. It’s much more ototropic than influenza, parainfluenza, enteroviruses, or adenoviruses (N Engl J Med. 1999 Jan 28;340[4]:260-4), he noted.
The Bill Marshall Award and Lecture, ESPID’s most prestigious award, is given annually to an individual recognized as having significantly advanced the field of pediatric infectious diseases. Dr. Heikkinen was singled out for his decades of work establishing that viruses, including RSV, play a key role in AOM, which had traditionally been regarded as a bacterial infection. He and his coinvestigators demonstrated that in about two-thirds of cases, AOM is actually caused by a combination of bacteria and viruses, which explains why patients’ clinical response to antibiotic therapy for AOM often is poor. They also described the chain of events whereby viral infection of the upper airway epithelium triggers an inflammatory response in the nasopharynx, with resultant Eustachian tube dysfunction and negative middle ear pressure, which in turn encourages microbial invasion of the middle ear. Moreover, they showed that the peak incidence of AOM isn’t on day 1 after onset of upper respiratory infection symptoms, but on day 3 or 4.
“What this tells us is that, once a child has a viral respiratory infection, there is a certain window of opportunity to try to prevent the development of the complication if we have the right tools in place,” Dr. Heikkinen said.
He and his colleagues put this lesson to good use nearly a decade ago in a randomized, double-blind trial in which they showed that giving oseltamivir (Tamiflu) within 12 hours after onset of influenza symptoms in children aged 1-3 years reduced the subsequent incidence of AOM by 85%, compared with placebo (Clin Infect Dis. 2010 Oct 15;51[8]:887-94).
These observations paved the way for the ongoing intensive research effort exploring ways of preventing AOM through interventions at two different levels: by developing viral vaccines to prevent a healthy child from contracting the viral upper respiratory infection that precedes AOM and by coming up with antiviral drugs or bacterial vaccines to prevent a upper respiratory infection from evolving into AOM.
The same applies to pneumonia. Other investigators showed years ago that both respiratory viruses and bacteria were present in two-thirds of sputum samples obtained from children with community-acquired pneumonia (Clin Microbiol Infect. 2012 Mar;18[3]:300-7).
RSV is the top cause of hospitalization for acute respiratory infection – pneumonia and bronchiolitis – in infants. Worldwide, it’s estimated that RSV accounts for more than 33 million episodes of pneumonia annually, with 3.2 million hospitalizations and 118,200 deaths.
Beyond the hospital, however, Dr. Heikkinen and colleagues conducted a prospective cohort study in Turku over the course of two consecutive respiratory infection seasons in which they captured the huge burden of RSV as an outpatient illness. It hit hardest in children younger than 3 years, in whom the average annual incidence of RSV infection was 275 cases per 1,000 children. In that youngest age population, RSV upper respiratory infection was followed by AOM 58% of the time, with antibiotics prescribed in 66% of the cases of this complication of RSV illness. The mean duration of RSV illness was greatest in this young age group, at 13 days, and it was associated with parental absenteeism from work at a rate of 136 days per 100 children with RSV illness.
Moreover, while AOM occurred less frequently in children aged 3-6 years, 46% of the cases were attributed to a preceding RSV infection, which led to antibiotic treatment nearly half of the time (J Infect Dis. 2017 Jan 1;215[1]:17-23). This documentation has spurred further efforts to develop RSV vaccines and antivirals.
He reported serving as a consultant to a half-dozen pharmaceutical companies, as well as having received research funding from Janssen, GlaxoSmithKline, and Novavax.
LJUBLJANA, SLOVENIA – Prevention or early effective treatment of respiratory syncytial virus (RSV) infection in infants and small children holds the promise of sharply reduced burdens of both acute otitis media (AOM) and pneumonia, Terho Heikkinen, MD, PhD, predicted in the Bill Marshall Award Lecture presented at the annual meeting of the European Society for Paediatric Infectious Diseases (ESPID).
RSV is by far the hottest virus in the world,” declared Dr. Heikkinen, professor of pediatrics at the University of Turku (Finland).
“A lot of progress is being made with respect to RSV. This increased understanding holds great promise for new interventions,” he explained. “Lots of different types of vaccines are being developed, monoclonal antibodies, antivirals. So
Today influenza is the only respiratory viral infection that’s preventable via vaccine or effectively treatable using antiviral drugs. That situation has to change, as Dr. Heikkinen demonstrated early in his career; RSV is the respiratory virus that’s most likely to invade the middle ear during AOM. It’s much more ototropic than influenza, parainfluenza, enteroviruses, or adenoviruses (N Engl J Med. 1999 Jan 28;340[4]:260-4), he noted.
The Bill Marshall Award and Lecture, ESPID’s most prestigious award, is given annually to an individual recognized as having significantly advanced the field of pediatric infectious diseases. Dr. Heikkinen was singled out for his decades of work establishing that viruses, including RSV, play a key role in AOM, which had traditionally been regarded as a bacterial infection. He and his coinvestigators demonstrated that in about two-thirds of cases, AOM is actually caused by a combination of bacteria and viruses, which explains why patients’ clinical response to antibiotic therapy for AOM often is poor. They also described the chain of events whereby viral infection of the upper airway epithelium triggers an inflammatory response in the nasopharynx, with resultant Eustachian tube dysfunction and negative middle ear pressure, which in turn encourages microbial invasion of the middle ear. Moreover, they showed that the peak incidence of AOM isn’t on day 1 after onset of upper respiratory infection symptoms, but on day 3 or 4.
“What this tells us is that, once a child has a viral respiratory infection, there is a certain window of opportunity to try to prevent the development of the complication if we have the right tools in place,” Dr. Heikkinen said.
He and his colleagues put this lesson to good use nearly a decade ago in a randomized, double-blind trial in which they showed that giving oseltamivir (Tamiflu) within 12 hours after onset of influenza symptoms in children aged 1-3 years reduced the subsequent incidence of AOM by 85%, compared with placebo (Clin Infect Dis. 2010 Oct 15;51[8]:887-94).
These observations paved the way for the ongoing intensive research effort exploring ways of preventing AOM through interventions at two different levels: by developing viral vaccines to prevent a healthy child from contracting the viral upper respiratory infection that precedes AOM and by coming up with antiviral drugs or bacterial vaccines to prevent a upper respiratory infection from evolving into AOM.
The same applies to pneumonia. Other investigators showed years ago that both respiratory viruses and bacteria were present in two-thirds of sputum samples obtained from children with community-acquired pneumonia (Clin Microbiol Infect. 2012 Mar;18[3]:300-7).
RSV is the top cause of hospitalization for acute respiratory infection – pneumonia and bronchiolitis – in infants. Worldwide, it’s estimated that RSV accounts for more than 33 million episodes of pneumonia annually, with 3.2 million hospitalizations and 118,200 deaths.
Beyond the hospital, however, Dr. Heikkinen and colleagues conducted a prospective cohort study in Turku over the course of two consecutive respiratory infection seasons in which they captured the huge burden of RSV as an outpatient illness. It hit hardest in children younger than 3 years, in whom the average annual incidence of RSV infection was 275 cases per 1,000 children. In that youngest age population, RSV upper respiratory infection was followed by AOM 58% of the time, with antibiotics prescribed in 66% of the cases of this complication of RSV illness. The mean duration of RSV illness was greatest in this young age group, at 13 days, and it was associated with parental absenteeism from work at a rate of 136 days per 100 children with RSV illness.
Moreover, while AOM occurred less frequently in children aged 3-6 years, 46% of the cases were attributed to a preceding RSV infection, which led to antibiotic treatment nearly half of the time (J Infect Dis. 2017 Jan 1;215[1]:17-23). This documentation has spurred further efforts to develop RSV vaccines and antivirals.
He reported serving as a consultant to a half-dozen pharmaceutical companies, as well as having received research funding from Janssen, GlaxoSmithKline, and Novavax.
EXPERT ANALYSIS FROM ESPID 2019
Cumulative smoking affects skin manifestations of SLE
SAN FRANCISCO – Nnenna Ezeh reported at an international congress on systemic lupus erythematosus.
“We saw in our study a suggestion of a dose-response relationship. If we tell patients, ‘The more you smoke, the more likely you are to have chronic skin disease or skin damage that’s permanent,’ it could be a way to trigger more smoking cessation strategies in their mind,” said Ms. Ezeh, of the University of Wisconsin, Madison. “We know that skin manifestations of lupus have a major negative impact on a patient’s quality of life, so this could be a way to decrease smoking by saying, ‘Not only does smoking impact your heart and put you at risk for cardiovascular disease, it also affects your skin.’ It’s a way to bridge the priorities that physicians have with the priorities that patients have.”
She presented a retrospective study of the medical records of 632 consecutive SLE patients seen at the university medical center’s ambulatory rheumatology clinic. Slightly more than 60% of them were never smokers; 8.7% had a history of low smoking exposure, defined as less than 5 pack-years; 5.8% had a medium-smoking history of 5-10 pack-years; 15% had a high-smoking history, with more than 10 pack-years; and the smoking history of 10% of the patients was unrecorded.
In a multivariate analysis adjusted for age, sex, and race, the low-smoking group was ninefold more likely than never smokers to develop any mucocutaneous manifestations of SLE, including a malar or discoid rash, mucosal ulcers, photosensitivity, alopecia, or scarring. They were also 3.7 times more likely to meet any Systemic Lupus International Collaborating Clinics (SLICC) cutaneous criteria and twofold more likely than never smokers to meet any of the American College of Rheumatology cutaneous criteria. Patients with an intermediate smoking exposure history of 5-10 pack-years were 2.3-fold more likely to meet any SLICC cutaneous criteria.
The risks of meeting SLICC chronic cutaneous criteria and SLICC Damage Index skin damage criteria rose in a linear fashion with the number of pack-years of smoking. Those SLE patients with more than a 10 pack-year smoking history were 4.2-fold more likely than never smokers to fulfill any SLICC Damage Index skin damage criteria, which consist of scarring alopecia, extensive scarring, or skin ulcers. The heaviest smokers were also at 2.1-fold increased risk of discoid lupus and 2.2-fold more likely to meet SLICC chronic cutaneous criteria, according to Ms. Ezeh.
Patients of color, who comprised 18% of the study population, were significantly more likely to smoke than white patients. Independent of their smoking history, however, they had significantly increased risks of chronic cutaneous manifestations of lupus and of irreversible skin damage.
Ms. Ezeh reported having no financial conflicts regarding her study, supported by a grant from the Rheumatology Research Foundation.
SAN FRANCISCO – Nnenna Ezeh reported at an international congress on systemic lupus erythematosus.
“We saw in our study a suggestion of a dose-response relationship. If we tell patients, ‘The more you smoke, the more likely you are to have chronic skin disease or skin damage that’s permanent,’ it could be a way to trigger more smoking cessation strategies in their mind,” said Ms. Ezeh, of the University of Wisconsin, Madison. “We know that skin manifestations of lupus have a major negative impact on a patient’s quality of life, so this could be a way to decrease smoking by saying, ‘Not only does smoking impact your heart and put you at risk for cardiovascular disease, it also affects your skin.’ It’s a way to bridge the priorities that physicians have with the priorities that patients have.”
She presented a retrospective study of the medical records of 632 consecutive SLE patients seen at the university medical center’s ambulatory rheumatology clinic. Slightly more than 60% of them were never smokers; 8.7% had a history of low smoking exposure, defined as less than 5 pack-years; 5.8% had a medium-smoking history of 5-10 pack-years; 15% had a high-smoking history, with more than 10 pack-years; and the smoking history of 10% of the patients was unrecorded.
In a multivariate analysis adjusted for age, sex, and race, the low-smoking group was ninefold more likely than never smokers to develop any mucocutaneous manifestations of SLE, including a malar or discoid rash, mucosal ulcers, photosensitivity, alopecia, or scarring. They were also 3.7 times more likely to meet any Systemic Lupus International Collaborating Clinics (SLICC) cutaneous criteria and twofold more likely than never smokers to meet any of the American College of Rheumatology cutaneous criteria. Patients with an intermediate smoking exposure history of 5-10 pack-years were 2.3-fold more likely to meet any SLICC cutaneous criteria.
The risks of meeting SLICC chronic cutaneous criteria and SLICC Damage Index skin damage criteria rose in a linear fashion with the number of pack-years of smoking. Those SLE patients with more than a 10 pack-year smoking history were 4.2-fold more likely than never smokers to fulfill any SLICC Damage Index skin damage criteria, which consist of scarring alopecia, extensive scarring, or skin ulcers. The heaviest smokers were also at 2.1-fold increased risk of discoid lupus and 2.2-fold more likely to meet SLICC chronic cutaneous criteria, according to Ms. Ezeh.
Patients of color, who comprised 18% of the study population, were significantly more likely to smoke than white patients. Independent of their smoking history, however, they had significantly increased risks of chronic cutaneous manifestations of lupus and of irreversible skin damage.
Ms. Ezeh reported having no financial conflicts regarding her study, supported by a grant from the Rheumatology Research Foundation.
SAN FRANCISCO – Nnenna Ezeh reported at an international congress on systemic lupus erythematosus.
“We saw in our study a suggestion of a dose-response relationship. If we tell patients, ‘The more you smoke, the more likely you are to have chronic skin disease or skin damage that’s permanent,’ it could be a way to trigger more smoking cessation strategies in their mind,” said Ms. Ezeh, of the University of Wisconsin, Madison. “We know that skin manifestations of lupus have a major negative impact on a patient’s quality of life, so this could be a way to decrease smoking by saying, ‘Not only does smoking impact your heart and put you at risk for cardiovascular disease, it also affects your skin.’ It’s a way to bridge the priorities that physicians have with the priorities that patients have.”
She presented a retrospective study of the medical records of 632 consecutive SLE patients seen at the university medical center’s ambulatory rheumatology clinic. Slightly more than 60% of them were never smokers; 8.7% had a history of low smoking exposure, defined as less than 5 pack-years; 5.8% had a medium-smoking history of 5-10 pack-years; 15% had a high-smoking history, with more than 10 pack-years; and the smoking history of 10% of the patients was unrecorded.
In a multivariate analysis adjusted for age, sex, and race, the low-smoking group was ninefold more likely than never smokers to develop any mucocutaneous manifestations of SLE, including a malar or discoid rash, mucosal ulcers, photosensitivity, alopecia, or scarring. They were also 3.7 times more likely to meet any Systemic Lupus International Collaborating Clinics (SLICC) cutaneous criteria and twofold more likely than never smokers to meet any of the American College of Rheumatology cutaneous criteria. Patients with an intermediate smoking exposure history of 5-10 pack-years were 2.3-fold more likely to meet any SLICC cutaneous criteria.
The risks of meeting SLICC chronic cutaneous criteria and SLICC Damage Index skin damage criteria rose in a linear fashion with the number of pack-years of smoking. Those SLE patients with more than a 10 pack-year smoking history were 4.2-fold more likely than never smokers to fulfill any SLICC Damage Index skin damage criteria, which consist of scarring alopecia, extensive scarring, or skin ulcers. The heaviest smokers were also at 2.1-fold increased risk of discoid lupus and 2.2-fold more likely to meet SLICC chronic cutaneous criteria, according to Ms. Ezeh.
Patients of color, who comprised 18% of the study population, were significantly more likely to smoke than white patients. Independent of their smoking history, however, they had significantly increased risks of chronic cutaneous manifestations of lupus and of irreversible skin damage.
Ms. Ezeh reported having no financial conflicts regarding her study, supported by a grant from the Rheumatology Research Foundation.
REPORTING FROM LUPUS 2019
Swedish OA self-management program earns high marks
TORONTO – A in an observational registry study of 47,035 participants, Therese S. Jönsson reported at the OARSI 2019 World Congress.
“The BOA [Better management of patients with Osteoarthritis] program is feasible and demonstrates positive results in a large clinical context. Our results indicate that offering this intervention as the first-line treatment for patients with hip and knee osteoarthritis may reduce the burden of disease,” she said at the meeting, sponsored by the Osteoarthritis Research Society International.
Indeed, the results of the Swedish BOA program for nonsurgical treatment of OA played an influential role in the new draft of OARSI guidelines for management of knee osteoarthritis. The program could serve as a template for implementation of a similar approach in other health care settings. The BOA program has been rolled out to more than 700 Swedish primary care practice sites, according to Ms. Jönsson, a PhD student at Lund (Sweden) University.
The program was created to meet a defined national goal that, as early as possible in the course of the disease, every Swedish patient with knee or hip OA should receive education about their disease and the importance of exercise as a means of improving their quality of life. The impetus for BOA was a widespread concern that, in Sweden and elsewhere, far too many OA patients were being referred for joint surgery without ever having tried the evidence-based core nonsurgical treatments.
The BOA intervention
Following patient referral by a primary care physician, the Swedish BOA program starts off with individual assessment and biomechanical testing by a physical therapist. This is followed by two small-group education sessions of about 90 minutes led by a physical therapist or occupational therapist. Session one includes information about the pathology of OA, risk factors, symptoms, and the available treatments. Session two focuses on coping skills, self-management strategies to reduce pain and symptoms, the central role of exercise as a core treatment in OA, and ways to incorporate physical activity into daily living.
Then comes a decision point. Having listened to a motivational message extolling the benefits of exercise as a means of empowering self-management of their chronic disease, participants next have three choices: They can attend supervised group exercise classes twice weekly for 6 weeks to kick-start a more physically active lifestyle, they can start an individually adapted home exercise program, or they can decline exercise.
Giving patients a choice in this matter is a strategy rooted in the psychological concept of motivational stages of change, which recognizes that some patients with a chronic illness whose course is modifiable through lifestyle change are initially in a precontemplation stage of change. And pushing them hard at that point is counterproductive. The home exercise option, which permits patients to take a low-and-slow approach to exercise, is based upon the BOA program developers’ stated philosophy that 5 minutes of exercise daily, performed as part of everyday life, has a bigger impact upon function than does a 30-minute exercise program that’s abandoned after a few weeks. The goal of the BOA program is for patients to eventually build up to at least 150 minutes of moderate-intensity exercise per week.
The results
Roughly 15% of patients enrolled in the registry declined the exercise option. Ms. Jönsson’s analysis focused on those who opted to participate in an exercise program, 40% of whom selected the home exercise option. This analysis included 30,682 patients with knee OA and 16,363 with hip OA. They returned to the physical therapist for a face-to-face reassessment after 3 months, and they completed a mailed outcome-oriented questionnaire at 12 months.
The BOA intervention was more effective in reducing pain in the knee OA group than in those with hip OA. A statistically significant reduction in self-assessed pain scores on a 0-10 scale was seen in both the knee and hip OA groups at 3 and 12 months; however, only the knee OA patients achieved a clinically important decrease in pain, defined as at least a 15% drop in pain scores. Their pain scores improved from 5.24 at baseline to 4.07 at 3 months and 4.23 at 12 months. In the hip OA patients, pain scores went from 5.39 at baseline to 4.56 at 3 months and 4.7 at 12 months.
However, at 3 and 12 months, significantly fewer patients in both the hip and knee OA groups reported experiencing pain more than once per week, compared with baseline. They also took fewer pain-killing medications, reported less avoidance behavior involving fear of movement, were less willing to undergo joint surgery, and scored significantly higher on the five-level EQ-5D quality-of-life measure than at baseline. Moreover, fewer patients were on sick leave at the 12-month follow-up than at baseline, an outcome that wasn’t assessed at 3 months.
Adherence to the group exercise classes was “quite low,” according to Ms. Jönsson, and poor adherence was reflected in smaller reductions in pain scores. Only 30% of patients who elected the supervised group exercise option attended 10 of the 12 sessions, she noted.
Ms. Jönsson reported having no financial conflicts regarding her study. The BOA program is funded by the Swedish government.
SOURCE: Jönsson TS et al. Osteoarthritis Cartilage. 2019 Apr;27(suppl 1):S497, Abstract 717.
TORONTO – A in an observational registry study of 47,035 participants, Therese S. Jönsson reported at the OARSI 2019 World Congress.
“The BOA [Better management of patients with Osteoarthritis] program is feasible and demonstrates positive results in a large clinical context. Our results indicate that offering this intervention as the first-line treatment for patients with hip and knee osteoarthritis may reduce the burden of disease,” she said at the meeting, sponsored by the Osteoarthritis Research Society International.
Indeed, the results of the Swedish BOA program for nonsurgical treatment of OA played an influential role in the new draft of OARSI guidelines for management of knee osteoarthritis. The program could serve as a template for implementation of a similar approach in other health care settings. The BOA program has been rolled out to more than 700 Swedish primary care practice sites, according to Ms. Jönsson, a PhD student at Lund (Sweden) University.
The program was created to meet a defined national goal that, as early as possible in the course of the disease, every Swedish patient with knee or hip OA should receive education about their disease and the importance of exercise as a means of improving their quality of life. The impetus for BOA was a widespread concern that, in Sweden and elsewhere, far too many OA patients were being referred for joint surgery without ever having tried the evidence-based core nonsurgical treatments.
The BOA intervention
Following patient referral by a primary care physician, the Swedish BOA program starts off with individual assessment and biomechanical testing by a physical therapist. This is followed by two small-group education sessions of about 90 minutes led by a physical therapist or occupational therapist. Session one includes information about the pathology of OA, risk factors, symptoms, and the available treatments. Session two focuses on coping skills, self-management strategies to reduce pain and symptoms, the central role of exercise as a core treatment in OA, and ways to incorporate physical activity into daily living.
Then comes a decision point. Having listened to a motivational message extolling the benefits of exercise as a means of empowering self-management of their chronic disease, participants next have three choices: They can attend supervised group exercise classes twice weekly for 6 weeks to kick-start a more physically active lifestyle, they can start an individually adapted home exercise program, or they can decline exercise.
Giving patients a choice in this matter is a strategy rooted in the psychological concept of motivational stages of change, which recognizes that some patients with a chronic illness whose course is modifiable through lifestyle change are initially in a precontemplation stage of change. And pushing them hard at that point is counterproductive. The home exercise option, which permits patients to take a low-and-slow approach to exercise, is based upon the BOA program developers’ stated philosophy that 5 minutes of exercise daily, performed as part of everyday life, has a bigger impact upon function than does a 30-minute exercise program that’s abandoned after a few weeks. The goal of the BOA program is for patients to eventually build up to at least 150 minutes of moderate-intensity exercise per week.
The results
Roughly 15% of patients enrolled in the registry declined the exercise option. Ms. Jönsson’s analysis focused on those who opted to participate in an exercise program, 40% of whom selected the home exercise option. This analysis included 30,682 patients with knee OA and 16,363 with hip OA. They returned to the physical therapist for a face-to-face reassessment after 3 months, and they completed a mailed outcome-oriented questionnaire at 12 months.
The BOA intervention was more effective in reducing pain in the knee OA group than in those with hip OA. A statistically significant reduction in self-assessed pain scores on a 0-10 scale was seen in both the knee and hip OA groups at 3 and 12 months; however, only the knee OA patients achieved a clinically important decrease in pain, defined as at least a 15% drop in pain scores. Their pain scores improved from 5.24 at baseline to 4.07 at 3 months and 4.23 at 12 months. In the hip OA patients, pain scores went from 5.39 at baseline to 4.56 at 3 months and 4.7 at 12 months.
However, at 3 and 12 months, significantly fewer patients in both the hip and knee OA groups reported experiencing pain more than once per week, compared with baseline. They also took fewer pain-killing medications, reported less avoidance behavior involving fear of movement, were less willing to undergo joint surgery, and scored significantly higher on the five-level EQ-5D quality-of-life measure than at baseline. Moreover, fewer patients were on sick leave at the 12-month follow-up than at baseline, an outcome that wasn’t assessed at 3 months.
Adherence to the group exercise classes was “quite low,” according to Ms. Jönsson, and poor adherence was reflected in smaller reductions in pain scores. Only 30% of patients who elected the supervised group exercise option attended 10 of the 12 sessions, she noted.
Ms. Jönsson reported having no financial conflicts regarding her study. The BOA program is funded by the Swedish government.
SOURCE: Jönsson TS et al. Osteoarthritis Cartilage. 2019 Apr;27(suppl 1):S497, Abstract 717.
TORONTO – A in an observational registry study of 47,035 participants, Therese S. Jönsson reported at the OARSI 2019 World Congress.
“The BOA [Better management of patients with Osteoarthritis] program is feasible and demonstrates positive results in a large clinical context. Our results indicate that offering this intervention as the first-line treatment for patients with hip and knee osteoarthritis may reduce the burden of disease,” she said at the meeting, sponsored by the Osteoarthritis Research Society International.
Indeed, the results of the Swedish BOA program for nonsurgical treatment of OA played an influential role in the new draft of OARSI guidelines for management of knee osteoarthritis. The program could serve as a template for implementation of a similar approach in other health care settings. The BOA program has been rolled out to more than 700 Swedish primary care practice sites, according to Ms. Jönsson, a PhD student at Lund (Sweden) University.
The program was created to meet a defined national goal that, as early as possible in the course of the disease, every Swedish patient with knee or hip OA should receive education about their disease and the importance of exercise as a means of improving their quality of life. The impetus for BOA was a widespread concern that, in Sweden and elsewhere, far too many OA patients were being referred for joint surgery without ever having tried the evidence-based core nonsurgical treatments.
The BOA intervention
Following patient referral by a primary care physician, the Swedish BOA program starts off with individual assessment and biomechanical testing by a physical therapist. This is followed by two small-group education sessions of about 90 minutes led by a physical therapist or occupational therapist. Session one includes information about the pathology of OA, risk factors, symptoms, and the available treatments. Session two focuses on coping skills, self-management strategies to reduce pain and symptoms, the central role of exercise as a core treatment in OA, and ways to incorporate physical activity into daily living.
Then comes a decision point. Having listened to a motivational message extolling the benefits of exercise as a means of empowering self-management of their chronic disease, participants next have three choices: They can attend supervised group exercise classes twice weekly for 6 weeks to kick-start a more physically active lifestyle, they can start an individually adapted home exercise program, or they can decline exercise.
Giving patients a choice in this matter is a strategy rooted in the psychological concept of motivational stages of change, which recognizes that some patients with a chronic illness whose course is modifiable through lifestyle change are initially in a precontemplation stage of change. And pushing them hard at that point is counterproductive. The home exercise option, which permits patients to take a low-and-slow approach to exercise, is based upon the BOA program developers’ stated philosophy that 5 minutes of exercise daily, performed as part of everyday life, has a bigger impact upon function than does a 30-minute exercise program that’s abandoned after a few weeks. The goal of the BOA program is for patients to eventually build up to at least 150 minutes of moderate-intensity exercise per week.
The results
Roughly 15% of patients enrolled in the registry declined the exercise option. Ms. Jönsson’s analysis focused on those who opted to participate in an exercise program, 40% of whom selected the home exercise option. This analysis included 30,682 patients with knee OA and 16,363 with hip OA. They returned to the physical therapist for a face-to-face reassessment after 3 months, and they completed a mailed outcome-oriented questionnaire at 12 months.
The BOA intervention was more effective in reducing pain in the knee OA group than in those with hip OA. A statistically significant reduction in self-assessed pain scores on a 0-10 scale was seen in both the knee and hip OA groups at 3 and 12 months; however, only the knee OA patients achieved a clinically important decrease in pain, defined as at least a 15% drop in pain scores. Their pain scores improved from 5.24 at baseline to 4.07 at 3 months and 4.23 at 12 months. In the hip OA patients, pain scores went from 5.39 at baseline to 4.56 at 3 months and 4.7 at 12 months.
However, at 3 and 12 months, significantly fewer patients in both the hip and knee OA groups reported experiencing pain more than once per week, compared with baseline. They also took fewer pain-killing medications, reported less avoidance behavior involving fear of movement, were less willing to undergo joint surgery, and scored significantly higher on the five-level EQ-5D quality-of-life measure than at baseline. Moreover, fewer patients were on sick leave at the 12-month follow-up than at baseline, an outcome that wasn’t assessed at 3 months.
Adherence to the group exercise classes was “quite low,” according to Ms. Jönsson, and poor adherence was reflected in smaller reductions in pain scores. Only 30% of patients who elected the supervised group exercise option attended 10 of the 12 sessions, she noted.
Ms. Jönsson reported having no financial conflicts regarding her study. The BOA program is funded by the Swedish government.
SOURCE: Jönsson TS et al. Osteoarthritis Cartilage. 2019 Apr;27(suppl 1):S497, Abstract 717.
REPORTING FROM OARSI 2019
OA is underrepresented in the medical literature
TORONTO – Osteoarthritis research doesn’t get nearly the respect it deserves in the medical literature, Elizabeth M. Badley, PhD, asserted at the OARSI 2019 World Congress.
“Osteoarthritis is by far the most common type of arthritis. There are easily 10 times more people who have osteoarthritis than any other joint disease, but when you look at the literature, the situation is kind of reversed. Osteoarthritis is brushed off by society to a degree,” she said at the meeting, sponsored by the Osteoarthritis Research Society International.
Dr. Bradley and colleagues performed a search of MEDLINE for 2007-2016, which turned up a total of 1,625 publications in 2016 on osteoarthritis, excluding those with an orthopedic surgery focus, compared with 10,904 results regarding the broader topic of joint diseases and 28,932 on musculoskeletal diseases.
The bottom line: “Progress is slow, and at this rate osteoarthritis will not be receiving the attention it deserves in our lifetime,” said Dr. Badley, of the department of epidemiology at the University of Toronto and a senior scientist at the Krembil Research Institute, also in Toronto.
The number of publications per year devoted to OA rose by a robust 88% during 2007-2016, while the number on OA not focused on orthopedic procedures grew by 65%. Both of these increases were greater than those for publications on musculoskeletal diseases and joint diseases overall, which were 41% and 51%, respectively. But the absolute number of OA publications was dwarfed by the numbers of those in the other search categories. For example, the number of publications on OA without an orthopedic surgery thrust was 985 in 2007, compared with 7,204 on joint diseases overall.
Among the striking findings of the investigators’ study of the medical literature was the disconnect between the amount of attention devoted to some of the joint-specific manifestations of OA and the actual prevalence of these conditions in the population. For example, the prevalence of hand OA in people living with OA was 52% according to the 2009 Survey on Living with Chronic Diseases in Canada, conducted by Statistics Canada, yet only 6.5% of the publications on OA in 2016 were devoted to hand/thumb OA. Similarly, the prevalence of spine OA was 52% among Canadians with OA, but only 4.3% of OA publications in 2016 focused on that topic. And while the number of publications devoted to elbow OA soared by a seemingly impressive 233% during the study period, the actual numbers were 3 publications in 2007 and 10 in 2016.
“Also, the average number of affected joints in people with osteoarthritis is four. Yet very, very few papers are about multijoint osteoarthritis. And when they do talk about multijoint osteoarthritis, they’re still only talking about hand/hip/knee. So we’re missing the bigger picture of osteoarthritis as a multijoint disease. We’re missing the spine, largely, as a part of osteoarthritis, and we’re missing the peripheral joints,” she said.
Dr. Badley reported having no financial conflicts regarding her study, conducted free of commercial support.
SOURCE: Badley EM et al. Osteoarthritis Cartilage. 2019 Apr;27(Suppl 1):S278, Abstract 393.
TORONTO – Osteoarthritis research doesn’t get nearly the respect it deserves in the medical literature, Elizabeth M. Badley, PhD, asserted at the OARSI 2019 World Congress.
“Osteoarthritis is by far the most common type of arthritis. There are easily 10 times more people who have osteoarthritis than any other joint disease, but when you look at the literature, the situation is kind of reversed. Osteoarthritis is brushed off by society to a degree,” she said at the meeting, sponsored by the Osteoarthritis Research Society International.
Dr. Bradley and colleagues performed a search of MEDLINE for 2007-2016, which turned up a total of 1,625 publications in 2016 on osteoarthritis, excluding those with an orthopedic surgery focus, compared with 10,904 results regarding the broader topic of joint diseases and 28,932 on musculoskeletal diseases.
The bottom line: “Progress is slow, and at this rate osteoarthritis will not be receiving the attention it deserves in our lifetime,” said Dr. Badley, of the department of epidemiology at the University of Toronto and a senior scientist at the Krembil Research Institute, also in Toronto.
The number of publications per year devoted to OA rose by a robust 88% during 2007-2016, while the number on OA not focused on orthopedic procedures grew by 65%. Both of these increases were greater than those for publications on musculoskeletal diseases and joint diseases overall, which were 41% and 51%, respectively. But the absolute number of OA publications was dwarfed by the numbers of those in the other search categories. For example, the number of publications on OA without an orthopedic surgery thrust was 985 in 2007, compared with 7,204 on joint diseases overall.
Among the striking findings of the investigators’ study of the medical literature was the disconnect between the amount of attention devoted to some of the joint-specific manifestations of OA and the actual prevalence of these conditions in the population. For example, the prevalence of hand OA in people living with OA was 52% according to the 2009 Survey on Living with Chronic Diseases in Canada, conducted by Statistics Canada, yet only 6.5% of the publications on OA in 2016 were devoted to hand/thumb OA. Similarly, the prevalence of spine OA was 52% among Canadians with OA, but only 4.3% of OA publications in 2016 focused on that topic. And while the number of publications devoted to elbow OA soared by a seemingly impressive 233% during the study period, the actual numbers were 3 publications in 2007 and 10 in 2016.
“Also, the average number of affected joints in people with osteoarthritis is four. Yet very, very few papers are about multijoint osteoarthritis. And when they do talk about multijoint osteoarthritis, they’re still only talking about hand/hip/knee. So we’re missing the bigger picture of osteoarthritis as a multijoint disease. We’re missing the spine, largely, as a part of osteoarthritis, and we’re missing the peripheral joints,” she said.
Dr. Badley reported having no financial conflicts regarding her study, conducted free of commercial support.
SOURCE: Badley EM et al. Osteoarthritis Cartilage. 2019 Apr;27(Suppl 1):S278, Abstract 393.
TORONTO – Osteoarthritis research doesn’t get nearly the respect it deserves in the medical literature, Elizabeth M. Badley, PhD, asserted at the OARSI 2019 World Congress.
“Osteoarthritis is by far the most common type of arthritis. There are easily 10 times more people who have osteoarthritis than any other joint disease, but when you look at the literature, the situation is kind of reversed. Osteoarthritis is brushed off by society to a degree,” she said at the meeting, sponsored by the Osteoarthritis Research Society International.
Dr. Bradley and colleagues performed a search of MEDLINE for 2007-2016, which turned up a total of 1,625 publications in 2016 on osteoarthritis, excluding those with an orthopedic surgery focus, compared with 10,904 results regarding the broader topic of joint diseases and 28,932 on musculoskeletal diseases.
The bottom line: “Progress is slow, and at this rate osteoarthritis will not be receiving the attention it deserves in our lifetime,” said Dr. Badley, of the department of epidemiology at the University of Toronto and a senior scientist at the Krembil Research Institute, also in Toronto.
The number of publications per year devoted to OA rose by a robust 88% during 2007-2016, while the number on OA not focused on orthopedic procedures grew by 65%. Both of these increases were greater than those for publications on musculoskeletal diseases and joint diseases overall, which were 41% and 51%, respectively. But the absolute number of OA publications was dwarfed by the numbers of those in the other search categories. For example, the number of publications on OA without an orthopedic surgery thrust was 985 in 2007, compared with 7,204 on joint diseases overall.
Among the striking findings of the investigators’ study of the medical literature was the disconnect between the amount of attention devoted to some of the joint-specific manifestations of OA and the actual prevalence of these conditions in the population. For example, the prevalence of hand OA in people living with OA was 52% according to the 2009 Survey on Living with Chronic Diseases in Canada, conducted by Statistics Canada, yet only 6.5% of the publications on OA in 2016 were devoted to hand/thumb OA. Similarly, the prevalence of spine OA was 52% among Canadians with OA, but only 4.3% of OA publications in 2016 focused on that topic. And while the number of publications devoted to elbow OA soared by a seemingly impressive 233% during the study period, the actual numbers were 3 publications in 2007 and 10 in 2016.
“Also, the average number of affected joints in people with osteoarthritis is four. Yet very, very few papers are about multijoint osteoarthritis. And when they do talk about multijoint osteoarthritis, they’re still only talking about hand/hip/knee. So we’re missing the bigger picture of osteoarthritis as a multijoint disease. We’re missing the spine, largely, as a part of osteoarthritis, and we’re missing the peripheral joints,” she said.
Dr. Badley reported having no financial conflicts regarding her study, conducted free of commercial support.
SOURCE: Badley EM et al. Osteoarthritis Cartilage. 2019 Apr;27(Suppl 1):S278, Abstract 393.
REPORTING FROM OARSI 2019
Pain coping skills training doesn’t improve knee arthroplasty outcomes
TORONTO – A high level of pain catastrophizing prior to scheduled knee arthroplasty is not, as previously thought, a harbinger of poor outcomes, and affected patients don’t benefit from cognitive-behavioral therapy–based training in pain coping skills, Daniel L. Riddle, PhD, reported at the OARSI 2019 World Congress.
“The take-home message for us is knee arthroplasty is incredibly effective and there really is no reason to do pain coping skills training in these high–pain catastrophizing patients because the great majority of them have such good outcomes,” said Dr. Riddle, professor of physical therapy at Virginia Commonwealth University, Richmond.
“The other clear message from our trial is that, when you have pain-catastrophizing patients and you lower their pain, their catastrophizing is also lowered. So pain catastrophizing is clearly a response to pain and not a personality trait per se,” he said at the meeting sponsored by the Osteoarthritis Research Society International.
He presented the results of a 402-patient, randomized, three-arm, single-blind trial conducted at five U.S. medical centers. All participants were scheduled for knee arthroplasty for osteoarthritis, and all had moderate- to high-level pain catastrophizing as reflected in the group’s average Pain Catastrophizing Score of 30. They were assigned to an arthritis education active control group, usual care, or an intervention developed specifically for this study: a cognitive-behavioral therapy–based training program for pain coping skills. Similar pain coping skills training interventions have been shown to be beneficial in patients with medically treated knee OA but hadn’t previously been evaluated in surgically treated patients. The primary study endpoint was change in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain Scale at 2, 6, and 12 months after surgery.
The improvement in WOMAC pain in the three study arms was virtually superimposable, going from an average pain score of about 12 preoperatively to 2 postoperatively.
“This was a clear no-effect trial,” Dr. Riddle observed. “These are patients we thought to be at increased risk for poor outcome, but indeed they’re not.”
Pain Catastrophizing Scores improved from 30 preoperatively to roughly 7 at 1 year. “We’ve never seen pain catastrophizing improvements of this magnitude,” the researcher commented.
The study participants typically had a large number of chronically painful areas, but only minimal change in pain scores occurred except in the surgically treated knee.
Of note, even with the impressively large improvements in knee pain, function, and other secondary endpoints in the study group as a whole, roughly 20% of study participants experienced essentially no improvement in their function-limiting knee pain during the first year after arthroplasty. These nonresponders were spread equally across all three study arms. Further research will be needed to develop interventions to help this challenging patient subgroup.
The pain coping skills training consisted of 8 weekly sessions, each an hour long, which began prior to surgery and continued afterward. The intervention was delivered by physical therapists who had been trained by pain psychologists with expertise in cognitive-behavioral therapy. The intervention was delivered by telephone and in face-to-face sessions. The trainers were tracked over the course of the study to make sure that the structured intervention was delivered as planned.
Dr. Riddle reported having no financial conflicts regarding the National Institutes of Health-funded study, the full details of which have been published (J Bone Joint Surg Am. 2019 Feb 6;101[3]:218-227).
TORONTO – A high level of pain catastrophizing prior to scheduled knee arthroplasty is not, as previously thought, a harbinger of poor outcomes, and affected patients don’t benefit from cognitive-behavioral therapy–based training in pain coping skills, Daniel L. Riddle, PhD, reported at the OARSI 2019 World Congress.
“The take-home message for us is knee arthroplasty is incredibly effective and there really is no reason to do pain coping skills training in these high–pain catastrophizing patients because the great majority of them have such good outcomes,” said Dr. Riddle, professor of physical therapy at Virginia Commonwealth University, Richmond.
“The other clear message from our trial is that, when you have pain-catastrophizing patients and you lower their pain, their catastrophizing is also lowered. So pain catastrophizing is clearly a response to pain and not a personality trait per se,” he said at the meeting sponsored by the Osteoarthritis Research Society International.
He presented the results of a 402-patient, randomized, three-arm, single-blind trial conducted at five U.S. medical centers. All participants were scheduled for knee arthroplasty for osteoarthritis, and all had moderate- to high-level pain catastrophizing as reflected in the group’s average Pain Catastrophizing Score of 30. They were assigned to an arthritis education active control group, usual care, or an intervention developed specifically for this study: a cognitive-behavioral therapy–based training program for pain coping skills. Similar pain coping skills training interventions have been shown to be beneficial in patients with medically treated knee OA but hadn’t previously been evaluated in surgically treated patients. The primary study endpoint was change in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain Scale at 2, 6, and 12 months after surgery.
The improvement in WOMAC pain in the three study arms was virtually superimposable, going from an average pain score of about 12 preoperatively to 2 postoperatively.
“This was a clear no-effect trial,” Dr. Riddle observed. “These are patients we thought to be at increased risk for poor outcome, but indeed they’re not.”
Pain Catastrophizing Scores improved from 30 preoperatively to roughly 7 at 1 year. “We’ve never seen pain catastrophizing improvements of this magnitude,” the researcher commented.
The study participants typically had a large number of chronically painful areas, but only minimal change in pain scores occurred except in the surgically treated knee.
Of note, even with the impressively large improvements in knee pain, function, and other secondary endpoints in the study group as a whole, roughly 20% of study participants experienced essentially no improvement in their function-limiting knee pain during the first year after arthroplasty. These nonresponders were spread equally across all three study arms. Further research will be needed to develop interventions to help this challenging patient subgroup.
The pain coping skills training consisted of 8 weekly sessions, each an hour long, which began prior to surgery and continued afterward. The intervention was delivered by physical therapists who had been trained by pain psychologists with expertise in cognitive-behavioral therapy. The intervention was delivered by telephone and in face-to-face sessions. The trainers were tracked over the course of the study to make sure that the structured intervention was delivered as planned.
Dr. Riddle reported having no financial conflicts regarding the National Institutes of Health-funded study, the full details of which have been published (J Bone Joint Surg Am. 2019 Feb 6;101[3]:218-227).
TORONTO – A high level of pain catastrophizing prior to scheduled knee arthroplasty is not, as previously thought, a harbinger of poor outcomes, and affected patients don’t benefit from cognitive-behavioral therapy–based training in pain coping skills, Daniel L. Riddle, PhD, reported at the OARSI 2019 World Congress.
“The take-home message for us is knee arthroplasty is incredibly effective and there really is no reason to do pain coping skills training in these high–pain catastrophizing patients because the great majority of them have such good outcomes,” said Dr. Riddle, professor of physical therapy at Virginia Commonwealth University, Richmond.
“The other clear message from our trial is that, when you have pain-catastrophizing patients and you lower their pain, their catastrophizing is also lowered. So pain catastrophizing is clearly a response to pain and not a personality trait per se,” he said at the meeting sponsored by the Osteoarthritis Research Society International.
He presented the results of a 402-patient, randomized, three-arm, single-blind trial conducted at five U.S. medical centers. All participants were scheduled for knee arthroplasty for osteoarthritis, and all had moderate- to high-level pain catastrophizing as reflected in the group’s average Pain Catastrophizing Score of 30. They were assigned to an arthritis education active control group, usual care, or an intervention developed specifically for this study: a cognitive-behavioral therapy–based training program for pain coping skills. Similar pain coping skills training interventions have been shown to be beneficial in patients with medically treated knee OA but hadn’t previously been evaluated in surgically treated patients. The primary study endpoint was change in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain Scale at 2, 6, and 12 months after surgery.
The improvement in WOMAC pain in the three study arms was virtually superimposable, going from an average pain score of about 12 preoperatively to 2 postoperatively.
“This was a clear no-effect trial,” Dr. Riddle observed. “These are patients we thought to be at increased risk for poor outcome, but indeed they’re not.”
Pain Catastrophizing Scores improved from 30 preoperatively to roughly 7 at 1 year. “We’ve never seen pain catastrophizing improvements of this magnitude,” the researcher commented.
The study participants typically had a large number of chronically painful areas, but only minimal change in pain scores occurred except in the surgically treated knee.
Of note, even with the impressively large improvements in knee pain, function, and other secondary endpoints in the study group as a whole, roughly 20% of study participants experienced essentially no improvement in their function-limiting knee pain during the first year after arthroplasty. These nonresponders were spread equally across all three study arms. Further research will be needed to develop interventions to help this challenging patient subgroup.
The pain coping skills training consisted of 8 weekly sessions, each an hour long, which began prior to surgery and continued afterward. The intervention was delivered by physical therapists who had been trained by pain psychologists with expertise in cognitive-behavioral therapy. The intervention was delivered by telephone and in face-to-face sessions. The trainers were tracked over the course of the study to make sure that the structured intervention was delivered as planned.
Dr. Riddle reported having no financial conflicts regarding the National Institutes of Health-funded study, the full details of which have been published (J Bone Joint Surg Am. 2019 Feb 6;101[3]:218-227).
REPORTING FROM OARSI 2019