Federal Practitioner

More than 170 million Americans – or about half of U.S. adults – were exposed to harmful levels of lead as children, according to a new study published in the Proceedings of the National Academy of Sciences.

In addition, the researchers found, 90% of children born in the United States between 1951 and 1980 had blood-lead levels higher than the Centers for Disease Control and Prevention threshold. On average, early childhood exposure to lead resulted in a 2.6-point drop in IQ per person.

“Most of what we think of as the Lost Generation and the Greatest Generation and Baby Boomers had a moderate amount of lead exposure,” Matt Hauer, PhD, one of the coauthors and an assistant professor of sociology at Florida State University, Tallahassee, said in a statement.

“Generation X was exposed to very high amounts of lead, and now Millennials and the generation following them have been exposed to very low amounts of lead,” he said.

The findings were “infuriating” because scientists have long known that lead exposure is harmful, Michael McFarland, PhD, coauthor and an associate professor of sociology at Florida State University, Tallahassee, told The Associated Press.

The research team analyzed blood-lead levels, census data, and the use of leaded gasoline to understand how widespread early childhood lead exposure was in the United States between 1940 and 2015. They looked mostly at exposure caused by leaded gasoline, which was the dominant form of exposure between the 1940s and 1980s.

They estimated that half of the U.S. adult population in 2015 had been exposed to lead levels that surpassed 5 micrograms per deciliter, which was the CDC threshold at the time. More than 54 million had been exposed to levels above 15 micrograms per deciliter, and 4.5 million were exposed to 30 micrograms per deciliter – or six times the threshold.

They found that estimated lead-linked deficits were greatest for the 21 million people born between 1966 and 1970, who had an average 5.9-point drop in IQ per person.

The United States has put in place tougher regulations to protect Americans from lead poisoning in recent decades, particularly from gasoline. The study team found that blood-lead levels were considerably lower than 5 micrograms per deciliter among those born since 2001.

At the same time, the public health effects of childhood exposure for older generations will last for years to come.

“Childhood lead exposure is not just here and now. It’s going to impact your lifelong health,” Abheet Solomon, a senior program manager at the United Nations Children’s Fund, told the AP.

Childhood lead exposure is known to affect the development of mental skills, and it raises the risk of hypertension, kidney damage, and heart disease. It has been linked to harm in pregnant women and developing children.

“The more tragic part is that we keep making the same … mistakes again,” Bruce Lanphear, MD, a health sciences professor at Simon Fraser University in Vancouver, B.C., told the AP.

Dr. Lanphear’s research on lead exposure has found loss of mental skills and IQ as well.

“First it was lead, then it was air pollution. Now it’s PFAS chemicals and phthalates (chemicals used to make plastics more durable),” he said. “And we can’t stop long enough to ask ourselves should we be regulating chemicals differently.”

A version of this article first appeared on WebMD.com.

More than 170 million Americans – or about half of U.S. adults – were exposed to harmful levels of lead as children, according to a new study published in the Proceedings of the National Academy of Sciences.

In addition, the researchers found, 90% of children born in the United States between 1951 and 1980 had blood-lead levels higher than the Centers for Disease Control and Prevention threshold. On average, early childhood exposure to lead resulted in a 2.6-point drop in IQ per person.

“Most of what we think of as the Lost Generation and the Greatest Generation and Baby Boomers had a moderate amount of lead exposure,” Matt Hauer, PhD, one of the coauthors and an assistant professor of sociology at Florida State University, Tallahassee, said in a statement.

“Generation X was exposed to very high amounts of lead, and now Millennials and the generation following them have been exposed to very low amounts of lead,” he said.

The findings were “infuriating” because scientists have long known that lead exposure is harmful, Michael McFarland, PhD, coauthor and an associate professor of sociology at Florida State University, Tallahassee, told The Associated Press.

The research team analyzed blood-lead levels, census data, and the use of leaded gasoline to understand how widespread early childhood lead exposure was in the United States between 1940 and 2015. They looked mostly at exposure caused by leaded gasoline, which was the dominant form of exposure between the 1940s and 1980s.

They estimated that half of the U.S. adult population in 2015 had been exposed to lead levels that surpassed 5 micrograms per deciliter, which was the CDC threshold at the time. More than 54 million had been exposed to levels above 15 micrograms per deciliter, and 4.5 million were exposed to 30 micrograms per deciliter – or six times the threshold.

They found that estimated lead-linked deficits were greatest for the 21 million people born between 1966 and 1970, who had an average 5.9-point drop in IQ per person.

The United States has put in place tougher regulations to protect Americans from lead poisoning in recent decades, particularly from gasoline. The study team found that blood-lead levels were considerably lower than 5 micrograms per deciliter among those born since 2001.

At the same time, the public health effects of childhood exposure for older generations will last for years to come.

“Childhood lead exposure is not just here and now. It’s going to impact your lifelong health,” Abheet Solomon, a senior program manager at the United Nations Children’s Fund, told the AP.

Childhood lead exposure is known to affect the development of mental skills, and it raises the risk of hypertension, kidney damage, and heart disease. It has been linked to harm in pregnant women and developing children.

“The more tragic part is that we keep making the same … mistakes again,” Bruce Lanphear, MD, a health sciences professor at Simon Fraser University in Vancouver, B.C., told the AP.

Dr. Lanphear’s research on lead exposure has found loss of mental skills and IQ as well.

“First it was lead, then it was air pollution. Now it’s PFAS chemicals and phthalates (chemicals used to make plastics more durable),” he said. “And we can’t stop long enough to ask ourselves should we be regulating chemicals differently.”

A version of this article first appeared on WebMD.com.

More than 170 million Americans – or about half of U.S. adults – were exposed to harmful levels of lead as children, according to a new study published in the Proceedings of the National Academy of Sciences.

In addition, the researchers found, 90% of children born in the United States between 1951 and 1980 had blood-lead levels higher than the Centers for Disease Control and Prevention threshold. On average, early childhood exposure to lead resulted in a 2.6-point drop in IQ per person.

“Most of what we think of as the Lost Generation and the Greatest Generation and Baby Boomers had a moderate amount of lead exposure,” Matt Hauer, PhD, one of the coauthors and an assistant professor of sociology at Florida State University, Tallahassee, said in a statement.

“Generation X was exposed to very high amounts of lead, and now Millennials and the generation following them have been exposed to very low amounts of lead,” he said.

The findings were “infuriating” because scientists have long known that lead exposure is harmful, Michael McFarland, PhD, coauthor and an associate professor of sociology at Florida State University, Tallahassee, told The Associated Press.

The research team analyzed blood-lead levels, census data, and the use of leaded gasoline to understand how widespread early childhood lead exposure was in the United States between 1940 and 2015. They looked mostly at exposure caused by leaded gasoline, which was the dominant form of exposure between the 1940s and 1980s.

They estimated that half of the U.S. adult population in 2015 had been exposed to lead levels that surpassed 5 micrograms per deciliter, which was the CDC threshold at the time. More than 54 million had been exposed to levels above 15 micrograms per deciliter, and 4.5 million were exposed to 30 micrograms per deciliter – or six times the threshold.

They found that estimated lead-linked deficits were greatest for the 21 million people born between 1966 and 1970, who had an average 5.9-point drop in IQ per person.

The United States has put in place tougher regulations to protect Americans from lead poisoning in recent decades, particularly from gasoline. The study team found that blood-lead levels were considerably lower than 5 micrograms per deciliter among those born since 2001.

At the same time, the public health effects of childhood exposure for older generations will last for years to come.

“Childhood lead exposure is not just here and now. It’s going to impact your lifelong health,” Abheet Solomon, a senior program manager at the United Nations Children’s Fund, told the AP.

Childhood lead exposure is known to affect the development of mental skills, and it raises the risk of hypertension, kidney damage, and heart disease. It has been linked to harm in pregnant women and developing children.

“The more tragic part is that we keep making the same … mistakes again,” Bruce Lanphear, MD, a health sciences professor at Simon Fraser University in Vancouver, B.C., told the AP.

Dr. Lanphear’s research on lead exposure has found loss of mental skills and IQ as well.

“First it was lead, then it was air pollution. Now it’s PFAS chemicals and phthalates (chemicals used to make plastics more durable),” he said. “And we can’t stop long enough to ask ourselves should we be regulating chemicals differently.”

A version of this article first appeared on WebMD.com.

Giving patients and their providers genetic test results for kidney failure risk promotes positive behavioral change that could decrease an individual’s likelihood of developing chronic kidney disease (CKD) and end-stage renal failure (ESRF), a new pilot study suggests.

“Disclosing APOL1 genetic testing results to patients of African ancestry with hypertension and their clinicians was associated with a greater reduction in systolic blood pressure [SBP], increased kidney disease screening, and positive self-reported behavior change in those with high-risk genotypes,” Girish Nadkarni, MD, MPH, Icahn Mount Sinai School of Medicine, New York, and colleagues reported.

“These two measurements – the change in blood pressure and increased kidney function tests – act as hallmarks for detecting beneficial lifestyle change,” Dr. Nadkarni noted in a statement from his institution.

“For many years, researchers have wondered whether reporting APOL1 genetic test results would help improve clinical management. This is the first pragmatic randomized clinical trial to test this out [and] these results suggest we are headed in the right direction,” he added.

The study was published online March 4, 2022, in JAMA Network Open.
 

A quarter of those with high-risk genotype changed medication behavior

High-risk APOL1 genotypes confer a 5- to 10-fold increased risk for CKD and ESRF caused by hypertension and are found in one out of seven individuals of African ancestry. People of African ancestry also have the highest age-adjusted prevalence of high BP and the lowest rates of BP control, Dr. Nadkarni and colleagues wrote.

They studied a total of 2,050 patients of African ancestry with hypertension but without CKD who were randomized to undergo either immediate APOL1 testing (intervention group) or delayed APOL1 testing (control group).

“Patients randomly assigned to the intervention group received APOL1 genetic testing results from trained staff [while] their clinicians received results through clinical decision support in electronic health records,” the investigators explained.

Control patients received results after 12 months of follow-up. The mean age of the cohort was 53 years and almost two-thirds were female. Mean baseline SBP was significantly higher in patients with high-risk APOL1 genotypes, at 137 mm Hg, compared with those with low-risk APOL1 genotypes, at 134 mm Hg (P = .003), and controls, at 133 mm Hg (P = .001), the authors reported. 

At 3 months, “all groups had some decrease in SBP,” Dr. Nadkarni and colleagues observed.

However, patients with high-risk APOL1 genotypes had a significantly greater decrease in SBP, at 6 mm Hg, compared with a mean decrease of 3 mm Hg for those with low-risk APOL1 genotypes (P = .004) as well as controls (P = .01). At 12 months, there was no significant difference in SBP or change in SBP from baseline to 12 months between the three groups.

“All three groups showed a significant increase in the rate of urine protein testing over time,” the authors added.

Again, however, the most significant increase in urine protein testing over time was seen in patients with high-risk APOL1 genotypes, with a 12% increase from baseline, compared with a 6% increase for patients with low-risk APOL1 genotypes and a 7% increase among controls. The difference was significant only between patients with high-risk APOL1 genotypes and controls (P = .01).

Significantly more patients with high-risk APOL1 genotypes, at 59%, reported making positive lifestyle changes as reflected in better dietary and exercise habits after receiving their test results than did those with low-risk APOL1 genotypes, at 37% (P < .001).

Moreover, 24% of those with high-risk genotypes reported that receiving test results changed how they take their BP medication, compared with only 10% of those with low-risk genotypes.

More high-risk genotype carriers also reported taking their medications more often, at 10%, compared with 5% of low-risk genotype carriers (P = .005).

On the other hand, more patients with the high-risk genotype, at 27%, worried that they would develop kidney problems than low-risk carriers, at 17% (P < .001). Although investigators did offer patients the opportunity to speak with a genetic counselor at no cost, none chose to do so, the authors noted.
 

Small improvements

As the investigators emphasized, the magnitude of BP improvement seen in high-risk APOL1 carriers was small. However, they did not provide specific BP target recommendations or BP-lowering strategies, which, had they done so, may have brought BP down to a greater degree.

Health behavior changes were similarly small and may not have been clinically that meaningful.

Still, “results suggest that the trial clearly influenced those who received positive results and may have had some positive effects on other patients,” Dr. Nadkarni concluded.

Dr. Nadkarni is a cofounder of and has equity in Renalytx, and has been a member of the scientific advisory board and received personal fees from the company. He is also a cofounder of Pensieve Health.

A version of this article first appeared on Medscape.com.

Giving patients and their providers genetic test results for kidney failure risk promotes positive behavioral change that could decrease an individual’s likelihood of developing chronic kidney disease (CKD) and end-stage renal failure (ESRF), a new pilot study suggests.

“Disclosing APOL1 genetic testing results to patients of African ancestry with hypertension and their clinicians was associated with a greater reduction in systolic blood pressure [SBP], increased kidney disease screening, and positive self-reported behavior change in those with high-risk genotypes,” Girish Nadkarni, MD, MPH, Icahn Mount Sinai School of Medicine, New York, and colleagues reported.

“These two measurements – the change in blood pressure and increased kidney function tests – act as hallmarks for detecting beneficial lifestyle change,” Dr. Nadkarni noted in a statement from his institution.

“For many years, researchers have wondered whether reporting APOL1 genetic test results would help improve clinical management. This is the first pragmatic randomized clinical trial to test this out [and] these results suggest we are headed in the right direction,” he added.

The study was published online March 4, 2022, in JAMA Network Open.
 

A quarter of those with high-risk genotype changed medication behavior

High-risk APOL1 genotypes confer a 5- to 10-fold increased risk for CKD and ESRF caused by hypertension and are found in one out of seven individuals of African ancestry. People of African ancestry also have the highest age-adjusted prevalence of high BP and the lowest rates of BP control, Dr. Nadkarni and colleagues wrote.

They studied a total of 2,050 patients of African ancestry with hypertension but without CKD who were randomized to undergo either immediate APOL1 testing (intervention group) or delayed APOL1 testing (control group).

“Patients randomly assigned to the intervention group received APOL1 genetic testing results from trained staff [while] their clinicians received results through clinical decision support in electronic health records,” the investigators explained.

Control patients received results after 12 months of follow-up. The mean age of the cohort was 53 years and almost two-thirds were female. Mean baseline SBP was significantly higher in patients with high-risk APOL1 genotypes, at 137 mm Hg, compared with those with low-risk APOL1 genotypes, at 134 mm Hg (P = .003), and controls, at 133 mm Hg (P = .001), the authors reported. 

At 3 months, “all groups had some decrease in SBP,” Dr. Nadkarni and colleagues observed.

However, patients with high-risk APOL1 genotypes had a significantly greater decrease in SBP, at 6 mm Hg, compared with a mean decrease of 3 mm Hg for those with low-risk APOL1 genotypes (P = .004) as well as controls (P = .01). At 12 months, there was no significant difference in SBP or change in SBP from baseline to 12 months between the three groups.

“All three groups showed a significant increase in the rate of urine protein testing over time,” the authors added.

Again, however, the most significant increase in urine protein testing over time was seen in patients with high-risk APOL1 genotypes, with a 12% increase from baseline, compared with a 6% increase for patients with low-risk APOL1 genotypes and a 7% increase among controls. The difference was significant only between patients with high-risk APOL1 genotypes and controls (P = .01).

Significantly more patients with high-risk APOL1 genotypes, at 59%, reported making positive lifestyle changes as reflected in better dietary and exercise habits after receiving their test results than did those with low-risk APOL1 genotypes, at 37% (P < .001).

Moreover, 24% of those with high-risk genotypes reported that receiving test results changed how they take their BP medication, compared with only 10% of those with low-risk genotypes.

More high-risk genotype carriers also reported taking their medications more often, at 10%, compared with 5% of low-risk genotype carriers (P = .005).

On the other hand, more patients with the high-risk genotype, at 27%, worried that they would develop kidney problems than low-risk carriers, at 17% (P < .001). Although investigators did offer patients the opportunity to speak with a genetic counselor at no cost, none chose to do so, the authors noted.
 

Small improvements

As the investigators emphasized, the magnitude of BP improvement seen in high-risk APOL1 carriers was small. However, they did not provide specific BP target recommendations or BP-lowering strategies, which, had they done so, may have brought BP down to a greater degree.

Health behavior changes were similarly small and may not have been clinically that meaningful.

Still, “results suggest that the trial clearly influenced those who received positive results and may have had some positive effects on other patients,” Dr. Nadkarni concluded.

Dr. Nadkarni is a cofounder of and has equity in Renalytx, and has been a member of the scientific advisory board and received personal fees from the company. He is also a cofounder of Pensieve Health.

A version of this article first appeared on Medscape.com.

Giving patients and their providers genetic test results for kidney failure risk promotes positive behavioral change that could decrease an individual’s likelihood of developing chronic kidney disease (CKD) and end-stage renal failure (ESRF), a new pilot study suggests.

“Disclosing APOL1 genetic testing results to patients of African ancestry with hypertension and their clinicians was associated with a greater reduction in systolic blood pressure [SBP], increased kidney disease screening, and positive self-reported behavior change in those with high-risk genotypes,” Girish Nadkarni, MD, MPH, Icahn Mount Sinai School of Medicine, New York, and colleagues reported.

“These two measurements – the change in blood pressure and increased kidney function tests – act as hallmarks for detecting beneficial lifestyle change,” Dr. Nadkarni noted in a statement from his institution.

“For many years, researchers have wondered whether reporting APOL1 genetic test results would help improve clinical management. This is the first pragmatic randomized clinical trial to test this out [and] these results suggest we are headed in the right direction,” he added.

The study was published online March 4, 2022, in JAMA Network Open.
 

A quarter of those with high-risk genotype changed medication behavior

High-risk APOL1 genotypes confer a 5- to 10-fold increased risk for CKD and ESRF caused by hypertension and are found in one out of seven individuals of African ancestry. People of African ancestry also have the highest age-adjusted prevalence of high BP and the lowest rates of BP control, Dr. Nadkarni and colleagues wrote.

They studied a total of 2,050 patients of African ancestry with hypertension but without CKD who were randomized to undergo either immediate APOL1 testing (intervention group) or delayed APOL1 testing (control group).

“Patients randomly assigned to the intervention group received APOL1 genetic testing results from trained staff [while] their clinicians received results through clinical decision support in electronic health records,” the investigators explained.

Control patients received results after 12 months of follow-up. The mean age of the cohort was 53 years and almost two-thirds were female. Mean baseline SBP was significantly higher in patients with high-risk APOL1 genotypes, at 137 mm Hg, compared with those with low-risk APOL1 genotypes, at 134 mm Hg (P = .003), and controls, at 133 mm Hg (P = .001), the authors reported. 

At 3 months, “all groups had some decrease in SBP,” Dr. Nadkarni and colleagues observed.

However, patients with high-risk APOL1 genotypes had a significantly greater decrease in SBP, at 6 mm Hg, compared with a mean decrease of 3 mm Hg for those with low-risk APOL1 genotypes (P = .004) as well as controls (P = .01). At 12 months, there was no significant difference in SBP or change in SBP from baseline to 12 months between the three groups.

“All three groups showed a significant increase in the rate of urine protein testing over time,” the authors added.

Again, however, the most significant increase in urine protein testing over time was seen in patients with high-risk APOL1 genotypes, with a 12% increase from baseline, compared with a 6% increase for patients with low-risk APOL1 genotypes and a 7% increase among controls. The difference was significant only between patients with high-risk APOL1 genotypes and controls (P = .01).

Significantly more patients with high-risk APOL1 genotypes, at 59%, reported making positive lifestyle changes as reflected in better dietary and exercise habits after receiving their test results than did those with low-risk APOL1 genotypes, at 37% (P < .001).

Moreover, 24% of those with high-risk genotypes reported that receiving test results changed how they take their BP medication, compared with only 10% of those with low-risk genotypes.

More high-risk genotype carriers also reported taking their medications more often, at 10%, compared with 5% of low-risk genotype carriers (P = .005).

On the other hand, more patients with the high-risk genotype, at 27%, worried that they would develop kidney problems than low-risk carriers, at 17% (P < .001). Although investigators did offer patients the opportunity to speak with a genetic counselor at no cost, none chose to do so, the authors noted.
 

Small improvements

As the investigators emphasized, the magnitude of BP improvement seen in high-risk APOL1 carriers was small. However, they did not provide specific BP target recommendations or BP-lowering strategies, which, had they done so, may have brought BP down to a greater degree.

Health behavior changes were similarly small and may not have been clinically that meaningful.

Still, “results suggest that the trial clearly influenced those who received positive results and may have had some positive effects on other patients,” Dr. Nadkarni concluded.

Dr. Nadkarni is a cofounder of and has equity in Renalytx, and has been a member of the scientific advisory board and received personal fees from the company. He is also a cofounder of Pensieve Health.

A version of this article first appeared on Medscape.com.

Patients with low-risk differentiated thyroid cancer (DTC) undergoing thyroidectomy show no improvements in outcomes with the use of postoperative radioiodine ablation compared to those who do not receive this therapy, suggesting these patients can be spared the previously common treatment.

The study’s take-home message for clinicians should be to “stop systematic radioiodine ablation administration in low-risk thyroid cancer patients,” lead author Sophie Leboulleux, MD, PhD, said in an interview.

The results were first reported at ENDO 2021 and have now been published in the New England Journal of Medicine by Dr. Leboulleux, of the department of nuclear medicine and endocrine oncology, Gustave Roussy Cancer Institute, Villejuif, France, and colleagues.

While American Thyroid Association (ATA) guidelines already indicate that radioiodine ablation is not routinely recommended after thyroidectomy for patients with low-risk thyroid cancer, the guidance is only a “weak recommendation,” supported by “low-quality evidence.”  

However, the new findings should give that level of evidence a much-needed boost, said one expert. “I think the main contribution of this paper is to change the evidence level to ‘high quality,’ therefore making the recommendation ‘strong,’ rather than ‘weak,’ ” David S. Cooper, MD, said in an interview.

Dr. Cooper, professor of medicine and radiology at Johns Hopkins University, Baltimore, wrote an editorial that accompanies Dr. Leboulleux’s study.

The ability to safely spare patients the radioiodine ablation step after thyroidectomy has important benefits in terms of cost and convenience, Dr. Cooper stressed.
 

ESTIMABL2 trial

The new findings are from the prospective, randomized, phase 3 Essai Stimulation Ablation 2 (ESTIMABL2) trial, in which 730 patients at 35 centers in France with low-risk DTC scheduled to undergo thyroidectomy were enrolled between May 2013 and March 2017.

Patients were randomized to receive either postoperative radioiodine ablation (1.1 GBq) after injections of recombinant human thyrotropin (n = 363) or no postoperative radioiodine (n = 367).

Patients were a mean age of 52 years and 83% were women. About 96% had papillary tumors, and pathological tumor node (pTN) stages were mostly pT1b thyroid with a nodal status of N0 or Nx (81.1%). It is these patients in particular in whom retrospective studies of the use of radioiodine ablation have yielded inconsistent results, Dr. Leboulleux and colleagues noted. Hence, their decision to look at this prospectively.

Outcomes were based on the groups’ rates of events, defined as the presence of abnormal foci of radioiodine uptake on whole-body scanning that required treatment (in the radioiodine group only), abnormal findings on neck ultrasonography, or increased levels of thyroglobulin or thyroglobulin antibodies.

After a 3-year follow-up, the rates of having no events in both groups were very high – and nearly identical – at 95.6% among those receiving no radioiodine ablation and 95.9% in the radioiodine group, for a between-group difference of –0.3 percentage points, which met the criteria for noninferiority for the no-radioiodine group.

Likewise, the events that did occur were nearly equally split between the no-radioiodine group (16 events, 4.4%) and the radioiodine group (15 events, 4.1%).

Among patients who had events, subsequent treatments, including surgery, radioiodine administration, or both, were necessary for four patients in the no-radioiodine group and 10 in the radioiodine group, and additional treatments were not necessary for the other patients who experienced events.

There were no differences between those who did and did not experience events in terms of molecular alterations, and 50 of the tumors had BRAF mutations, with no significant differences between groups.

Of the adverse events that occurred in 30 patients, none were determined to be related to treatment, and there were no thyroid-related deaths.

The recurrence rates align with the rates observed overall with low-risk thyroid cancer, the authors noted. 

“We observed that less than 5% of the patients in the two groups had events that included abnormal findings on whole-body scanning or neck ultrasonography or elevated levels of thyroglobulin or thyroglobulin antibodies during the first 3 years of follow-up,” they reported.

“This rate is concordant with the definition of low-risk thyroid cancer, and our trial showed that the risk of events was not higher in the absence of postoperative administration of radioiodine.”
 

Patients spared costs, work losses

Dr. Cooper elaborated on the advantages, for patients, of avoiding radioiodine ablation.

For one thing, the recombinant human TSH that is necessary to prepare for radioiodine therapy is very expensive, ranging from $2,000 to $3,000, with patients often having a copay, he explained.

“Patients usually have to take time off work, which is also an expense to society and to them if they don’t get paid for days that they don’t work,” Dr. Cooper added.

A possible study limitation is the question of whether 3 years is an ample follow-up period to detect events. However, Dr. Cooper said he considers the period to be sufficient.

“As the authors point out, most recurrences of thyroid cancer are detected within the first 3-5 years of initial treatment, so ... the 3-year window is still clinically relevant,” he said.

Regarding the study’s inclusion of centers only in France, Dr. Cooper added, “I do not think that this is a study limitation. There is nothing specific about the French population that would lead me to conclude that the results were not generalizable to all populations with low-risk papillary thyroid cancer.”
 

Some continue radioiodine use, but lobectomies add to decline

Despite the mounting evidence of the lack of benefit of radioiodine ablation in low-risk patients, some centers, particularly in Europe, continue the practice, which was standard in the treatment of DTC until relatively recently.

“[While] U.S. guidelines changed in 2015 in favor of no radioiodine in low-risk differentiated thyroid cancer patients, this study should help to change European guidelines,” Dr. Leboulleux said. “The results will help to change practice both in the U.S. and in Europe.”

In addition to awareness of guidelines and new evidence, another reason for the decline in radioiodine ablation for low-risk DTC is the increasing use of thyroid lobectomy, which does not involve the use of radioiodine ablation, rather than total thyroidectomy, Dr. Cooper noted.

“The [new] NEJM paper will hopefully decrease the inappropriate use of radioiodine in low-risk patients even further,” he concluded.

The study received support from the French Ministry of Health through a grant from the National Cancer Institute. The authors have reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Patients with low-risk differentiated thyroid cancer (DTC) undergoing thyroidectomy show no improvements in outcomes with the use of postoperative radioiodine ablation compared to those who do not receive this therapy, suggesting these patients can be spared the previously common treatment.

The study’s take-home message for clinicians should be to “stop systematic radioiodine ablation administration in low-risk thyroid cancer patients,” lead author Sophie Leboulleux, MD, PhD, said in an interview.

The results were first reported at ENDO 2021 and have now been published in the New England Journal of Medicine by Dr. Leboulleux, of the department of nuclear medicine and endocrine oncology, Gustave Roussy Cancer Institute, Villejuif, France, and colleagues.

While American Thyroid Association (ATA) guidelines already indicate that radioiodine ablation is not routinely recommended after thyroidectomy for patients with low-risk thyroid cancer, the guidance is only a “weak recommendation,” supported by “low-quality evidence.”  

However, the new findings should give that level of evidence a much-needed boost, said one expert. “I think the main contribution of this paper is to change the evidence level to ‘high quality,’ therefore making the recommendation ‘strong,’ rather than ‘weak,’ ” David S. Cooper, MD, said in an interview.

Dr. Cooper, professor of medicine and radiology at Johns Hopkins University, Baltimore, wrote an editorial that accompanies Dr. Leboulleux’s study.

The ability to safely spare patients the radioiodine ablation step after thyroidectomy has important benefits in terms of cost and convenience, Dr. Cooper stressed.
 

ESTIMABL2 trial

The new findings are from the prospective, randomized, phase 3 Essai Stimulation Ablation 2 (ESTIMABL2) trial, in which 730 patients at 35 centers in France with low-risk DTC scheduled to undergo thyroidectomy were enrolled between May 2013 and March 2017.

Patients were randomized to receive either postoperative radioiodine ablation (1.1 GBq) after injections of recombinant human thyrotropin (n = 363) or no postoperative radioiodine (n = 367).

Patients were a mean age of 52 years and 83% were women. About 96% had papillary tumors, and pathological tumor node (pTN) stages were mostly pT1b thyroid with a nodal status of N0 or Nx (81.1%). It is these patients in particular in whom retrospective studies of the use of radioiodine ablation have yielded inconsistent results, Dr. Leboulleux and colleagues noted. Hence, their decision to look at this prospectively.

Outcomes were based on the groups’ rates of events, defined as the presence of abnormal foci of radioiodine uptake on whole-body scanning that required treatment (in the radioiodine group only), abnormal findings on neck ultrasonography, or increased levels of thyroglobulin or thyroglobulin antibodies.

After a 3-year follow-up, the rates of having no events in both groups were very high – and nearly identical – at 95.6% among those receiving no radioiodine ablation and 95.9% in the radioiodine group, for a between-group difference of –0.3 percentage points, which met the criteria for noninferiority for the no-radioiodine group.

Likewise, the events that did occur were nearly equally split between the no-radioiodine group (16 events, 4.4%) and the radioiodine group (15 events, 4.1%).

Among patients who had events, subsequent treatments, including surgery, radioiodine administration, or both, were necessary for four patients in the no-radioiodine group and 10 in the radioiodine group, and additional treatments were not necessary for the other patients who experienced events.

There were no differences between those who did and did not experience events in terms of molecular alterations, and 50 of the tumors had BRAF mutations, with no significant differences between groups.

Of the adverse events that occurred in 30 patients, none were determined to be related to treatment, and there were no thyroid-related deaths.

The recurrence rates align with the rates observed overall with low-risk thyroid cancer, the authors noted. 

“We observed that less than 5% of the patients in the two groups had events that included abnormal findings on whole-body scanning or neck ultrasonography or elevated levels of thyroglobulin or thyroglobulin antibodies during the first 3 years of follow-up,” they reported.

“This rate is concordant with the definition of low-risk thyroid cancer, and our trial showed that the risk of events was not higher in the absence of postoperative administration of radioiodine.”
 

Patients spared costs, work losses

Dr. Cooper elaborated on the advantages, for patients, of avoiding radioiodine ablation.

For one thing, the recombinant human TSH that is necessary to prepare for radioiodine therapy is very expensive, ranging from $2,000 to $3,000, with patients often having a copay, he explained.

“Patients usually have to take time off work, which is also an expense to society and to them if they don’t get paid for days that they don’t work,” Dr. Cooper added.

A possible study limitation is the question of whether 3 years is an ample follow-up period to detect events. However, Dr. Cooper said he considers the period to be sufficient.

“As the authors point out, most recurrences of thyroid cancer are detected within the first 3-5 years of initial treatment, so ... the 3-year window is still clinically relevant,” he said.

Regarding the study’s inclusion of centers only in France, Dr. Cooper added, “I do not think that this is a study limitation. There is nothing specific about the French population that would lead me to conclude that the results were not generalizable to all populations with low-risk papillary thyroid cancer.”
 

Some continue radioiodine use, but lobectomies add to decline

Despite the mounting evidence of the lack of benefit of radioiodine ablation in low-risk patients, some centers, particularly in Europe, continue the practice, which was standard in the treatment of DTC until relatively recently.

“[While] U.S. guidelines changed in 2015 in favor of no radioiodine in low-risk differentiated thyroid cancer patients, this study should help to change European guidelines,” Dr. Leboulleux said. “The results will help to change practice both in the U.S. and in Europe.”

In addition to awareness of guidelines and new evidence, another reason for the decline in radioiodine ablation for low-risk DTC is the increasing use of thyroid lobectomy, which does not involve the use of radioiodine ablation, rather than total thyroidectomy, Dr. Cooper noted.

“The [new] NEJM paper will hopefully decrease the inappropriate use of radioiodine in low-risk patients even further,” he concluded.

The study received support from the French Ministry of Health through a grant from the National Cancer Institute. The authors have reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Patients with low-risk differentiated thyroid cancer (DTC) undergoing thyroidectomy show no improvements in outcomes with the use of postoperative radioiodine ablation compared to those who do not receive this therapy, suggesting these patients can be spared the previously common treatment.

The study’s take-home message for clinicians should be to “stop systematic radioiodine ablation administration in low-risk thyroid cancer patients,” lead author Sophie Leboulleux, MD, PhD, said in an interview.

The results were first reported at ENDO 2021 and have now been published in the New England Journal of Medicine by Dr. Leboulleux, of the department of nuclear medicine and endocrine oncology, Gustave Roussy Cancer Institute, Villejuif, France, and colleagues.

While American Thyroid Association (ATA) guidelines already indicate that radioiodine ablation is not routinely recommended after thyroidectomy for patients with low-risk thyroid cancer, the guidance is only a “weak recommendation,” supported by “low-quality evidence.”  

However, the new findings should give that level of evidence a much-needed boost, said one expert. “I think the main contribution of this paper is to change the evidence level to ‘high quality,’ therefore making the recommendation ‘strong,’ rather than ‘weak,’ ” David S. Cooper, MD, said in an interview.

Dr. Cooper, professor of medicine and radiology at Johns Hopkins University, Baltimore, wrote an editorial that accompanies Dr. Leboulleux’s study.

The ability to safely spare patients the radioiodine ablation step after thyroidectomy has important benefits in terms of cost and convenience, Dr. Cooper stressed.
 

ESTIMABL2 trial

The new findings are from the prospective, randomized, phase 3 Essai Stimulation Ablation 2 (ESTIMABL2) trial, in which 730 patients at 35 centers in France with low-risk DTC scheduled to undergo thyroidectomy were enrolled between May 2013 and March 2017.

Patients were randomized to receive either postoperative radioiodine ablation (1.1 GBq) after injections of recombinant human thyrotropin (n = 363) or no postoperative radioiodine (n = 367).

Patients were a mean age of 52 years and 83% were women. About 96% had papillary tumors, and pathological tumor node (pTN) stages were mostly pT1b thyroid with a nodal status of N0 or Nx (81.1%). It is these patients in particular in whom retrospective studies of the use of radioiodine ablation have yielded inconsistent results, Dr. Leboulleux and colleagues noted. Hence, their decision to look at this prospectively.

Outcomes were based on the groups’ rates of events, defined as the presence of abnormal foci of radioiodine uptake on whole-body scanning that required treatment (in the radioiodine group only), abnormal findings on neck ultrasonography, or increased levels of thyroglobulin or thyroglobulin antibodies.

After a 3-year follow-up, the rates of having no events in both groups were very high – and nearly identical – at 95.6% among those receiving no radioiodine ablation and 95.9% in the radioiodine group, for a between-group difference of –0.3 percentage points, which met the criteria for noninferiority for the no-radioiodine group.

Likewise, the events that did occur were nearly equally split between the no-radioiodine group (16 events, 4.4%) and the radioiodine group (15 events, 4.1%).

Among patients who had events, subsequent treatments, including surgery, radioiodine administration, or both, were necessary for four patients in the no-radioiodine group and 10 in the radioiodine group, and additional treatments were not necessary for the other patients who experienced events.

There were no differences between those who did and did not experience events in terms of molecular alterations, and 50 of the tumors had BRAF mutations, with no significant differences between groups.

Of the adverse events that occurred in 30 patients, none were determined to be related to treatment, and there were no thyroid-related deaths.

The recurrence rates align with the rates observed overall with low-risk thyroid cancer, the authors noted. 

“We observed that less than 5% of the patients in the two groups had events that included abnormal findings on whole-body scanning or neck ultrasonography or elevated levels of thyroglobulin or thyroglobulin antibodies during the first 3 years of follow-up,” they reported.

“This rate is concordant with the definition of low-risk thyroid cancer, and our trial showed that the risk of events was not higher in the absence of postoperative administration of radioiodine.”
 

Patients spared costs, work losses

Dr. Cooper elaborated on the advantages, for patients, of avoiding radioiodine ablation.

For one thing, the recombinant human TSH that is necessary to prepare for radioiodine therapy is very expensive, ranging from $2,000 to $3,000, with patients often having a copay, he explained.

“Patients usually have to take time off work, which is also an expense to society and to them if they don’t get paid for days that they don’t work,” Dr. Cooper added.

A possible study limitation is the question of whether 3 years is an ample follow-up period to detect events. However, Dr. Cooper said he considers the period to be sufficient.

“As the authors point out, most recurrences of thyroid cancer are detected within the first 3-5 years of initial treatment, so ... the 3-year window is still clinically relevant,” he said.

Regarding the study’s inclusion of centers only in France, Dr. Cooper added, “I do not think that this is a study limitation. There is nothing specific about the French population that would lead me to conclude that the results were not generalizable to all populations with low-risk papillary thyroid cancer.”
 

Some continue radioiodine use, but lobectomies add to decline

Despite the mounting evidence of the lack of benefit of radioiodine ablation in low-risk patients, some centers, particularly in Europe, continue the practice, which was standard in the treatment of DTC until relatively recently.

“[While] U.S. guidelines changed in 2015 in favor of no radioiodine in low-risk differentiated thyroid cancer patients, this study should help to change European guidelines,” Dr. Leboulleux said. “The results will help to change practice both in the U.S. and in Europe.”

In addition to awareness of guidelines and new evidence, another reason for the decline in radioiodine ablation for low-risk DTC is the increasing use of thyroid lobectomy, which does not involve the use of radioiodine ablation, rather than total thyroidectomy, Dr. Cooper noted.

“The [new] NEJM paper will hopefully decrease the inappropriate use of radioiodine in low-risk patients even further,” he concluded.

The study received support from the French Ministry of Health through a grant from the National Cancer Institute. The authors have reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

LAS VEGAS – Is the relationship between major depressive disorder and the development of cancer, cardiovascular disease, and other medical conditions a coincidence, or is there more at play?

According to Charles B. Nemeroff, MD, PhD, a host of circumstances potentially underlies this association, including treatment of the medical disorder itself.

Courtesy University of Texas, Austin

“The best example of that is probably the use of interferon-alpha for the treatment of malignant melanoma,” Dr. Nemeroff, professor and chair of the department of psychiatry and behavioral sciences at the University of Texas at Austin, said during an annual psychopharmacology update held by the Nevada Psychiatric Association. “Many patients treated with interferon-alpha ended up with very severe depression, including several documented suicides. Another possibility of the relationship between depression and medical disorders is that treating a patient for depression could result in a medical disorder. The best example of this is the use of 20 mg of olanzapine to augment the effects of an antidepressant, resulting in a 50-pound weight gain and the development of type 2 diabetes and metabolic syndrome. Both of those scenarios are well understood.”

Then there’s the behavioral aspects of the relationship, he continued, in which patients adopt the mindset that “I’m depressed. I don’t want to exercise. I’m a couch potato. I have been gaining a lot of weight. It’s bad for my heart.”

Converging biology is another possibility. “Is it possible that the biology of depression is linked to the biology of other disorders?” asked Dr. Nemeroff, who directs the university’s Institute for Early Life Adversity Research. “We can talk about this in relation to thyroid disease, a well known cause of depression, but we can also talk about the relationship to other disorders. There’s amazing epidemiologic evidence that patients with PTSD are much more likely to develop Alzheimer’s disease than patients without PTSD.”

Psychosocial issues also play a role. He recalled seeing patient in a clinic for the underserved who had underlying severe ulcerative colitis and anemia and couldn’t afford medical treatment. “The patient had a low hemoglobin, so it was impossible to distinguish between that and whether they had a primary depressive disorder or not,” he said.

In a study that explored the relationship between major depression and cancer, Dr. Nemeroff and colleagues found that the prevalence was highest in those with pancreatic cancer (50%), followed by oropharyngeal (40%), colon (13-25%), breast (18-25%), and gynecologic (23%), and Hodgkin’s lymphoma (17%) (Arch Gen Psychiatry 1995;52[2]:89-99). “Not all cancers have the same rate of depression,” he said. “One of the central questions is, not so much is the cancer patient depressed, but is depression a risk factor for developing cancer? The answer is a resounding yes. But what we don’t know is if you treat the depression aggressively, can you reduce that risk of either developing cancer or the progression of cancer?”

Dr. Nemeroff spotlighted several studies largely from the oncology literature, including a prospective survival analysis of 578 women with early-stage breast cancer (Lancet 1999;354:1331-6). After 5 years, 395 were alive and without relapse, 50 were alive with relapse, and 133 had died. The researchers found a significantly increased risk of death from all causes by 5 years in women with a high depression score (HR 3.59). There was a significantly increased risk of relapse or death at 5 years in women with high scores on helplessness and hopelessness measures.

In an analysis of the association between breast cancer and traumatic events, women who had severe stress or a traumatic event had lower rates of disease-free intervals (J Psychosomatic Res 2007;63:233-9). Another study by the same investigators found that a decrease in depression symptoms is associated with longer survival in patients with metastatic breast cancer (J Clin Oncol 2010;29:413-20). The median survival was 53.6 months for women with decreasing depression scores over 1 year and 25.1 months for women with increasing depression scores.

A more recent study of cervical cancer patients found that those exposed to psychological stress had an increased risk of cancer-specific mortality (HR 1.33) (Cancer Res 2019;79:3965-72). The association was mainly driven by distress experienced within 1 year before or after diagnosis (HR 1.30) but not afterward (HR 1.12). In addition, data from the large longitudinal Nurses’ Health Study II found that women with high PTSD symptoms had a twofold greater risk of ovarian cancer compared with women who had no trauma exposure (Cancer Res 2019;79:5113-20).

Authors of a separate study analyzed data from the Women’s Health Initiative to examine if depression precedes the development of a cancer diagnosis. They found that depression 3 years before a diagnosis of breast cancer was associated with all-cause mortality (HR 1.35) (Cancer 2017;123[16]:3107-15). Meanwhile, among women with late-stage breast cancer, newly developed depression at year 3 was significantly associated with all-cause mortality (HR 2.0) and breast cancer-specific mortality (HR 2.42). “That’s a pretty amazing finding,” Dr. Nemeroff said. “We have to think about depression as a systemic illness. What is depression doing that’s creating a fertile environment for cancer or worsening of cancer?”

He then discussed the risk of suicide in patients who are newly diagnosed with cancer. “No one ever talks about this, and I can’t get anybody to support research in this area,” he said. In one of the first studies on the topic, researchers conducted a case-control study of Medicare patients and determined risk of suicide among those with cancer was 2.3-fold higher compared with controls, even after adjustment for psychiatric illness and the risk of dying within a year (J Clin Oncol 2008;26[29]:4720-4). More recently, authors of a large population-based study in England found that the overall standardized mortality ratio for suicide was 1.20 (JAMA Psychiatry 2019;76[1]51-60). The risk was highest among patients with mesothelioma, with a 4.51-fold risk, followed by pancreatic (3.89-fold), esophageal (2.65-fold), lung (2.57-fold), and stomach cancer (2.20-fold). “They reported that the first 6 months after the diagnosis is associated with an increased risk of suicide – unrelated to prognosis,” Dr. Nemeroff said.

A separate analysis of SEER data from 1973-2014 and comprising more than 8.6 million cancer patients found that newly diagnosed cancer patients are 4.4 times more likely to die from suicide than patients in the same age group without cancer (Nat Commun 2019;10[1]:207). The highest risk was in lung cancer, followed by head and neck, testes, bladder, and Hodgkin’s lymphoma.

According to Dr. Nemeroff, the association between depression and the risk of certain forms of cancer or with a poor cancer prognosis “may have to do with immune function. Depression is associated with a change in inflammatory markers that very likely control the microenvironment of the tumor.” For example, he said, if the depressed environment is associated with a marked increase in tumor necrosis factor, interleukin 6, and other inflammatory markers, “that probably contributes to the body’s ability to fight disease. Ironically, depression is associated with an increase in inflammation but a decreased in T cell function. Remember, there are two fundamental types of immunity: the antibody response and the cellular response. What’s odd about depression is that there’s an increase in inflammatory markers but a decrease in the ability of T cells to function in terms of cellular immunity.”

Dr. Nemeroff disclosed that he has served as a consultant and/or scientific adviser for numerous pharmaceutical companies. He has received research and grant support from the National Institutes of Health.

LAS VEGAS – Is the relationship between major depressive disorder and the development of cancer, cardiovascular disease, and other medical conditions a coincidence, or is there more at play?

According to Charles B. Nemeroff, MD, PhD, a host of circumstances potentially underlies this association, including treatment of the medical disorder itself.

Courtesy University of Texas, Austin

“The best example of that is probably the use of interferon-alpha for the treatment of malignant melanoma,” Dr. Nemeroff, professor and chair of the department of psychiatry and behavioral sciences at the University of Texas at Austin, said during an annual psychopharmacology update held by the Nevada Psychiatric Association. “Many patients treated with interferon-alpha ended up with very severe depression, including several documented suicides. Another possibility of the relationship between depression and medical disorders is that treating a patient for depression could result in a medical disorder. The best example of this is the use of 20 mg of olanzapine to augment the effects of an antidepressant, resulting in a 50-pound weight gain and the development of type 2 diabetes and metabolic syndrome. Both of those scenarios are well understood.”

Then there’s the behavioral aspects of the relationship, he continued, in which patients adopt the mindset that “I’m depressed. I don’t want to exercise. I’m a couch potato. I have been gaining a lot of weight. It’s bad for my heart.”

Converging biology is another possibility. “Is it possible that the biology of depression is linked to the biology of other disorders?” asked Dr. Nemeroff, who directs the university’s Institute for Early Life Adversity Research. “We can talk about this in relation to thyroid disease, a well known cause of depression, but we can also talk about the relationship to other disorders. There’s amazing epidemiologic evidence that patients with PTSD are much more likely to develop Alzheimer’s disease than patients without PTSD.”

Psychosocial issues also play a role. He recalled seeing patient in a clinic for the underserved who had underlying severe ulcerative colitis and anemia and couldn’t afford medical treatment. “The patient had a low hemoglobin, so it was impossible to distinguish between that and whether they had a primary depressive disorder or not,” he said.

In a study that explored the relationship between major depression and cancer, Dr. Nemeroff and colleagues found that the prevalence was highest in those with pancreatic cancer (50%), followed by oropharyngeal (40%), colon (13-25%), breast (18-25%), and gynecologic (23%), and Hodgkin’s lymphoma (17%) (Arch Gen Psychiatry 1995;52[2]:89-99). “Not all cancers have the same rate of depression,” he said. “One of the central questions is, not so much is the cancer patient depressed, but is depression a risk factor for developing cancer? The answer is a resounding yes. But what we don’t know is if you treat the depression aggressively, can you reduce that risk of either developing cancer or the progression of cancer?”

Dr. Nemeroff spotlighted several studies largely from the oncology literature, including a prospective survival analysis of 578 women with early-stage breast cancer (Lancet 1999;354:1331-6). After 5 years, 395 were alive and without relapse, 50 were alive with relapse, and 133 had died. The researchers found a significantly increased risk of death from all causes by 5 years in women with a high depression score (HR 3.59). There was a significantly increased risk of relapse or death at 5 years in women with high scores on helplessness and hopelessness measures.

In an analysis of the association between breast cancer and traumatic events, women who had severe stress or a traumatic event had lower rates of disease-free intervals (J Psychosomatic Res 2007;63:233-9). Another study by the same investigators found that a decrease in depression symptoms is associated with longer survival in patients with metastatic breast cancer (J Clin Oncol 2010;29:413-20). The median survival was 53.6 months for women with decreasing depression scores over 1 year and 25.1 months for women with increasing depression scores.

A more recent study of cervical cancer patients found that those exposed to psychological stress had an increased risk of cancer-specific mortality (HR 1.33) (Cancer Res 2019;79:3965-72). The association was mainly driven by distress experienced within 1 year before or after diagnosis (HR 1.30) but not afterward (HR 1.12). In addition, data from the large longitudinal Nurses’ Health Study II found that women with high PTSD symptoms had a twofold greater risk of ovarian cancer compared with women who had no trauma exposure (Cancer Res 2019;79:5113-20).

Authors of a separate study analyzed data from the Women’s Health Initiative to examine if depression precedes the development of a cancer diagnosis. They found that depression 3 years before a diagnosis of breast cancer was associated with all-cause mortality (HR 1.35) (Cancer 2017;123[16]:3107-15). Meanwhile, among women with late-stage breast cancer, newly developed depression at year 3 was significantly associated with all-cause mortality (HR 2.0) and breast cancer-specific mortality (HR 2.42). “That’s a pretty amazing finding,” Dr. Nemeroff said. “We have to think about depression as a systemic illness. What is depression doing that’s creating a fertile environment for cancer or worsening of cancer?”

He then discussed the risk of suicide in patients who are newly diagnosed with cancer. “No one ever talks about this, and I can’t get anybody to support research in this area,” he said. In one of the first studies on the topic, researchers conducted a case-control study of Medicare patients and determined risk of suicide among those with cancer was 2.3-fold higher compared with controls, even after adjustment for psychiatric illness and the risk of dying within a year (J Clin Oncol 2008;26[29]:4720-4). More recently, authors of a large population-based study in England found that the overall standardized mortality ratio for suicide was 1.20 (JAMA Psychiatry 2019;76[1]51-60). The risk was highest among patients with mesothelioma, with a 4.51-fold risk, followed by pancreatic (3.89-fold), esophageal (2.65-fold), lung (2.57-fold), and stomach cancer (2.20-fold). “They reported that the first 6 months after the diagnosis is associated with an increased risk of suicide – unrelated to prognosis,” Dr. Nemeroff said.

A separate analysis of SEER data from 1973-2014 and comprising more than 8.6 million cancer patients found that newly diagnosed cancer patients are 4.4 times more likely to die from suicide than patients in the same age group without cancer (Nat Commun 2019;10[1]:207). The highest risk was in lung cancer, followed by head and neck, testes, bladder, and Hodgkin’s lymphoma.

According to Dr. Nemeroff, the association between depression and the risk of certain forms of cancer or with a poor cancer prognosis “may have to do with immune function. Depression is associated with a change in inflammatory markers that very likely control the microenvironment of the tumor.” For example, he said, if the depressed environment is associated with a marked increase in tumor necrosis factor, interleukin 6, and other inflammatory markers, “that probably contributes to the body’s ability to fight disease. Ironically, depression is associated with an increase in inflammation but a decreased in T cell function. Remember, there are two fundamental types of immunity: the antibody response and the cellular response. What’s odd about depression is that there’s an increase in inflammatory markers but a decrease in the ability of T cells to function in terms of cellular immunity.”

Dr. Nemeroff disclosed that he has served as a consultant and/or scientific adviser for numerous pharmaceutical companies. He has received research and grant support from the National Institutes of Health.

LAS VEGAS – Is the relationship between major depressive disorder and the development of cancer, cardiovascular disease, and other medical conditions a coincidence, or is there more at play?

According to Charles B. Nemeroff, MD, PhD, a host of circumstances potentially underlies this association, including treatment of the medical disorder itself.

Courtesy University of Texas, Austin

“The best example of that is probably the use of interferon-alpha for the treatment of malignant melanoma,” Dr. Nemeroff, professor and chair of the department of psychiatry and behavioral sciences at the University of Texas at Austin, said during an annual psychopharmacology update held by the Nevada Psychiatric Association. “Many patients treated with interferon-alpha ended up with very severe depression, including several documented suicides. Another possibility of the relationship between depression and medical disorders is that treating a patient for depression could result in a medical disorder. The best example of this is the use of 20 mg of olanzapine to augment the effects of an antidepressant, resulting in a 50-pound weight gain and the development of type 2 diabetes and metabolic syndrome. Both of those scenarios are well understood.”

Then there’s the behavioral aspects of the relationship, he continued, in which patients adopt the mindset that “I’m depressed. I don’t want to exercise. I’m a couch potato. I have been gaining a lot of weight. It’s bad for my heart.”

Converging biology is another possibility. “Is it possible that the biology of depression is linked to the biology of other disorders?” asked Dr. Nemeroff, who directs the university’s Institute for Early Life Adversity Research. “We can talk about this in relation to thyroid disease, a well known cause of depression, but we can also talk about the relationship to other disorders. There’s amazing epidemiologic evidence that patients with PTSD are much more likely to develop Alzheimer’s disease than patients without PTSD.”

Psychosocial issues also play a role. He recalled seeing patient in a clinic for the underserved who had underlying severe ulcerative colitis and anemia and couldn’t afford medical treatment. “The patient had a low hemoglobin, so it was impossible to distinguish between that and whether they had a primary depressive disorder or not,” he said.

In a study that explored the relationship between major depression and cancer, Dr. Nemeroff and colleagues found that the prevalence was highest in those with pancreatic cancer (50%), followed by oropharyngeal (40%), colon (13-25%), breast (18-25%), and gynecologic (23%), and Hodgkin’s lymphoma (17%) (Arch Gen Psychiatry 1995;52[2]:89-99). “Not all cancers have the same rate of depression,” he said. “One of the central questions is, not so much is the cancer patient depressed, but is depression a risk factor for developing cancer? The answer is a resounding yes. But what we don’t know is if you treat the depression aggressively, can you reduce that risk of either developing cancer or the progression of cancer?”

Dr. Nemeroff spotlighted several studies largely from the oncology literature, including a prospective survival analysis of 578 women with early-stage breast cancer (Lancet 1999;354:1331-6). After 5 years, 395 were alive and without relapse, 50 were alive with relapse, and 133 had died. The researchers found a significantly increased risk of death from all causes by 5 years in women with a high depression score (HR 3.59). There was a significantly increased risk of relapse or death at 5 years in women with high scores on helplessness and hopelessness measures.

In an analysis of the association between breast cancer and traumatic events, women who had severe stress or a traumatic event had lower rates of disease-free intervals (J Psychosomatic Res 2007;63:233-9). Another study by the same investigators found that a decrease in depression symptoms is associated with longer survival in patients with metastatic breast cancer (J Clin Oncol 2010;29:413-20). The median survival was 53.6 months for women with decreasing depression scores over 1 year and 25.1 months for women with increasing depression scores.

A more recent study of cervical cancer patients found that those exposed to psychological stress had an increased risk of cancer-specific mortality (HR 1.33) (Cancer Res 2019;79:3965-72). The association was mainly driven by distress experienced within 1 year before or after diagnosis (HR 1.30) but not afterward (HR 1.12). In addition, data from the large longitudinal Nurses’ Health Study II found that women with high PTSD symptoms had a twofold greater risk of ovarian cancer compared with women who had no trauma exposure (Cancer Res 2019;79:5113-20).

Authors of a separate study analyzed data from the Women’s Health Initiative to examine if depression precedes the development of a cancer diagnosis. They found that depression 3 years before a diagnosis of breast cancer was associated with all-cause mortality (HR 1.35) (Cancer 2017;123[16]:3107-15). Meanwhile, among women with late-stage breast cancer, newly developed depression at year 3 was significantly associated with all-cause mortality (HR 2.0) and breast cancer-specific mortality (HR 2.42). “That’s a pretty amazing finding,” Dr. Nemeroff said. “We have to think about depression as a systemic illness. What is depression doing that’s creating a fertile environment for cancer or worsening of cancer?”

He then discussed the risk of suicide in patients who are newly diagnosed with cancer. “No one ever talks about this, and I can’t get anybody to support research in this area,” he said. In one of the first studies on the topic, researchers conducted a case-control study of Medicare patients and determined risk of suicide among those with cancer was 2.3-fold higher compared with controls, even after adjustment for psychiatric illness and the risk of dying within a year (J Clin Oncol 2008;26[29]:4720-4). More recently, authors of a large population-based study in England found that the overall standardized mortality ratio for suicide was 1.20 (JAMA Psychiatry 2019;76[1]51-60). The risk was highest among patients with mesothelioma, with a 4.51-fold risk, followed by pancreatic (3.89-fold), esophageal (2.65-fold), lung (2.57-fold), and stomach cancer (2.20-fold). “They reported that the first 6 months after the diagnosis is associated with an increased risk of suicide – unrelated to prognosis,” Dr. Nemeroff said.

A separate analysis of SEER data from 1973-2014 and comprising more than 8.6 million cancer patients found that newly diagnosed cancer patients are 4.4 times more likely to die from suicide than patients in the same age group without cancer (Nat Commun 2019;10[1]:207). The highest risk was in lung cancer, followed by head and neck, testes, bladder, and Hodgkin’s lymphoma.

According to Dr. Nemeroff, the association between depression and the risk of certain forms of cancer or with a poor cancer prognosis “may have to do with immune function. Depression is associated with a change in inflammatory markers that very likely control the microenvironment of the tumor.” For example, he said, if the depressed environment is associated with a marked increase in tumor necrosis factor, interleukin 6, and other inflammatory markers, “that probably contributes to the body’s ability to fight disease. Ironically, depression is associated with an increase in inflammation but a decreased in T cell function. Remember, there are two fundamental types of immunity: the antibody response and the cellular response. What’s odd about depression is that there’s an increase in inflammatory markers but a decrease in the ability of T cells to function in terms of cellular immunity.”

Dr. Nemeroff disclosed that he has served as a consultant and/or scientific adviser for numerous pharmaceutical companies. He has received research and grant support from the National Institutes of Health.

Owning an outdoor cat as a child is associated with an increased risk of psychotic experiences in adulthood – but only in males, new research suggests.

Investigators found male children who owned cats that went outside had a small, but significantly increased, risk of psychotic experiences in adulthood, compared with their counterparts who had no cat during childhood or who had an indoor cat.

Courtesy McGill University

The suspected culprit is not the cat itself but rather exposure to Toxoplasma gondii, a common parasite carried by rodents and sometimes found in cat feces. The study adds to a growing evidence showing exposure to T. gondii may be a risk factor for schizophrenia and other psychotic disorders.

“These are small pieces of evidence but it’s interesting to consider that there might be combinations of risk factors at play,” lead author Vincent Paquin, MD, psychiatry resident at McGill University, Montreal, said in an interview.

“And even if the magnitude of the risk is small at the individual level,” he added, “cats and Toxoplasma gondii are so present in our society that if we add up all these small potential effects then it becomes a potential public health question.”

The study was published online Jan. 30, 2022, in the Journal of Psychiatric Research.
 

Inconsistent evidence

T. gondii infects about 30% of the human population and is usually transmitted by cats. Most infections are asymptomatic, but T. gondii can cause toxoplasmosis in humans, which has been linked to increased risk of schizophrenia, suicide attempts, and more recently, mild cognitive impairment.

Although some studies show an association between cat ownership and increased risk of mental illness, the research findings have been inconsistent.

“The evidence has been mixed about the association between cat ownership and psychosis expression, so our approach was to consider whether specific factors or combinations of factors could explain this mixed evidence,” Dr. Paquin said.

For the study, 2206 individuals aged 18-40 years completed the Community Assessment of Psychic Experiences (CAPE-42) and a questionnaire to gather information about cat ownership at any time between birth and age 13 and if the cats lived exclusively indoors (nonhunting) or if they were allowed outside (rodent hunting).

Participants were also asked about the number of residential moves between birth and age 15, date and place of birth, lifetime history of head trauma, and tobacco smoking history.

Rodent-hunting cat ownership was associated with higher risk of psychosis in male participants, compared with owning no cat or a nonhunting cat. When the investigators added head trauma and residential moves to rodent-hunting cat ownership, psychosis risk was elevated in both men and women.

Independent of cat ownership, younger age, moving more than three times as a child, a history of head trauma, and being a smoker were all associated with higher psychosis risk.

Courtesy McGill University

The study wasn’t designed to explore potential biological mechanisms to explain the sex differences in psychosis risk seen among rodent-hunting cat owners, but “one possible explanation based on the animal model literature is that the neurobiological effects of parasitic exposure may be greater with male sex,” senior author Suzanne King, PhD, professor of psychiatry at McGill, said in an interview.

The new study is part of a larger, long-term project called EnviroGen, led by Dr. King, examining the environmental and genetic risk factors for schizophrenia.
 

Need for replication

Commenting on the findings, E. Fuller Torrey, MD, who was among the first researchers to identify a link between cat ownership, T. gondii infection, and schizophrenia, said the study is “an interesting addition to the studies of cat ownership in childhood as a risk factor for psychosis.”

Of the approximately 10 published studies on the topic, about half suggest a link between cat ownership and psychosis later in life, said Dr. Torrey, associate director for research at the Stanley Medical Research Institute in Rockville, Md.

“The Canadian study is interesting in that it is the first study that separates exposure to permanently indoor cats from cats that are allowed to go outdoors, and the results were positive only for outdoor cats,” Dr. Torrey said.

The study has limitations, Dr. Torrey added, including its retrospective design and the use of a self-report questionnaire to assess psychotic experiences in adulthood.

Also commenting on findings, James Kirkbride, PhD, professor of psychiatric and social epidemiology, University College London, noted the same limitations.

Dr. Kirkbride is the lead author of a 2017 study that showed no link between cat ownership and serious mental illness that included nearly 5,000 people born in 1991 or 1992 and followed until age 18. In this study, there was no link between psychosis and cat ownership during pregnancy or at ages 4 or 10 years.

“Researchers have long been fascinated with the idea that cat ownership may affect mental health. This paper may have them chasing their own tail,” Dr. Kirkbride said.

“Evidence of any association is limited to certain subgroups without a strong theoretical basis for why this may be the case,” he added. “The retrospective and cross-sectional nature of the survey also raise the possibility that the results are impacted by differential recall bias, as well as the broader issues of chance and unobserved confounding.”

Dr. King noted that recall bias is a limitation the researchers highlighted in their study, but “considering the exposures are relatively objective and factual, we do not believe the potential for recall bias is substantial.”

“Nonetheless, we strongly believe that replication of our results in prospective, population-representative cohorts will be crucial to making firmer conclusions,” he added.

The study was funded by grants from the Quebec Health Research Fund. The study authors and Dr. Kirkbride disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Owning an outdoor cat as a child is associated with an increased risk of psychotic experiences in adulthood – but only in males, new research suggests.

Investigators found male children who owned cats that went outside had a small, but significantly increased, risk of psychotic experiences in adulthood, compared with their counterparts who had no cat during childhood or who had an indoor cat.

Courtesy McGill University

The suspected culprit is not the cat itself but rather exposure to Toxoplasma gondii, a common parasite carried by rodents and sometimes found in cat feces. The study adds to a growing evidence showing exposure to T. gondii may be a risk factor for schizophrenia and other psychotic disorders.

“These are small pieces of evidence but it’s interesting to consider that there might be combinations of risk factors at play,” lead author Vincent Paquin, MD, psychiatry resident at McGill University, Montreal, said in an interview.

“And even if the magnitude of the risk is small at the individual level,” he added, “cats and Toxoplasma gondii are so present in our society that if we add up all these small potential effects then it becomes a potential public health question.”

The study was published online Jan. 30, 2022, in the Journal of Psychiatric Research.
 

Inconsistent evidence

T. gondii infects about 30% of the human population and is usually transmitted by cats. Most infections are asymptomatic, but T. gondii can cause toxoplasmosis in humans, which has been linked to increased risk of schizophrenia, suicide attempts, and more recently, mild cognitive impairment.

Although some studies show an association between cat ownership and increased risk of mental illness, the research findings have been inconsistent.

“The evidence has been mixed about the association between cat ownership and psychosis expression, so our approach was to consider whether specific factors or combinations of factors could explain this mixed evidence,” Dr. Paquin said.

For the study, 2206 individuals aged 18-40 years completed the Community Assessment of Psychic Experiences (CAPE-42) and a questionnaire to gather information about cat ownership at any time between birth and age 13 and if the cats lived exclusively indoors (nonhunting) or if they were allowed outside (rodent hunting).

Participants were also asked about the number of residential moves between birth and age 15, date and place of birth, lifetime history of head trauma, and tobacco smoking history.

Rodent-hunting cat ownership was associated with higher risk of psychosis in male participants, compared with owning no cat or a nonhunting cat. When the investigators added head trauma and residential moves to rodent-hunting cat ownership, psychosis risk was elevated in both men and women.

Independent of cat ownership, younger age, moving more than three times as a child, a history of head trauma, and being a smoker were all associated with higher psychosis risk.

Courtesy McGill University

The study wasn’t designed to explore potential biological mechanisms to explain the sex differences in psychosis risk seen among rodent-hunting cat owners, but “one possible explanation based on the animal model literature is that the neurobiological effects of parasitic exposure may be greater with male sex,” senior author Suzanne King, PhD, professor of psychiatry at McGill, said in an interview.

The new study is part of a larger, long-term project called EnviroGen, led by Dr. King, examining the environmental and genetic risk factors for schizophrenia.
 

Need for replication

Commenting on the findings, E. Fuller Torrey, MD, who was among the first researchers to identify a link between cat ownership, T. gondii infection, and schizophrenia, said the study is “an interesting addition to the studies of cat ownership in childhood as a risk factor for psychosis.”

Of the approximately 10 published studies on the topic, about half suggest a link between cat ownership and psychosis later in life, said Dr. Torrey, associate director for research at the Stanley Medical Research Institute in Rockville, Md.

“The Canadian study is interesting in that it is the first study that separates exposure to permanently indoor cats from cats that are allowed to go outdoors, and the results were positive only for outdoor cats,” Dr. Torrey said.

The study has limitations, Dr. Torrey added, including its retrospective design and the use of a self-report questionnaire to assess psychotic experiences in adulthood.

Also commenting on findings, James Kirkbride, PhD, professor of psychiatric and social epidemiology, University College London, noted the same limitations.

Dr. Kirkbride is the lead author of a 2017 study that showed no link between cat ownership and serious mental illness that included nearly 5,000 people born in 1991 or 1992 and followed until age 18. In this study, there was no link between psychosis and cat ownership during pregnancy or at ages 4 or 10 years.

“Researchers have long been fascinated with the idea that cat ownership may affect mental health. This paper may have them chasing their own tail,” Dr. Kirkbride said.

“Evidence of any association is limited to certain subgroups without a strong theoretical basis for why this may be the case,” he added. “The retrospective and cross-sectional nature of the survey also raise the possibility that the results are impacted by differential recall bias, as well as the broader issues of chance and unobserved confounding.”

Dr. King noted that recall bias is a limitation the researchers highlighted in their study, but “considering the exposures are relatively objective and factual, we do not believe the potential for recall bias is substantial.”

“Nonetheless, we strongly believe that replication of our results in prospective, population-representative cohorts will be crucial to making firmer conclusions,” he added.

The study was funded by grants from the Quebec Health Research Fund. The study authors and Dr. Kirkbride disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Owning an outdoor cat as a child is associated with an increased risk of psychotic experiences in adulthood – but only in males, new research suggests.

Investigators found male children who owned cats that went outside had a small, but significantly increased, risk of psychotic experiences in adulthood, compared with their counterparts who had no cat during childhood or who had an indoor cat.

Courtesy McGill University

The suspected culprit is not the cat itself but rather exposure to Toxoplasma gondii, a common parasite carried by rodents and sometimes found in cat feces. The study adds to a growing evidence showing exposure to T. gondii may be a risk factor for schizophrenia and other psychotic disorders.

“These are small pieces of evidence but it’s interesting to consider that there might be combinations of risk factors at play,” lead author Vincent Paquin, MD, psychiatry resident at McGill University, Montreal, said in an interview.

“And even if the magnitude of the risk is small at the individual level,” he added, “cats and Toxoplasma gondii are so present in our society that if we add up all these small potential effects then it becomes a potential public health question.”

The study was published online Jan. 30, 2022, in the Journal of Psychiatric Research.
 

Inconsistent evidence

T. gondii infects about 30% of the human population and is usually transmitted by cats. Most infections are asymptomatic, but T. gondii can cause toxoplasmosis in humans, which has been linked to increased risk of schizophrenia, suicide attempts, and more recently, mild cognitive impairment.

Although some studies show an association between cat ownership and increased risk of mental illness, the research findings have been inconsistent.

“The evidence has been mixed about the association between cat ownership and psychosis expression, so our approach was to consider whether specific factors or combinations of factors could explain this mixed evidence,” Dr. Paquin said.

For the study, 2206 individuals aged 18-40 years completed the Community Assessment of Psychic Experiences (CAPE-42) and a questionnaire to gather information about cat ownership at any time between birth and age 13 and if the cats lived exclusively indoors (nonhunting) or if they were allowed outside (rodent hunting).

Participants were also asked about the number of residential moves between birth and age 15, date and place of birth, lifetime history of head trauma, and tobacco smoking history.

Rodent-hunting cat ownership was associated with higher risk of psychosis in male participants, compared with owning no cat or a nonhunting cat. When the investigators added head trauma and residential moves to rodent-hunting cat ownership, psychosis risk was elevated in both men and women.

Independent of cat ownership, younger age, moving more than three times as a child, a history of head trauma, and being a smoker were all associated with higher psychosis risk.

Courtesy McGill University

The study wasn’t designed to explore potential biological mechanisms to explain the sex differences in psychosis risk seen among rodent-hunting cat owners, but “one possible explanation based on the animal model literature is that the neurobiological effects of parasitic exposure may be greater with male sex,” senior author Suzanne King, PhD, professor of psychiatry at McGill, said in an interview.

The new study is part of a larger, long-term project called EnviroGen, led by Dr. King, examining the environmental and genetic risk factors for schizophrenia.
 

Need for replication

Commenting on the findings, E. Fuller Torrey, MD, who was among the first researchers to identify a link between cat ownership, T. gondii infection, and schizophrenia, said the study is “an interesting addition to the studies of cat ownership in childhood as a risk factor for psychosis.”

Of the approximately 10 published studies on the topic, about half suggest a link between cat ownership and psychosis later in life, said Dr. Torrey, associate director for research at the Stanley Medical Research Institute in Rockville, Md.

“The Canadian study is interesting in that it is the first study that separates exposure to permanently indoor cats from cats that are allowed to go outdoors, and the results were positive only for outdoor cats,” Dr. Torrey said.

The study has limitations, Dr. Torrey added, including its retrospective design and the use of a self-report questionnaire to assess psychotic experiences in adulthood.

Also commenting on findings, James Kirkbride, PhD, professor of psychiatric and social epidemiology, University College London, noted the same limitations.

Dr. Kirkbride is the lead author of a 2017 study that showed no link between cat ownership and serious mental illness that included nearly 5,000 people born in 1991 or 1992 and followed until age 18. In this study, there was no link between psychosis and cat ownership during pregnancy or at ages 4 or 10 years.

“Researchers have long been fascinated with the idea that cat ownership may affect mental health. This paper may have them chasing their own tail,” Dr. Kirkbride said.

“Evidence of any association is limited to certain subgroups without a strong theoretical basis for why this may be the case,” he added. “The retrospective and cross-sectional nature of the survey also raise the possibility that the results are impacted by differential recall bias, as well as the broader issues of chance and unobserved confounding.”

Dr. King noted that recall bias is a limitation the researchers highlighted in their study, but “considering the exposures are relatively objective and factual, we do not believe the potential for recall bias is substantial.”

“Nonetheless, we strongly believe that replication of our results in prospective, population-representative cohorts will be crucial to making firmer conclusions,” he added.

The study was funded by grants from the Quebec Health Research Fund. The study authors and Dr. Kirkbride disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Magnetic Resonance Imaging has long been the standard for diagnosing and surveilling multiple sclerosis (MS), and new guidelines provide updates on the use of MRI for the diagnosis, prognosis, and treatment monitoring of MS.

MS affects approximately one million people in the United States. As family physicians, these guidelines are important to know, because we are often the ones who make the initial diagnosis of MS. Similarly, if we order the wrong imaging study, we can miss making an accurate diagnosis.

The new guidelines (MAGNIMS), which were sponsored by the Consortium of Multiple Sclerosis Centres, were published in August. The documents offers detailed guidance on the use of standardized MRI protocols as well as the use of IV gadolinium contrast agents, including in children and pregnant patients.

It is advised to use 3-D techniques (as opposed to two-dimensional) and it is noted that this is becoming more clinically available. Sagittal 3-D T2-weighted fluid-attenuated inversion recovery (FLAIR) is the core sequence considered for MS diagnosis and monitoring because of its high sensitivity. High-quality 2-D pulse sequences can be used alternatively when 3-D FLAIR is not available.

When 3 T scanners are not available, 1.5 T scanners are sufficient. However, 3 T scanners do have a higher detection rate for MS lesions. In evaluating the imaging, T2 lesion counts, gadolinium lesion counts, and interval changes should be reported.

The use of GBCAs (gadolinium-based contrast agents) is needed to diagnose MS and rule out other diseases. The time between injection of contrast should ideally be 10 minutes but no less than 5. Optic nerve MRI is recommended only in patients with atypical symptoms, such as new visual symptoms. Spinal cord MRI is also not routinely advised unless it is needed for prognosis.

When the initial MRI does not meet the full criteria of MS, brain MRI should be repeated every 6-12 months in suspected cases. The same modality should be used each time. After treatment is started, it is recommended to perform MRI without GBCAs for 3 months and annual follow ups. The use of GBCAs-free MRIs for routine follow up is a new recommendation compared to previous ones. However, if the use of GBCAs would change the management, then they should be utilized for monitoring.

The same imaging standards are recommended in pediatric patients. Spinal cord MRI should be utilized in kids with spinal cord symptoms or inconclusive brain MRI. Similar scan frequency is recommended as in adults. MRI is not contraindicated during pregnancy but should be decided on an individual basis. Standard protocols should be used as well as a magnetic field strength of 1.5 T. GBCAs should not be used during pregnancy. There are no limitations in the postpartum period.

The complete set of guidelines is quite extensive and adds to the previous guidelines published in 2017. They were first published in The Lancet Neurology.

While most of these patients will be referred to neurologists, as the primary care physician it is our responsibility to know all aspects of our patients’ diseases and treatments. While we may not be actively treating MS in these patients, we need to know their medications, how they interact with others, and how their disease is progressing

Additionally, we may be the ones asked to order MRIs for monitoring. It is imperative that we know the guidelines for how to do this.

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J. You can contact her at [email protected].

Magnetic Resonance Imaging has long been the standard for diagnosing and surveilling multiple sclerosis (MS), and new guidelines provide updates on the use of MRI for the diagnosis, prognosis, and treatment monitoring of MS.

MS affects approximately one million people in the United States. As family physicians, these guidelines are important to know, because we are often the ones who make the initial diagnosis of MS. Similarly, if we order the wrong imaging study, we can miss making an accurate diagnosis.

The new guidelines (MAGNIMS), which were sponsored by the Consortium of Multiple Sclerosis Centres, were published in August. The documents offers detailed guidance on the use of standardized MRI protocols as well as the use of IV gadolinium contrast agents, including in children and pregnant patients.

It is advised to use 3-D techniques (as opposed to two-dimensional) and it is noted that this is becoming more clinically available. Sagittal 3-D T2-weighted fluid-attenuated inversion recovery (FLAIR) is the core sequence considered for MS diagnosis and monitoring because of its high sensitivity. High-quality 2-D pulse sequences can be used alternatively when 3-D FLAIR is not available.

When 3 T scanners are not available, 1.5 T scanners are sufficient. However, 3 T scanners do have a higher detection rate for MS lesions. In evaluating the imaging, T2 lesion counts, gadolinium lesion counts, and interval changes should be reported.

The use of GBCAs (gadolinium-based contrast agents) is needed to diagnose MS and rule out other diseases. The time between injection of contrast should ideally be 10 minutes but no less than 5. Optic nerve MRI is recommended only in patients with atypical symptoms, such as new visual symptoms. Spinal cord MRI is also not routinely advised unless it is needed for prognosis.

When the initial MRI does not meet the full criteria of MS, brain MRI should be repeated every 6-12 months in suspected cases. The same modality should be used each time. After treatment is started, it is recommended to perform MRI without GBCAs for 3 months and annual follow ups. The use of GBCAs-free MRIs for routine follow up is a new recommendation compared to previous ones. However, if the use of GBCAs would change the management, then they should be utilized for monitoring.

The same imaging standards are recommended in pediatric patients. Spinal cord MRI should be utilized in kids with spinal cord symptoms or inconclusive brain MRI. Similar scan frequency is recommended as in adults. MRI is not contraindicated during pregnancy but should be decided on an individual basis. Standard protocols should be used as well as a magnetic field strength of 1.5 T. GBCAs should not be used during pregnancy. There are no limitations in the postpartum period.

The complete set of guidelines is quite extensive and adds to the previous guidelines published in 2017. They were first published in The Lancet Neurology.

While most of these patients will be referred to neurologists, as the primary care physician it is our responsibility to know all aspects of our patients’ diseases and treatments. While we may not be actively treating MS in these patients, we need to know their medications, how they interact with others, and how their disease is progressing

Additionally, we may be the ones asked to order MRIs for monitoring. It is imperative that we know the guidelines for how to do this.

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J. You can contact her at [email protected].

Magnetic Resonance Imaging has long been the standard for diagnosing and surveilling multiple sclerosis (MS), and new guidelines provide updates on the use of MRI for the diagnosis, prognosis, and treatment monitoring of MS.

MS affects approximately one million people in the United States. As family physicians, these guidelines are important to know, because we are often the ones who make the initial diagnosis of MS. Similarly, if we order the wrong imaging study, we can miss making an accurate diagnosis.

The new guidelines (MAGNIMS), which were sponsored by the Consortium of Multiple Sclerosis Centres, were published in August. The documents offers detailed guidance on the use of standardized MRI protocols as well as the use of IV gadolinium contrast agents, including in children and pregnant patients.

It is advised to use 3-D techniques (as opposed to two-dimensional) and it is noted that this is becoming more clinically available. Sagittal 3-D T2-weighted fluid-attenuated inversion recovery (FLAIR) is the core sequence considered for MS diagnosis and monitoring because of its high sensitivity. High-quality 2-D pulse sequences can be used alternatively when 3-D FLAIR is not available.

When 3 T scanners are not available, 1.5 T scanners are sufficient. However, 3 T scanners do have a higher detection rate for MS lesions. In evaluating the imaging, T2 lesion counts, gadolinium lesion counts, and interval changes should be reported.

The use of GBCAs (gadolinium-based contrast agents) is needed to diagnose MS and rule out other diseases. The time between injection of contrast should ideally be 10 minutes but no less than 5. Optic nerve MRI is recommended only in patients with atypical symptoms, such as new visual symptoms. Spinal cord MRI is also not routinely advised unless it is needed for prognosis.

When the initial MRI does not meet the full criteria of MS, brain MRI should be repeated every 6-12 months in suspected cases. The same modality should be used each time. After treatment is started, it is recommended to perform MRI without GBCAs for 3 months and annual follow ups. The use of GBCAs-free MRIs for routine follow up is a new recommendation compared to previous ones. However, if the use of GBCAs would change the management, then they should be utilized for monitoring.

The same imaging standards are recommended in pediatric patients. Spinal cord MRI should be utilized in kids with spinal cord symptoms or inconclusive brain MRI. Similar scan frequency is recommended as in adults. MRI is not contraindicated during pregnancy but should be decided on an individual basis. Standard protocols should be used as well as a magnetic field strength of 1.5 T. GBCAs should not be used during pregnancy. There are no limitations in the postpartum period.

The complete set of guidelines is quite extensive and adds to the previous guidelines published in 2017. They were first published in The Lancet Neurology.

While most of these patients will be referred to neurologists, as the primary care physician it is our responsibility to know all aspects of our patients’ diseases and treatments. While we may not be actively treating MS in these patients, we need to know their medications, how they interact with others, and how their disease is progressing

Additionally, we may be the ones asked to order MRIs for monitoring. It is imperative that we know the guidelines for how to do this.

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J. You can contact her at [email protected].

A new meta-analysis provides more evidence that taller people may be more likely than their shorter peers to develop colorectal cancer (CRC) or colon polyps.

“There are well-known modifiable dietary associations for colorectal cancer, such as processed red meats and smoking, but guidelines currently are fixated on family history, and height is clinically neglected when it comes to risk screening,” study investigator Gerard Mullin, MD, with Johns Hopkins University, Baltimore, said in a news release. This large study “builds on evidence that taller height is an overlooked risk factor and should be considered when evaluating and recommending patients for colorectal cancer screenings.”

The study was published online March 1 in Cancer Epidemiology, Biomarkers & Prevention.
 

The evidence: Height and cancer risk

Height has been actively studied as a potential nonmodifiable risk factor for a range of cancers, including CRC.

In one large prospective study of postmenopausal women, researchers found a modest but statistically significant positive association between height and risk for any cancer and for melanoma, multiple myeloma, and cancers of the thyroid, ovary, colorectum, and endometrium. 

A separate study found that tall men, especially those who are long-legged, may be at increased risk for prostate cancer, including high-grade tumors, relative to men of more modest stature.

However, the study authors point out, past studies have also produced mixed results, used inconsistent measures of height, and failed to include the risk of adenomas.  

In the current meta-analysis, the investigators included 47 international, observational studies involving 280,644 adults with CRC and 14,139 cases of colorectal adenoma.

Because the definition of tallness differs around the world, the researchers compared the highest versus the lowest height percentile of various study groups. The findings were adjusted for demographic, socioeconomic, behavioral, and other known risk factors for CRC.

Overall, the investigators found that the tallest individuals within the highest percentile of height had a 24% higher risk of developing CRC compared to the shortest individuals within the lowest percentile (hazard ratio [HR], 1.24; P < .001).

In addition, they found that every 10-cm increase (about 4 inches) in height was associated with a 14% increased risk of developing CRC (HR, 1.14; P < .001) and a 6% increased likelihood of adenomas (odds ratio [OR], 1.06; P = .03).

In the United States, the average height for men is 5 feet, 9 inches, and for women it is 5 feet, 4 inches, which means men who are 6 feet, 1 inch and women who are 5 feet, 8 inches or taller have a 14% increased risk of CRC and a 6% increased risk of adenomas, the researchers explained.

According to co–first author Elinor Zhou, MD, also with Johns Hopkins University, a potential explanation for this link “is that adult height correlates with body organ size. More active proliferation in organs of taller people could increase the possibility of mutations leading to malignant transformation.”

The study authors said more research is needed to identify particular subgroups of tall people at risk for CRC.

“For instance, tall athletes and individuals with inherited tallness, such as those with Marfan syndrome, could be screened earlier and the impact of height further explored,” Dr. Zhou said.

Plus, Dr. Zhou added, more studies are needed to “definitively say at what height you would need earlier colorectal cancer screening.”

The current study was supported by grants from Bloomberg Philanthropies, intramural funds, and the Johns Hopkins Cancer Center Support Grant. The authors declared no conflicts of interest.

A version of this article first appeared on Medscape.com.

A new meta-analysis provides more evidence that taller people may be more likely than their shorter peers to develop colorectal cancer (CRC) or colon polyps.

“There are well-known modifiable dietary associations for colorectal cancer, such as processed red meats and smoking, but guidelines currently are fixated on family history, and height is clinically neglected when it comes to risk screening,” study investigator Gerard Mullin, MD, with Johns Hopkins University, Baltimore, said in a news release. This large study “builds on evidence that taller height is an overlooked risk factor and should be considered when evaluating and recommending patients for colorectal cancer screenings.”

The study was published online March 1 in Cancer Epidemiology, Biomarkers & Prevention.
 

The evidence: Height and cancer risk

Height has been actively studied as a potential nonmodifiable risk factor for a range of cancers, including CRC.

In one large prospective study of postmenopausal women, researchers found a modest but statistically significant positive association between height and risk for any cancer and for melanoma, multiple myeloma, and cancers of the thyroid, ovary, colorectum, and endometrium. 

A separate study found that tall men, especially those who are long-legged, may be at increased risk for prostate cancer, including high-grade tumors, relative to men of more modest stature.

However, the study authors point out, past studies have also produced mixed results, used inconsistent measures of height, and failed to include the risk of adenomas.  

In the current meta-analysis, the investigators included 47 international, observational studies involving 280,644 adults with CRC and 14,139 cases of colorectal adenoma.

Because the definition of tallness differs around the world, the researchers compared the highest versus the lowest height percentile of various study groups. The findings were adjusted for demographic, socioeconomic, behavioral, and other known risk factors for CRC.

Overall, the investigators found that the tallest individuals within the highest percentile of height had a 24% higher risk of developing CRC compared to the shortest individuals within the lowest percentile (hazard ratio [HR], 1.24; P < .001).

In addition, they found that every 10-cm increase (about 4 inches) in height was associated with a 14% increased risk of developing CRC (HR, 1.14; P < .001) and a 6% increased likelihood of adenomas (odds ratio [OR], 1.06; P = .03).

In the United States, the average height for men is 5 feet, 9 inches, and for women it is 5 feet, 4 inches, which means men who are 6 feet, 1 inch and women who are 5 feet, 8 inches or taller have a 14% increased risk of CRC and a 6% increased risk of adenomas, the researchers explained.

According to co–first author Elinor Zhou, MD, also with Johns Hopkins University, a potential explanation for this link “is that adult height correlates with body organ size. More active proliferation in organs of taller people could increase the possibility of mutations leading to malignant transformation.”

The study authors said more research is needed to identify particular subgroups of tall people at risk for CRC.

“For instance, tall athletes and individuals with inherited tallness, such as those with Marfan syndrome, could be screened earlier and the impact of height further explored,” Dr. Zhou said.

Plus, Dr. Zhou added, more studies are needed to “definitively say at what height you would need earlier colorectal cancer screening.”

The current study was supported by grants from Bloomberg Philanthropies, intramural funds, and the Johns Hopkins Cancer Center Support Grant. The authors declared no conflicts of interest.

A version of this article first appeared on Medscape.com.

A new meta-analysis provides more evidence that taller people may be more likely than their shorter peers to develop colorectal cancer (CRC) or colon polyps.

“There are well-known modifiable dietary associations for colorectal cancer, such as processed red meats and smoking, but guidelines currently are fixated on family history, and height is clinically neglected when it comes to risk screening,” study investigator Gerard Mullin, MD, with Johns Hopkins University, Baltimore, said in a news release. This large study “builds on evidence that taller height is an overlooked risk factor and should be considered when evaluating and recommending patients for colorectal cancer screenings.”

The study was published online March 1 in Cancer Epidemiology, Biomarkers & Prevention.
 

The evidence: Height and cancer risk

Height has been actively studied as a potential nonmodifiable risk factor for a range of cancers, including CRC.

In one large prospective study of postmenopausal women, researchers found a modest but statistically significant positive association between height and risk for any cancer and for melanoma, multiple myeloma, and cancers of the thyroid, ovary, colorectum, and endometrium. 

A separate study found that tall men, especially those who are long-legged, may be at increased risk for prostate cancer, including high-grade tumors, relative to men of more modest stature.

However, the study authors point out, past studies have also produced mixed results, used inconsistent measures of height, and failed to include the risk of adenomas.  

In the current meta-analysis, the investigators included 47 international, observational studies involving 280,644 adults with CRC and 14,139 cases of colorectal adenoma.

Because the definition of tallness differs around the world, the researchers compared the highest versus the lowest height percentile of various study groups. The findings were adjusted for demographic, socioeconomic, behavioral, and other known risk factors for CRC.

Overall, the investigators found that the tallest individuals within the highest percentile of height had a 24% higher risk of developing CRC compared to the shortest individuals within the lowest percentile (hazard ratio [HR], 1.24; P < .001).

In addition, they found that every 10-cm increase (about 4 inches) in height was associated with a 14% increased risk of developing CRC (HR, 1.14; P < .001) and a 6% increased likelihood of adenomas (odds ratio [OR], 1.06; P = .03).

In the United States, the average height for men is 5 feet, 9 inches, and for women it is 5 feet, 4 inches, which means men who are 6 feet, 1 inch and women who are 5 feet, 8 inches or taller have a 14% increased risk of CRC and a 6% increased risk of adenomas, the researchers explained.

According to co–first author Elinor Zhou, MD, also with Johns Hopkins University, a potential explanation for this link “is that adult height correlates with body organ size. More active proliferation in organs of taller people could increase the possibility of mutations leading to malignant transformation.”

The study authors said more research is needed to identify particular subgroups of tall people at risk for CRC.

“For instance, tall athletes and individuals with inherited tallness, such as those with Marfan syndrome, could be screened earlier and the impact of height further explored,” Dr. Zhou said.

Plus, Dr. Zhou added, more studies are needed to “definitively say at what height you would need earlier colorectal cancer screening.”

The current study was supported by grants from Bloomberg Philanthropies, intramural funds, and the Johns Hopkins Cancer Center Support Grant. The authors declared no conflicts of interest.

A version of this article first appeared on Medscape.com.

All 15 members of Wake Forest Baptist Comprehensive Cancer Center’s external advisory board (EAB) resigned on February 18 and withdrew their endorsement for renewal of the center’s National Cancer Institute comprehensive cancer center support grant.

The move was prompted by the abrupt firing of center director Boris Pasche, MD, PhD, on February 10, one day after NCI renewed a multimillion dollar grant.

The Cancer Letter broke the story and published the resignation letter from the EAB. It was signed by board chair Gerold Bepler, MD, PhD, CEO and director of the Karmanos Cancer Institute, Detroit, on behalf of the board.

The mass resignation of an EAB, a panel of outside experts that help shepherd cancer centers through the NCI grant process, is “highly unusual,” according to The Cancer Letter. It also raises concerns about the “immediate future” of Wake Forest’s cancer center, the publication added.

Numerous people involved with the situation did not respond or declined to comment when this news organization requested additional information and updates, including questions about the reason for Dr. Pasche’s termination; whether or not withdrawal of the endorsement puts Wake’s NCI designation in jeopardy; and if the EAB is being reconstituted.

A written statement from Wake Forest simply said that “the situation involving Dr. Pasche is an administrative decision. Various administrative changes occur regularly in organizations across the country. Dr. Pasche remains employed by Atrium Health Wake Forest Baptist. We are very grateful to Dr. Pasche for his years of service and many contributions to the mission and vision of our NCI-designated Comprehensive Cancer Center in Winston-Salem.”

Wake’s cancer center is in the process of combining with the Atrium Health Levine Cancer Center, which is not NCI-designated, following Atrium Health system’s recent acquisition of the Wake Forest Baptist Medical Center.

The NCI renewal notice, dated February 9, states that Dr. Pasche “and his leadership team have built a robust, transdisciplinary center that includes 140 scientists.”

Dr. Pasche was fired a day later.

The EAB resignation letter states that during Wake Forest’s recent NCI review process, “leadership gave their glowing endorsement of Dr. Pasche...This endorsement included unequivocal statements of support for Dr. Pasche’s oversight of the combined Atrium-Wake Forest cancer program.”

“What followed was his rapid dismissal after the...notice of award was issued, following a period during which the approach to integration was apparently being revisited,” Dr. Bepler said on behalf of the board.

“It is with sadness and dismay that we witnessed the change in approach by the institutional leadership towards” the merger, he wrote.

The Cancer Letter quotes an unnamed board member as saying, “EABs for cancer centers can only provide value to the center when there is openness and transparency in the process. In the absence of such, I believe the members felt that there was no further utility in providing guidance to the organization.”

The resignation letter was sent to the interim director of Wake’s cancer center, radiation oncologist William Blackstock, Jr, MD, and also copied to Atrium-Wake and NCI leadership.

The resignation letter endorsed Dr. Blackstock’s qualifications to run the center, and noted that as the board is reconstituted, “some of us would be honored to discuss participation...if there is unequivocal evidence from the health system’s senior management for support of a single, academically driven, comprehensive, and integrated cancer center.”

A version of this article first appeared on Medscape.com.

All 15 members of Wake Forest Baptist Comprehensive Cancer Center’s external advisory board (EAB) resigned on February 18 and withdrew their endorsement for renewal of the center’s National Cancer Institute comprehensive cancer center support grant.

The move was prompted by the abrupt firing of center director Boris Pasche, MD, PhD, on February 10, one day after NCI renewed a multimillion dollar grant.

The Cancer Letter broke the story and published the resignation letter from the EAB. It was signed by board chair Gerold Bepler, MD, PhD, CEO and director of the Karmanos Cancer Institute, Detroit, on behalf of the board.

The mass resignation of an EAB, a panel of outside experts that help shepherd cancer centers through the NCI grant process, is “highly unusual,” according to The Cancer Letter. It also raises concerns about the “immediate future” of Wake Forest’s cancer center, the publication added.

Numerous people involved with the situation did not respond or declined to comment when this news organization requested additional information and updates, including questions about the reason for Dr. Pasche’s termination; whether or not withdrawal of the endorsement puts Wake’s NCI designation in jeopardy; and if the EAB is being reconstituted.

A written statement from Wake Forest simply said that “the situation involving Dr. Pasche is an administrative decision. Various administrative changes occur regularly in organizations across the country. Dr. Pasche remains employed by Atrium Health Wake Forest Baptist. We are very grateful to Dr. Pasche for his years of service and many contributions to the mission and vision of our NCI-designated Comprehensive Cancer Center in Winston-Salem.”

Wake’s cancer center is in the process of combining with the Atrium Health Levine Cancer Center, which is not NCI-designated, following Atrium Health system’s recent acquisition of the Wake Forest Baptist Medical Center.

The NCI renewal notice, dated February 9, states that Dr. Pasche “and his leadership team have built a robust, transdisciplinary center that includes 140 scientists.”

Dr. Pasche was fired a day later.

The EAB resignation letter states that during Wake Forest’s recent NCI review process, “leadership gave their glowing endorsement of Dr. Pasche...This endorsement included unequivocal statements of support for Dr. Pasche’s oversight of the combined Atrium-Wake Forest cancer program.”

“What followed was his rapid dismissal after the...notice of award was issued, following a period during which the approach to integration was apparently being revisited,” Dr. Bepler said on behalf of the board.

“It is with sadness and dismay that we witnessed the change in approach by the institutional leadership towards” the merger, he wrote.

The Cancer Letter quotes an unnamed board member as saying, “EABs for cancer centers can only provide value to the center when there is openness and transparency in the process. In the absence of such, I believe the members felt that there was no further utility in providing guidance to the organization.”

The resignation letter was sent to the interim director of Wake’s cancer center, radiation oncologist William Blackstock, Jr, MD, and also copied to Atrium-Wake and NCI leadership.

The resignation letter endorsed Dr. Blackstock’s qualifications to run the center, and noted that as the board is reconstituted, “some of us would be honored to discuss participation...if there is unequivocal evidence from the health system’s senior management for support of a single, academically driven, comprehensive, and integrated cancer center.”

A version of this article first appeared on Medscape.com.

All 15 members of Wake Forest Baptist Comprehensive Cancer Center’s external advisory board (EAB) resigned on February 18 and withdrew their endorsement for renewal of the center’s National Cancer Institute comprehensive cancer center support grant.

The move was prompted by the abrupt firing of center director Boris Pasche, MD, PhD, on February 10, one day after NCI renewed a multimillion dollar grant.

The Cancer Letter broke the story and published the resignation letter from the EAB. It was signed by board chair Gerold Bepler, MD, PhD, CEO and director of the Karmanos Cancer Institute, Detroit, on behalf of the board.

The mass resignation of an EAB, a panel of outside experts that help shepherd cancer centers through the NCI grant process, is “highly unusual,” according to The Cancer Letter. It also raises concerns about the “immediate future” of Wake Forest’s cancer center, the publication added.

Numerous people involved with the situation did not respond or declined to comment when this news organization requested additional information and updates, including questions about the reason for Dr. Pasche’s termination; whether or not withdrawal of the endorsement puts Wake’s NCI designation in jeopardy; and if the EAB is being reconstituted.

A written statement from Wake Forest simply said that “the situation involving Dr. Pasche is an administrative decision. Various administrative changes occur regularly in organizations across the country. Dr. Pasche remains employed by Atrium Health Wake Forest Baptist. We are very grateful to Dr. Pasche for his years of service and many contributions to the mission and vision of our NCI-designated Comprehensive Cancer Center in Winston-Salem.”

Wake’s cancer center is in the process of combining with the Atrium Health Levine Cancer Center, which is not NCI-designated, following Atrium Health system’s recent acquisition of the Wake Forest Baptist Medical Center.

The NCI renewal notice, dated February 9, states that Dr. Pasche “and his leadership team have built a robust, transdisciplinary center that includes 140 scientists.”

Dr. Pasche was fired a day later.

The EAB resignation letter states that during Wake Forest’s recent NCI review process, “leadership gave their glowing endorsement of Dr. Pasche...This endorsement included unequivocal statements of support for Dr. Pasche’s oversight of the combined Atrium-Wake Forest cancer program.”

“What followed was his rapid dismissal after the...notice of award was issued, following a period during which the approach to integration was apparently being revisited,” Dr. Bepler said on behalf of the board.

“It is with sadness and dismay that we witnessed the change in approach by the institutional leadership towards” the merger, he wrote.

The Cancer Letter quotes an unnamed board member as saying, “EABs for cancer centers can only provide value to the center when there is openness and transparency in the process. In the absence of such, I believe the members felt that there was no further utility in providing guidance to the organization.”

The resignation letter was sent to the interim director of Wake’s cancer center, radiation oncologist William Blackstock, Jr, MD, and also copied to Atrium-Wake and NCI leadership.

The resignation letter endorsed Dr. Blackstock’s qualifications to run the center, and noted that as the board is reconstituted, “some of us would be honored to discuss participation...if there is unequivocal evidence from the health system’s senior management for support of a single, academically driven, comprehensive, and integrated cancer center.”

A version of this article first appeared on Medscape.com.

Everyone’s been there. You’ve arrived for your scheduled doctor’s office visit and the first order of real business is the reunion with the blood pressure cuff. The first reading might be high. A second reading looks a bit better – or maybe a bit worse. Which one’s right?

The answer: Perhaps neither. Individual measures of blood pressure are not as accurate as taking multiple readings over a day and averaging them.

Blood pressure varies throughout the day – by about 30 points for systolic pressure, or the pressure when the heart beats – and one or two measurements in a doctor’s office may not accurately reflect the average figure, said Beverly B. Green, MD, a senior investigator at Kaiser Permanente Washington Health Research Institute in Seattle.

Average blood pressure reading is the only measurement on which a doctor can accurately diagnose and treat high blood pressure, she said. A new study by Dr. Green and other researchers at Kaiser Permanente showed that giving patients the chance to monitor their blood pressure at home could help get more reliable measurements.

Nearly one in four adults in the United States with high blood pressure are unaware they have the condition and are not getting treatment to control it. Without treatment, the condition can cause heart attacks, strokes, kidney damage, and other potentially life-threatening health problems.

Current guidelines for diagnosing high blood pressure recommend that patients whose pressure is high in the clinic get tested again to confirm the results. While the guidelines recommend home monitoring before diagnosing high blood pressure, research shows that doctors continue to measure blood pressure in their clinics for the second reading.

In their study, Dr. Green and colleagues found that home readings were more accurate than measurements taken in clinics or at pharmacy kiosks.

“Home blood pressure monitoring was a better option, because it was more accurate” than clinic blood pressure readings, Green said. A companion study found that patients preferred taking their blood pressure at home.

For their study, Dr. Green’s group used Kaiser’s electronic health record system to identify people at high risk for high blood pressure based on a recent clinic visit. They then randomly assigned the participants to get their follow-up blood pressure readings in the clinic, at home, or at kiosks in clinics or pharmacies.

Each participant also received a 24-hour ambulatory blood pressure monitor (ABPM). These devices, which people must wear continuously for 24 hours, have cuffs that inflate every 20-0 minutes during the day and every 30-60 minutes at night. Although ABPMs are the preferred test for accurately diagnosing high blood pressure, they aren’t available for widespread use.

The Kaiser researchers found that people’s systolic BP readings at clinics were generally lower than their ABPM measurements, leading to undiagnosed high BP in more than 50% of cases. Kiosk readings were much higher than the ABPM measurements and tended to overdiagnose high BP.
 

The value of home monitoring

Branden Villavaso, a 48-year-old attorney in New Orleans who was diagnosed with high BP at age 32, attributes his condition to genetics. He says an at-home monitor plus the occasional use of an ABPM finally provided his doctor with an accurate assessment of his condition.

Thanks to this aggressive approach, over the past 3 years, Mr. Villavaso’s diastolic reading has dropped from a previous range of between 90 and 100 to a healthier but not quite ideal value of about 80. Meanwhile, his systolic pressure has dropped to about 120, well below the goal of 130.

Mr. Villavaso said his doctor has relied on the averages of the BP readings to tailor his medication, and he also credited his wife, Chloe, a clinical nurse specialist, for monitoring his progress.

While previous studies have found similar benefits for measuring BP at home, Dr. Green said the latest study may offer the most powerful evidence to date because of the large number of people who took part, the involvement of primary care clinics, and the use of real-world health care professionals to take measurements instead of people who usually do health research. She said this study is the first to compare kiosk and ABPM results.

“The study indicates that assisting patients with getting access to valid blood pressure readings so they can measure their blood pressure at home will give a better picture of the true burden of [high BP],” said Keith C. Ferdinand, MD, a cardiologist at Tulane University, New Orleans.

He recommended patients select a home monitoring device from www.validatebp.org, a noncommercial website that lists home BP systems that have proven to be accurate.

“We know that [high blood pressure] is the most common and powerful cause of heart disease and death,” Dr. Ferdinand said. “Patients are pleased to participate in shared decision-making and actively assist in the control of a potentially deadly disease.”

A version of this article first appeared on WebMD.com.

Everyone’s been there. You’ve arrived for your scheduled doctor’s office visit and the first order of real business is the reunion with the blood pressure cuff. The first reading might be high. A second reading looks a bit better – or maybe a bit worse. Which one’s right?

The answer: Perhaps neither. Individual measures of blood pressure are not as accurate as taking multiple readings over a day and averaging them.

Blood pressure varies throughout the day – by about 30 points for systolic pressure, or the pressure when the heart beats – and one or two measurements in a doctor’s office may not accurately reflect the average figure, said Beverly B. Green, MD, a senior investigator at Kaiser Permanente Washington Health Research Institute in Seattle.

Average blood pressure reading is the only measurement on which a doctor can accurately diagnose and treat high blood pressure, she said. A new study by Dr. Green and other researchers at Kaiser Permanente showed that giving patients the chance to monitor their blood pressure at home could help get more reliable measurements.

Nearly one in four adults in the United States with high blood pressure are unaware they have the condition and are not getting treatment to control it. Without treatment, the condition can cause heart attacks, strokes, kidney damage, and other potentially life-threatening health problems.

Current guidelines for diagnosing high blood pressure recommend that patients whose pressure is high in the clinic get tested again to confirm the results. While the guidelines recommend home monitoring before diagnosing high blood pressure, research shows that doctors continue to measure blood pressure in their clinics for the second reading.

In their study, Dr. Green and colleagues found that home readings were more accurate than measurements taken in clinics or at pharmacy kiosks.

“Home blood pressure monitoring was a better option, because it was more accurate” than clinic blood pressure readings, Green said. A companion study found that patients preferred taking their blood pressure at home.

For their study, Dr. Green’s group used Kaiser’s electronic health record system to identify people at high risk for high blood pressure based on a recent clinic visit. They then randomly assigned the participants to get their follow-up blood pressure readings in the clinic, at home, or at kiosks in clinics or pharmacies.

Each participant also received a 24-hour ambulatory blood pressure monitor (ABPM). These devices, which people must wear continuously for 24 hours, have cuffs that inflate every 20-0 minutes during the day and every 30-60 minutes at night. Although ABPMs are the preferred test for accurately diagnosing high blood pressure, they aren’t available for widespread use.

The Kaiser researchers found that people’s systolic BP readings at clinics were generally lower than their ABPM measurements, leading to undiagnosed high BP in more than 50% of cases. Kiosk readings were much higher than the ABPM measurements and tended to overdiagnose high BP.
 

The value of home monitoring

Branden Villavaso, a 48-year-old attorney in New Orleans who was diagnosed with high BP at age 32, attributes his condition to genetics. He says an at-home monitor plus the occasional use of an ABPM finally provided his doctor with an accurate assessment of his condition.

Thanks to this aggressive approach, over the past 3 years, Mr. Villavaso’s diastolic reading has dropped from a previous range of between 90 and 100 to a healthier but not quite ideal value of about 80. Meanwhile, his systolic pressure has dropped to about 120, well below the goal of 130.

Mr. Villavaso said his doctor has relied on the averages of the BP readings to tailor his medication, and he also credited his wife, Chloe, a clinical nurse specialist, for monitoring his progress.

While previous studies have found similar benefits for measuring BP at home, Dr. Green said the latest study may offer the most powerful evidence to date because of the large number of people who took part, the involvement of primary care clinics, and the use of real-world health care professionals to take measurements instead of people who usually do health research. She said this study is the first to compare kiosk and ABPM results.

“The study indicates that assisting patients with getting access to valid blood pressure readings so they can measure their blood pressure at home will give a better picture of the true burden of [high BP],” said Keith C. Ferdinand, MD, a cardiologist at Tulane University, New Orleans.

He recommended patients select a home monitoring device from www.validatebp.org, a noncommercial website that lists home BP systems that have proven to be accurate.

“We know that [high blood pressure] is the most common and powerful cause of heart disease and death,” Dr. Ferdinand said. “Patients are pleased to participate in shared decision-making and actively assist in the control of a potentially deadly disease.”

A version of this article first appeared on WebMD.com.

Everyone’s been there. You’ve arrived for your scheduled doctor’s office visit and the first order of real business is the reunion with the blood pressure cuff. The first reading might be high. A second reading looks a bit better – or maybe a bit worse. Which one’s right?

The answer: Perhaps neither. Individual measures of blood pressure are not as accurate as taking multiple readings over a day and averaging them.

Blood pressure varies throughout the day – by about 30 points for systolic pressure, or the pressure when the heart beats – and one or two measurements in a doctor’s office may not accurately reflect the average figure, said Beverly B. Green, MD, a senior investigator at Kaiser Permanente Washington Health Research Institute in Seattle.

Average blood pressure reading is the only measurement on which a doctor can accurately diagnose and treat high blood pressure, she said. A new study by Dr. Green and other researchers at Kaiser Permanente showed that giving patients the chance to monitor their blood pressure at home could help get more reliable measurements.

Nearly one in four adults in the United States with high blood pressure are unaware they have the condition and are not getting treatment to control it. Without treatment, the condition can cause heart attacks, strokes, kidney damage, and other potentially life-threatening health problems.

Current guidelines for diagnosing high blood pressure recommend that patients whose pressure is high in the clinic get tested again to confirm the results. While the guidelines recommend home monitoring before diagnosing high blood pressure, research shows that doctors continue to measure blood pressure in their clinics for the second reading.

In their study, Dr. Green and colleagues found that home readings were more accurate than measurements taken in clinics or at pharmacy kiosks.

“Home blood pressure monitoring was a better option, because it was more accurate” than clinic blood pressure readings, Green said. A companion study found that patients preferred taking their blood pressure at home.

For their study, Dr. Green’s group used Kaiser’s electronic health record system to identify people at high risk for high blood pressure based on a recent clinic visit. They then randomly assigned the participants to get their follow-up blood pressure readings in the clinic, at home, or at kiosks in clinics or pharmacies.

Each participant also received a 24-hour ambulatory blood pressure monitor (ABPM). These devices, which people must wear continuously for 24 hours, have cuffs that inflate every 20-0 minutes during the day and every 30-60 minutes at night. Although ABPMs are the preferred test for accurately diagnosing high blood pressure, they aren’t available for widespread use.

The Kaiser researchers found that people’s systolic BP readings at clinics were generally lower than their ABPM measurements, leading to undiagnosed high BP in more than 50% of cases. Kiosk readings were much higher than the ABPM measurements and tended to overdiagnose high BP.
 

The value of home monitoring

Branden Villavaso, a 48-year-old attorney in New Orleans who was diagnosed with high BP at age 32, attributes his condition to genetics. He says an at-home monitor plus the occasional use of an ABPM finally provided his doctor with an accurate assessment of his condition.

Thanks to this aggressive approach, over the past 3 years, Mr. Villavaso’s diastolic reading has dropped from a previous range of between 90 and 100 to a healthier but not quite ideal value of about 80. Meanwhile, his systolic pressure has dropped to about 120, well below the goal of 130.

Mr. Villavaso said his doctor has relied on the averages of the BP readings to tailor his medication, and he also credited his wife, Chloe, a clinical nurse specialist, for monitoring his progress.

While previous studies have found similar benefits for measuring BP at home, Dr. Green said the latest study may offer the most powerful evidence to date because of the large number of people who took part, the involvement of primary care clinics, and the use of real-world health care professionals to take measurements instead of people who usually do health research. She said this study is the first to compare kiosk and ABPM results.

“The study indicates that assisting patients with getting access to valid blood pressure readings so they can measure their blood pressure at home will give a better picture of the true burden of [high BP],” said Keith C. Ferdinand, MD, a cardiologist at Tulane University, New Orleans.

He recommended patients select a home monitoring device from www.validatebp.org, a noncommercial website that lists home BP systems that have proven to be accurate.

“We know that [high blood pressure] is the most common and powerful cause of heart disease and death,” Dr. Ferdinand said. “Patients are pleased to participate in shared decision-making and actively assist in the control of a potentially deadly disease.”

A version of this article first appeared on WebMD.com.

Even mild cases of COVID-19 are associated with brain changes, including decreased gray matter, an overall reduction in brain volume, and cognitive decline, a new imaging study shows.

In the first study to use magnetic resonance brain imaging, before and after COVID-19, investigators found “greater reduction in grey matter thickness and tissue-contrast in the orbitofrontal cortex and parahippocampal gyrus, greater changes in markers of tissue damage in regions functionally connected to the primary olfactory cortex and greater reduction in global brain size.” However, the researchers urge caution when interpreting the findings.

Gwenaëlle Douaud, PhD, Wellcome Center for Integrative Neuroimaging, Nuffield Department of Clinical Neurosciences, University of Oxford, England, and colleagues describe these brain changes as “modest.”

“Whether these abnormal changes are the hallmark of the spread of the pathogenic effects in the brain, or of the virus itself, and whether these may prefigure a future vulnerability of the limbic system in particular, including memory, for these participants, remains to be investigated,” the researchers wrote.

The findings were published online March 7 in the journal Nature.