Federal Practitioner

SAN ANTONIO – Breast cancer survivors with chronic musculoskeletal pain may experience relief from pain with electroacupuncture and auricular acupuncture, according to a new study recently presented at the 2021 San Antonio Breast Cancer Symposium.

Both techniques led to clinically meaningful and persistent reduction of pain, but electroacupuncture was more effective in reducing pain severity, according to study author Wanqing Iris Zhi, MD, PhD, of the Breast Medicine Service at Memorial Sloan Kettering Cancer Center in New York.

Among breast cancer survivors, Dr. Zhi said, chronic musculoskeletal pain is common and debilitating. In earlier results of the PEACE (Personalized Electroacupuncture versus Auricular Acupuncture Comparative Effectiveness) trial, both electroacupuncture and auricular acupuncture improved pain control better than usual care in cancer survivors. The comparative effectiveness between electroacupuncture and auricular acupuncture among breast cancer survivors, specifically for chronic musculoskeletal pain, remains unknown.

To evaluate potential differences between electroacupuncture and auricular acupuncture, Dr. Zhi et al. examined data from PEACE, a three-arm, parallel, single center randomized trial investigating electroacupuncture and auricular acupuncture for chronic musculoskeletal pain, compared with usual care. Among 360 cancer survivors in PEACE, mean age in 165 cancer survivors with a primary diagnosis of breast cancer was 60.3 years (35.8 percent non-White) with a mean of 5.4 years since their cancer diagnoses. Patients in both the electroacupuncture and auricular acupuncture groups received 10 weekly treatments. Change in mean Brief Pain Inventory (BPI) pain severity from baseline to week 12 was the primary endpoint, with BPI change to week 24 as a secondary endpoint. Usual care patients, after week 12, could receive 10 electroacupuncture treatments.

The most common locations of chronic musculoskeletal pain, Dr. Zhi observed, were lower back (24 percent), knee/leg (24 percent) and shoulder/elbow (14 percent). About 70 percent of patients were taking pain medication. Both electroacupuncture and auricular acupuncture were associated with clinically meaningful and persistent pain reductions among the evaluated breast cancer survivors. The change in BPI severity from baseline to week 12 was –0.29 (confidence interval, –0.08, 0.28) in the UC group. In the electroacupuncture group it was –2.65 (CI, –3.06, –2.25; P ≤0.001 from baseline) and –2.37 versus usual care (CI, –3.05, –1.68; P ≤0.001 versus UC). For the auricular acupuncture group, the change from baseline was –1.75 (CI, –2.15, –1.35; P ≤0.001 from baseline) and –1.46 versus usual care (CI, –2.14, –0.78; P ≤0.001 versus UC). The difference in BPI pain severity reduction from baseline between electroacupuncture and auricular acupuncture of –0.90 (CI, –1.45, –0.36) was statistically significant (P ≤0.001). Electroacupuncture also reduced pain severity significantly more than auricular acupuncture at week 24 (CI, –0.82, [–1.38, –0.27], P = 0.004).

Dr. Zhi concluded that among breast cancer survivors, although both electroacupuncture and auricular acupuncture were associated with clinically meaningful and persistent pain reduction, electroacupuncture was more effective at reducing pain severity.

She pointed out also that neither surgery type (mastectomy versus lumpectomy; P = 0.83) nor aromatase inhibitor versus tamoxifen versus neither (P = 0.59) was associated with BPI/severity response among electroacupuncture and auricular acupuncture patients.

“Both electroacupuncture and auricular acupuncture are significantly better than usual care, so it suggests that both acupuncture methods can be utilized for treating chronic muscle skeletal pain in breast cancer survivors, but electroacupuncture is preferred,” Dr. Zhi said.

“Auricular acupuncture can be more painful,” said PEACE principal investigator Jun Mao, MD, who is chair of integrative medicine at Memorial Sloan Kettering. “Ten percent of women could not tolerate the ear pain or discomfort. Electroacupuncture is generally well tolerated. People are more relaxed after treatment. If both are available, start with electroacupuncture,” he said.

SAN ANTONIO – Breast cancer survivors with chronic musculoskeletal pain may experience relief from pain with electroacupuncture and auricular acupuncture, according to a new study recently presented at the 2021 San Antonio Breast Cancer Symposium.

Both techniques led to clinically meaningful and persistent reduction of pain, but electroacupuncture was more effective in reducing pain severity, according to study author Wanqing Iris Zhi, MD, PhD, of the Breast Medicine Service at Memorial Sloan Kettering Cancer Center in New York.

Among breast cancer survivors, Dr. Zhi said, chronic musculoskeletal pain is common and debilitating. In earlier results of the PEACE (Personalized Electroacupuncture versus Auricular Acupuncture Comparative Effectiveness) trial, both electroacupuncture and auricular acupuncture improved pain control better than usual care in cancer survivors. The comparative effectiveness between electroacupuncture and auricular acupuncture among breast cancer survivors, specifically for chronic musculoskeletal pain, remains unknown.

To evaluate potential differences between electroacupuncture and auricular acupuncture, Dr. Zhi et al. examined data from PEACE, a three-arm, parallel, single center randomized trial investigating electroacupuncture and auricular acupuncture for chronic musculoskeletal pain, compared with usual care. Among 360 cancer survivors in PEACE, mean age in 165 cancer survivors with a primary diagnosis of breast cancer was 60.3 years (35.8 percent non-White) with a mean of 5.4 years since their cancer diagnoses. Patients in both the electroacupuncture and auricular acupuncture groups received 10 weekly treatments. Change in mean Brief Pain Inventory (BPI) pain severity from baseline to week 12 was the primary endpoint, with BPI change to week 24 as a secondary endpoint. Usual care patients, after week 12, could receive 10 electroacupuncture treatments.

The most common locations of chronic musculoskeletal pain, Dr. Zhi observed, were lower back (24 percent), knee/leg (24 percent) and shoulder/elbow (14 percent). About 70 percent of patients were taking pain medication. Both electroacupuncture and auricular acupuncture were associated with clinically meaningful and persistent pain reductions among the evaluated breast cancer survivors. The change in BPI severity from baseline to week 12 was –0.29 (confidence interval, –0.08, 0.28) in the UC group. In the electroacupuncture group it was –2.65 (CI, –3.06, –2.25; P ≤0.001 from baseline) and –2.37 versus usual care (CI, –3.05, –1.68; P ≤0.001 versus UC). For the auricular acupuncture group, the change from baseline was –1.75 (CI, –2.15, –1.35; P ≤0.001 from baseline) and –1.46 versus usual care (CI, –2.14, –0.78; P ≤0.001 versus UC). The difference in BPI pain severity reduction from baseline between electroacupuncture and auricular acupuncture of –0.90 (CI, –1.45, –0.36) was statistically significant (P ≤0.001). Electroacupuncture also reduced pain severity significantly more than auricular acupuncture at week 24 (CI, –0.82, [–1.38, –0.27], P = 0.004).

Dr. Zhi concluded that among breast cancer survivors, although both electroacupuncture and auricular acupuncture were associated with clinically meaningful and persistent pain reduction, electroacupuncture was more effective at reducing pain severity.

She pointed out also that neither surgery type (mastectomy versus lumpectomy; P = 0.83) nor aromatase inhibitor versus tamoxifen versus neither (P = 0.59) was associated with BPI/severity response among electroacupuncture and auricular acupuncture patients.

“Both electroacupuncture and auricular acupuncture are significantly better than usual care, so it suggests that both acupuncture methods can be utilized for treating chronic muscle skeletal pain in breast cancer survivors, but electroacupuncture is preferred,” Dr. Zhi said.

“Auricular acupuncture can be more painful,” said PEACE principal investigator Jun Mao, MD, who is chair of integrative medicine at Memorial Sloan Kettering. “Ten percent of women could not tolerate the ear pain or discomfort. Electroacupuncture is generally well tolerated. People are more relaxed after treatment. If both are available, start with electroacupuncture,” he said.

SAN ANTONIO – Breast cancer survivors with chronic musculoskeletal pain may experience relief from pain with electroacupuncture and auricular acupuncture, according to a new study recently presented at the 2021 San Antonio Breast Cancer Symposium.

Both techniques led to clinically meaningful and persistent reduction of pain, but electroacupuncture was more effective in reducing pain severity, according to study author Wanqing Iris Zhi, MD, PhD, of the Breast Medicine Service at Memorial Sloan Kettering Cancer Center in New York.

Among breast cancer survivors, Dr. Zhi said, chronic musculoskeletal pain is common and debilitating. In earlier results of the PEACE (Personalized Electroacupuncture versus Auricular Acupuncture Comparative Effectiveness) trial, both electroacupuncture and auricular acupuncture improved pain control better than usual care in cancer survivors. The comparative effectiveness between electroacupuncture and auricular acupuncture among breast cancer survivors, specifically for chronic musculoskeletal pain, remains unknown.

To evaluate potential differences between electroacupuncture and auricular acupuncture, Dr. Zhi et al. examined data from PEACE, a three-arm, parallel, single center randomized trial investigating electroacupuncture and auricular acupuncture for chronic musculoskeletal pain, compared with usual care. Among 360 cancer survivors in PEACE, mean age in 165 cancer survivors with a primary diagnosis of breast cancer was 60.3 years (35.8 percent non-White) with a mean of 5.4 years since their cancer diagnoses. Patients in both the electroacupuncture and auricular acupuncture groups received 10 weekly treatments. Change in mean Brief Pain Inventory (BPI) pain severity from baseline to week 12 was the primary endpoint, with BPI change to week 24 as a secondary endpoint. Usual care patients, after week 12, could receive 10 electroacupuncture treatments.

The most common locations of chronic musculoskeletal pain, Dr. Zhi observed, were lower back (24 percent), knee/leg (24 percent) and shoulder/elbow (14 percent). About 70 percent of patients were taking pain medication. Both electroacupuncture and auricular acupuncture were associated with clinically meaningful and persistent pain reductions among the evaluated breast cancer survivors. The change in BPI severity from baseline to week 12 was –0.29 (confidence interval, –0.08, 0.28) in the UC group. In the electroacupuncture group it was –2.65 (CI, –3.06, –2.25; P ≤0.001 from baseline) and –2.37 versus usual care (CI, –3.05, –1.68; P ≤0.001 versus UC). For the auricular acupuncture group, the change from baseline was –1.75 (CI, –2.15, –1.35; P ≤0.001 from baseline) and –1.46 versus usual care (CI, –2.14, –0.78; P ≤0.001 versus UC). The difference in BPI pain severity reduction from baseline between electroacupuncture and auricular acupuncture of –0.90 (CI, –1.45, –0.36) was statistically significant (P ≤0.001). Electroacupuncture also reduced pain severity significantly more than auricular acupuncture at week 24 (CI, –0.82, [–1.38, –0.27], P = 0.004).

Dr. Zhi concluded that among breast cancer survivors, although both electroacupuncture and auricular acupuncture were associated with clinically meaningful and persistent pain reduction, electroacupuncture was more effective at reducing pain severity.

She pointed out also that neither surgery type (mastectomy versus lumpectomy; P = 0.83) nor aromatase inhibitor versus tamoxifen versus neither (P = 0.59) was associated with BPI/severity response among electroacupuncture and auricular acupuncture patients.

“Both electroacupuncture and auricular acupuncture are significantly better than usual care, so it suggests that both acupuncture methods can be utilized for treating chronic muscle skeletal pain in breast cancer survivors, but electroacupuncture is preferred,” Dr. Zhi said.

“Auricular acupuncture can be more painful,” said PEACE principal investigator Jun Mao, MD, who is chair of integrative medicine at Memorial Sloan Kettering. “Ten percent of women could not tolerate the ear pain or discomfort. Electroacupuncture is generally well tolerated. People are more relaxed after treatment. If both are available, start with electroacupuncture,” he said.

On a recent Friday, oncologist Christine Berg, MD, devoted 3 hours to a webinar about electrification of heavy- and medium-duty trucks in Maryland.

It’s not the way most cancer specialists choose to spend their time. But Dr. Berg, who is board certified in medical oncology, radiation oncology, and internal medicine, has made air pollution her current focus. Through organizations such as the Public Employees for Environmental Responsibility, she is working to raise awareness of the huge impact it can have on cancer.

“I think oncologists can make a difference,” she said.

That’s why Dr. Berg took a keen interest in a recent study by ProPublica, the nonprofit journalism organization, that identified previously ignored “hot spots of cancer-causing air.” While the ProPublica report gives an incomplete picture of airborne carcinogens, it puts an important spotlight on industrial air pollution, Dr. Berg and other experts say.

Relying on data from the Environmental Protection Agency’s Risk-Screening Environmental Indicators (RSEI), ProPublica researchers estimated the effects of industrial air pollution around the country and found problems the EPA overlooked, they reported. “The EPA collects data on each individual facility, but it doesn’t consider the excess cancer risk from all of the facilities’ combined emissions,” reporter Lylla Younes and colleagues wrote. “ProPublica did.”

The ProPublica team produced a map of cancer-causing industrial air pollution hot spots. They estimated that 256,000 people in the United States live in areas where incidences of cancer caused by air pollution exceed the EPA’s upper limit of acceptable risk.

While some of the spots are scattered around the country, they are concentrated along the Gulf Coast of Texas and Louisiana. For example, near the Equistar Chemicals Bayport Chemical Plant in Pasadena, Texas, ProPublica calculated the increased risk of cancer at 1 in 220, “46 times the EPA’s acceptable risk.” (The agency defines an acceptable risk as less than a 1 in 10,000 chance of developing cancer.)

Almost all the hot spots with the highest level of risk are in southern United States “known for having weaker environmental regulations,” the report said.

The researchers also identified race as a risk factor. In predominantly Black census tracts, they estimated the risk from toxic air pollution is more than double the risk in predominantly White census tracts. It attributed this pattern to deliberate policies of redlining that segregated neighborhoods and to zoning ordinances that encouraged industry in communities of color.
 

Measuring risk not straightforward

In response to a query from this news organization, an EPA spokesperson provided a statement saying the RSEI data are not intended for the purpose used by ProPublica. “RSEI does not provide a risk assessment (e.g., excess cancer case estimates),” the statement said. The RSEI data are poorly suited to this purpose because they use “worst-case assumptions about toxicity and potential exposure where data are lacking, and also use simplifying assumptions to reduce the complexity of the calculations,” the statement said.

Instead, the data are meant as a kind of index to compare one place to another, or show changes over time, the agency said. In this way, it can prompt regulators to investigate further. “A more refined assessment is required before any conclusions about health impacts can be drawn.” The agency is working on just such a refined approach, per the EPA statement.

That’s not just bureaucratic stonewalling, said Stan Meiberg, PhD, MA, a former EPA official and director of graduate studies in sustainability at Wake Forest University in Winston-Salem, N.C. “To say that you can speak with great precision, that the risk of individuals getting cancer is 1 in 100, may be a little overstating the date on which that statement is based.”

Risk estimates are improving as citizens gain access to more sophisticated monitoring devices, he said. And the primary point of the ProPublica report, that the EPA has underestimated risk by looking at individual sources of pollution rather than combining them, is not an original one, Dr. Meiberg said. “This is an issue that’s been kicking around for quite some time.”

Still, it’s one that demands attention. EPA regulations have succeeded in reducing the overall risk from industrial air pollution over the past few decades. “But there remain areas of particular geographic concentrations,” he said. “And the ProPublica article hit two of them, which have been the subject of discussion for many years, the Houston Ship Channel area and the Baton Rouge to New Orleans industrial corridor where you have a significant proportion of all the chemical petrochemical industry in the United States.”

Improvements in containment of the pollutants, and changes to the industrial processes that produce them, can also help reduce exposure. These changes should occur in the context of dialogue within the communities exposed to the pollution, Dr. Meiberg said.
 

The role of cancer-causing airborne particulate matter

But even if measures are perfectly implemented, Joan Schiller, MD, will not breathe easy. An adjunct professor of oncology at the University of Virginia in Charlottesville, Dr. Schiller has researched the role of airborne particulate matter in causing cancer, a correlation barely mentioned in the ProPublica analysis, she pointed out.

Particulate matter contains a wide range of toxic substances, she said. Researchers have focused on particles 2.5 microns in diameter, or PM 2.5. Some studies have indicated that it’s responsible for one in seven deaths from lung cancer, Dr. Schiller said. “Air pollution also causes lung cancer in never smokers, people who’ve never smoked, not just in smokers.”

Power plants and automobile traffic may be more significant sources of PM 2.5 than industry, and wildfires have recently emerged as increasingly important source, a result of climate change and poor forest management, she said.

PM 2.5 doesn’t affect just lung cancer, said Alexandra White, PhD, an investigator at the National Institute of Environmental Health Sciences in Research Triangle Park, N.C. “My work, as well as work of others, is increasingly suggesting that air pollution is also related to breast cancer risk, in particular, air pollution that is arising from traffic related forces.” And more research is needed on other cancers, she said. “I think that the lack of findings of other cancer sites reflects a lack of study.”

Other pollutants not analyzed in the ProPublica report are also correlated to cancer risk. In a recent meta-analysis, researcher Stephan Gabet, PhD, PharmD, and colleagues at the University of Grenoble, France, estimated that 3.15% of new breast cancer cases in that country could be attributed to nitrogen dioxide and 2.15% to PM 10.

Sources of nitrogen dioxide, PM 2.5, and PM 10 in France include automobile traffic, inefficient wood-burning stoves, and coal-burning power plants in neighboring countries, Dr. Gabet said.

A good approach to reducing pollution from road traffic is the implementation of low-emission zones that prohibit the most polluting vehicles, he said. But a 2019 United Kingdom government study found that brake wear, tire wear, and road surface wear account for 72% of the PM 10 and 60% of the PM 2.5 pollution from road traffic, suggesting that a transition to electric vehicles won’t fix the problem. Better yet, is “the promotion of active modes like walking, cycling, etc., because like this, you can bring additional health gains due to the increase in physical activity,” he said.

Oncologists can help their patients reduce their exposure to air pollution, Dr. Schiller said. “If you have lung cancer, air pollution will hasten your demise. It makes you sicker. Oncologists should be telling their patients about this and advising them to move away from air pollution if possible, and also making sure they know to monitor the health of the air.”

On days when air pollution is high, patients may want to avoid exercising outdoors, or stay indoors altogether, Dr. Berg said. Air purifiers and N95 masks may also help.

And physicians can make a difference by speaking out in their communities, Dr. Schiller said. She is inviting oncologists to join a new group, Oncologists Understanding for Climate and Health. Through this group or on their own, oncologists can speak to their local legislatures or city councils in support of measures to reduce pollution, she said. “Doctors are trusted messengers.”

Dr. Berg disclosed affiliations with Grail, Mercy BioAnalytics and Lucid Diagnostics.

On a recent Friday, oncologist Christine Berg, MD, devoted 3 hours to a webinar about electrification of heavy- and medium-duty trucks in Maryland.

It’s not the way most cancer specialists choose to spend their time. But Dr. Berg, who is board certified in medical oncology, radiation oncology, and internal medicine, has made air pollution her current focus. Through organizations such as the Public Employees for Environmental Responsibility, she is working to raise awareness of the huge impact it can have on cancer.

“I think oncologists can make a difference,” she said.

That’s why Dr. Berg took a keen interest in a recent study by ProPublica, the nonprofit journalism organization, that identified previously ignored “hot spots of cancer-causing air.” While the ProPublica report gives an incomplete picture of airborne carcinogens, it puts an important spotlight on industrial air pollution, Dr. Berg and other experts say.

Relying on data from the Environmental Protection Agency’s Risk-Screening Environmental Indicators (RSEI), ProPublica researchers estimated the effects of industrial air pollution around the country and found problems the EPA overlooked, they reported. “The EPA collects data on each individual facility, but it doesn’t consider the excess cancer risk from all of the facilities’ combined emissions,” reporter Lylla Younes and colleagues wrote. “ProPublica did.”

The ProPublica team produced a map of cancer-causing industrial air pollution hot spots. They estimated that 256,000 people in the United States live in areas where incidences of cancer caused by air pollution exceed the EPA’s upper limit of acceptable risk.

While some of the spots are scattered around the country, they are concentrated along the Gulf Coast of Texas and Louisiana. For example, near the Equistar Chemicals Bayport Chemical Plant in Pasadena, Texas, ProPublica calculated the increased risk of cancer at 1 in 220, “46 times the EPA’s acceptable risk.” (The agency defines an acceptable risk as less than a 1 in 10,000 chance of developing cancer.)

Almost all the hot spots with the highest level of risk are in southern United States “known for having weaker environmental regulations,” the report said.

The researchers also identified race as a risk factor. In predominantly Black census tracts, they estimated the risk from toxic air pollution is more than double the risk in predominantly White census tracts. It attributed this pattern to deliberate policies of redlining that segregated neighborhoods and to zoning ordinances that encouraged industry in communities of color.
 

Measuring risk not straightforward

In response to a query from this news organization, an EPA spokesperson provided a statement saying the RSEI data are not intended for the purpose used by ProPublica. “RSEI does not provide a risk assessment (e.g., excess cancer case estimates),” the statement said. The RSEI data are poorly suited to this purpose because they use “worst-case assumptions about toxicity and potential exposure where data are lacking, and also use simplifying assumptions to reduce the complexity of the calculations,” the statement said.

Instead, the data are meant as a kind of index to compare one place to another, or show changes over time, the agency said. In this way, it can prompt regulators to investigate further. “A more refined assessment is required before any conclusions about health impacts can be drawn.” The agency is working on just such a refined approach, per the EPA statement.

That’s not just bureaucratic stonewalling, said Stan Meiberg, PhD, MA, a former EPA official and director of graduate studies in sustainability at Wake Forest University in Winston-Salem, N.C. “To say that you can speak with great precision, that the risk of individuals getting cancer is 1 in 100, may be a little overstating the date on which that statement is based.”

Risk estimates are improving as citizens gain access to more sophisticated monitoring devices, he said. And the primary point of the ProPublica report, that the EPA has underestimated risk by looking at individual sources of pollution rather than combining them, is not an original one, Dr. Meiberg said. “This is an issue that’s been kicking around for quite some time.”

Still, it’s one that demands attention. EPA regulations have succeeded in reducing the overall risk from industrial air pollution over the past few decades. “But there remain areas of particular geographic concentrations,” he said. “And the ProPublica article hit two of them, which have been the subject of discussion for many years, the Houston Ship Channel area and the Baton Rouge to New Orleans industrial corridor where you have a significant proportion of all the chemical petrochemical industry in the United States.”

Improvements in containment of the pollutants, and changes to the industrial processes that produce them, can also help reduce exposure. These changes should occur in the context of dialogue within the communities exposed to the pollution, Dr. Meiberg said.
 

The role of cancer-causing airborne particulate matter

But even if measures are perfectly implemented, Joan Schiller, MD, will not breathe easy. An adjunct professor of oncology at the University of Virginia in Charlottesville, Dr. Schiller has researched the role of airborne particulate matter in causing cancer, a correlation barely mentioned in the ProPublica analysis, she pointed out.

Particulate matter contains a wide range of toxic substances, she said. Researchers have focused on particles 2.5 microns in diameter, or PM 2.5. Some studies have indicated that it’s responsible for one in seven deaths from lung cancer, Dr. Schiller said. “Air pollution also causes lung cancer in never smokers, people who’ve never smoked, not just in smokers.”

Power plants and automobile traffic may be more significant sources of PM 2.5 than industry, and wildfires have recently emerged as increasingly important source, a result of climate change and poor forest management, she said.

PM 2.5 doesn’t affect just lung cancer, said Alexandra White, PhD, an investigator at the National Institute of Environmental Health Sciences in Research Triangle Park, N.C. “My work, as well as work of others, is increasingly suggesting that air pollution is also related to breast cancer risk, in particular, air pollution that is arising from traffic related forces.” And more research is needed on other cancers, she said. “I think that the lack of findings of other cancer sites reflects a lack of study.”

Other pollutants not analyzed in the ProPublica report are also correlated to cancer risk. In a recent meta-analysis, researcher Stephan Gabet, PhD, PharmD, and colleagues at the University of Grenoble, France, estimated that 3.15% of new breast cancer cases in that country could be attributed to nitrogen dioxide and 2.15% to PM 10.

Sources of nitrogen dioxide, PM 2.5, and PM 10 in France include automobile traffic, inefficient wood-burning stoves, and coal-burning power plants in neighboring countries, Dr. Gabet said.

A good approach to reducing pollution from road traffic is the implementation of low-emission zones that prohibit the most polluting vehicles, he said. But a 2019 United Kingdom government study found that brake wear, tire wear, and road surface wear account for 72% of the PM 10 and 60% of the PM 2.5 pollution from road traffic, suggesting that a transition to electric vehicles won’t fix the problem. Better yet, is “the promotion of active modes like walking, cycling, etc., because like this, you can bring additional health gains due to the increase in physical activity,” he said.

Oncologists can help their patients reduce their exposure to air pollution, Dr. Schiller said. “If you have lung cancer, air pollution will hasten your demise. It makes you sicker. Oncologists should be telling their patients about this and advising them to move away from air pollution if possible, and also making sure they know to monitor the health of the air.”

On days when air pollution is high, patients may want to avoid exercising outdoors, or stay indoors altogether, Dr. Berg said. Air purifiers and N95 masks may also help.

And physicians can make a difference by speaking out in their communities, Dr. Schiller said. She is inviting oncologists to join a new group, Oncologists Understanding for Climate and Health. Through this group or on their own, oncologists can speak to their local legislatures or city councils in support of measures to reduce pollution, she said. “Doctors are trusted messengers.”

Dr. Berg disclosed affiliations with Grail, Mercy BioAnalytics and Lucid Diagnostics.

On a recent Friday, oncologist Christine Berg, MD, devoted 3 hours to a webinar about electrification of heavy- and medium-duty trucks in Maryland.

It’s not the way most cancer specialists choose to spend their time. But Dr. Berg, who is board certified in medical oncology, radiation oncology, and internal medicine, has made air pollution her current focus. Through organizations such as the Public Employees for Environmental Responsibility, she is working to raise awareness of the huge impact it can have on cancer.

“I think oncologists can make a difference,” she said.

That’s why Dr. Berg took a keen interest in a recent study by ProPublica, the nonprofit journalism organization, that identified previously ignored “hot spots of cancer-causing air.” While the ProPublica report gives an incomplete picture of airborne carcinogens, it puts an important spotlight on industrial air pollution, Dr. Berg and other experts say.

Relying on data from the Environmental Protection Agency’s Risk-Screening Environmental Indicators (RSEI), ProPublica researchers estimated the effects of industrial air pollution around the country and found problems the EPA overlooked, they reported. “The EPA collects data on each individual facility, but it doesn’t consider the excess cancer risk from all of the facilities’ combined emissions,” reporter Lylla Younes and colleagues wrote. “ProPublica did.”

The ProPublica team produced a map of cancer-causing industrial air pollution hot spots. They estimated that 256,000 people in the United States live in areas where incidences of cancer caused by air pollution exceed the EPA’s upper limit of acceptable risk.

While some of the spots are scattered around the country, they are concentrated along the Gulf Coast of Texas and Louisiana. For example, near the Equistar Chemicals Bayport Chemical Plant in Pasadena, Texas, ProPublica calculated the increased risk of cancer at 1 in 220, “46 times the EPA’s acceptable risk.” (The agency defines an acceptable risk as less than a 1 in 10,000 chance of developing cancer.)

Almost all the hot spots with the highest level of risk are in southern United States “known for having weaker environmental regulations,” the report said.

The researchers also identified race as a risk factor. In predominantly Black census tracts, they estimated the risk from toxic air pollution is more than double the risk in predominantly White census tracts. It attributed this pattern to deliberate policies of redlining that segregated neighborhoods and to zoning ordinances that encouraged industry in communities of color.
 

Measuring risk not straightforward

In response to a query from this news organization, an EPA spokesperson provided a statement saying the RSEI data are not intended for the purpose used by ProPublica. “RSEI does not provide a risk assessment (e.g., excess cancer case estimates),” the statement said. The RSEI data are poorly suited to this purpose because they use “worst-case assumptions about toxicity and potential exposure where data are lacking, and also use simplifying assumptions to reduce the complexity of the calculations,” the statement said.

Instead, the data are meant as a kind of index to compare one place to another, or show changes over time, the agency said. In this way, it can prompt regulators to investigate further. “A more refined assessment is required before any conclusions about health impacts can be drawn.” The agency is working on just such a refined approach, per the EPA statement.

That’s not just bureaucratic stonewalling, said Stan Meiberg, PhD, MA, a former EPA official and director of graduate studies in sustainability at Wake Forest University in Winston-Salem, N.C. “To say that you can speak with great precision, that the risk of individuals getting cancer is 1 in 100, may be a little overstating the date on which that statement is based.”

Risk estimates are improving as citizens gain access to more sophisticated monitoring devices, he said. And the primary point of the ProPublica report, that the EPA has underestimated risk by looking at individual sources of pollution rather than combining them, is not an original one, Dr. Meiberg said. “This is an issue that’s been kicking around for quite some time.”

Still, it’s one that demands attention. EPA regulations have succeeded in reducing the overall risk from industrial air pollution over the past few decades. “But there remain areas of particular geographic concentrations,” he said. “And the ProPublica article hit two of them, which have been the subject of discussion for many years, the Houston Ship Channel area and the Baton Rouge to New Orleans industrial corridor where you have a significant proportion of all the chemical petrochemical industry in the United States.”

Improvements in containment of the pollutants, and changes to the industrial processes that produce them, can also help reduce exposure. These changes should occur in the context of dialogue within the communities exposed to the pollution, Dr. Meiberg said.
 

The role of cancer-causing airborne particulate matter

But even if measures are perfectly implemented, Joan Schiller, MD, will not breathe easy. An adjunct professor of oncology at the University of Virginia in Charlottesville, Dr. Schiller has researched the role of airborne particulate matter in causing cancer, a correlation barely mentioned in the ProPublica analysis, she pointed out.

Particulate matter contains a wide range of toxic substances, she said. Researchers have focused on particles 2.5 microns in diameter, or PM 2.5. Some studies have indicated that it’s responsible for one in seven deaths from lung cancer, Dr. Schiller said. “Air pollution also causes lung cancer in never smokers, people who’ve never smoked, not just in smokers.”

Power plants and automobile traffic may be more significant sources of PM 2.5 than industry, and wildfires have recently emerged as increasingly important source, a result of climate change and poor forest management, she said.

PM 2.5 doesn’t affect just lung cancer, said Alexandra White, PhD, an investigator at the National Institute of Environmental Health Sciences in Research Triangle Park, N.C. “My work, as well as work of others, is increasingly suggesting that air pollution is also related to breast cancer risk, in particular, air pollution that is arising from traffic related forces.” And more research is needed on other cancers, she said. “I think that the lack of findings of other cancer sites reflects a lack of study.”

Other pollutants not analyzed in the ProPublica report are also correlated to cancer risk. In a recent meta-analysis, researcher Stephan Gabet, PhD, PharmD, and colleagues at the University of Grenoble, France, estimated that 3.15% of new breast cancer cases in that country could be attributed to nitrogen dioxide and 2.15% to PM 10.

Sources of nitrogen dioxide, PM 2.5, and PM 10 in France include automobile traffic, inefficient wood-burning stoves, and coal-burning power plants in neighboring countries, Dr. Gabet said.

A good approach to reducing pollution from road traffic is the implementation of low-emission zones that prohibit the most polluting vehicles, he said. But a 2019 United Kingdom government study found that brake wear, tire wear, and road surface wear account for 72% of the PM 10 and 60% of the PM 2.5 pollution from road traffic, suggesting that a transition to electric vehicles won’t fix the problem. Better yet, is “the promotion of active modes like walking, cycling, etc., because like this, you can bring additional health gains due to the increase in physical activity,” he said.

Oncologists can help their patients reduce their exposure to air pollution, Dr. Schiller said. “If you have lung cancer, air pollution will hasten your demise. It makes you sicker. Oncologists should be telling their patients about this and advising them to move away from air pollution if possible, and also making sure they know to monitor the health of the air.”

On days when air pollution is high, patients may want to avoid exercising outdoors, or stay indoors altogether, Dr. Berg said. Air purifiers and N95 masks may also help.

And physicians can make a difference by speaking out in their communities, Dr. Schiller said. She is inviting oncologists to join a new group, Oncologists Understanding for Climate and Health. Through this group or on their own, oncologists can speak to their local legislatures or city councils in support of measures to reduce pollution, she said. “Doctors are trusted messengers.”

Dr. Berg disclosed affiliations with Grail, Mercy BioAnalytics and Lucid Diagnostics.

Identification of pulmonary nodules in older adults who smoke immediately brings concern for malignancy in the mind of clinicians. This is particularly the case in patients with significant smoking history. According to the National Cancer Institute in 2019, 12.9% of all new cancer cases were lung cancers.¹ Screening for lung cancer, especially in patients with increased risk from smoking, is imperative to early detection and treatment. However, 20% of patients will be overdiagnosed by lung cancer-screening techniques.² The rate of malignancy noted on a patient’s first screening computed tomography (CT) scan was between 3.7% and 5.5%.³

Rheumatoid arthritis (RA) is an autoimmune inflammatory condition that mainly affects the joints. Extraarticular manifestations can arise in various locations throughout the body, however. These manifestations are commonly observed in the skin, heart, and lungs.⁴ Prevalence of pulmonary rheumatoid nodules ranges from < 0.4% in radiologic studies to 32% in lung biopsies of patients with RA and nodules.⁵

Furthermore, there is a strong association between the risk of rheumatoid nodules in patients with positive serum rheumatoid factor (RF) and smoking history.⁶ Solitary pulmonary nodules in patients with RA can coexist with bronchogenic carcinoma, making their diagnosis more important.⁷

Case Presentation

A 54-year-old woman with a 30 pack-year smoking history and history of RA initially presented to the emergency department for cough and dyspnea for 5-day duration. Her initial diagnosis was bronchitis based on presenting symptom profile. A chest CT demonstrated 3 cavitary pulmonary nodules, 1 measuring 2.4 x 2.0 cm in the right middle lobe, and 2 additional nodules, measuring 1.8 x 1.4 and 1.5 x 1.4 in the left upper lobe (Figure). She had no improvement of symptoms after a 7-day course of doxycycline. The patient was taking methotrexate 15 mg weekly and golimumab 50 mg subcutaneously every 4 weeks as treatment for RA, prescribed by her rheumatologist.

Pulmonology was consulted and a positron emission tomography-CT (PET-CT) confirmed several cavitary pulmonary nodules involving both lungs with no suspicious fluorodeoxyglucose (FDG) uptake. The largest lesion was in the right middle lobe with FDG uptake of 1.9. Additional nodules were found in the left upper lobe, measuring 1.8 x 1.4 cm with FDG of 4.01, and in the left lung apex, measuring 1.5 x 1.4 cm with uptake of 3.53. CTguided percutaneous fine needle aspiration (PFNA) of the right middle lobe lung nodule demonstrated granuloma with central inflammatory debris. Grocott methenamine silver (GMS) stain was negative for fungal organism, acid-fast bacteria (AFB) stain was negative for acid-fast bacilli, and CD20 and CD3 immunostaining demonstrated mixed B- and T-cell populations. There was no evidence of atypia or malignancy. The biopsy demonstrated granuloma with central inflammatory debris on a background of densely fibrotic tissue and lympho-plasmatic inflammation. This finding confirmed the diagnosis of RA with pulmonary involvement.

Outpatient follow-up was established with a pulmonologist and rheumatologist. Methotrexate 15 mg weekly and golimumab subcutaneously 50 mg every 4 weeks were prescribed for the patient. The nodules are being monitored based on Fleischer guidelines with CT imaging 3 to 6 months following initial presentation. Further imaging will be considered at 18 to 24 months as well to further assess stability of the nodules and monitor for changes in size, shape, and necrosis. The patient also was encouraged to quit smoking. Her clinical course since the diagnosis has been stable.

Discussion

The differential diagnosis for new multiple pulmonary nodules on imaging studies is broad and includes infectious processes, such as tuberculosis, as well as other mycobacterial, fungal, and bacterial infections. Noninfectious causes of lung disease are an even broader category of consideration. Noninfectious pulmonary nodules differential includes sarcoidosis, granulomatous with polyangiitis, hypersensitivity pneumonitis, methotrexate drug reaction, pulmonary manifestations of systemic conditions, such as RA chronic granulomatous disease and malignancy.⁸ Bronchogenic carcinoma was suspected in this patient due to her smoking history. Squamous cell carcinoma was also considered as the lesion was cavitary. AFB and GMS stains were negative for fungi. Langerhans cell histiocytosis were considered but ruled out as these lesions contain larger numbers of eosinophils than described in the pathology report. Histoplasma and coccidiosis laboratory tests were obtained as the patient lived in a region endemic to both these fungi but were negative (Table). A diagnosis of rheumatoid nodule was made based on the clinical setting, typical radiographic, histopathology features, and negative cultures.

This case is unique due to the quality and location of the rheumatoid nodules within the lungs. Pulmonary manifestations of RA are usually subcutaneous or subpleural, solid, and peripherally located^.9 This patient’s nodules were necrobiotic and located within the lung parenchyma. There was significant cavitation. These factors are atypical features of pulmonary RA.

Pulmonary RA can have many associated symptoms and remains an important factor in patient mortality. Estimates demonstrate that 10 to 20% of RA-related deaths are secondary to pulmonary manifestations.¹⁰ There are a wide array of symptoms and presentations to be aware of clinically. These symptoms are often nondescript, widely sensitive to many disease processes, and nonspecific to pulmonary RA. These symptoms include dyspnea, wheezing, and nonproductive cough.¹⁰ Bronchiectasis is a common symptom as well as small airway obstruction.¹⁰ Consolidated necrobiotic lesions are present in up to 20% of pulmonary RA cases.¹⁰ Generally these lesions are asymptomatic but can also be associated with pneumothorax, hemoptysis, and airway obstruction.10 Awareness of these symptoms is important for diagnosis and monitoring clinical improvement in patients.

Further workup is necessary to differentiate malignancy-related pulmonary nodules and other causes; if the index of suspicion is high for malignancy as in our case, the workup should be more aggressive. Biopsy is mandatory in such cases to rule out infections and malignancy, as it is highly sensitive and specific. The main problem hindering management is when a clinician fails to include this in their differential diagnosis. This further elucidates the importance of awareness of this diagnosis. Suspicious lesions in a proper clinical setting should be followed up by imaging studies and confirmatory histopathological diagnosis. Typical follow-up is 3 months after initial presentation to assess stability and possibly 18 to 24 months as well based on Fleischer guidelines.

Various treatment modalities have been tried as per literature, including tocilizumab and rituximab. ^11,12 Our patient is currently being treated with golimumab based on outpatient rheumatologist recommendations.

Conclusions

This case demonstrates the importance of a careful workup to narrow a broad differential. Medical diagnosis of pulmonary nodules requires an in-depth workup, including clinical evaluation, laboratory and pulmonary functions tests, as well as various imaging studies.

Identification of pulmonary nodules in older adults who smoke immediately brings concern for malignancy in the mind of clinicians. This is particularly the case in patients with significant smoking history. According to the National Cancer Institute in 2019, 12.9% of all new cancer cases were lung cancers.¹ Screening for lung cancer, especially in patients with increased risk from smoking, is imperative to early detection and treatment. However, 20% of patients will be overdiagnosed by lung cancer-screening techniques.² The rate of malignancy noted on a patient’s first screening computed tomography (CT) scan was between 3.7% and 5.5%.³

Rheumatoid arthritis (RA) is an autoimmune inflammatory condition that mainly affects the joints. Extraarticular manifestations can arise in various locations throughout the body, however. These manifestations are commonly observed in the skin, heart, and lungs.⁴ Prevalence of pulmonary rheumatoid nodules ranges from < 0.4% in radiologic studies to 32% in lung biopsies of patients with RA and nodules.⁵

Furthermore, there is a strong association between the risk of rheumatoid nodules in patients with positive serum rheumatoid factor (RF) and smoking history.⁶ Solitary pulmonary nodules in patients with RA can coexist with bronchogenic carcinoma, making their diagnosis more important.⁷

Case Presentation

A 54-year-old woman with a 30 pack-year smoking history and history of RA initially presented to the emergency department for cough and dyspnea for 5-day duration. Her initial diagnosis was bronchitis based on presenting symptom profile. A chest CT demonstrated 3 cavitary pulmonary nodules, 1 measuring 2.4 x 2.0 cm in the right middle lobe, and 2 additional nodules, measuring 1.8 x 1.4 and 1.5 x 1.4 in the left upper lobe (Figure). She had no improvement of symptoms after a 7-day course of doxycycline. The patient was taking methotrexate 15 mg weekly and golimumab 50 mg subcutaneously every 4 weeks as treatment for RA, prescribed by her rheumatologist.

Pulmonology was consulted and a positron emission tomography-CT (PET-CT) confirmed several cavitary pulmonary nodules involving both lungs with no suspicious fluorodeoxyglucose (FDG) uptake. The largest lesion was in the right middle lobe with FDG uptake of 1.9. Additional nodules were found in the left upper lobe, measuring 1.8 x 1.4 cm with FDG of 4.01, and in the left lung apex, measuring 1.5 x 1.4 cm with uptake of 3.53. CTguided percutaneous fine needle aspiration (PFNA) of the right middle lobe lung nodule demonstrated granuloma with central inflammatory debris. Grocott methenamine silver (GMS) stain was negative for fungal organism, acid-fast bacteria (AFB) stain was negative for acid-fast bacilli, and CD20 and CD3 immunostaining demonstrated mixed B- and T-cell populations. There was no evidence of atypia or malignancy. The biopsy demonstrated granuloma with central inflammatory debris on a background of densely fibrotic tissue and lympho-plasmatic inflammation. This finding confirmed the diagnosis of RA with pulmonary involvement.

Outpatient follow-up was established with a pulmonologist and rheumatologist. Methotrexate 15 mg weekly and golimumab subcutaneously 50 mg every 4 weeks were prescribed for the patient. The nodules are being monitored based on Fleischer guidelines with CT imaging 3 to 6 months following initial presentation. Further imaging will be considered at 18 to 24 months as well to further assess stability of the nodules and monitor for changes in size, shape, and necrosis. The patient also was encouraged to quit smoking. Her clinical course since the diagnosis has been stable.

Discussion

The differential diagnosis for new multiple pulmonary nodules on imaging studies is broad and includes infectious processes, such as tuberculosis, as well as other mycobacterial, fungal, and bacterial infections. Noninfectious causes of lung disease are an even broader category of consideration. Noninfectious pulmonary nodules differential includes sarcoidosis, granulomatous with polyangiitis, hypersensitivity pneumonitis, methotrexate drug reaction, pulmonary manifestations of systemic conditions, such as RA chronic granulomatous disease and malignancy.⁸ Bronchogenic carcinoma was suspected in this patient due to her smoking history. Squamous cell carcinoma was also considered as the lesion was cavitary. AFB and GMS stains were negative for fungi. Langerhans cell histiocytosis were considered but ruled out as these lesions contain larger numbers of eosinophils than described in the pathology report. Histoplasma and coccidiosis laboratory tests were obtained as the patient lived in a region endemic to both these fungi but were negative (Table). A diagnosis of rheumatoid nodule was made based on the clinical setting, typical radiographic, histopathology features, and negative cultures.

This case is unique due to the quality and location of the rheumatoid nodules within the lungs. Pulmonary manifestations of RA are usually subcutaneous or subpleural, solid, and peripherally located^.9 This patient’s nodules were necrobiotic and located within the lung parenchyma. There was significant cavitation. These factors are atypical features of pulmonary RA.

Pulmonary RA can have many associated symptoms and remains an important factor in patient mortality. Estimates demonstrate that 10 to 20% of RA-related deaths are secondary to pulmonary manifestations.¹⁰ There are a wide array of symptoms and presentations to be aware of clinically. These symptoms are often nondescript, widely sensitive to many disease processes, and nonspecific to pulmonary RA. These symptoms include dyspnea, wheezing, and nonproductive cough.¹⁰ Bronchiectasis is a common symptom as well as small airway obstruction.¹⁰ Consolidated necrobiotic lesions are present in up to 20% of pulmonary RA cases.¹⁰ Generally these lesions are asymptomatic but can also be associated with pneumothorax, hemoptysis, and airway obstruction.10 Awareness of these symptoms is important for diagnosis and monitoring clinical improvement in patients.

Further workup is necessary to differentiate malignancy-related pulmonary nodules and other causes; if the index of suspicion is high for malignancy as in our case, the workup should be more aggressive. Biopsy is mandatory in such cases to rule out infections and malignancy, as it is highly sensitive and specific. The main problem hindering management is when a clinician fails to include this in their differential diagnosis. This further elucidates the importance of awareness of this diagnosis. Suspicious lesions in a proper clinical setting should be followed up by imaging studies and confirmatory histopathological diagnosis. Typical follow-up is 3 months after initial presentation to assess stability and possibly 18 to 24 months as well based on Fleischer guidelines.

Various treatment modalities have been tried as per literature, including tocilizumab and rituximab. ^11,12 Our patient is currently being treated with golimumab based on outpatient rheumatologist recommendations.

Conclusions

This case demonstrates the importance of a careful workup to narrow a broad differential. Medical diagnosis of pulmonary nodules requires an in-depth workup, including clinical evaluation, laboratory and pulmonary functions tests, as well as various imaging studies.

Identification of pulmonary nodules in older adults who smoke immediately brings concern for malignancy in the mind of clinicians. This is particularly the case in patients with significant smoking history. According to the National Cancer Institute in 2019, 12.9% of all new cancer cases were lung cancers.¹ Screening for lung cancer, especially in patients with increased risk from smoking, is imperative to early detection and treatment. However, 20% of patients will be overdiagnosed by lung cancer-screening techniques.² The rate of malignancy noted on a patient’s first screening computed tomography (CT) scan was between 3.7% and 5.5%.³

Rheumatoid arthritis (RA) is an autoimmune inflammatory condition that mainly affects the joints. Extraarticular manifestations can arise in various locations throughout the body, however. These manifestations are commonly observed in the skin, heart, and lungs.⁴ Prevalence of pulmonary rheumatoid nodules ranges from < 0.4% in radiologic studies to 32% in lung biopsies of patients with RA and nodules.⁵

Furthermore, there is a strong association between the risk of rheumatoid nodules in patients with positive serum rheumatoid factor (RF) and smoking history.⁶ Solitary pulmonary nodules in patients with RA can coexist with bronchogenic carcinoma, making their diagnosis more important.⁷

Case Presentation

A 54-year-old woman with a 30 pack-year smoking history and history of RA initially presented to the emergency department for cough and dyspnea for 5-day duration. Her initial diagnosis was bronchitis based on presenting symptom profile. A chest CT demonstrated 3 cavitary pulmonary nodules, 1 measuring 2.4 x 2.0 cm in the right middle lobe, and 2 additional nodules, measuring 1.8 x 1.4 and 1.5 x 1.4 in the left upper lobe (Figure). She had no improvement of symptoms after a 7-day course of doxycycline. The patient was taking methotrexate 15 mg weekly and golimumab 50 mg subcutaneously every 4 weeks as treatment for RA, prescribed by her rheumatologist.

Pulmonology was consulted and a positron emission tomography-CT (PET-CT) confirmed several cavitary pulmonary nodules involving both lungs with no suspicious fluorodeoxyglucose (FDG) uptake. The largest lesion was in the right middle lobe with FDG uptake of 1.9. Additional nodules were found in the left upper lobe, measuring 1.8 x 1.4 cm with FDG of 4.01, and in the left lung apex, measuring 1.5 x 1.4 cm with uptake of 3.53. CTguided percutaneous fine needle aspiration (PFNA) of the right middle lobe lung nodule demonstrated granuloma with central inflammatory debris. Grocott methenamine silver (GMS) stain was negative for fungal organism, acid-fast bacteria (AFB) stain was negative for acid-fast bacilli, and CD20 and CD3 immunostaining demonstrated mixed B- and T-cell populations. There was no evidence of atypia or malignancy. The biopsy demonstrated granuloma with central inflammatory debris on a background of densely fibrotic tissue and lympho-plasmatic inflammation. This finding confirmed the diagnosis of RA with pulmonary involvement.

Outpatient follow-up was established with a pulmonologist and rheumatologist. Methotrexate 15 mg weekly and golimumab subcutaneously 50 mg every 4 weeks were prescribed for the patient. The nodules are being monitored based on Fleischer guidelines with CT imaging 3 to 6 months following initial presentation. Further imaging will be considered at 18 to 24 months as well to further assess stability of the nodules and monitor for changes in size, shape, and necrosis. The patient also was encouraged to quit smoking. Her clinical course since the diagnosis has been stable.

Discussion

The differential diagnosis for new multiple pulmonary nodules on imaging studies is broad and includes infectious processes, such as tuberculosis, as well as other mycobacterial, fungal, and bacterial infections. Noninfectious causes of lung disease are an even broader category of consideration. Noninfectious pulmonary nodules differential includes sarcoidosis, granulomatous with polyangiitis, hypersensitivity pneumonitis, methotrexate drug reaction, pulmonary manifestations of systemic conditions, such as RA chronic granulomatous disease and malignancy.⁸ Bronchogenic carcinoma was suspected in this patient due to her smoking history. Squamous cell carcinoma was also considered as the lesion was cavitary. AFB and GMS stains were negative for fungi. Langerhans cell histiocytosis were considered but ruled out as these lesions contain larger numbers of eosinophils than described in the pathology report. Histoplasma and coccidiosis laboratory tests were obtained as the patient lived in a region endemic to both these fungi but were negative (Table). A diagnosis of rheumatoid nodule was made based on the clinical setting, typical radiographic, histopathology features, and negative cultures.

This case is unique due to the quality and location of the rheumatoid nodules within the lungs. Pulmonary manifestations of RA are usually subcutaneous or subpleural, solid, and peripherally located^.9 This patient’s nodules were necrobiotic and located within the lung parenchyma. There was significant cavitation. These factors are atypical features of pulmonary RA.

Pulmonary RA can have many associated symptoms and remains an important factor in patient mortality. Estimates demonstrate that 10 to 20% of RA-related deaths are secondary to pulmonary manifestations.¹⁰ There are a wide array of symptoms and presentations to be aware of clinically. These symptoms are often nondescript, widely sensitive to many disease processes, and nonspecific to pulmonary RA. These symptoms include dyspnea, wheezing, and nonproductive cough.¹⁰ Bronchiectasis is a common symptom as well as small airway obstruction.¹⁰ Consolidated necrobiotic lesions are present in up to 20% of pulmonary RA cases.¹⁰ Generally these lesions are asymptomatic but can also be associated with pneumothorax, hemoptysis, and airway obstruction.10 Awareness of these symptoms is important for diagnosis and monitoring clinical improvement in patients.

Further workup is necessary to differentiate malignancy-related pulmonary nodules and other causes; if the index of suspicion is high for malignancy as in our case, the workup should be more aggressive. Biopsy is mandatory in such cases to rule out infections and malignancy, as it is highly sensitive and specific. The main problem hindering management is when a clinician fails to include this in their differential diagnosis. This further elucidates the importance of awareness of this diagnosis. Suspicious lesions in a proper clinical setting should be followed up by imaging studies and confirmatory histopathological diagnosis. Typical follow-up is 3 months after initial presentation to assess stability and possibly 18 to 24 months as well based on Fleischer guidelines.

Various treatment modalities have been tried as per literature, including tocilizumab and rituximab. ^11,12 Our patient is currently being treated with golimumab based on outpatient rheumatologist recommendations.

Conclusions

This case demonstrates the importance of a careful workup to narrow a broad differential. Medical diagnosis of pulmonary nodules requires an in-depth workup, including clinical evaluation, laboratory and pulmonary functions tests, as well as various imaging studies.

Highly selected low-risk patients can be safely sent home about 24 hours after successful percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) when supported by intense, multidisciplinary virtual follow-up, a prospective study suggests for the first time.

The risk for major adverse cardiac events (MACE) in STEMI patients following an early hospital discharge (EHD) pathway was similar at 9 months to that seen for propensity-matched historic control subjects who met the same EHD criteria but were discharged later than 48 hours.

The stay in almost half (48%) the early discharge group was 24 hours or less, according to the study, published Dec. 13 in the Journal of the American College of Cardiology.

“We’ve shown that if we use appropriate risk criteria and instigate the appropriate, safe follow-up that it’s safe to select and discharge low-risk patients at an earlier time period, such as 24 hours,” senior author Daniel A. Jones, PhD, Barts Heart Centre, London, this news organization.

“Obviously, it’s one center in one city in the world,” he said. “Whether it’s applicable at other heart site centers, I believe it is, but I think we need more data to be able to change guidelines.”

Current European Society of Cardiology guidelines say that select patients should be considered for early discharge 48 to 72 hours after STEMI, but the COVID-19 pandemic incentivized the team to try and push that window.

“The COVID pandemic essentially brought a focus on resources, on minimizing the risk to our patient population in terms of catching COVID within hospital,” he said. “It became clear that to maintain the heart site service, we probably needed to get people out a bit quicker than we did before, so we came up with this pathway.”

Between March 2020 and June 2021, 600 patients presenting with STEMI were entered into the EHD pathway if they met the following pre-existing criteria for 48- to 72-hour discharge:

• Left ventricular ejection fraction 40% or greater
• Successful primary PCI with TIMI flow grade 3
• Absence of bystander disease requiring inpatient revascularization
• No recurrent ischemic symptoms
• No heart failure
• No significant arrhythmias
• No hemodynamic instability
• No significant comorbidity
• Suitable social circumstances for early discharge

The patients were given cardiac rehabilitation counseling over the phone within 48 hours and blood pressure machines if not available at home. At weeks 2 and 8, they spoke virtually with a dedicated cardiology advanced care practitioner who up-titrated medications and answered any questions. At week 12, they were seen by an interventional cardiologist or at a high-risk prevention clinic.

Their mean age was 59.2 years, 86% were male, the median symptom-to-balloon time was 80 minutes, and median door-to-balloon time was 50 minutes.

The early discharge patients were compared with 700 historic control subjects who met the EHD criteria and were discharged after 48 hours from Oct. 2018 to June 2021 and 560 patients discharged on standard-care pathways between April 2020 and June 2021.

Those discharged after 48 hours were more likely to have an anterior MI, multivessel disease, and multivessel PCI.
 

Comparable outcomes

The median length of stay was 24.6 hours (minimum 17 hours, maximum 40 hours) for the EHD group, 56.1 hours for historic control subjects, and 78.9 hours for the standard-care group.

The introduction of the EHD pathway significantly reduced the overall length of stay for all STEMI patients compared with the pre-pathway period of Oct. 2018 to March 2020 (median, 3 vs. 2 days; P < .0001).

Length of stay varied among patients; however, 420 patients stayed 1 less night in the hospital with the remaining patients staying about 8 to 12 fewer hours, resulting in approximate savings of £450,000, the authors note.

Over a median follow-up of 271 days, there were no cardiovascular deaths, two deaths from COVID-19, and a MACE rate of 1.2% (two deaths, three unscheduled revascularizations, and two further MI presentations) in the EHD group. That compares with a 0.7% mortality and 1.9% rate of MACE among historic control subjects, neither of which were significantly different.

There was also no difference in mortality (0.34% vs. 0.69%; P = .410) or MACE (1.2% vs. 1.9%; P = .342) among 560 pairs of propensity-matched EHD patients and historic control subjects.

Mortality was 4.1% in the standard-care group; cardiovascular mortality was 2.2%, and the rate of MACE was 8.6%.

When patients were surveyed, 85% were “satisfied” or “very satisfied” with the EHD pathway, whereas 73% of control and standard-care patients were satisfied with their care. Three-fourths of EHD patients also reported saving money and 62.5% saved time off work because of the virtual follow-up.
 

Judgment calls

“They didn’t really tell us much about the patients who didn’t qualify into this ultra–low-risk group but, obviously, it’s highly selected,” Cindy Grines, MD, Northside Hospital Cardiovascular Institute, Lawrenceville, Georgia, said in an interview. “In the U.S., you don’t get those chest pain onset-to-reperfusion in 80 minutes. So that was really kind of shocking.”

It also suggests that early discharge was applied to patients who may have had minimal myocardial damage from the STEMI, she suggested. “Even in their own hospital system, a lot of patients who met the criteria on paper were kept longer than 48 hours. So a lot of it’s a judgment call.”

Additional red flags where physicians may overrule the early discharge protocol are very late perfusion, advanced age, severe renal insufficiency, profound anemia, cardiac arrest requiring more than brief resuscitation, bleeding complications, or symptomatic coronavirus, Dr. Grines and J. Jeffrey Marshall, MD, also from Northside, observe in an accompanying editorial.

About 60% of patients were suitable for the EHD pathway, Dr. Jones said. “Typically, they are quite low risk, but we still had four in 10 anterior infarct, and about 25% had left ventricular function between 40% and 45%. So even though the majority are low risk, there are patients in there that you would consider to have had a decent infarct.”

“I think this is applicable to patients at most centers, and probably anywhere between a third to a fifth of all patients presenting to heart centers would be suitable for this discharge pathway,” he said.

Dr. Grines said the pathway is “definitely feasible” but there aren’t enough patients studied to know with 100% certainty whether it’s safe. A single observational study also isn’t enough to change guidelines, which in the United States do not comment on length of stay.

“In the ultra-low-risk patients – such as the ones where you got them in very early and you almost aborted the infarct or if it was a very small infarct – you can kind of treat them like an unstable angina patient, where you can do the PCI and potentially discharge them in 24 hours,” Dr. Grines said. “I think most of us might agree on that.”

“The other thing you have to weigh is the risk/benefit ratio,” she said. “If you have no beds available, you end up rationing care to some extent. So if you have a patient that’s otherwise doing well after a very small MI and have an emergency room full of people that need to be admitted and they’re sicker, then you end up making those judgment calls.”

Dr. Jones pointed out that current guidelines are based largely on observational data and that the team is planning to pilot the EHD pathway at five to 10 centers around the United Kingdom or potentially in Europe or the United States.

“This is an area where a [randomized controlled trial] RCT would be expensive, whereas a well-coordinated multicenter registry would probably provide enough information to change guidelines,” he said. “We’re not suggesting that every STEMI patient is suitable, but people that are low risk that you would already be considering for early discharge I think can go a bit quicker.”

Dr. Jones has received funding from the Barts Charity and financial support for blood pressure machines from the Barts Guild. First author Krishnaraj Rathod has received funding from the National Institute for Health and Research in the form of an Academic Clinical Lectureship. All other authors, Dr. Grines, and Dr. Marshall report having no relevant financial relationships.

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

Highly selected low-risk patients can be safely sent home about 24 hours after successful percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) when supported by intense, multidisciplinary virtual follow-up, a prospective study suggests for the first time.

The risk for major adverse cardiac events (MACE) in STEMI patients following an early hospital discharge (EHD) pathway was similar at 9 months to that seen for propensity-matched historic control subjects who met the same EHD criteria but were discharged later than 48 hours.

The stay in almost half (48%) the early discharge group was 24 hours or less, according to the study, published Dec. 13 in the Journal of the American College of Cardiology.

“We’ve shown that if we use appropriate risk criteria and instigate the appropriate, safe follow-up that it’s safe to select and discharge low-risk patients at an earlier time period, such as 24 hours,” senior author Daniel A. Jones, PhD, Barts Heart Centre, London, this news organization.

“Obviously, it’s one center in one city in the world,” he said. “Whether it’s applicable at other heart site centers, I believe it is, but I think we need more data to be able to change guidelines.”

Current European Society of Cardiology guidelines say that select patients should be considered for early discharge 48 to 72 hours after STEMI, but the COVID-19 pandemic incentivized the team to try and push that window.

“The COVID pandemic essentially brought a focus on resources, on minimizing the risk to our patient population in terms of catching COVID within hospital,” he said. “It became clear that to maintain the heart site service, we probably needed to get people out a bit quicker than we did before, so we came up with this pathway.”

Between March 2020 and June 2021, 600 patients presenting with STEMI were entered into the EHD pathway if they met the following pre-existing criteria for 48- to 72-hour discharge:

• Left ventricular ejection fraction 40% or greater
• Successful primary PCI with TIMI flow grade 3
• Absence of bystander disease requiring inpatient revascularization
• No recurrent ischemic symptoms
• No heart failure
• No significant arrhythmias
• No hemodynamic instability
• No significant comorbidity
• Suitable social circumstances for early discharge

The patients were given cardiac rehabilitation counseling over the phone within 48 hours and blood pressure machines if not available at home. At weeks 2 and 8, they spoke virtually with a dedicated cardiology advanced care practitioner who up-titrated medications and answered any questions. At week 12, they were seen by an interventional cardiologist or at a high-risk prevention clinic.

Their mean age was 59.2 years, 86% were male, the median symptom-to-balloon time was 80 minutes, and median door-to-balloon time was 50 minutes.

The early discharge patients were compared with 700 historic control subjects who met the EHD criteria and were discharged after 48 hours from Oct. 2018 to June 2021 and 560 patients discharged on standard-care pathways between April 2020 and June 2021.

Those discharged after 48 hours were more likely to have an anterior MI, multivessel disease, and multivessel PCI.
 

Comparable outcomes

The median length of stay was 24.6 hours (minimum 17 hours, maximum 40 hours) for the EHD group, 56.1 hours for historic control subjects, and 78.9 hours for the standard-care group.

The introduction of the EHD pathway significantly reduced the overall length of stay for all STEMI patients compared with the pre-pathway period of Oct. 2018 to March 2020 (median, 3 vs. 2 days; P < .0001).

Length of stay varied among patients; however, 420 patients stayed 1 less night in the hospital with the remaining patients staying about 8 to 12 fewer hours, resulting in approximate savings of £450,000, the authors note.

Over a median follow-up of 271 days, there were no cardiovascular deaths, two deaths from COVID-19, and a MACE rate of 1.2% (two deaths, three unscheduled revascularizations, and two further MI presentations) in the EHD group. That compares with a 0.7% mortality and 1.9% rate of MACE among historic control subjects, neither of which were significantly different.

There was also no difference in mortality (0.34% vs. 0.69%; P = .410) or MACE (1.2% vs. 1.9%; P = .342) among 560 pairs of propensity-matched EHD patients and historic control subjects.

Mortality was 4.1% in the standard-care group; cardiovascular mortality was 2.2%, and the rate of MACE was 8.6%.

When patients were surveyed, 85% were “satisfied” or “very satisfied” with the EHD pathway, whereas 73% of control and standard-care patients were satisfied with their care. Three-fourths of EHD patients also reported saving money and 62.5% saved time off work because of the virtual follow-up.
 

Judgment calls

“They didn’t really tell us much about the patients who didn’t qualify into this ultra–low-risk group but, obviously, it’s highly selected,” Cindy Grines, MD, Northside Hospital Cardiovascular Institute, Lawrenceville, Georgia, said in an interview. “In the U.S., you don’t get those chest pain onset-to-reperfusion in 80 minutes. So that was really kind of shocking.”

It also suggests that early discharge was applied to patients who may have had minimal myocardial damage from the STEMI, she suggested. “Even in their own hospital system, a lot of patients who met the criteria on paper were kept longer than 48 hours. So a lot of it’s a judgment call.”

Additional red flags where physicians may overrule the early discharge protocol are very late perfusion, advanced age, severe renal insufficiency, profound anemia, cardiac arrest requiring more than brief resuscitation, bleeding complications, or symptomatic coronavirus, Dr. Grines and J. Jeffrey Marshall, MD, also from Northside, observe in an accompanying editorial.

About 60% of patients were suitable for the EHD pathway, Dr. Jones said. “Typically, they are quite low risk, but we still had four in 10 anterior infarct, and about 25% had left ventricular function between 40% and 45%. So even though the majority are low risk, there are patients in there that you would consider to have had a decent infarct.”

“I think this is applicable to patients at most centers, and probably anywhere between a third to a fifth of all patients presenting to heart centers would be suitable for this discharge pathway,” he said.

Dr. Grines said the pathway is “definitely feasible” but there aren’t enough patients studied to know with 100% certainty whether it’s safe. A single observational study also isn’t enough to change guidelines, which in the United States do not comment on length of stay.

“In the ultra-low-risk patients – such as the ones where you got them in very early and you almost aborted the infarct or if it was a very small infarct – you can kind of treat them like an unstable angina patient, where you can do the PCI and potentially discharge them in 24 hours,” Dr. Grines said. “I think most of us might agree on that.”

“The other thing you have to weigh is the risk/benefit ratio,” she said. “If you have no beds available, you end up rationing care to some extent. So if you have a patient that’s otherwise doing well after a very small MI and have an emergency room full of people that need to be admitted and they’re sicker, then you end up making those judgment calls.”

Dr. Jones pointed out that current guidelines are based largely on observational data and that the team is planning to pilot the EHD pathway at five to 10 centers around the United Kingdom or potentially in Europe or the United States.

“This is an area where a [randomized controlled trial] RCT would be expensive, whereas a well-coordinated multicenter registry would probably provide enough information to change guidelines,” he said. “We’re not suggesting that every STEMI patient is suitable, but people that are low risk that you would already be considering for early discharge I think can go a bit quicker.”

Dr. Jones has received funding from the Barts Charity and financial support for blood pressure machines from the Barts Guild. First author Krishnaraj Rathod has received funding from the National Institute for Health and Research in the form of an Academic Clinical Lectureship. All other authors, Dr. Grines, and Dr. Marshall report having no relevant financial relationships.

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

Highly selected low-risk patients can be safely sent home about 24 hours after successful percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) when supported by intense, multidisciplinary virtual follow-up, a prospective study suggests for the first time.

The risk for major adverse cardiac events (MACE) in STEMI patients following an early hospital discharge (EHD) pathway was similar at 9 months to that seen for propensity-matched historic control subjects who met the same EHD criteria but were discharged later than 48 hours.

The stay in almost half (48%) the early discharge group was 24 hours or less, according to the study, published Dec. 13 in the Journal of the American College of Cardiology.

“We’ve shown that if we use appropriate risk criteria and instigate the appropriate, safe follow-up that it’s safe to select and discharge low-risk patients at an earlier time period, such as 24 hours,” senior author Daniel A. Jones, PhD, Barts Heart Centre, London, this news organization.

“Obviously, it’s one center in one city in the world,” he said. “Whether it’s applicable at other heart site centers, I believe it is, but I think we need more data to be able to change guidelines.”

Current European Society of Cardiology guidelines say that select patients should be considered for early discharge 48 to 72 hours after STEMI, but the COVID-19 pandemic incentivized the team to try and push that window.

“The COVID pandemic essentially brought a focus on resources, on minimizing the risk to our patient population in terms of catching COVID within hospital,” he said. “It became clear that to maintain the heart site service, we probably needed to get people out a bit quicker than we did before, so we came up with this pathway.”

Between March 2020 and June 2021, 600 patients presenting with STEMI were entered into the EHD pathway if they met the following pre-existing criteria for 48- to 72-hour discharge:

• Left ventricular ejection fraction 40% or greater
• Successful primary PCI with TIMI flow grade 3
• Absence of bystander disease requiring inpatient revascularization
• No recurrent ischemic symptoms
• No heart failure
• No significant arrhythmias
• No hemodynamic instability
• No significant comorbidity
• Suitable social circumstances for early discharge

The patients were given cardiac rehabilitation counseling over the phone within 48 hours and blood pressure machines if not available at home. At weeks 2 and 8, they spoke virtually with a dedicated cardiology advanced care practitioner who up-titrated medications and answered any questions. At week 12, they were seen by an interventional cardiologist or at a high-risk prevention clinic.

Their mean age was 59.2 years, 86% were male, the median symptom-to-balloon time was 80 minutes, and median door-to-balloon time was 50 minutes.

The early discharge patients were compared with 700 historic control subjects who met the EHD criteria and were discharged after 48 hours from Oct. 2018 to June 2021 and 560 patients discharged on standard-care pathways between April 2020 and June 2021.

Those discharged after 48 hours were more likely to have an anterior MI, multivessel disease, and multivessel PCI.
 

Comparable outcomes

The median length of stay was 24.6 hours (minimum 17 hours, maximum 40 hours) for the EHD group, 56.1 hours for historic control subjects, and 78.9 hours for the standard-care group.

The introduction of the EHD pathway significantly reduced the overall length of stay for all STEMI patients compared with the pre-pathway period of Oct. 2018 to March 2020 (median, 3 vs. 2 days; P < .0001).

Length of stay varied among patients; however, 420 patients stayed 1 less night in the hospital with the remaining patients staying about 8 to 12 fewer hours, resulting in approximate savings of £450,000, the authors note.

Over a median follow-up of 271 days, there were no cardiovascular deaths, two deaths from COVID-19, and a MACE rate of 1.2% (two deaths, three unscheduled revascularizations, and two further MI presentations) in the EHD group. That compares with a 0.7% mortality and 1.9% rate of MACE among historic control subjects, neither of which were significantly different.

There was also no difference in mortality (0.34% vs. 0.69%; P = .410) or MACE (1.2% vs. 1.9%; P = .342) among 560 pairs of propensity-matched EHD patients and historic control subjects.

Mortality was 4.1% in the standard-care group; cardiovascular mortality was 2.2%, and the rate of MACE was 8.6%.

When patients were surveyed, 85% were “satisfied” or “very satisfied” with the EHD pathway, whereas 73% of control and standard-care patients were satisfied with their care. Three-fourths of EHD patients also reported saving money and 62.5% saved time off work because of the virtual follow-up.
 

Judgment calls

“They didn’t really tell us much about the patients who didn’t qualify into this ultra–low-risk group but, obviously, it’s highly selected,” Cindy Grines, MD, Northside Hospital Cardiovascular Institute, Lawrenceville, Georgia, said in an interview. “In the U.S., you don’t get those chest pain onset-to-reperfusion in 80 minutes. So that was really kind of shocking.”

It also suggests that early discharge was applied to patients who may have had minimal myocardial damage from the STEMI, she suggested. “Even in their own hospital system, a lot of patients who met the criteria on paper were kept longer than 48 hours. So a lot of it’s a judgment call.”

Additional red flags where physicians may overrule the early discharge protocol are very late perfusion, advanced age, severe renal insufficiency, profound anemia, cardiac arrest requiring more than brief resuscitation, bleeding complications, or symptomatic coronavirus, Dr. Grines and J. Jeffrey Marshall, MD, also from Northside, observe in an accompanying editorial.

About 60% of patients were suitable for the EHD pathway, Dr. Jones said. “Typically, they are quite low risk, but we still had four in 10 anterior infarct, and about 25% had left ventricular function between 40% and 45%. So even though the majority are low risk, there are patients in there that you would consider to have had a decent infarct.”

“I think this is applicable to patients at most centers, and probably anywhere between a third to a fifth of all patients presenting to heart centers would be suitable for this discharge pathway,” he said.

Dr. Grines said the pathway is “definitely feasible” but there aren’t enough patients studied to know with 100% certainty whether it’s safe. A single observational study also isn’t enough to change guidelines, which in the United States do not comment on length of stay.

“In the ultra-low-risk patients – such as the ones where you got them in very early and you almost aborted the infarct or if it was a very small infarct – you can kind of treat them like an unstable angina patient, where you can do the PCI and potentially discharge them in 24 hours,” Dr. Grines said. “I think most of us might agree on that.”

“The other thing you have to weigh is the risk/benefit ratio,” she said. “If you have no beds available, you end up rationing care to some extent. So if you have a patient that’s otherwise doing well after a very small MI and have an emergency room full of people that need to be admitted and they’re sicker, then you end up making those judgment calls.”

Dr. Jones pointed out that current guidelines are based largely on observational data and that the team is planning to pilot the EHD pathway at five to 10 centers around the United Kingdom or potentially in Europe or the United States.

“This is an area where a [randomized controlled trial] RCT would be expensive, whereas a well-coordinated multicenter registry would probably provide enough information to change guidelines,” he said. “We’re not suggesting that every STEMI patient is suitable, but people that are low risk that you would already be considering for early discharge I think can go a bit quicker.”

Dr. Jones has received funding from the Barts Charity and financial support for blood pressure machines from the Barts Guild. First author Krishnaraj Rathod has received funding from the National Institute for Health and Research in the form of an Academic Clinical Lectureship. All other authors, Dr. Grines, and Dr. Marshall report having no relevant financial relationships.

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

The clinical presentation of atopic dermatitis (AD) in skin of color varies widely, which may create a challenge for clinicians.

“We see very heterogenous and broad clinical presentations across the diverse patient populations that we see,” Andrew F. Alexis, MD, MPH, said at the Revolutionizing Atopic Dermatitis symposium. “Some of these differences might be related to population variations in skin barrier function, immunologic factors, genetic factors, and environmental factors, which all interplay to produce variations in the clinical presentation and overall impact of AD. Many nongenetic factors also contribute to differences that we see, including some socioeconomic and other factors that feed into health disparities.”

Dr. Alexis, professor of clinical dermatology at Weill Cornell Medicine, New York, discussed four main clinical features of AD in skin of color.
 

Erythema is less visible because it is masked by pigment

“There can be some masking of the redness and alteration of that color such that it doesn’t look bright red as it would in the background of lightly pigmented skin,” Dr. Alexis said. “Instead, the [AD lesions] have shades of grayish-red or grayish-brown or reddish-brown. It’s important to recognize this clinical presentation and look carefully and assess the patient – not just visually but with palpation and take into consideration symptomatology so that you don’t fall into the trap of calling an AD lesion postinflammatory hyperpigmentation. It’s also helpful to isolate the islands of normal or nonlesional skin and contrast that with the areas of lesional skin, to get a sense of how active and inflamed the areas are. Palpation really helps to appreciate the elevation of the lesions that are involved.”

Follicular accentuation

Morphological variants common in skin of color include the follicular variant or micropapular variant of AD. “You might just see a collection of papules that are 1-2 mm in size and pruritic and in typical sites of predilection [for] eczema,” he said. Prurigo nodularis–like lesions or prurigo nodularis in association with AD are also seen more frequently in skin of color.

Lichenification

The lichenoid variant of AD is characterized by a violaceous hue and other features that resemble lichen planus and has been reported to be more common in individuals of African descent. A prospective study of about 1,000 patients with AD seen over 2 years at a dermatology clinic in southeastern Nigeria found that 54% of patients had papular lichenoid lesions. In addition, 51% had elevated blood eosinophil counts, especially those with severe disease.

Dr. Alexis added that psoriasiform features have been reported in studies of East Asian populations with AD. These plaques may be more well demarcated and have clinical and histologic features that resemble psoriasis.
 

Dyspigmentation

One common feature across the spectrum of patients with skin of color “is the risk of longstanding pigmentary sequelae in the form of hyperpigmentation or hypopigmentation,” said Dr. Alexis, who is also vice chair for diversity and inclusion for the department of dermatology at Weill Cornell Medicine. “In very severe longstanding areas with chronic excoriation to the point of breaking of the skin, eroding of the skin, causing permanent damage to the melanocytes, dyspigmentation that resembles vitiligo can be seen. We can also see hypopigmentation as a consequence of topical corticosteroids, particularly those that are class I or class II and are used for prolonged periods of time.”

Dr. Alexis noted that delays in treatment and undertreatment can contribute to a higher risk of pigmentary and other long-term sequelae. “New therapies show promise in improving outcomes in AD patients with skin of color. When it comes to therapeutic responses, there are some post hoc studies that have investigated potential differences in safety and efficacy of the agents that have been recently approved. We clearly need more data to better understand if there are potential racial or ethnic differences.”

Dr. Alexis reported no relevant financial relationships.

Commentary by Lawrence F. Eichenfield, MD

Atopic dermatitis (AD) is highly heterogenous, with tremendous variations in extent, qualities of eczema, symptom complex, and physical presentation. Prior studies have reported disparities of care delivered to racial and ethnic minorities in the United States, as well as higher susceptibility to AD and odds of persistent disease into adulthood from child-onset AD. Recognizing some differences in presentation of AD in patients with skin of color is important as we select our therapeutic interventions, including assessing new treatments being added to our armamentarium. Erythema may be harder to notice in darker skin, but attempting to blanch the skin with pressure can help to assess the color and inflammation. Appreciating lichenoid changes, including papular and “micropapular” AD, and psoriasiform-like thickening in certain patients (reportedly more common in East Asian populations) are important as well. And dyspigmentation is an important aspect of the disease presentation and patient and parental concern, given both hypopigmentaton and hyperpigmentation commonly seen over the course of AD.

Dr. Eichenfield is chief of pediatric and adolescent dermatology at Rady Children's Hospital-San Diego. He is vice chair of the department of dermatology and professor of dermatology and pediatrics at the University of California, San Diego. He disclosed that he has served as an investigator and/or consultant to AbbVie, Lilly, Pfizer, Regeneron, Sanofi-Genzyme, and Verrica.

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

This article was updated 6/18/22.

The clinical presentation of atopic dermatitis (AD) in skin of color varies widely, which may create a challenge for clinicians.

“We see very heterogenous and broad clinical presentations across the diverse patient populations that we see,” Andrew F. Alexis, MD, MPH, said at the Revolutionizing Atopic Dermatitis symposium. “Some of these differences might be related to population variations in skin barrier function, immunologic factors, genetic factors, and environmental factors, which all interplay to produce variations in the clinical presentation and overall impact of AD. Many nongenetic factors also contribute to differences that we see, including some socioeconomic and other factors that feed into health disparities.”

Dr. Alexis, professor of clinical dermatology at Weill Cornell Medicine, New York, discussed four main clinical features of AD in skin of color.
 

Erythema is less visible because it is masked by pigment

“There can be some masking of the redness and alteration of that color such that it doesn’t look bright red as it would in the background of lightly pigmented skin,” Dr. Alexis said. “Instead, the [AD lesions] have shades of grayish-red or grayish-brown or reddish-brown. It’s important to recognize this clinical presentation and look carefully and assess the patient – not just visually but with palpation and take into consideration symptomatology so that you don’t fall into the trap of calling an AD lesion postinflammatory hyperpigmentation. It’s also helpful to isolate the islands of normal or nonlesional skin and contrast that with the areas of lesional skin, to get a sense of how active and inflamed the areas are. Palpation really helps to appreciate the elevation of the lesions that are involved.”

Follicular accentuation

Morphological variants common in skin of color include the follicular variant or micropapular variant of AD. “You might just see a collection of papules that are 1-2 mm in size and pruritic and in typical sites of predilection [for] eczema,” he said. Prurigo nodularis–like lesions or prurigo nodularis in association with AD are also seen more frequently in skin of color.

Lichenification

The lichenoid variant of AD is characterized by a violaceous hue and other features that resemble lichen planus and has been reported to be more common in individuals of African descent. A prospective study of about 1,000 patients with AD seen over 2 years at a dermatology clinic in southeastern Nigeria found that 54% of patients had papular lichenoid lesions. In addition, 51% had elevated blood eosinophil counts, especially those with severe disease.

Dr. Alexis added that psoriasiform features have been reported in studies of East Asian populations with AD. These plaques may be more well demarcated and have clinical and histologic features that resemble psoriasis.
 

Dyspigmentation

One common feature across the spectrum of patients with skin of color “is the risk of longstanding pigmentary sequelae in the form of hyperpigmentation or hypopigmentation,” said Dr. Alexis, who is also vice chair for diversity and inclusion for the department of dermatology at Weill Cornell Medicine. “In very severe longstanding areas with chronic excoriation to the point of breaking of the skin, eroding of the skin, causing permanent damage to the melanocytes, dyspigmentation that resembles vitiligo can be seen. We can also see hypopigmentation as a consequence of topical corticosteroids, particularly those that are class I or class II and are used for prolonged periods of time.”

Dr. Alexis noted that delays in treatment and undertreatment can contribute to a higher risk of pigmentary and other long-term sequelae. “New therapies show promise in improving outcomes in AD patients with skin of color. When it comes to therapeutic responses, there are some post hoc studies that have investigated potential differences in safety and efficacy of the agents that have been recently approved. We clearly need more data to better understand if there are potential racial or ethnic differences.”

Dr. Alexis reported no relevant financial relationships.

Commentary by Lawrence F. Eichenfield, MD

Atopic dermatitis (AD) is highly heterogenous, with tremendous variations in extent, qualities of eczema, symptom complex, and physical presentation. Prior studies have reported disparities of care delivered to racial and ethnic minorities in the United States, as well as higher susceptibility to AD and odds of persistent disease into adulthood from child-onset AD. Recognizing some differences in presentation of AD in patients with skin of color is important as we select our therapeutic interventions, including assessing new treatments being added to our armamentarium. Erythema may be harder to notice in darker skin, but attempting to blanch the skin with pressure can help to assess the color and inflammation. Appreciating lichenoid changes, including papular and “micropapular” AD, and psoriasiform-like thickening in certain patients (reportedly more common in East Asian populations) are important as well. And dyspigmentation is an important aspect of the disease presentation and patient and parental concern, given both hypopigmentaton and hyperpigmentation commonly seen over the course of AD.

Dr. Eichenfield is chief of pediatric and adolescent dermatology at Rady Children's Hospital-San Diego. He is vice chair of the department of dermatology and professor of dermatology and pediatrics at the University of California, San Diego. He disclosed that he has served as an investigator and/or consultant to AbbVie, Lilly, Pfizer, Regeneron, Sanofi-Genzyme, and Verrica.

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

This article was updated 6/18/22.

The clinical presentation of atopic dermatitis (AD) in skin of color varies widely, which may create a challenge for clinicians.

“We see very heterogenous and broad clinical presentations across the diverse patient populations that we see,” Andrew F. Alexis, MD, MPH, said at the Revolutionizing Atopic Dermatitis symposium. “Some of these differences might be related to population variations in skin barrier function, immunologic factors, genetic factors, and environmental factors, which all interplay to produce variations in the clinical presentation and overall impact of AD. Many nongenetic factors also contribute to differences that we see, including some socioeconomic and other factors that feed into health disparities.”

Dr. Alexis, professor of clinical dermatology at Weill Cornell Medicine, New York, discussed four main clinical features of AD in skin of color.
 

Erythema is less visible because it is masked by pigment

“There can be some masking of the redness and alteration of that color such that it doesn’t look bright red as it would in the background of lightly pigmented skin,” Dr. Alexis said. “Instead, the [AD lesions] have shades of grayish-red or grayish-brown or reddish-brown. It’s important to recognize this clinical presentation and look carefully and assess the patient – not just visually but with palpation and take into consideration symptomatology so that you don’t fall into the trap of calling an AD lesion postinflammatory hyperpigmentation. It’s also helpful to isolate the islands of normal or nonlesional skin and contrast that with the areas of lesional skin, to get a sense of how active and inflamed the areas are. Palpation really helps to appreciate the elevation of the lesions that are involved.”

Follicular accentuation

Morphological variants common in skin of color include the follicular variant or micropapular variant of AD. “You might just see a collection of papules that are 1-2 mm in size and pruritic and in typical sites of predilection [for] eczema,” he said. Prurigo nodularis–like lesions or prurigo nodularis in association with AD are also seen more frequently in skin of color.

Lichenification

The lichenoid variant of AD is characterized by a violaceous hue and other features that resemble lichen planus and has been reported to be more common in individuals of African descent. A prospective study of about 1,000 patients with AD seen over 2 years at a dermatology clinic in southeastern Nigeria found that 54% of patients had papular lichenoid lesions. In addition, 51% had elevated blood eosinophil counts, especially those with severe disease.

Dr. Alexis added that psoriasiform features have been reported in studies of East Asian populations with AD. These plaques may be more well demarcated and have clinical and histologic features that resemble psoriasis.
 

Dyspigmentation

One common feature across the spectrum of patients with skin of color “is the risk of longstanding pigmentary sequelae in the form of hyperpigmentation or hypopigmentation,” said Dr. Alexis, who is also vice chair for diversity and inclusion for the department of dermatology at Weill Cornell Medicine. “In very severe longstanding areas with chronic excoriation to the point of breaking of the skin, eroding of the skin, causing permanent damage to the melanocytes, dyspigmentation that resembles vitiligo can be seen. We can also see hypopigmentation as a consequence of topical corticosteroids, particularly those that are class I or class II and are used for prolonged periods of time.”

Dr. Alexis noted that delays in treatment and undertreatment can contribute to a higher risk of pigmentary and other long-term sequelae. “New therapies show promise in improving outcomes in AD patients with skin of color. When it comes to therapeutic responses, there are some post hoc studies that have investigated potential differences in safety and efficacy of the agents that have been recently approved. We clearly need more data to better understand if there are potential racial or ethnic differences.”

Dr. Alexis reported no relevant financial relationships.

Commentary by Lawrence F. Eichenfield, MD

Atopic dermatitis (AD) is highly heterogenous, with tremendous variations in extent, qualities of eczema, symptom complex, and physical presentation. Prior studies have reported disparities of care delivered to racial and ethnic minorities in the United States, as well as higher susceptibility to AD and odds of persistent disease into adulthood from child-onset AD. Recognizing some differences in presentation of AD in patients with skin of color is important as we select our therapeutic interventions, including assessing new treatments being added to our armamentarium. Erythema may be harder to notice in darker skin, but attempting to blanch the skin with pressure can help to assess the color and inflammation. Appreciating lichenoid changes, including papular and “micropapular” AD, and psoriasiform-like thickening in certain patients (reportedly more common in East Asian populations) are important as well. And dyspigmentation is an important aspect of the disease presentation and patient and parental concern, given both hypopigmentaton and hyperpigmentation commonly seen over the course of AD.

Dr. Eichenfield is chief of pediatric and adolescent dermatology at Rady Children's Hospital-San Diego. He is vice chair of the department of dermatology and professor of dermatology and pediatrics at the University of California, San Diego. He disclosed that he has served as an investigator and/or consultant to AbbVie, Lilly, Pfizer, Regeneron, Sanofi-Genzyme, and Verrica.

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

This article was updated 6/18/22.

HIV testing centers across the United States showed reductions in testing of nearly 50% during the height of the COVID-19 pandemic in 2020, raising concerns of a subsequent increase in transmission by people unaware of their HIV-positive status.

“Testing strategies need to be ramped up to cover this decrease in testing while adapting to the continuing COVID-19 environment,” reported Deesha Patel, MPH, and colleagues with the Centers for Disease Control and Prevention’s division of HIV prevention, Atlanta, in research presented at the annual meeting of the United States Conference on HIV/AIDS.

According to their data from the National HIV Prevention Program Monitoring and Evaluation system, the number of CDC-funded HIV tests declined by more than 1 million in 2020 amid the COVID-19 restrictions, with 1,228,142 tests reported that year, compared with 2,301,669 tests in 2019, a reduction of 46.6%.

The number of persons who were newly diagnosed with HIV, based on the tests, declined by 29.7%, from 7,692 newly diagnosed in 2019 to 5,409 persons in 2020, the authors reported.

The reasons for the reduction in new HIV diagnoses in 2020 could be multifactorial, possibly reflecting not just the reduced rates of testing but also possibly lower rates of transmission because of the lockdowns and social distancing, Mr. Patel said in an interview.

“Both [of those] interpretations are plausible, and the reductions are likely due to a combination of reasons,” she said.

Of note, the percentage of tests that were positive did not show a decline and was in fact slightly higher in 2020 (0.4%), compared with 2019 (0.3%; rate ratio, 1.32). But the increase may reflect that those seeking testing during the pandemic were more likely to be symptomatic.

“It is plausible that the smaller pool of people getting tested represented those with a higher likelihood of receiving a positive HIV test, [for instance] having a recent exposure, exhibiting symptoms,” Mr. Patel explained. “Furthermore, it is possible that some health departments specifically focused outreach efforts to serve persons with increased potential for HIV acquisition, thus identifying a higher proportion of persons with HIV.”

The declines in testing are nevertheless of particular concern in light of recent pre-COVID data indicating that as many as 13% of people who were infected with HIV were unaware of their positive status, placing them at high risk of transmitting the virus.

And on a broader level, the declines could negatively affect the goal to eradicate HIV through the federal Ending the HIV Epidemic in the U.S. (EHE) initiative, which aims to reduce new HIV infections in the United States by 90% by 2030 through the scaling up of key HIV prevention and treatment strategies, Mr. Patel noted.

“The first pillar of EHE is to diagnose all people with HIV as early as possible, and to accomplish that, there needs to be sufficient HIV testing,” Mr. Patel explained. “With fewer HIV tests being conducted, there are missed opportunities to identify persons with newly diagnosed HIV, which affects the entire continuum of care, [including] linkage to medical care, receiving antiretroviral treatment, getting and keeping viral suppression, and reducing transmission.”
 

At the local level: Adaptations allowed for continued testing

In a separate report presented at the meeting detailing the experiences at a more local level, Joseph Olsen, MPH, and colleagues with CrescentCare, New Orleans, described a similar reduction of HIV testing in 2020 of 49% in their system, compared with the previous year, down from 7,952 rapid HIV tests in 2019 to 4,034 in 2020.

However, through efforts to continue to provide services during the pandemic, the program was able to link 182 patients to HIV care in 2020, which was up from 172 in 2019.

In addition to offering the rapid HIV testing in conjunction with COVID-19 testing at their urgent care centers, the center adapted to the pandemic’s challenges with strategies including a new at-home testing program; providing testing at a hotel shelter for the homeless; and testing as part of walk-in testing with a syringe access component.

Mr. Olsen credited the swift program adaptations with maintaining testing during the time of crisis.

“Without [those] measures, it would have been a near-zero number of tests provided,” he said in an interview. “It would have been easy to blame the pandemic and not try to find innovations to deliver services, but I credit our incredibly motivated team for wanting to make sure every possible resource was available.”

But now there are signs of possible fallout from the testing reductions that did occur, Mr. Olsen said.

“We are already seeing the increase with other sexually transmitted infections [STIs], and I expect that we will see this with HIV as well,” he said.

In response, clinicians should use diligence in providing HIV testing, Mr. Olsen asserted.

“The take-home message for clinicians is that anyone having sex should get tested for HIV. It’s as easy as that!” he said.

“If they are getting tested for any other STI, make sure an HIV panel is added and discussed. If someone is pregnant, make sure an HIV panel is added and discussed. If someone has never had an HIV test before in their life – and I would add if they haven’t had an HIV test since March of 2020 – make sure an HIV panel is added/discussed,” he said. “Doing this for everyone also reduces stigma around testing. It’s not because any one person or group or risk behavior is being targeted, it is just good public health practice.”

The authors disclosed no relevant financial relationships. Mr. Patel noted that the findings and conclusions of her poster are those of the authors and do not necessarily represent the official position of the CDC.

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

HIV testing centers across the United States showed reductions in testing of nearly 50% during the height of the COVID-19 pandemic in 2020, raising concerns of a subsequent increase in transmission by people unaware of their HIV-positive status.

“Testing strategies need to be ramped up to cover this decrease in testing while adapting to the continuing COVID-19 environment,” reported Deesha Patel, MPH, and colleagues with the Centers for Disease Control and Prevention’s division of HIV prevention, Atlanta, in research presented at the annual meeting of the United States Conference on HIV/AIDS.

According to their data from the National HIV Prevention Program Monitoring and Evaluation system, the number of CDC-funded HIV tests declined by more than 1 million in 2020 amid the COVID-19 restrictions, with 1,228,142 tests reported that year, compared with 2,301,669 tests in 2019, a reduction of 46.6%.

The number of persons who were newly diagnosed with HIV, based on the tests, declined by 29.7%, from 7,692 newly diagnosed in 2019 to 5,409 persons in 2020, the authors reported.

The reasons for the reduction in new HIV diagnoses in 2020 could be multifactorial, possibly reflecting not just the reduced rates of testing but also possibly lower rates of transmission because of the lockdowns and social distancing, Mr. Patel said in an interview.

“Both [of those] interpretations are plausible, and the reductions are likely due to a combination of reasons,” she said.

Of note, the percentage of tests that were positive did not show a decline and was in fact slightly higher in 2020 (0.4%), compared with 2019 (0.3%; rate ratio, 1.32). But the increase may reflect that those seeking testing during the pandemic were more likely to be symptomatic.

“It is plausible that the smaller pool of people getting tested represented those with a higher likelihood of receiving a positive HIV test, [for instance] having a recent exposure, exhibiting symptoms,” Mr. Patel explained. “Furthermore, it is possible that some health departments specifically focused outreach efforts to serve persons with increased potential for HIV acquisition, thus identifying a higher proportion of persons with HIV.”

The declines in testing are nevertheless of particular concern in light of recent pre-COVID data indicating that as many as 13% of people who were infected with HIV were unaware of their positive status, placing them at high risk of transmitting the virus.

And on a broader level, the declines could negatively affect the goal to eradicate HIV through the federal Ending the HIV Epidemic in the U.S. (EHE) initiative, which aims to reduce new HIV infections in the United States by 90% by 2030 through the scaling up of key HIV prevention and treatment strategies, Mr. Patel noted.

“The first pillar of EHE is to diagnose all people with HIV as early as possible, and to accomplish that, there needs to be sufficient HIV testing,” Mr. Patel explained. “With fewer HIV tests being conducted, there are missed opportunities to identify persons with newly diagnosed HIV, which affects the entire continuum of care, [including] linkage to medical care, receiving antiretroviral treatment, getting and keeping viral suppression, and reducing transmission.”
 

At the local level: Adaptations allowed for continued testing

In a separate report presented at the meeting detailing the experiences at a more local level, Joseph Olsen, MPH, and colleagues with CrescentCare, New Orleans, described a similar reduction of HIV testing in 2020 of 49% in their system, compared with the previous year, down from 7,952 rapid HIV tests in 2019 to 4,034 in 2020.

However, through efforts to continue to provide services during the pandemic, the program was able to link 182 patients to HIV care in 2020, which was up from 172 in 2019.

In addition to offering the rapid HIV testing in conjunction with COVID-19 testing at their urgent care centers, the center adapted to the pandemic’s challenges with strategies including a new at-home testing program; providing testing at a hotel shelter for the homeless; and testing as part of walk-in testing with a syringe access component.

Mr. Olsen credited the swift program adaptations with maintaining testing during the time of crisis.

“Without [those] measures, it would have been a near-zero number of tests provided,” he said in an interview. “It would have been easy to blame the pandemic and not try to find innovations to deliver services, but I credit our incredibly motivated team for wanting to make sure every possible resource was available.”

But now there are signs of possible fallout from the testing reductions that did occur, Mr. Olsen said.

“We are already seeing the increase with other sexually transmitted infections [STIs], and I expect that we will see this with HIV as well,” he said.

In response, clinicians should use diligence in providing HIV testing, Mr. Olsen asserted.

“The take-home message for clinicians is that anyone having sex should get tested for HIV. It’s as easy as that!” he said.

“If they are getting tested for any other STI, make sure an HIV panel is added and discussed. If someone is pregnant, make sure an HIV panel is added and discussed. If someone has never had an HIV test before in their life – and I would add if they haven’t had an HIV test since March of 2020 – make sure an HIV panel is added/discussed,” he said. “Doing this for everyone also reduces stigma around testing. It’s not because any one person or group or risk behavior is being targeted, it is just good public health practice.”

The authors disclosed no relevant financial relationships. Mr. Patel noted that the findings and conclusions of her poster are those of the authors and do not necessarily represent the official position of the CDC.

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

HIV testing centers across the United States showed reductions in testing of nearly 50% during the height of the COVID-19 pandemic in 2020, raising concerns of a subsequent increase in transmission by people unaware of their HIV-positive status.

“Testing strategies need to be ramped up to cover this decrease in testing while adapting to the continuing COVID-19 environment,” reported Deesha Patel, MPH, and colleagues with the Centers for Disease Control and Prevention’s division of HIV prevention, Atlanta, in research presented at the annual meeting of the United States Conference on HIV/AIDS.

According to their data from the National HIV Prevention Program Monitoring and Evaluation system, the number of CDC-funded HIV tests declined by more than 1 million in 2020 amid the COVID-19 restrictions, with 1,228,142 tests reported that year, compared with 2,301,669 tests in 2019, a reduction of 46.6%.

The number of persons who were newly diagnosed with HIV, based on the tests, declined by 29.7%, from 7,692 newly diagnosed in 2019 to 5,409 persons in 2020, the authors reported.

The reasons for the reduction in new HIV diagnoses in 2020 could be multifactorial, possibly reflecting not just the reduced rates of testing but also possibly lower rates of transmission because of the lockdowns and social distancing, Mr. Patel said in an interview.

“Both [of those] interpretations are plausible, and the reductions are likely due to a combination of reasons,” she said.

Of note, the percentage of tests that were positive did not show a decline and was in fact slightly higher in 2020 (0.4%), compared with 2019 (0.3%; rate ratio, 1.32). But the increase may reflect that those seeking testing during the pandemic were more likely to be symptomatic.

“It is plausible that the smaller pool of people getting tested represented those with a higher likelihood of receiving a positive HIV test, [for instance] having a recent exposure, exhibiting symptoms,” Mr. Patel explained. “Furthermore, it is possible that some health departments specifically focused outreach efforts to serve persons with increased potential for HIV acquisition, thus identifying a higher proportion of persons with HIV.”

The declines in testing are nevertheless of particular concern in light of recent pre-COVID data indicating that as many as 13% of people who were infected with HIV were unaware of their positive status, placing them at high risk of transmitting the virus.

And on a broader level, the declines could negatively affect the goal to eradicate HIV through the federal Ending the HIV Epidemic in the U.S. (EHE) initiative, which aims to reduce new HIV infections in the United States by 90% by 2030 through the scaling up of key HIV prevention and treatment strategies, Mr. Patel noted.

“The first pillar of EHE is to diagnose all people with HIV as early as possible, and to accomplish that, there needs to be sufficient HIV testing,” Mr. Patel explained. “With fewer HIV tests being conducted, there are missed opportunities to identify persons with newly diagnosed HIV, which affects the entire continuum of care, [including] linkage to medical care, receiving antiretroviral treatment, getting and keeping viral suppression, and reducing transmission.”
 

At the local level: Adaptations allowed for continued testing

In a separate report presented at the meeting detailing the experiences at a more local level, Joseph Olsen, MPH, and colleagues with CrescentCare, New Orleans, described a similar reduction of HIV testing in 2020 of 49% in their system, compared with the previous year, down from 7,952 rapid HIV tests in 2019 to 4,034 in 2020.

However, through efforts to continue to provide services during the pandemic, the program was able to link 182 patients to HIV care in 2020, which was up from 172 in 2019.

In addition to offering the rapid HIV testing in conjunction with COVID-19 testing at their urgent care centers, the center adapted to the pandemic’s challenges with strategies including a new at-home testing program; providing testing at a hotel shelter for the homeless; and testing as part of walk-in testing with a syringe access component.

Mr. Olsen credited the swift program adaptations with maintaining testing during the time of crisis.

“Without [those] measures, it would have been a near-zero number of tests provided,” he said in an interview. “It would have been easy to blame the pandemic and not try to find innovations to deliver services, but I credit our incredibly motivated team for wanting to make sure every possible resource was available.”

But now there are signs of possible fallout from the testing reductions that did occur, Mr. Olsen said.

“We are already seeing the increase with other sexually transmitted infections [STIs], and I expect that we will see this with HIV as well,” he said.

In response, clinicians should use diligence in providing HIV testing, Mr. Olsen asserted.

“The take-home message for clinicians is that anyone having sex should get tested for HIV. It’s as easy as that!” he said.

“If they are getting tested for any other STI, make sure an HIV panel is added and discussed. If someone is pregnant, make sure an HIV panel is added and discussed. If someone has never had an HIV test before in their life – and I would add if they haven’t had an HIV test since March of 2020 – make sure an HIV panel is added/discussed,” he said. “Doing this for everyone also reduces stigma around testing. It’s not because any one person or group or risk behavior is being targeted, it is just good public health practice.”

The authors disclosed no relevant financial relationships. Mr. Patel noted that the findings and conclusions of her poster are those of the authors and do not necessarily represent the official position of the CDC.

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

Diabetes mellitus (DM) is associated with Parkinson’s disease (PD) development, as well as more severe symptoms and more rapid disease progression, new research suggests.

In a systematic review, patients with type 2 diabetes were 34% more likely to develop PD than those without comorbid DM. In addition, patients with both conditions had significantly worse scores on the Unified Parkinson’s Disease Rating Scale (UPDRS) and worse cognitive performance.

Together, the results suggest that “DM may be a facilitating factor of neurodegeneration,” wrote the investigators, led by Gennaro Pagano, MD, PhD, expert medical director at Roche Pharma Research and Early Development, in Basel, Switzerland.

The findings were published in a recent issue of the Journal of Parkinson’s Disease.
 

Unanswered questions

Researchers have long proposed a potential relationship between diabetes and PD. However, case-control studies have yielded conflicting results about this relationship – and previous systematic reviews have failed to clarify the question.

In the current systematic review and meta-analysis, investigators identified relevant studies in databases such as MEDLINE/PubMed, Cochrane CENTRAL, and Scopus.

Eligible studies reported prevalence of DM in patients with PD, reported incidence of PD in those with and those without DM, and analyzed Parkinson’s phenotype and progression in those with and those without DM.

The researchers identified 3,829 articles in their initial search, evaluated 90 articles in detail, and included 43 studies in their analysis. Study quality was judged to be moderate or good, and the investigators did not find significant publication bias.

Twenty-one studies that encompassed 11,396 patients were examined to determine prevalence of DM in PD. This prevalence was calculated to be 10.02%, which is similar to the global prevalence of 9.3% reported in 2019.

The researchers also analyzed 12 cohort studies that included 17,797,221 patients to calculate risk for PD in patients with comorbid diabetes. The pooled summary odds ratio for incident PD among patients with type 2 diabetes was 1.34.

The evaluation of the effect of diabetes on PD severity was based on 10 studies that included 603 patients with both diseases. Because data on motor symptoms were not available for all studies, the researchers considered Hoehn and Yahr stage, UPDRS score, and cognitive impairment.

Patients with both conditions had a worse Hoehn and Yahr stage (standardized mean difference, 0.36; P < .001), and higher UPDRS score (SMD, 0.60; P < .001). In 7 of the 10 studies, diabetes was associated with worse cognitive performance in patients with PD.
 

Mechanisms uncertain

The mechanisms of the effect of diabetes on risk for and severity of PD are uncertain, but the researchers have developed hypotheses.

“Overlapping mechanisms between insulin resistance, mitochondrial dysfunction, oxidative stress, and alpha-synuclein expression could influence the development of the neurodegeneration process,” they wrote.

Because the current analysis demonstrated a trend toward more pronounced cognitive decline in patients with the comorbidities, clinicians should pay particular attention to the progression of motor and cognitive symptoms in patients with these diseases, the investigators noted.

“Additional studies are needed in order to better define the clinical phenotype of PD-DM patients and explore the role of antidiabetic drugs on PD progression,” they wrote.

They add that future studies also are needed to evaluate whether antidiabetic drugs might reduce risk for PD in these patients.

The investigators noted several limitations of their research. In many of the studies they examined, for example, diagnostic criteria of type 2 diabetes and PD were based only on medical records or self-reported health questionnaires. The diagnoses were rarely confirmed.

In addition, not all studies clearly stated that their populations presented with type 2 diabetes. Finally, patients with diabetes may be at increased risk for cardiovascular death, which could affect follow-up related to the development of PD, the investigators noted.

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

Diabetes mellitus (DM) is associated with Parkinson’s disease (PD) development, as well as more severe symptoms and more rapid disease progression, new research suggests.

In a systematic review, patients with type 2 diabetes were 34% more likely to develop PD than those without comorbid DM. In addition, patients with both conditions had significantly worse scores on the Unified Parkinson’s Disease Rating Scale (UPDRS) and worse cognitive performance.

Together, the results suggest that “DM may be a facilitating factor of neurodegeneration,” wrote the investigators, led by Gennaro Pagano, MD, PhD, expert medical director at Roche Pharma Research and Early Development, in Basel, Switzerland.

The findings were published in a recent issue of the Journal of Parkinson’s Disease.
 

Unanswered questions

Researchers have long proposed a potential relationship between diabetes and PD. However, case-control studies have yielded conflicting results about this relationship – and previous systematic reviews have failed to clarify the question.

In the current systematic review and meta-analysis, investigators identified relevant studies in databases such as MEDLINE/PubMed, Cochrane CENTRAL, and Scopus.

Eligible studies reported prevalence of DM in patients with PD, reported incidence of PD in those with and those without DM, and analyzed Parkinson’s phenotype and progression in those with and those without DM.

The researchers identified 3,829 articles in their initial search, evaluated 90 articles in detail, and included 43 studies in their analysis. Study quality was judged to be moderate or good, and the investigators did not find significant publication bias.

Twenty-one studies that encompassed 11,396 patients were examined to determine prevalence of DM in PD. This prevalence was calculated to be 10.02%, which is similar to the global prevalence of 9.3% reported in 2019.

The researchers also analyzed 12 cohort studies that included 17,797,221 patients to calculate risk for PD in patients with comorbid diabetes. The pooled summary odds ratio for incident PD among patients with type 2 diabetes was 1.34.

The evaluation of the effect of diabetes on PD severity was based on 10 studies that included 603 patients with both diseases. Because data on motor symptoms were not available for all studies, the researchers considered Hoehn and Yahr stage, UPDRS score, and cognitive impairment.

Patients with both conditions had a worse Hoehn and Yahr stage (standardized mean difference, 0.36; P < .001), and higher UPDRS score (SMD, 0.60; P < .001). In 7 of the 10 studies, diabetes was associated with worse cognitive performance in patients with PD.
 

Mechanisms uncertain

The mechanisms of the effect of diabetes on risk for and severity of PD are uncertain, but the researchers have developed hypotheses.

“Overlapping mechanisms between insulin resistance, mitochondrial dysfunction, oxidative stress, and alpha-synuclein expression could influence the development of the neurodegeneration process,” they wrote.

Because the current analysis demonstrated a trend toward more pronounced cognitive decline in patients with the comorbidities, clinicians should pay particular attention to the progression of motor and cognitive symptoms in patients with these diseases, the investigators noted.

“Additional studies are needed in order to better define the clinical phenotype of PD-DM patients and explore the role of antidiabetic drugs on PD progression,” they wrote.

They add that future studies also are needed to evaluate whether antidiabetic drugs might reduce risk for PD in these patients.

The investigators noted several limitations of their research. In many of the studies they examined, for example, diagnostic criteria of type 2 diabetes and PD were based only on medical records or self-reported health questionnaires. The diagnoses were rarely confirmed.

In addition, not all studies clearly stated that their populations presented with type 2 diabetes. Finally, patients with diabetes may be at increased risk for cardiovascular death, which could affect follow-up related to the development of PD, the investigators noted.

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

Diabetes mellitus (DM) is associated with Parkinson’s disease (PD) development, as well as more severe symptoms and more rapid disease progression, new research suggests.

In a systematic review, patients with type 2 diabetes were 34% more likely to develop PD than those without comorbid DM. In addition, patients with both conditions had significantly worse scores on the Unified Parkinson’s Disease Rating Scale (UPDRS) and worse cognitive performance.

Together, the results suggest that “DM may be a facilitating factor of neurodegeneration,” wrote the investigators, led by Gennaro Pagano, MD, PhD, expert medical director at Roche Pharma Research and Early Development, in Basel, Switzerland.

The findings were published in a recent issue of the Journal of Parkinson’s Disease.
 

Unanswered questions

Researchers have long proposed a potential relationship between diabetes and PD. However, case-control studies have yielded conflicting results about this relationship – and previous systematic reviews have failed to clarify the question.

In the current systematic review and meta-analysis, investigators identified relevant studies in databases such as MEDLINE/PubMed, Cochrane CENTRAL, and Scopus.

Eligible studies reported prevalence of DM in patients with PD, reported incidence of PD in those with and those without DM, and analyzed Parkinson’s phenotype and progression in those with and those without DM.

The researchers identified 3,829 articles in their initial search, evaluated 90 articles in detail, and included 43 studies in their analysis. Study quality was judged to be moderate or good, and the investigators did not find significant publication bias.

Twenty-one studies that encompassed 11,396 patients were examined to determine prevalence of DM in PD. This prevalence was calculated to be 10.02%, which is similar to the global prevalence of 9.3% reported in 2019.

The researchers also analyzed 12 cohort studies that included 17,797,221 patients to calculate risk for PD in patients with comorbid diabetes. The pooled summary odds ratio for incident PD among patients with type 2 diabetes was 1.34.

The evaluation of the effect of diabetes on PD severity was based on 10 studies that included 603 patients with both diseases. Because data on motor symptoms were not available for all studies, the researchers considered Hoehn and Yahr stage, UPDRS score, and cognitive impairment.

Patients with both conditions had a worse Hoehn and Yahr stage (standardized mean difference, 0.36; P < .001), and higher UPDRS score (SMD, 0.60; P < .001). In 7 of the 10 studies, diabetes was associated with worse cognitive performance in patients with PD.
 

Mechanisms uncertain

The mechanisms of the effect of diabetes on risk for and severity of PD are uncertain, but the researchers have developed hypotheses.

“Overlapping mechanisms between insulin resistance, mitochondrial dysfunction, oxidative stress, and alpha-synuclein expression could influence the development of the neurodegeneration process,” they wrote.

Because the current analysis demonstrated a trend toward more pronounced cognitive decline in patients with the comorbidities, clinicians should pay particular attention to the progression of motor and cognitive symptoms in patients with these diseases, the investigators noted.

“Additional studies are needed in order to better define the clinical phenotype of PD-DM patients and explore the role of antidiabetic drugs on PD progression,” they wrote.

They add that future studies also are needed to evaluate whether antidiabetic drugs might reduce risk for PD in these patients.

The investigators noted several limitations of their research. In many of the studies they examined, for example, diagnostic criteria of type 2 diabetes and PD were based only on medical records or self-reported health questionnaires. The diagnoses were rarely confirmed.

In addition, not all studies clearly stated that their populations presented with type 2 diabetes. Finally, patients with diabetes may be at increased risk for cardiovascular death, which could affect follow-up related to the development of PD, the investigators noted.

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

New research provides more evidence that antipsychotics that raise prolactin levels are tied to a significantly increased risk for breast cancer.

The relative risk for breast cancer was 62% higher in women who took category 1 antipsychotic medications associated with high prolactin levels. These include haloperidol (Haldol), paliperidone (Invega), and risperidone (Risperdal). Additionally, the risk was 54% higher in those taking category 2 antipsychotics that have mid-range effects on prolactin. These include iloperidone (Fanapt), lurasidone (Latuda), and olanzapine (Zyprexa).

In contrast, category 3 antipsychotics which have a lesser effect on prolactin levels were not associated with any increase in breast cancer risk. These drugs include aripiprazole (Abilify), asenapine (Saphris), brexpiprazole (Rexulti), cariprazine (Vraylar), clozapine (multiple brands), quetiapine (Seroquel), and ziprasidone (Geodon).

While the “absolute” breast cancer risk for these drugs is unclear, “we can make the case that high circulating prolactin levels are associated with breast cancer risk. This follows what is already known about prolactin from prior studies, notably the nurses’ health studies,” Tahir Rahman, MD, associate professor of psychiatry, Washington University School of Medicine, St. Louis, told this news organization.

“We don’t want to alarm patients taking antipsychotic drugs for life-threatening mental health problems, but we also think it is time for doctors to track prolactin levels and vigilantly monitor their patients who are being treated with antipsychotics,” Dr. Rahman added in a news release.

The study was published online Dec. 3 in the Journal of Clinical Psychopharmacology.
 

Test prolactin levels

Using administrative claims data, the researchers evaluated breast cancer risk in women aged 18-64 exposed to antipsychotic medications compared with anticonvulsants and/or lithium. 

They identified 914 cases of invasive breast cancer among 540,737 women.

Roughly 52% of the study population filled at least one prescription for a category 3 antipsychotic agent, whereas 15% filled at least one prescription for a category 1 agent; 49% of women filled at least one prescription for an anticonvulsant medication during the study period.

Exposure to all antipsychotics was independently associated with a 35% increased risk for breast cancer (adjusted hazard ratio, 1.35; 95% CI, 1.14-1.61), the study team found.

Compared with anticonvulsants or lithium, the risk for breast cancer was significantly increased for high prolactin (category 1) antipsychotics (adjusted hazard ratio, 1.62; 95% CI, 1.30-2.03) and for mid-prolactin (category 2) drugs (aHR 1.54; 95% CI, 1.19-1.99), with no increased risk for category 3 antipsychotics.

“Our research is obviously of interest for preventing breast cancer in antipsychotic-treated patients. Checking a blood prolactin level is cheap and easy [and a high level is] fairly simple to mitigate,” said Dr. Rahman.
 

A matter of debate

Reached for comment, Christoph Correll, MD, professor of psychiatry and molecular medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, said, “The potential elevation of breast cancer risk depending on the dose and time of treatment with antipsychotic medications with varying degrees of prolactin-raising properties has been a topic of research and matter of debate.”

This new study “adds another data point indicating that antipsychotics that are associated on average with a higher prolactin-raising effect than other antipsychotics may increase the risk of breast cancer in women to some degree,” said Dr. Correll, who was not involved with the study.

However, he cautioned that “naturalistic data are always vulnerable to residual confounding, for example, unmeasured effects that could also at least partially explain the results, and the follow-up time of only 4 years (maximum 6 years) in this study was relatively short.

“Nevertheless, given availability of many different antipsychotics with varying degrees of prolactin-raising potential, in women requiring antipsychotic treatment, less prolactin-raising antipsychotics may be preferable,” Dr. Correll said.

“In women receiving prolactin-raising antipsychotics for medium- and longer-term maintenance therapy, prolactin levels should be monitored,” he added.

When an elevated prolactin level is detected, this should be addressed “either via dose reduction, a switch to an alternative antipsychotic that does not raise prolactin levels significantly, or the addition of a partial or full D2 agonist when the prolactin-raising antipsychotic should be continued based on individualized risk assessment,” Dr. Correll advised.

This work was supported by an award from the Alvin J. Siteman Cancer Center; the National Cancer Institute and the National Center for Advancing Translational Sciences of the National Institutes of Health; the Taylor Family Institute for Innovative Psychiatric Research; and the Center for Brain Research in Mood Disorders. The authors have disclosed no relevant financial relationships. Dr. Correll has received royalties from UpToDate and is a stock option holder of LB Pharma.

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

New research provides more evidence that antipsychotics that raise prolactin levels are tied to a significantly increased risk for breast cancer.

The relative risk for breast cancer was 62% higher in women who took category 1 antipsychotic medications associated with high prolactin levels. These include haloperidol (Haldol), paliperidone (Invega), and risperidone (Risperdal). Additionally, the risk was 54% higher in those taking category 2 antipsychotics that have mid-range effects on prolactin. These include iloperidone (Fanapt), lurasidone (Latuda), and olanzapine (Zyprexa).

In contrast, category 3 antipsychotics which have a lesser effect on prolactin levels were not associated with any increase in breast cancer risk. These drugs include aripiprazole (Abilify), asenapine (Saphris), brexpiprazole (Rexulti), cariprazine (Vraylar), clozapine (multiple brands), quetiapine (Seroquel), and ziprasidone (Geodon).

While the “absolute” breast cancer risk for these drugs is unclear, “we can make the case that high circulating prolactin levels are associated with breast cancer risk. This follows what is already known about prolactin from prior studies, notably the nurses’ health studies,” Tahir Rahman, MD, associate professor of psychiatry, Washington University School of Medicine, St. Louis, told this news organization.

“We don’t want to alarm patients taking antipsychotic drugs for life-threatening mental health problems, but we also think it is time for doctors to track prolactin levels and vigilantly monitor their patients who are being treated with antipsychotics,” Dr. Rahman added in a news release.

The study was published online Dec. 3 in the Journal of Clinical Psychopharmacology.
 

Test prolactin levels

Using administrative claims data, the researchers evaluated breast cancer risk in women aged 18-64 exposed to antipsychotic medications compared with anticonvulsants and/or lithium. 

They identified 914 cases of invasive breast cancer among 540,737 women.

Roughly 52% of the study population filled at least one prescription for a category 3 antipsychotic agent, whereas 15% filled at least one prescription for a category 1 agent; 49% of women filled at least one prescription for an anticonvulsant medication during the study period.

Exposure to all antipsychotics was independently associated with a 35% increased risk for breast cancer (adjusted hazard ratio, 1.35; 95% CI, 1.14-1.61), the study team found.

Compared with anticonvulsants or lithium, the risk for breast cancer was significantly increased for high prolactin (category 1) antipsychotics (adjusted hazard ratio, 1.62; 95% CI, 1.30-2.03) and for mid-prolactin (category 2) drugs (aHR 1.54; 95% CI, 1.19-1.99), with no increased risk for category 3 antipsychotics.

“Our research is obviously of interest for preventing breast cancer in antipsychotic-treated patients. Checking a blood prolactin level is cheap and easy [and a high level is] fairly simple to mitigate,” said Dr. Rahman.
 

A matter of debate

Reached for comment, Christoph Correll, MD, professor of psychiatry and molecular medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, said, “The potential elevation of breast cancer risk depending on the dose and time of treatment with antipsychotic medications with varying degrees of prolactin-raising properties has been a topic of research and matter of debate.”

This new study “adds another data point indicating that antipsychotics that are associated on average with a higher prolactin-raising effect than other antipsychotics may increase the risk of breast cancer in women to some degree,” said Dr. Correll, who was not involved with the study.

However, he cautioned that “naturalistic data are always vulnerable to residual confounding, for example, unmeasured effects that could also at least partially explain the results, and the follow-up time of only 4 years (maximum 6 years) in this study was relatively short.

“Nevertheless, given availability of many different antipsychotics with varying degrees of prolactin-raising potential, in women requiring antipsychotic treatment, less prolactin-raising antipsychotics may be preferable,” Dr. Correll said.

“In women receiving prolactin-raising antipsychotics for medium- and longer-term maintenance therapy, prolactin levels should be monitored,” he added.

When an elevated prolactin level is detected, this should be addressed “either via dose reduction, a switch to an alternative antipsychotic that does not raise prolactin levels significantly, or the addition of a partial or full D2 agonist when the prolactin-raising antipsychotic should be continued based on individualized risk assessment,” Dr. Correll advised.

This work was supported by an award from the Alvin J. Siteman Cancer Center; the National Cancer Institute and the National Center for Advancing Translational Sciences of the National Institutes of Health; the Taylor Family Institute for Innovative Psychiatric Research; and the Center for Brain Research in Mood Disorders. The authors have disclosed no relevant financial relationships. Dr. Correll has received royalties from UpToDate and is a stock option holder of LB Pharma.

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

New research provides more evidence that antipsychotics that raise prolactin levels are tied to a significantly increased risk for breast cancer.

The relative risk for breast cancer was 62% higher in women who took category 1 antipsychotic medications associated with high prolactin levels. These include haloperidol (Haldol), paliperidone (Invega), and risperidone (Risperdal). Additionally, the risk was 54% higher in those taking category 2 antipsychotics that have mid-range effects on prolactin. These include iloperidone (Fanapt), lurasidone (Latuda), and olanzapine (Zyprexa).

In contrast, category 3 antipsychotics which have a lesser effect on prolactin levels were not associated with any increase in breast cancer risk. These drugs include aripiprazole (Abilify), asenapine (Saphris), brexpiprazole (Rexulti), cariprazine (Vraylar), clozapine (multiple brands), quetiapine (Seroquel), and ziprasidone (Geodon).

While the “absolute” breast cancer risk for these drugs is unclear, “we can make the case that high circulating prolactin levels are associated with breast cancer risk. This follows what is already known about prolactin from prior studies, notably the nurses’ health studies,” Tahir Rahman, MD, associate professor of psychiatry, Washington University School of Medicine, St. Louis, told this news organization.

“We don’t want to alarm patients taking antipsychotic drugs for life-threatening mental health problems, but we also think it is time for doctors to track prolactin levels and vigilantly monitor their patients who are being treated with antipsychotics,” Dr. Rahman added in a news release.

The study was published online Dec. 3 in the Journal of Clinical Psychopharmacology.
 

Test prolactin levels

Using administrative claims data, the researchers evaluated breast cancer risk in women aged 18-64 exposed to antipsychotic medications compared with anticonvulsants and/or lithium. 

They identified 914 cases of invasive breast cancer among 540,737 women.

Roughly 52% of the study population filled at least one prescription for a category 3 antipsychotic agent, whereas 15% filled at least one prescription for a category 1 agent; 49% of women filled at least one prescription for an anticonvulsant medication during the study period.

Exposure to all antipsychotics was independently associated with a 35% increased risk for breast cancer (adjusted hazard ratio, 1.35; 95% CI, 1.14-1.61), the study team found.

Compared with anticonvulsants or lithium, the risk for breast cancer was significantly increased for high prolactin (category 1) antipsychotics (adjusted hazard ratio, 1.62; 95% CI, 1.30-2.03) and for mid-prolactin (category 2) drugs (aHR 1.54; 95% CI, 1.19-1.99), with no increased risk for category 3 antipsychotics.

“Our research is obviously of interest for preventing breast cancer in antipsychotic-treated patients. Checking a blood prolactin level is cheap and easy [and a high level is] fairly simple to mitigate,” said Dr. Rahman.
 

A matter of debate

Reached for comment, Christoph Correll, MD, professor of psychiatry and molecular medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, said, “The potential elevation of breast cancer risk depending on the dose and time of treatment with antipsychotic medications with varying degrees of prolactin-raising properties has been a topic of research and matter of debate.”

This new study “adds another data point indicating that antipsychotics that are associated on average with a higher prolactin-raising effect than other antipsychotics may increase the risk of breast cancer in women to some degree,” said Dr. Correll, who was not involved with the study.

However, he cautioned that “naturalistic data are always vulnerable to residual confounding, for example, unmeasured effects that could also at least partially explain the results, and the follow-up time of only 4 years (maximum 6 years) in this study was relatively short.

“Nevertheless, given availability of many different antipsychotics with varying degrees of prolactin-raising potential, in women requiring antipsychotic treatment, less prolactin-raising antipsychotics may be preferable,” Dr. Correll said.

“In women receiving prolactin-raising antipsychotics for medium- and longer-term maintenance therapy, prolactin levels should be monitored,” he added.

When an elevated prolactin level is detected, this should be addressed “either via dose reduction, a switch to an alternative antipsychotic that does not raise prolactin levels significantly, or the addition of a partial or full D2 agonist when the prolactin-raising antipsychotic should be continued based on individualized risk assessment,” Dr. Correll advised.

This work was supported by an award from the Alvin J. Siteman Cancer Center; the National Cancer Institute and the National Center for Advancing Translational Sciences of the National Institutes of Health; the Taylor Family Institute for Innovative Psychiatric Research; and the Center for Brain Research in Mood Disorders. The authors have disclosed no relevant financial relationships. Dr. Correll has received royalties from UpToDate and is a stock option holder of LB Pharma.

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

The majority of people with HIV and type 2 diabetes do not receive the recommended routine screenings necessary to prevent chronic complications associated with that comorbidity, research shows.

“Despite known risk in this patient population, most patients were not up to date with routine preventative screenings,” report Maya Hardman, PharmD, and colleagues with Southwest CARE Center, in Santa Fe, New Mexico, in research presented at the United States Conference on HIV/AIDS (USCHA) 2021 Annual Meeting.

“Routine preventative screenings can help identify chronic complications of diabetes early, if performed at the recommended intervals,” they write.

People with HIV are known to be at an increased risk of diabetes and the long-term complications of the disease, making the need for routine screening to prevent such complications all the more pressing due to their higher-risk health status.

Among the key routine diabetes care quality measures recommended by the Healthcare Effectiveness Data and Information Set (HEDIS) for people with HIV are testing for A1c once every 3 months, foot and eye exams every 12 months, urine albumin creatinine ratio (UACR) screenings every 12 months, and two controlled blood pressure readings every 12 months.

To investigate the rates of adherence to the HEDIS screening recommendations and identify predictors of poor compliance among people with HIV, Dr. Hardman and her colleagues evaluated data on 121 adult patients at the Southwest CARE Center who had been diagnosed with diabetes and HIV and were treated between 2019 and 2020.

The patients had a mean age of 57.5, and 9% were female. Their mean duration of being HIV positive was 19.8 years, and they had an intermediate Atherosclerotic Cardiovascular Disease (ASCVD) risk score of 17.08%.

Despite their known diagnoses of having diabetes, as many as 93.4% were found not to be up to date on their routine preventive screenings.

Of the 121 patients, only 30 had received the recommended A1c screenings, 37 had the recommended UACR screenings, and just 18 had received the recommended foot exam screenings.

Only blood pressure screenings, reported in 90 of the 121 patients, were up to date in the majority of patients in the group.

In looking at factors associated with compliance with A1c screening, only age (OR, 0.95; P = .04) was a significant predictor.

The authors pointed out that routine screenings for diabetes complications are relatively easy to implement.

“Screening for these chronic complications is minimally invasive and can be provided by individuals trained in diabetes management during routine clinic appointments.”

The team’s ongoing research is evaluating the potential benefits of clinical pharmacy services in assisting with the screenings for patients with HIV.

Research underscoring the increased risk and poorer treatment outcomes of diabetes in people with HIV include a study comparing 337 people with HIV in 2005 with a cohort of 338 participants in 2015.

The study showed the prevalence of type 2 diabetes had increased to 15.1% in 2015 from 6.8% 10 years earlier, for a relative risk of 2.4 compared with the general population.

“The alarmingly high prevalence of type 2 diabetes in HIV requires improved screening, targeted to older patients and those with a longer duration of exposure to antiretrovirals,” the authors wrote.

“Effective diabetes prevention and management strategies are needed urgently to reduce this risk; such interventions should target both conventional risk factors, such as abdominal obesity and HIV-specific risk factors such as weight gain following initiation of antiretrovirals.”

Of note, the 2015 cohort was significantly older and had higher BMI and higher hypertension than the 2005 cohort.

First author Alastair Duncan, PhD, principal dietitian at Guy’s & St. Thomas’ Hospital and lecturer, King’s College London, noted that since that 2015 study was published, concerns particularly with weight gain in the HIV population have only increased.

“Weight gain appears to be more of an issue [now],” he told this news organization in an interview.

“As in the general population, people living with HIV experienced significant weight gain during COVID-related lockdowns. Added to the high number of people living with HIV being treated with integrase inhibitors, weight gain remains a challenge.”

Meanwhile, “there are not enough studies comparing people living with HIV with the general population,” Dr. Duncan added. “We need to conduct studies where participants are matched.”

Sudipa Sarkar, MD, who co-authored a report on the issue of diabetes and HIV this year but was not involved in the study presented at USCHA, noted that the setting of care could play an important role in the quality of screening for diabetes that people with HIV receive.

“It may depend on factors such as whether a patient is being followed regularly by an HIV care provider and the larger health care system that the patient is in,” Dr. Sarkar, an assistant professor of medicine at Johns Hopkins University School of Medicine, Division of Endocrinology, Diabetes, and Metabolism, told this news organization.

“For example, one might find differences between a patient being seen in a managed care group versus not.”

The issue of how the strikingly high rates of inadequate screening in the current study compare with routine screening in the general diabetes population “is a good question and warrants more research,” she said.

The authors and Dr. Sarkar have disclosed no relevant financial relationships.

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

The majority of people with HIV and type 2 diabetes do not receive the recommended routine screenings necessary to prevent chronic complications associated with that comorbidity, research shows.

“Despite known risk in this patient population, most patients were not up to date with routine preventative screenings,” report Maya Hardman, PharmD, and colleagues with Southwest CARE Center, in Santa Fe, New Mexico, in research presented at the United States Conference on HIV/AIDS (USCHA) 2021 Annual Meeting.

“Routine preventative screenings can help identify chronic complications of diabetes early, if performed at the recommended intervals,” they write.

People with HIV are known to be at an increased risk of diabetes and the long-term complications of the disease, making the need for routine screening to prevent such complications all the more pressing due to their higher-risk health status.

Among the key routine diabetes care quality measures recommended by the Healthcare Effectiveness Data and Information Set (HEDIS) for people with HIV are testing for A1c once every 3 months, foot and eye exams every 12 months, urine albumin creatinine ratio (UACR) screenings every 12 months, and two controlled blood pressure readings every 12 months.

To investigate the rates of adherence to the HEDIS screening recommendations and identify predictors of poor compliance among people with HIV, Dr. Hardman and her colleagues evaluated data on 121 adult patients at the Southwest CARE Center who had been diagnosed with diabetes and HIV and were treated between 2019 and 2020.

The patients had a mean age of 57.5, and 9% were female. Their mean duration of being HIV positive was 19.8 years, and they had an intermediate Atherosclerotic Cardiovascular Disease (ASCVD) risk score of 17.08%.

Despite their known diagnoses of having diabetes, as many as 93.4% were found not to be up to date on their routine preventive screenings.

Of the 121 patients, only 30 had received the recommended A1c screenings, 37 had the recommended UACR screenings, and just 18 had received the recommended foot exam screenings.

Only blood pressure screenings, reported in 90 of the 121 patients, were up to date in the majority of patients in the group.

In looking at factors associated with compliance with A1c screening, only age (OR, 0.95; P = .04) was a significant predictor.

The authors pointed out that routine screenings for diabetes complications are relatively easy to implement.

“Screening for these chronic complications is minimally invasive and can be provided by individuals trained in diabetes management during routine clinic appointments.”

The team’s ongoing research is evaluating the potential benefits of clinical pharmacy services in assisting with the screenings for patients with HIV.

Research underscoring the increased risk and poorer treatment outcomes of diabetes in people with HIV include a study comparing 337 people with HIV in 2005 with a cohort of 338 participants in 2015.

The study showed the prevalence of type 2 diabetes had increased to 15.1% in 2015 from 6.8% 10 years earlier, for a relative risk of 2.4 compared with the general population.

“The alarmingly high prevalence of type 2 diabetes in HIV requires improved screening, targeted to older patients and those with a longer duration of exposure to antiretrovirals,” the authors wrote.

“Effective diabetes prevention and management strategies are needed urgently to reduce this risk; such interventions should target both conventional risk factors, such as abdominal obesity and HIV-specific risk factors such as weight gain following initiation of antiretrovirals.”

Of note, the 2015 cohort was significantly older and had higher BMI and higher hypertension than the 2005 cohort.

First author Alastair Duncan, PhD, principal dietitian at Guy’s & St. Thomas’ Hospital and lecturer, King’s College London, noted that since that 2015 study was published, concerns particularly with weight gain in the HIV population have only increased.

“Weight gain appears to be more of an issue [now],” he told this news organization in an interview.

“As in the general population, people living with HIV experienced significant weight gain during COVID-related lockdowns. Added to the high number of people living with HIV being treated with integrase inhibitors, weight gain remains a challenge.”

Meanwhile, “there are not enough studies comparing people living with HIV with the general population,” Dr. Duncan added. “We need to conduct studies where participants are matched.”

Sudipa Sarkar, MD, who co-authored a report on the issue of diabetes and HIV this year but was not involved in the study presented at USCHA, noted that the setting of care could play an important role in the quality of screening for diabetes that people with HIV receive.

“It may depend on factors such as whether a patient is being followed regularly by an HIV care provider and the larger health care system that the patient is in,” Dr. Sarkar, an assistant professor of medicine at Johns Hopkins University School of Medicine, Division of Endocrinology, Diabetes, and Metabolism, told this news organization.

“For example, one might find differences between a patient being seen in a managed care group versus not.”

The issue of how the strikingly high rates of inadequate screening in the current study compare with routine screening in the general diabetes population “is a good question and warrants more research,” she said.

The authors and Dr. Sarkar have disclosed no relevant financial relationships.

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

The majority of people with HIV and type 2 diabetes do not receive the recommended routine screenings necessary to prevent chronic complications associated with that comorbidity, research shows.

“Despite known risk in this patient population, most patients were not up to date with routine preventative screenings,” report Maya Hardman, PharmD, and colleagues with Southwest CARE Center, in Santa Fe, New Mexico, in research presented at the United States Conference on HIV/AIDS (USCHA) 2021 Annual Meeting.

“Routine preventative screenings can help identify chronic complications of diabetes early, if performed at the recommended intervals,” they write.

People with HIV are known to be at an increased risk of diabetes and the long-term complications of the disease, making the need for routine screening to prevent such complications all the more pressing due to their higher-risk health status.

Among the key routine diabetes care quality measures recommended by the Healthcare Effectiveness Data and Information Set (HEDIS) for people with HIV are testing for A1c once every 3 months, foot and eye exams every 12 months, urine albumin creatinine ratio (UACR) screenings every 12 months, and two controlled blood pressure readings every 12 months.

To investigate the rates of adherence to the HEDIS screening recommendations and identify predictors of poor compliance among people with HIV, Dr. Hardman and her colleagues evaluated data on 121 adult patients at the Southwest CARE Center who had been diagnosed with diabetes and HIV and were treated between 2019 and 2020.

The patients had a mean age of 57.5, and 9% were female. Their mean duration of being HIV positive was 19.8 years, and they had an intermediate Atherosclerotic Cardiovascular Disease (ASCVD) risk score of 17.08%.

Despite their known diagnoses of having diabetes, as many as 93.4% were found not to be up to date on their routine preventive screenings.

Of the 121 patients, only 30 had received the recommended A1c screenings, 37 had the recommended UACR screenings, and just 18 had received the recommended foot exam screenings.

Only blood pressure screenings, reported in 90 of the 121 patients, were up to date in the majority of patients in the group.

In looking at factors associated with compliance with A1c screening, only age (OR, 0.95; P = .04) was a significant predictor.

The authors pointed out that routine screenings for diabetes complications are relatively easy to implement.

“Screening for these chronic complications is minimally invasive and can be provided by individuals trained in diabetes management during routine clinic appointments.”

The team’s ongoing research is evaluating the potential benefits of clinical pharmacy services in assisting with the screenings for patients with HIV.

Research underscoring the increased risk and poorer treatment outcomes of diabetes in people with HIV include a study comparing 337 people with HIV in 2005 with a cohort of 338 participants in 2015.

The study showed the prevalence of type 2 diabetes had increased to 15.1% in 2015 from 6.8% 10 years earlier, for a relative risk of 2.4 compared with the general population.

“The alarmingly high prevalence of type 2 diabetes in HIV requires improved screening, targeted to older patients and those with a longer duration of exposure to antiretrovirals,” the authors wrote.

“Effective diabetes prevention and management strategies are needed urgently to reduce this risk; such interventions should target both conventional risk factors, such as abdominal obesity and HIV-specific risk factors such as weight gain following initiation of antiretrovirals.”

Of note, the 2015 cohort was significantly older and had higher BMI and higher hypertension than the 2005 cohort.

First author Alastair Duncan, PhD, principal dietitian at Guy’s & St. Thomas’ Hospital and lecturer, King’s College London, noted that since that 2015 study was published, concerns particularly with weight gain in the HIV population have only increased.

“Weight gain appears to be more of an issue [now],” he told this news organization in an interview.

“As in the general population, people living with HIV experienced significant weight gain during COVID-related lockdowns. Added to the high number of people living with HIV being treated with integrase inhibitors, weight gain remains a challenge.”

Meanwhile, “there are not enough studies comparing people living with HIV with the general population,” Dr. Duncan added. “We need to conduct studies where participants are matched.”

Sudipa Sarkar, MD, who co-authored a report on the issue of diabetes and HIV this year but was not involved in the study presented at USCHA, noted that the setting of care could play an important role in the quality of screening for diabetes that people with HIV receive.

“It may depend on factors such as whether a patient is being followed regularly by an HIV care provider and the larger health care system that the patient is in,” Dr. Sarkar, an assistant professor of medicine at Johns Hopkins University School of Medicine, Division of Endocrinology, Diabetes, and Metabolism, told this news organization.

“For example, one might find differences between a patient being seen in a managed care group versus not.”

The issue of how the strikingly high rates of inadequate screening in the current study compare with routine screening in the general diabetes population “is a good question and warrants more research,” she said.

The authors and Dr. Sarkar have disclosed no relevant financial relationships.