After 2 years of virtual gatherings, the annual European Society of Cardiology Congress 2022 is back and celebrating its 70th birthday live in the raucously beautiful city of Barcelona.

Much of the upcoming event, scheduled for Aug. 26 to 29, however, will also be broadcast online, and the full program will be available on-demand after the meeting.

The hybrid format is intentional, leveraging the social interaction that only live meetings can provide and the global reach of online access, Program Committee Chair Stephan Windecker, MD, Bern University Hospital, Switzerland, told this news organization.

“It enables a lot of people who, for some reason, cannot travel to still connect, and it also provides what we’ve done in the past, but I think in a more natural way of doing it,” he said. “You can connect later on again, read, digest, look at sessions that you may have missed, and that’s a nice experience to take advantage of.”

Thus far, early registrations are favoring the sunny climes, with about 14,000 onsite and 4,200 online attendees.

This year’s spotlight theme is cardiac imaging, with programming throughout the Congress devoted to its role in diagnosis, treatment, follow-up, and, increasingly, guidance of interventions.

“Particularly as it relates to the transcatheter heart valves, it’s really a new discipline, and I think you can’t overemphasize that enough, because the interventional result directly depends on the quality of imaging,” Dr. Windecker said. “This will certainly logarithmically increase during the next few years.”

The always highly anticipated Hot Line sessions mushroomed this year to 10, featuring 36 studies, up from just 4 sessions and 20 studies last year.

“Especially during the COVID pandemic, many investigators and trialists experienced difficulties in recruitment, difficulties in terms of also personnel shortages, and so on. So really, we feel very privileged at the large number of submissions,” he said. “I think there are really very interesting ones, which we tried to spread throughout the 4 days.”
 

Hot Line sessions 1-5

Among the studies Dr. Windecker highlighted is TIME, which kicks off Hot Line 1 on Friday, Aug. 26, and aimed to establish whether antihypertensive medications taken at night are truly more cardioprotective than those taken in the morning.

The topic has been hotly debated, with proponents pointing to a near halving of mortality and cardiovascular events with bedtime dosing in the Hygia Chronotherapy trial. Skeptics question the validity and conduct of the trial, however, prompting an investigation by the European Heart Journal, which found no evidence of misconduct but has many looking for more definitive data.

Also in this session is SECURE, pitting a cardiovascular polypill that contains aspirin, ramipril, and atorvastatin against usual care in secondary prevention, and PERSPECTIVE, comparing the effects of sacubitril/valsartan with valsartan on cognitive function in patients with chronic heart failure and preserved ejection fraction (HFpEF).

Hot Line 2, the first of three Hot Lines taking place on Saturday, Aug. 27, features the Danish cardiovascular screening trial DANCAVAS, the phase 4 ADVOR trial of acetazolamide (Diamox) in acute decompensated heart failure (HF), and the DANFLU-1 trial of high- versus standard-dose influenza vaccine in the elderly.

Also on tap is the BOX trial, comparing two blood pressure and two oxygenation targets in comatose out-of-hospital cardiac arrest patients.

“It addresses an understudied patient population, and the second element is that sometimes things you do out of ordinary application – so, the application of oxygen – may have beneficial but also adverse impact,” Dr. Windecker said. “So, to study this in a randomized clinical trial is really important.”

Additionally, he highlighted REVIVED, which will be presented in Hot Line 3 and is the first trial to examine percutaneous coronary intervention (PCI) with optimal medical therapy (OMT) versus OMT alone in the setting of severe ischemic cardiomyopathy.

“We have data from the STICH trial, where surgical revascularization was investigated in ischemic cardiomyopathy, but the open question is: What about PCI as revascularization?” Dr. Windecker said. “The other reason it’s interesting is that we have these evidence-based drugs that have dramatically improved outcomes in patients with heart failure, and REVIVED certainly has been conducted now in an era where at least some of these drugs are more systematically implemented.”

Rounding out this session are the Scottish ALL-HEART study of allopurinol in ischemic heart disease and EchoNet-RCT, looking at whether artificial intelligence (AI) can improve the accuracy of echocardiograms.

Hot Line 4 features DELIVER, a phase 3 trial of the SGLT2 inhibitor dapagliflozin (Farxiga) in HF with preserved or mildly reduced ejection fraction. Topline results, released in May, showed that the study has met its primary endpoint of cardiovascular death or worsening HF.

Dr. Windecker said DELIVER will be a “highlight” of the meeting, particularly because EMPEROR-Preserved, presented at ESC 2021, showed a benefit for another SGLT2 inhibitor, empagliflozin, in this very specific setting. Two prespecified analyses will also be presented, pooling data from EMPEROR-Preserved and from the DAPA-HF study of dapagliflozin in patients with reduced EF. “This will be a session very rich in terms of information.”

Another not-to-be-missed session is Hot Line 5, which will focus on antithrombotic therapy, according to Dr. Windecker, who will cochair the Sunday, Aug. 28 session.

First up is the investigator-initiated INVICTUS-VKA, testing rivaroxaban noninferiority versus standard vitamin K antagonists in patients with atrial fibrillation (AFib) and rheumatic heart disease, a setting in which non–vitamin K antagonists have not been sufficiently tested.

This is followed by three phase 2 trials – PACIFIC-AMI, PACIFIC-STROKE, and AXIOMATIC-SSP – investigating the novel factor XIa inhibitors BAY 2433334 and BMS-986177 in patients with myocardial infarction or stroke.
 

Hot Line sessions 6-10

Sunday’s Hot Line 6 takes another look at smartphone-based AFib screening in eBRAVE-HF, use of causal AI to improve the validity of cardiovascular risk prediction, and AI-enhanced detection of aortic stenosis.

Hot Line 7 rounds out the day, putting coronary imaging center stage. It includes perfusion scanning with MR or PET after a positive angiogram in DanNICAD-2, the PET tracer 18F-sodium fluoride as a marker of high-risk coronary plaques in patients with recent MIs in PREFFIR, and fractional flow reserve- versus angiography-guided PCI in acute MI with multivessel disease in FRAME-AMI.

After a weekend of top-notch science and, no doubt, a spot of revelry, the focus returns on Monday, Aug. 29 to three Hot Line sessions. The first of these, Hot Line 8, updates five clinical trials, including 5-year outcomes from ISCHEMIA-CKD EXTEND, 15-month results from MASTER DAPT, and primary results from FOURIER-OLE, the open-label extension study of evolocumab out to 5 years in approximately 1,600 study participants.

The session closes out with causes of mortality in the FIDELITY trial of finerenone and a win-ratio analysis of PARADISE-MI.

Hot Line 9, billed as an “evidence synthesis on clinically important questions,” includes a Cholesterol Treatment Trialists’ (CTT) Collaboration meta-analysis on the effects of statins on muscle symptoms and a meta-analysis of angiotensin-receptor blockers and beta-blockers in Marfan syndrome from the Marfan Treatment Trialists’ Collaboration.

Also featured is evidence on radial versus femoral access for coronary procedures, and PANTHER, a patient-level meta-analysis of aspirin or P2Y12 inhibitor monotherapy as secondary prevention in patients with established coronary artery disease.

COVID-19, deeply rooted in the minds of attendees and considered in 52 separate sessions, takes over the final Hot Line session of the Congress. Hot Line 10 will report on antithrombotic therapy in critically ill patients in COVID-PACT and on anti-inflammatory therapy with colchicine and antithrombotic therapy with aspirin alone or in combination with rivaroxaban in the ACT inpatient and outpatient trials. Although such early trials have been largely negative, the latest details will be interesting to see, Dr. Windecker suggested.

In terms of COVID-19 protocols, ESC will recommend but not mandate masks and will have test kits available should attendees wish to have a test or if they become symptomatic, he noted.
 

New guidelines released

Four new ESC guidelines will be released during the congress on cardio-oncology, ventricular arrhythmias and sudden cardiac death, pulmonary hypertension, and cardiovascular assessment and management of patients undergoing noncardiac surgery.

In addition to a guideline overview on Friday, one guideline will be featured each day in a 1-hour session, with additional time for discussions with guideline task force members, and six sessions devoted to the implementation of existing guidelines in clinical practice.

The ESC already has a position paper on cardio-oncology, but now, for the first time, has a full guideline with formal laws and level-of-evidence recommendations, Dr. Windecker pointed out.

“I think what will be the great asset, not only of the guideline but out of this emerging field, is that people in the future will probably not only be treated when it’s too late or suffer from toxicity but that there will be screening, and people will be aware before the implementation of therapy,” he added.

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

After 2 years of virtual gatherings, the annual European Society of Cardiology Congress 2022 is back and celebrating its 70th birthday live in the raucously beautiful city of Barcelona.

Much of the upcoming event, scheduled for Aug. 26 to 29, however, will also be broadcast online, and the full program will be available on-demand after the meeting.

The hybrid format is intentional, leveraging the social interaction that only live meetings can provide and the global reach of online access, Program Committee Chair Stephan Windecker, MD, Bern University Hospital, Switzerland, told this news organization.

“It enables a lot of people who, for some reason, cannot travel to still connect, and it also provides what we’ve done in the past, but I think in a more natural way of doing it,” he said. “You can connect later on again, read, digest, look at sessions that you may have missed, and that’s a nice experience to take advantage of.”

Thus far, early registrations are favoring the sunny climes, with about 14,000 onsite and 4,200 online attendees.

This year’s spotlight theme is cardiac imaging, with programming throughout the Congress devoted to its role in diagnosis, treatment, follow-up, and, increasingly, guidance of interventions.

“Particularly as it relates to the transcatheter heart valves, it’s really a new discipline, and I think you can’t overemphasize that enough, because the interventional result directly depends on the quality of imaging,” Dr. Windecker said. “This will certainly logarithmically increase during the next few years.”

The always highly anticipated Hot Line sessions mushroomed this year to 10, featuring 36 studies, up from just 4 sessions and 20 studies last year.

“Especially during the COVID pandemic, many investigators and trialists experienced difficulties in recruitment, difficulties in terms of also personnel shortages, and so on. So really, we feel very privileged at the large number of submissions,” he said. “I think there are really very interesting ones, which we tried to spread throughout the 4 days.”
 

Hot Line sessions 1-5

Among the studies Dr. Windecker highlighted is TIME, which kicks off Hot Line 1 on Friday, Aug. 26, and aimed to establish whether antihypertensive medications taken at night are truly more cardioprotective than those taken in the morning.

The topic has been hotly debated, with proponents pointing to a near halving of mortality and cardiovascular events with bedtime dosing in the Hygia Chronotherapy trial. Skeptics question the validity and conduct of the trial, however, prompting an investigation by the European Heart Journal, which found no evidence of misconduct but has many looking for more definitive data.

Also in this session is SECURE, pitting a cardiovascular polypill that contains aspirin, ramipril, and atorvastatin against usual care in secondary prevention, and PERSPECTIVE, comparing the effects of sacubitril/valsartan with valsartan on cognitive function in patients with chronic heart failure and preserved ejection fraction (HFpEF).

Hot Line 2, the first of three Hot Lines taking place on Saturday, Aug. 27, features the Danish cardiovascular screening trial DANCAVAS, the phase 4 ADVOR trial of acetazolamide (Diamox) in acute decompensated heart failure (HF), and the DANFLU-1 trial of high- versus standard-dose influenza vaccine in the elderly.

Also on tap is the BOX trial, comparing two blood pressure and two oxygenation targets in comatose out-of-hospital cardiac arrest patients.

“It addresses an understudied patient population, and the second element is that sometimes things you do out of ordinary application – so, the application of oxygen – may have beneficial but also adverse impact,” Dr. Windecker said. “So, to study this in a randomized clinical trial is really important.”

Additionally, he highlighted REVIVED, which will be presented in Hot Line 3 and is the first trial to examine percutaneous coronary intervention (PCI) with optimal medical therapy (OMT) versus OMT alone in the setting of severe ischemic cardiomyopathy.

“We have data from the STICH trial, where surgical revascularization was investigated in ischemic cardiomyopathy, but the open question is: What about PCI as revascularization?” Dr. Windecker said. “The other reason it’s interesting is that we have these evidence-based drugs that have dramatically improved outcomes in patients with heart failure, and REVIVED certainly has been conducted now in an era where at least some of these drugs are more systematically implemented.”

Rounding out this session are the Scottish ALL-HEART study of allopurinol in ischemic heart disease and EchoNet-RCT, looking at whether artificial intelligence (AI) can improve the accuracy of echocardiograms.

Hot Line 4 features DELIVER, a phase 3 trial of the SGLT2 inhibitor dapagliflozin (Farxiga) in HF with preserved or mildly reduced ejection fraction. Topline results, released in May, showed that the study has met its primary endpoint of cardiovascular death or worsening HF.

Dr. Windecker said DELIVER will be a “highlight” of the meeting, particularly because EMPEROR-Preserved, presented at ESC 2021, showed a benefit for another SGLT2 inhibitor, empagliflozin, in this very specific setting. Two prespecified analyses will also be presented, pooling data from EMPEROR-Preserved and from the DAPA-HF study of dapagliflozin in patients with reduced EF. “This will be a session very rich in terms of information.”

Another not-to-be-missed session is Hot Line 5, which will focus on antithrombotic therapy, according to Dr. Windecker, who will cochair the Sunday, Aug. 28 session.

First up is the investigator-initiated INVICTUS-VKA, testing rivaroxaban noninferiority versus standard vitamin K antagonists in patients with atrial fibrillation (AFib) and rheumatic heart disease, a setting in which non–vitamin K antagonists have not been sufficiently tested.

This is followed by three phase 2 trials – PACIFIC-AMI, PACIFIC-STROKE, and AXIOMATIC-SSP – investigating the novel factor XIa inhibitors BAY 2433334 and BMS-986177 in patients with myocardial infarction or stroke.
 

Hot Line sessions 6-10

Sunday’s Hot Line 6 takes another look at smartphone-based AFib screening in eBRAVE-HF, use of causal AI to improve the validity of cardiovascular risk prediction, and AI-enhanced detection of aortic stenosis.

Hot Line 7 rounds out the day, putting coronary imaging center stage. It includes perfusion scanning with MR or PET after a positive angiogram in DanNICAD-2, the PET tracer 18F-sodium fluoride as a marker of high-risk coronary plaques in patients with recent MIs in PREFFIR, and fractional flow reserve- versus angiography-guided PCI in acute MI with multivessel disease in FRAME-AMI.

After a weekend of top-notch science and, no doubt, a spot of revelry, the focus returns on Monday, Aug. 29 to three Hot Line sessions. The first of these, Hot Line 8, updates five clinical trials, including 5-year outcomes from ISCHEMIA-CKD EXTEND, 15-month results from MASTER DAPT, and primary results from FOURIER-OLE, the open-label extension study of evolocumab out to 5 years in approximately 1,600 study participants.

The session closes out with causes of mortality in the FIDELITY trial of finerenone and a win-ratio analysis of PARADISE-MI.

Hot Line 9, billed as an “evidence synthesis on clinically important questions,” includes a Cholesterol Treatment Trialists’ (CTT) Collaboration meta-analysis on the effects of statins on muscle symptoms and a meta-analysis of angiotensin-receptor blockers and beta-blockers in Marfan syndrome from the Marfan Treatment Trialists’ Collaboration.

Also featured is evidence on radial versus femoral access for coronary procedures, and PANTHER, a patient-level meta-analysis of aspirin or P2Y12 inhibitor monotherapy as secondary prevention in patients with established coronary artery disease.

COVID-19, deeply rooted in the minds of attendees and considered in 52 separate sessions, takes over the final Hot Line session of the Congress. Hot Line 10 will report on antithrombotic therapy in critically ill patients in COVID-PACT and on anti-inflammatory therapy with colchicine and antithrombotic therapy with aspirin alone or in combination with rivaroxaban in the ACT inpatient and outpatient trials. Although such early trials have been largely negative, the latest details will be interesting to see, Dr. Windecker suggested.

In terms of COVID-19 protocols, ESC will recommend but not mandate masks and will have test kits available should attendees wish to have a test or if they become symptomatic, he noted.
 

New guidelines released

Four new ESC guidelines will be released during the congress on cardio-oncology, ventricular arrhythmias and sudden cardiac death, pulmonary hypertension, and cardiovascular assessment and management of patients undergoing noncardiac surgery.

In addition to a guideline overview on Friday, one guideline will be featured each day in a 1-hour session, with additional time for discussions with guideline task force members, and six sessions devoted to the implementation of existing guidelines in clinical practice.

The ESC already has a position paper on cardio-oncology, but now, for the first time, has a full guideline with formal laws and level-of-evidence recommendations, Dr. Windecker pointed out.

“I think what will be the great asset, not only of the guideline but out of this emerging field, is that people in the future will probably not only be treated when it’s too late or suffer from toxicity but that there will be screening, and people will be aware before the implementation of therapy,” he added.

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

After 2 years of virtual gatherings, the annual European Society of Cardiology Congress 2022 is back and celebrating its 70th birthday live in the raucously beautiful city of Barcelona.

Much of the upcoming event, scheduled for Aug. 26 to 29, however, will also be broadcast online, and the full program will be available on-demand after the meeting.

The hybrid format is intentional, leveraging the social interaction that only live meetings can provide and the global reach of online access, Program Committee Chair Stephan Windecker, MD, Bern University Hospital, Switzerland, told this news organization.

“It enables a lot of people who, for some reason, cannot travel to still connect, and it also provides what we’ve done in the past, but I think in a more natural way of doing it,” he said. “You can connect later on again, read, digest, look at sessions that you may have missed, and that’s a nice experience to take advantage of.”

Thus far, early registrations are favoring the sunny climes, with about 14,000 onsite and 4,200 online attendees.

This year’s spotlight theme is cardiac imaging, with programming throughout the Congress devoted to its role in diagnosis, treatment, follow-up, and, increasingly, guidance of interventions.

“Particularly as it relates to the transcatheter heart valves, it’s really a new discipline, and I think you can’t overemphasize that enough, because the interventional result directly depends on the quality of imaging,” Dr. Windecker said. “This will certainly logarithmically increase during the next few years.”

The always highly anticipated Hot Line sessions mushroomed this year to 10, featuring 36 studies, up from just 4 sessions and 20 studies last year.

“Especially during the COVID pandemic, many investigators and trialists experienced difficulties in recruitment, difficulties in terms of also personnel shortages, and so on. So really, we feel very privileged at the large number of submissions,” he said. “I think there are really very interesting ones, which we tried to spread throughout the 4 days.”
 

Hot Line sessions 1-5

Among the studies Dr. Windecker highlighted is TIME, which kicks off Hot Line 1 on Friday, Aug. 26, and aimed to establish whether antihypertensive medications taken at night are truly more cardioprotective than those taken in the morning.

The topic has been hotly debated, with proponents pointing to a near halving of mortality and cardiovascular events with bedtime dosing in the Hygia Chronotherapy trial. Skeptics question the validity and conduct of the trial, however, prompting an investigation by the European Heart Journal, which found no evidence of misconduct but has many looking for more definitive data.

Also in this session is SECURE, pitting a cardiovascular polypill that contains aspirin, ramipril, and atorvastatin against usual care in secondary prevention, and PERSPECTIVE, comparing the effects of sacubitril/valsartan with valsartan on cognitive function in patients with chronic heart failure and preserved ejection fraction (HFpEF).

Hot Line 2, the first of three Hot Lines taking place on Saturday, Aug. 27, features the Danish cardiovascular screening trial DANCAVAS, the phase 4 ADVOR trial of acetazolamide (Diamox) in acute decompensated heart failure (HF), and the DANFLU-1 trial of high- versus standard-dose influenza vaccine in the elderly.

Also on tap is the BOX trial, comparing two blood pressure and two oxygenation targets in comatose out-of-hospital cardiac arrest patients.

“It addresses an understudied patient population, and the second element is that sometimes things you do out of ordinary application – so, the application of oxygen – may have beneficial but also adverse impact,” Dr. Windecker said. “So, to study this in a randomized clinical trial is really important.”

Additionally, he highlighted REVIVED, which will be presented in Hot Line 3 and is the first trial to examine percutaneous coronary intervention (PCI) with optimal medical therapy (OMT) versus OMT alone in the setting of severe ischemic cardiomyopathy.

“We have data from the STICH trial, where surgical revascularization was investigated in ischemic cardiomyopathy, but the open question is: What about PCI as revascularization?” Dr. Windecker said. “The other reason it’s interesting is that we have these evidence-based drugs that have dramatically improved outcomes in patients with heart failure, and REVIVED certainly has been conducted now in an era where at least some of these drugs are more systematically implemented.”

Rounding out this session are the Scottish ALL-HEART study of allopurinol in ischemic heart disease and EchoNet-RCT, looking at whether artificial intelligence (AI) can improve the accuracy of echocardiograms.

Hot Line 4 features DELIVER, a phase 3 trial of the SGLT2 inhibitor dapagliflozin (Farxiga) in HF with preserved or mildly reduced ejection fraction. Topline results, released in May, showed that the study has met its primary endpoint of cardiovascular death or worsening HF.

Dr. Windecker said DELIVER will be a “highlight” of the meeting, particularly because EMPEROR-Preserved, presented at ESC 2021, showed a benefit for another SGLT2 inhibitor, empagliflozin, in this very specific setting. Two prespecified analyses will also be presented, pooling data from EMPEROR-Preserved and from the DAPA-HF study of dapagliflozin in patients with reduced EF. “This will be a session very rich in terms of information.”

Another not-to-be-missed session is Hot Line 5, which will focus on antithrombotic therapy, according to Dr. Windecker, who will cochair the Sunday, Aug. 28 session.

First up is the investigator-initiated INVICTUS-VKA, testing rivaroxaban noninferiority versus standard vitamin K antagonists in patients with atrial fibrillation (AFib) and rheumatic heart disease, a setting in which non–vitamin K antagonists have not been sufficiently tested.

This is followed by three phase 2 trials – PACIFIC-AMI, PACIFIC-STROKE, and AXIOMATIC-SSP – investigating the novel factor XIa inhibitors BAY 2433334 and BMS-986177 in patients with myocardial infarction or stroke.
 

Hot Line sessions 6-10

Sunday’s Hot Line 6 takes another look at smartphone-based AFib screening in eBRAVE-HF, use of causal AI to improve the validity of cardiovascular risk prediction, and AI-enhanced detection of aortic stenosis.

Hot Line 7 rounds out the day, putting coronary imaging center stage. It includes perfusion scanning with MR or PET after a positive angiogram in DanNICAD-2, the PET tracer 18F-sodium fluoride as a marker of high-risk coronary plaques in patients with recent MIs in PREFFIR, and fractional flow reserve- versus angiography-guided PCI in acute MI with multivessel disease in FRAME-AMI.

After a weekend of top-notch science and, no doubt, a spot of revelry, the focus returns on Monday, Aug. 29 to three Hot Line sessions. The first of these, Hot Line 8, updates five clinical trials, including 5-year outcomes from ISCHEMIA-CKD EXTEND, 15-month results from MASTER DAPT, and primary results from FOURIER-OLE, the open-label extension study of evolocumab out to 5 years in approximately 1,600 study participants.

The session closes out with causes of mortality in the FIDELITY trial of finerenone and a win-ratio analysis of PARADISE-MI.

Hot Line 9, billed as an “evidence synthesis on clinically important questions,” includes a Cholesterol Treatment Trialists’ (CTT) Collaboration meta-analysis on the effects of statins on muscle symptoms and a meta-analysis of angiotensin-receptor blockers and beta-blockers in Marfan syndrome from the Marfan Treatment Trialists’ Collaboration.

Also featured is evidence on radial versus femoral access for coronary procedures, and PANTHER, a patient-level meta-analysis of aspirin or P2Y12 inhibitor monotherapy as secondary prevention in patients with established coronary artery disease.

COVID-19, deeply rooted in the minds of attendees and considered in 52 separate sessions, takes over the final Hot Line session of the Congress. Hot Line 10 will report on antithrombotic therapy in critically ill patients in COVID-PACT and on anti-inflammatory therapy with colchicine and antithrombotic therapy with aspirin alone or in combination with rivaroxaban in the ACT inpatient and outpatient trials. Although such early trials have been largely negative, the latest details will be interesting to see, Dr. Windecker suggested.

In terms of COVID-19 protocols, ESC will recommend but not mandate masks and will have test kits available should attendees wish to have a test or if they become symptomatic, he noted.
 

New guidelines released

Four new ESC guidelines will be released during the congress on cardio-oncology, ventricular arrhythmias and sudden cardiac death, pulmonary hypertension, and cardiovascular assessment and management of patients undergoing noncardiac surgery.

In addition to a guideline overview on Friday, one guideline will be featured each day in a 1-hour session, with additional time for discussions with guideline task force members, and six sessions devoted to the implementation of existing guidelines in clinical practice.

The ESC already has a position paper on cardio-oncology, but now, for the first time, has a full guideline with formal laws and level-of-evidence recommendations, Dr. Windecker pointed out.

“I think what will be the great asset, not only of the guideline but out of this emerging field, is that people in the future will probably not only be treated when it’s too late or suffer from toxicity but that there will be screening, and people will be aware before the implementation of therapy,” he added.

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

What is the real goal of weight loss? In health care, reducing excess body fat is known to improve many complications faced by patients with obesity. Even modest to moderate weight loss contributes to improvements in health. Normalizing body weight is not required.

While our culture promotes an ideal body size, in the health care setting, our attention must focus on achieving health improvement. We need to be more tolerant of variations in body size if patients are healthy. Of note, varying amounts of weight loss produce improvement in the different complications of obesity, so the amount of weight loss required for improving one condition differs from that required to improve another condition.

When we prescribe weight loss for health improvement, we are trying to reduce both the mechanical burden of fat and the excess ectopic and visceral body fat that is driving disease. The good news about the physiology of weight loss is that we do not need to attain a body mass index (BMI) of 25 or even 30 to have health improvement. The excess abnormal body fat is the first to go!

Losing weight causes a disproportional reduction in ectopic and visceral fat depots. With a 5% weight loss, visceral fat is reduced by 9%. With 16% weight loss, visceral fat is reduced by 30%. Clearing of liver fat is even more dramatic. With 16% weight loss, 65% of liver fat is cleared.

Because ectopic abnormal fat is cleared preferentially with weight loss, it affects different tissues with varying amounts of weight loss.
 

Weight loss and diabetes

A close relationship exists between weight loss and insulin sensitivity. With just 5% weight loss, insulin sensitivity in the liver and adipose tissue is greatly improved, but while muscle insulin sensitivity is improved at just 5% weight loss, it continues to improve with further weight loss. Indeed, weight loss has enormous benefits in improving glycemia in prediabetes and diabetes.

In patients with impaired glucose tolerance, weight loss of 10% can eliminate progression to type 2 diabetes. In patients with type 2 diabetes who still have beta-cell reserve, 15% weight loss can produce diabetes remission – normoglycemia without diabetes medications.
 

Weight loss and cardiovascular risk factors

Even very small amounts of weight loss – 3% – can improve triglycerides and glycemia. It takes 5% weight loss to show benefits in systolic and diastolic blood pressure, as well as in HDL and LDL cholesterol levels. For all of these, additional weight loss brings more improvement. Inflammatory markers are more difficult. It takes 10%-15% weight loss to improve most of these – for example, C-reactive protein.

Weight loss and other complications

It takes 10% or more weight loss to demonstrate improvements in symptoms in obstructive sleep apnea and gastroesophageal reflux disease. For knee pain, the relationship to improvement is not based on achieving a percentage loss. Each pound of weight lost can result in a fourfold reduction in the load exerted on the knee per step during daily activities, but it is important to reduce weight before there is structural damage, because weight loss can’t repair damaged knee joints. Moderate weight loss (5%-10%) produces improvements in quality-of-life measures, in urinary stress incontinence symptoms, and in measures of sexual function. It probably takes 15% or more weight loss to demonstrate improvement in cardiovascular events.

Must heavier patients lose more weight?

To answer this question, it is important to think in terms of percent weight loss rather than pounds or kilograms. In large studies of lifestyle intervention, of course individuals with higher BMI lost more weight. But the percentage weight loss was the same across BMI categories: class 1 (BMI 30-35), class 2 (BMI 35-40), class 3 (BMI > 40). Furthermore, the improvement in risk factors was the same across BMI categories. Those with class 3 obesity had the same improvements as those with class 1. This provides further rationale for thinking about weight loss as a percentage from baseline weight rather than as simply a weight-loss goal in pounds.

Goal setting is an important part of any behavioral intervention

At the start of a weight-loss intervention, the health care provider should raise the issue of the goal and the time course for achieving it. Patients often have unrealistic expectations, wanting to achieve large amounts of weight loss rapidly. Unfortunately, popular culture has reinforced this idea with advertisements using “lose 10 pounds the first week” and promoting before-and-after pictures of weight-loss results. The job of the health care provider is to coach and guide the patient in terms of achievable weight loss that can bring health improvement safely. Managing patient expectations is critical to long-term success.

Think in terms of percentage weight loss, not pounds, and set goals at achievable time points

Help patients translate a percent weight-loss goal to a pounds goal at 3, 6, and 12 months. With the emergence of medications approved for chronic weight management with robust weight-loss efficacy, it now is possible to achieve a weight-loss goal of 10% or 15% with regularity, and some patients will be able to achieve 20% or 25% weight loss with newer medications.

We should help our patients set a goal by calculating a goal for certain time points. A good goal for 3 months would be 5% weight loss. For our 200-lb patient, we would translate that to 10 lb in 3 months. For 6 months, the goal should be 10% (20 lb for our 200-lb patient). The usual trajectory of weight loss with lifestyle intervention alone is for a “plateau” at 6 months, although with newer medications, weight loss will continue for more than a year. That 1-year goal might be 15% (30 lb for our 200-lb patient) or even more, based on the patient’s baseline weight and body composition.

Weight-loss calculators can be useful tools for patients and health care providers. They can be found online and include the National Institutes of Health Body Weight Planner and the Pennington Biomedical Weight Loss Predictor Calculator. These tools give patients a realistic expectation of how fast weight loss can occur and provide guidelines to measure success.
 

Can patients lose too much weight?

In this patient population, losing too much weight is not typically a concern. However, newer medications are achieving average weight losses of 17% and 22% at 62 weeks, as reported by this news organization. There is a wide variation in response to these newer agents which target appetite, and many patients are losing more than the average percentages.

Remembering that the goal of weight loss is the reduction of excess abnormal body fat, we want patients to preserve as much lean mass as possible. Weight-bearing exercise can help during the weight-loss phase, but large or rapid weight loss can be concerning, especially in older individuals. When the BMI drops below 25, we want to watch patients carefully. Measurement of body composition, including bone mineral density, with dual-energy x-ray absorptiometry (DEXA) can help. This is a scenario where dose reduction of antiobesity medication can be indicated, and good clinical judgment is required to keep weight loss at healthy levels.
 

The future of weight loss

In the past, our strategy has been to promote as much weight loss as possible. With more effective medications, our strategy will have to change to a treat-to-target approach, such as we already use in hypertension and diabetes.

With the ability to produce powerful effects on appetite will come the need to not only target weight loss but to target preservation of lean mass and even to target different approaches for weight-loss maintenance. At present, we have no evidence that stopping medications results in anything other than weight regain. The study of different approaches to weight-loss maintenance will require our full attention.

Dr. Ryan has disclosed the following relevant financial relationships: Serve(d) as a director, officer, partner, employee, consultant, or trustee for: Altimmune; Amgen; Calibrate; Epitomee; Gila; Lilly; Novo Nordisk; Scientific Intake; Wondr Health; Xeno Biosciences; YSOPIA; Zealand. Received income in an amount equal to or greater than $250 from: Altimmune; Amgen; Calibrate; Epitomee; Gila; Lilly; Novo Nordisk; Scientific Intake; Wondr Health; Xeno Biosciences; YSOPIA; Zealand.

Donna Ryan, MD, is Professor Emerita, Pennington Biomedical Research Center, Louisiana State University, New Orleans.

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

What is the real goal of weight loss? In health care, reducing excess body fat is known to improve many complications faced by patients with obesity. Even modest to moderate weight loss contributes to improvements in health. Normalizing body weight is not required.

While our culture promotes an ideal body size, in the health care setting, our attention must focus on achieving health improvement. We need to be more tolerant of variations in body size if patients are healthy. Of note, varying amounts of weight loss produce improvement in the different complications of obesity, so the amount of weight loss required for improving one condition differs from that required to improve another condition.

When we prescribe weight loss for health improvement, we are trying to reduce both the mechanical burden of fat and the excess ectopic and visceral body fat that is driving disease. The good news about the physiology of weight loss is that we do not need to attain a body mass index (BMI) of 25 or even 30 to have health improvement. The excess abnormal body fat is the first to go!

Losing weight causes a disproportional reduction in ectopic and visceral fat depots. With a 5% weight loss, visceral fat is reduced by 9%. With 16% weight loss, visceral fat is reduced by 30%. Clearing of liver fat is even more dramatic. With 16% weight loss, 65% of liver fat is cleared.

Because ectopic abnormal fat is cleared preferentially with weight loss, it affects different tissues with varying amounts of weight loss.
 

Weight loss and diabetes

A close relationship exists between weight loss and insulin sensitivity. With just 5% weight loss, insulin sensitivity in the liver and adipose tissue is greatly improved, but while muscle insulin sensitivity is improved at just 5% weight loss, it continues to improve with further weight loss. Indeed, weight loss has enormous benefits in improving glycemia in prediabetes and diabetes.

In patients with impaired glucose tolerance, weight loss of 10% can eliminate progression to type 2 diabetes. In patients with type 2 diabetes who still have beta-cell reserve, 15% weight loss can produce diabetes remission – normoglycemia without diabetes medications.
 

Weight loss and cardiovascular risk factors

Even very small amounts of weight loss – 3% – can improve triglycerides and glycemia. It takes 5% weight loss to show benefits in systolic and diastolic blood pressure, as well as in HDL and LDL cholesterol levels. For all of these, additional weight loss brings more improvement. Inflammatory markers are more difficult. It takes 10%-15% weight loss to improve most of these – for example, C-reactive protein.

Weight loss and other complications

It takes 10% or more weight loss to demonstrate improvements in symptoms in obstructive sleep apnea and gastroesophageal reflux disease. For knee pain, the relationship to improvement is not based on achieving a percentage loss. Each pound of weight lost can result in a fourfold reduction in the load exerted on the knee per step during daily activities, but it is important to reduce weight before there is structural damage, because weight loss can’t repair damaged knee joints. Moderate weight loss (5%-10%) produces improvements in quality-of-life measures, in urinary stress incontinence symptoms, and in measures of sexual function. It probably takes 15% or more weight loss to demonstrate improvement in cardiovascular events.

Must heavier patients lose more weight?

To answer this question, it is important to think in terms of percent weight loss rather than pounds or kilograms. In large studies of lifestyle intervention, of course individuals with higher BMI lost more weight. But the percentage weight loss was the same across BMI categories: class 1 (BMI 30-35), class 2 (BMI 35-40), class 3 (BMI > 40). Furthermore, the improvement in risk factors was the same across BMI categories. Those with class 3 obesity had the same improvements as those with class 1. This provides further rationale for thinking about weight loss as a percentage from baseline weight rather than as simply a weight-loss goal in pounds.

Goal setting is an important part of any behavioral intervention

At the start of a weight-loss intervention, the health care provider should raise the issue of the goal and the time course for achieving it. Patients often have unrealistic expectations, wanting to achieve large amounts of weight loss rapidly. Unfortunately, popular culture has reinforced this idea with advertisements using “lose 10 pounds the first week” and promoting before-and-after pictures of weight-loss results. The job of the health care provider is to coach and guide the patient in terms of achievable weight loss that can bring health improvement safely. Managing patient expectations is critical to long-term success.

Think in terms of percentage weight loss, not pounds, and set goals at achievable time points

Help patients translate a percent weight-loss goal to a pounds goal at 3, 6, and 12 months. With the emergence of medications approved for chronic weight management with robust weight-loss efficacy, it now is possible to achieve a weight-loss goal of 10% or 15% with regularity, and some patients will be able to achieve 20% or 25% weight loss with newer medications.

We should help our patients set a goal by calculating a goal for certain time points. A good goal for 3 months would be 5% weight loss. For our 200-lb patient, we would translate that to 10 lb in 3 months. For 6 months, the goal should be 10% (20 lb for our 200-lb patient). The usual trajectory of weight loss with lifestyle intervention alone is for a “plateau” at 6 months, although with newer medications, weight loss will continue for more than a year. That 1-year goal might be 15% (30 lb for our 200-lb patient) or even more, based on the patient’s baseline weight and body composition.

Weight-loss calculators can be useful tools for patients and health care providers. They can be found online and include the National Institutes of Health Body Weight Planner and the Pennington Biomedical Weight Loss Predictor Calculator. These tools give patients a realistic expectation of how fast weight loss can occur and provide guidelines to measure success.
 

Can patients lose too much weight?

In this patient population, losing too much weight is not typically a concern. However, newer medications are achieving average weight losses of 17% and 22% at 62 weeks, as reported by this news organization. There is a wide variation in response to these newer agents which target appetite, and many patients are losing more than the average percentages.

Remembering that the goal of weight loss is the reduction of excess abnormal body fat, we want patients to preserve as much lean mass as possible. Weight-bearing exercise can help during the weight-loss phase, but large or rapid weight loss can be concerning, especially in older individuals. When the BMI drops below 25, we want to watch patients carefully. Measurement of body composition, including bone mineral density, with dual-energy x-ray absorptiometry (DEXA) can help. This is a scenario where dose reduction of antiobesity medication can be indicated, and good clinical judgment is required to keep weight loss at healthy levels.
 

The future of weight loss

In the past, our strategy has been to promote as much weight loss as possible. With more effective medications, our strategy will have to change to a treat-to-target approach, such as we already use in hypertension and diabetes.

With the ability to produce powerful effects on appetite will come the need to not only target weight loss but to target preservation of lean mass and even to target different approaches for weight-loss maintenance. At present, we have no evidence that stopping medications results in anything other than weight regain. The study of different approaches to weight-loss maintenance will require our full attention.

Dr. Ryan has disclosed the following relevant financial relationships: Serve(d) as a director, officer, partner, employee, consultant, or trustee for: Altimmune; Amgen; Calibrate; Epitomee; Gila; Lilly; Novo Nordisk; Scientific Intake; Wondr Health; Xeno Biosciences; YSOPIA; Zealand. Received income in an amount equal to or greater than $250 from: Altimmune; Amgen; Calibrate; Epitomee; Gila; Lilly; Novo Nordisk; Scientific Intake; Wondr Health; Xeno Biosciences; YSOPIA; Zealand.

Donna Ryan, MD, is Professor Emerita, Pennington Biomedical Research Center, Louisiana State University, New Orleans.

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

What is the real goal of weight loss? In health care, reducing excess body fat is known to improve many complications faced by patients with obesity. Even modest to moderate weight loss contributes to improvements in health. Normalizing body weight is not required.

While our culture promotes an ideal body size, in the health care setting, our attention must focus on achieving health improvement. We need to be more tolerant of variations in body size if patients are healthy. Of note, varying amounts of weight loss produce improvement in the different complications of obesity, so the amount of weight loss required for improving one condition differs from that required to improve another condition.

When we prescribe weight loss for health improvement, we are trying to reduce both the mechanical burden of fat and the excess ectopic and visceral body fat that is driving disease. The good news about the physiology of weight loss is that we do not need to attain a body mass index (BMI) of 25 or even 30 to have health improvement. The excess abnormal body fat is the first to go!

Losing weight causes a disproportional reduction in ectopic and visceral fat depots. With a 5% weight loss, visceral fat is reduced by 9%. With 16% weight loss, visceral fat is reduced by 30%. Clearing of liver fat is even more dramatic. With 16% weight loss, 65% of liver fat is cleared.

Because ectopic abnormal fat is cleared preferentially with weight loss, it affects different tissues with varying amounts of weight loss.
 

Weight loss and diabetes

A close relationship exists between weight loss and insulin sensitivity. With just 5% weight loss, insulin sensitivity in the liver and adipose tissue is greatly improved, but while muscle insulin sensitivity is improved at just 5% weight loss, it continues to improve with further weight loss. Indeed, weight loss has enormous benefits in improving glycemia in prediabetes and diabetes.

In patients with impaired glucose tolerance, weight loss of 10% can eliminate progression to type 2 diabetes. In patients with type 2 diabetes who still have beta-cell reserve, 15% weight loss can produce diabetes remission – normoglycemia without diabetes medications.
 

Weight loss and cardiovascular risk factors

Even very small amounts of weight loss – 3% – can improve triglycerides and glycemia. It takes 5% weight loss to show benefits in systolic and diastolic blood pressure, as well as in HDL and LDL cholesterol levels. For all of these, additional weight loss brings more improvement. Inflammatory markers are more difficult. It takes 10%-15% weight loss to improve most of these – for example, C-reactive protein.

Weight loss and other complications

It takes 10% or more weight loss to demonstrate improvements in symptoms in obstructive sleep apnea and gastroesophageal reflux disease. For knee pain, the relationship to improvement is not based on achieving a percentage loss. Each pound of weight lost can result in a fourfold reduction in the load exerted on the knee per step during daily activities, but it is important to reduce weight before there is structural damage, because weight loss can’t repair damaged knee joints. Moderate weight loss (5%-10%) produces improvements in quality-of-life measures, in urinary stress incontinence symptoms, and in measures of sexual function. It probably takes 15% or more weight loss to demonstrate improvement in cardiovascular events.

Must heavier patients lose more weight?

To answer this question, it is important to think in terms of percent weight loss rather than pounds or kilograms. In large studies of lifestyle intervention, of course individuals with higher BMI lost more weight. But the percentage weight loss was the same across BMI categories: class 1 (BMI 30-35), class 2 (BMI 35-40), class 3 (BMI > 40). Furthermore, the improvement in risk factors was the same across BMI categories. Those with class 3 obesity had the same improvements as those with class 1. This provides further rationale for thinking about weight loss as a percentage from baseline weight rather than as simply a weight-loss goal in pounds.

Goal setting is an important part of any behavioral intervention

At the start of a weight-loss intervention, the health care provider should raise the issue of the goal and the time course for achieving it. Patients often have unrealistic expectations, wanting to achieve large amounts of weight loss rapidly. Unfortunately, popular culture has reinforced this idea with advertisements using “lose 10 pounds the first week” and promoting before-and-after pictures of weight-loss results. The job of the health care provider is to coach and guide the patient in terms of achievable weight loss that can bring health improvement safely. Managing patient expectations is critical to long-term success.

Think in terms of percentage weight loss, not pounds, and set goals at achievable time points

Help patients translate a percent weight-loss goal to a pounds goal at 3, 6, and 12 months. With the emergence of medications approved for chronic weight management with robust weight-loss efficacy, it now is possible to achieve a weight-loss goal of 10% or 15% with regularity, and some patients will be able to achieve 20% or 25% weight loss with newer medications.

We should help our patients set a goal by calculating a goal for certain time points. A good goal for 3 months would be 5% weight loss. For our 200-lb patient, we would translate that to 10 lb in 3 months. For 6 months, the goal should be 10% (20 lb for our 200-lb patient). The usual trajectory of weight loss with lifestyle intervention alone is for a “plateau” at 6 months, although with newer medications, weight loss will continue for more than a year. That 1-year goal might be 15% (30 lb for our 200-lb patient) or even more, based on the patient’s baseline weight and body composition.

Weight-loss calculators can be useful tools for patients and health care providers. They can be found online and include the National Institutes of Health Body Weight Planner and the Pennington Biomedical Weight Loss Predictor Calculator. These tools give patients a realistic expectation of how fast weight loss can occur and provide guidelines to measure success.
 

Can patients lose too much weight?

In this patient population, losing too much weight is not typically a concern. However, newer medications are achieving average weight losses of 17% and 22% at 62 weeks, as reported by this news organization. There is a wide variation in response to these newer agents which target appetite, and many patients are losing more than the average percentages.

Remembering that the goal of weight loss is the reduction of excess abnormal body fat, we want patients to preserve as much lean mass as possible. Weight-bearing exercise can help during the weight-loss phase, but large or rapid weight loss can be concerning, especially in older individuals. When the BMI drops below 25, we want to watch patients carefully. Measurement of body composition, including bone mineral density, with dual-energy x-ray absorptiometry (DEXA) can help. This is a scenario where dose reduction of antiobesity medication can be indicated, and good clinical judgment is required to keep weight loss at healthy levels.
 

The future of weight loss

In the past, our strategy has been to promote as much weight loss as possible. With more effective medications, our strategy will have to change to a treat-to-target approach, such as we already use in hypertension and diabetes.

With the ability to produce powerful effects on appetite will come the need to not only target weight loss but to target preservation of lean mass and even to target different approaches for weight-loss maintenance. At present, we have no evidence that stopping medications results in anything other than weight regain. The study of different approaches to weight-loss maintenance will require our full attention.

Dr. Ryan has disclosed the following relevant financial relationships: Serve(d) as a director, officer, partner, employee, consultant, or trustee for: Altimmune; Amgen; Calibrate; Epitomee; Gila; Lilly; Novo Nordisk; Scientific Intake; Wondr Health; Xeno Biosciences; YSOPIA; Zealand. Received income in an amount equal to or greater than $250 from: Altimmune; Amgen; Calibrate; Epitomee; Gila; Lilly; Novo Nordisk; Scientific Intake; Wondr Health; Xeno Biosciences; YSOPIA; Zealand.

Donna Ryan, MD, is Professor Emerita, Pennington Biomedical Research Center, Louisiana State University, New Orleans.

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

Dermatologists spent less time with Asian patients with psoriasis than patients of other races and ethnicities in a cross-sectional study using data from the National Ambulatory Medical Care Survey (NAMCS) from 2010 to 2016.

Yet the reasons for the difference are unclear and in need of further research, said the investigators and dermatologists who were asked to comment on the research.

The study covered over 4 million visits for psoriasis and found that the mean duration of visits for Asian patients was 9.2 minutes, compared with 15.7 minutes for Hispanic or Latino patients, 20.7 minutes for non-Hispanic Black patients, and 15.4 minutes for non-Hispanic White patients.

The mean duration of visits with Asian patients was 39.9% shorter, compared with visits with White patients (beta coefficient, –5,747; 95% confidence interval, –11.026 to –0.469; P = .03), and 40.6% shorter, compared with visits with non-Asian patients combined (beta coefficient, –5.908; 95% CI, –11.147 to –0.669, P = .03), April W. Armstrong, MD, MPH, professor of dermatology and director of the psoriasis program at the University of Southern California, Los Angeles, and Kevin K. Wu, MD, a dermatology resident at USC, said in a research letter published in JAMA Dermatology.

“The etiology of these differences is unclear,” they wrote. “It is possible that factors such as unconscious bias, cultural differences in communication, or residual confounding may be responsible for the observed findings.”

Their findings came from multivariable linear regression analyses that adjusted for age, sex, type of visit (new or follow-up), visit complexity based on the number of reasons for the visit, insurance status (such as private insurance or Medicaid), psoriasis severity on the basis of systemic psoriasis treatment or phototherapy, and complex topical regimens (three or more topical agents).

Commenting on the results, Deborah A. Scott, MD, codirector of the skin of color dermatology program at Brigham and Women’s Hospital and assistant professor at Harvard Medical School, both in Boston, said in an interview that visit length “is a reasonable parameter to look at among many others” when investigating potential disparities in care.

“They’re equating [shorter visit times] with lack of time spent counseling patients,” said Dr. Scott, who was not involved in the research. But there are “many variables” that can affect visit time, such as language differences, time spent with interpreters, and differences in patient educational levels.

Clarissa Yang, MD, dermatologist-in-chief at Tufts Medical Center, Boston, agreed. “We’re worried about there being a quality of care issue. However, there could also be differences culturally in how [the patients] interact with their physicians – their styles and the questions they ask,” she said in an interview. “The study is a good first step to noting that there may be a disparity,” and there is a need to break down the differences “into more granularity.”

Previous research, the authors wrote, has found that Asian patients were less likely to receive counseling from physicians, compared with White patients. And “paradoxically,” they noted, Asian individuals tend to present with more severe psoriasis than patients of other races and ethnicities.

Dr. Scott said the tendency to present with more severe psoriasis has been documented in patients with skin of color broadly – likely because of delays in recognition and treatment.

Race and ethnicity in the study were self-reported by patients, and missing data were imputed by NAMCS researchers using a sequential regression method. Patients who did not report race and ethnicity may have different characteristics affecting visit duration than those who did report the information, Dr. Armstrong and Dr. Wu said in describing their study’s limitations.

Other differences found

In addition to visit length, they found significant differences in mean age and in the use of complex topical regimens. The mean ages of Asian, Hispanic or Latino, and non-Hispanic Black patients were 37.2, 44.7, and 33.3 years, respectively. Complex topical regimens were prescribed to 11.8% of Asian patients, compared with 1.5% of Black and 1.1% of White patients.

For practicing dermatologists, knowing for now that Asian patients have shorter visits “may bring to light some consciousness to how we practice,” Dr. Yang noted. “We may counsel differently, we may spend differing amounts of time – for reasons still unknown. But being generally aware can help us to shift any unconscious bias that may be there.”

Dermatologists, Dr. Armstrong and Dr. Wu wrote, “need to allow sufficient time to develop strong physician-patient communication regardless of patient background.”

The NAMCS – administered by the Center for Disease Control and Prevention’s National Center for Health Statistics – collects data on a sample of visits provided by non–federally employed office-based physicians.

Dr. Armstrong disclosed receiving personal fees from AbbVie and Regeneron for research funding and serving as a scientific adviser and speaker for additional pharmaceutical and therapeutic companies. Dr. Wu, Dr. Scott, and Dr. Yang did not report any disclosures.
 

Dermatologists spent less time with Asian patients with psoriasis than patients of other races and ethnicities in a cross-sectional study using data from the National Ambulatory Medical Care Survey (NAMCS) from 2010 to 2016.

Yet the reasons for the difference are unclear and in need of further research, said the investigators and dermatologists who were asked to comment on the research.

The study covered over 4 million visits for psoriasis and found that the mean duration of visits for Asian patients was 9.2 minutes, compared with 15.7 minutes for Hispanic or Latino patients, 20.7 minutes for non-Hispanic Black patients, and 15.4 minutes for non-Hispanic White patients.

The mean duration of visits with Asian patients was 39.9% shorter, compared with visits with White patients (beta coefficient, –5,747; 95% confidence interval, –11.026 to –0.469; P = .03), and 40.6% shorter, compared with visits with non-Asian patients combined (beta coefficient, –5.908; 95% CI, –11.147 to –0.669, P = .03), April W. Armstrong, MD, MPH, professor of dermatology and director of the psoriasis program at the University of Southern California, Los Angeles, and Kevin K. Wu, MD, a dermatology resident at USC, said in a research letter published in JAMA Dermatology.

“The etiology of these differences is unclear,” they wrote. “It is possible that factors such as unconscious bias, cultural differences in communication, or residual confounding may be responsible for the observed findings.”

Their findings came from multivariable linear regression analyses that adjusted for age, sex, type of visit (new or follow-up), visit complexity based on the number of reasons for the visit, insurance status (such as private insurance or Medicaid), psoriasis severity on the basis of systemic psoriasis treatment or phototherapy, and complex topical regimens (three or more topical agents).

Commenting on the results, Deborah A. Scott, MD, codirector of the skin of color dermatology program at Brigham and Women’s Hospital and assistant professor at Harvard Medical School, both in Boston, said in an interview that visit length “is a reasonable parameter to look at among many others” when investigating potential disparities in care.

“They’re equating [shorter visit times] with lack of time spent counseling patients,” said Dr. Scott, who was not involved in the research. But there are “many variables” that can affect visit time, such as language differences, time spent with interpreters, and differences in patient educational levels.

Clarissa Yang, MD, dermatologist-in-chief at Tufts Medical Center, Boston, agreed. “We’re worried about there being a quality of care issue. However, there could also be differences culturally in how [the patients] interact with their physicians – their styles and the questions they ask,” she said in an interview. “The study is a good first step to noting that there may be a disparity,” and there is a need to break down the differences “into more granularity.”

Previous research, the authors wrote, has found that Asian patients were less likely to receive counseling from physicians, compared with White patients. And “paradoxically,” they noted, Asian individuals tend to present with more severe psoriasis than patients of other races and ethnicities.

Dr. Scott said the tendency to present with more severe psoriasis has been documented in patients with skin of color broadly – likely because of delays in recognition and treatment.

Race and ethnicity in the study were self-reported by patients, and missing data were imputed by NAMCS researchers using a sequential regression method. Patients who did not report race and ethnicity may have different characteristics affecting visit duration than those who did report the information, Dr. Armstrong and Dr. Wu said in describing their study’s limitations.

Other differences found

In addition to visit length, they found significant differences in mean age and in the use of complex topical regimens. The mean ages of Asian, Hispanic or Latino, and non-Hispanic Black patients were 37.2, 44.7, and 33.3 years, respectively. Complex topical regimens were prescribed to 11.8% of Asian patients, compared with 1.5% of Black and 1.1% of White patients.

For practicing dermatologists, knowing for now that Asian patients have shorter visits “may bring to light some consciousness to how we practice,” Dr. Yang noted. “We may counsel differently, we may spend differing amounts of time – for reasons still unknown. But being generally aware can help us to shift any unconscious bias that may be there.”

Dermatologists, Dr. Armstrong and Dr. Wu wrote, “need to allow sufficient time to develop strong physician-patient communication regardless of patient background.”

The NAMCS – administered by the Center for Disease Control and Prevention’s National Center for Health Statistics – collects data on a sample of visits provided by non–federally employed office-based physicians.

Dr. Armstrong disclosed receiving personal fees from AbbVie and Regeneron for research funding and serving as a scientific adviser and speaker for additional pharmaceutical and therapeutic companies. Dr. Wu, Dr. Scott, and Dr. Yang did not report any disclosures.
 

Dermatologists spent less time with Asian patients with psoriasis than patients of other races and ethnicities in a cross-sectional study using data from the National Ambulatory Medical Care Survey (NAMCS) from 2010 to 2016.

Yet the reasons for the difference are unclear and in need of further research, said the investigators and dermatologists who were asked to comment on the research.

The study covered over 4 million visits for psoriasis and found that the mean duration of visits for Asian patients was 9.2 minutes, compared with 15.7 minutes for Hispanic or Latino patients, 20.7 minutes for non-Hispanic Black patients, and 15.4 minutes for non-Hispanic White patients.

The mean duration of visits with Asian patients was 39.9% shorter, compared with visits with White patients (beta coefficient, –5,747; 95% confidence interval, –11.026 to –0.469; P = .03), and 40.6% shorter, compared with visits with non-Asian patients combined (beta coefficient, –5.908; 95% CI, –11.147 to –0.669, P = .03), April W. Armstrong, MD, MPH, professor of dermatology and director of the psoriasis program at the University of Southern California, Los Angeles, and Kevin K. Wu, MD, a dermatology resident at USC, said in a research letter published in JAMA Dermatology.

“The etiology of these differences is unclear,” they wrote. “It is possible that factors such as unconscious bias, cultural differences in communication, or residual confounding may be responsible for the observed findings.”

Their findings came from multivariable linear regression analyses that adjusted for age, sex, type of visit (new or follow-up), visit complexity based on the number of reasons for the visit, insurance status (such as private insurance or Medicaid), psoriasis severity on the basis of systemic psoriasis treatment or phototherapy, and complex topical regimens (three or more topical agents).

Commenting on the results, Deborah A. Scott, MD, codirector of the skin of color dermatology program at Brigham and Women’s Hospital and assistant professor at Harvard Medical School, both in Boston, said in an interview that visit length “is a reasonable parameter to look at among many others” when investigating potential disparities in care.

“They’re equating [shorter visit times] with lack of time spent counseling patients,” said Dr. Scott, who was not involved in the research. But there are “many variables” that can affect visit time, such as language differences, time spent with interpreters, and differences in patient educational levels.

Clarissa Yang, MD, dermatologist-in-chief at Tufts Medical Center, Boston, agreed. “We’re worried about there being a quality of care issue. However, there could also be differences culturally in how [the patients] interact with their physicians – their styles and the questions they ask,” she said in an interview. “The study is a good first step to noting that there may be a disparity,” and there is a need to break down the differences “into more granularity.”

Previous research, the authors wrote, has found that Asian patients were less likely to receive counseling from physicians, compared with White patients. And “paradoxically,” they noted, Asian individuals tend to present with more severe psoriasis than patients of other races and ethnicities.

Dr. Scott said the tendency to present with more severe psoriasis has been documented in patients with skin of color broadly – likely because of delays in recognition and treatment.

Race and ethnicity in the study were self-reported by patients, and missing data were imputed by NAMCS researchers using a sequential regression method. Patients who did not report race and ethnicity may have different characteristics affecting visit duration than those who did report the information, Dr. Armstrong and Dr. Wu said in describing their study’s limitations.

Other differences found

In addition to visit length, they found significant differences in mean age and in the use of complex topical regimens. The mean ages of Asian, Hispanic or Latino, and non-Hispanic Black patients were 37.2, 44.7, and 33.3 years, respectively. Complex topical regimens were prescribed to 11.8% of Asian patients, compared with 1.5% of Black and 1.1% of White patients.

For practicing dermatologists, knowing for now that Asian patients have shorter visits “may bring to light some consciousness to how we practice,” Dr. Yang noted. “We may counsel differently, we may spend differing amounts of time – for reasons still unknown. But being generally aware can help us to shift any unconscious bias that may be there.”

Dermatologists, Dr. Armstrong and Dr. Wu wrote, “need to allow sufficient time to develop strong physician-patient communication regardless of patient background.”

The NAMCS – administered by the Center for Disease Control and Prevention’s National Center for Health Statistics – collects data on a sample of visits provided by non–federally employed office-based physicians.

Dr. Armstrong disclosed receiving personal fees from AbbVie and Regeneron for research funding and serving as a scientific adviser and speaker for additional pharmaceutical and therapeutic companies. Dr. Wu, Dr. Scott, and Dr. Yang did not report any disclosures.
 

Alcohol is a major preventable risk factor for cancer. New data suggest that reducing alcohol intake reduces the risk of developing an alcohol-related cancer.

The findings, from a large population-based study conducted in Korea, underscore the importance of encouraging individuals to quit drinking or to reduce alcohol consumption to help reduce cancer risk, the authors noted.

The study was published online in JAMA Network Open.

It provides evidence “suggesting that cancer risk can be meaningfully altered by changing the amount of alcoholic beverages consumed,” wrote the authors of an accompanying editorial, Neal D. Freedman, PhD, and Christian C. Abnet, PhD, of the division of cancer epidemiology and genetics at the National Cancer Institute, Rockville, Md.

“Alcohol consumption is an important cancer risk factor,” they wrote, adding that a “well examined dose-response association has been reported, with highest risks observed among people who drink 3 alcoholic beverages per day and higher.”

The new study shows that a “reduction in use was associated with lower risk, particularly among participants who started drinking at a heavy level,” they noted.

Previous studies have estimated that alcohol use accounts for nearly 4% of newly diagnosed cancers worldwide and nearly 5% of U.S. cancer cases overall.

But the figures are much higher for some specific cancers. That same U.S. study found that alcohol accounts for at least 45% of oral cavity/pharyngeal cancers and at least 25% of laryngeal cancers, as well as 12.1% of female breast cancers, 11.1% of colorectal cancers, 10.5% of liver cancers, and 7.7% of esophageal cancers, as previously reported by this news organization.
 

New findings on reducing intake

This latest study involved an analysis of data on 4.5 million individuals who were adult beneficiaries of the Korean National Health Insurance Service. The median age of the participants was 53.6 years, and they underwent a national health screening in 2009 and 2011.

During median follow-up of 6.4 years, the cancer incidence rate was 7.7 per 1,000 person-years.

Information on alcohol consumption was collected from self-administered questionnaires completed during the health screenings. Participants were categorized on the basis of alcohol consumption: none (0 g/d), mild ( less than 15 g/d), moderate (15-29.9 g/d), and heavy (30 or more g/d).

Compared with those who sustained their alcohol consumption level during the study period, those who increased their level were at higher risk of alcohol-related cancers and all cancers, the investigators found.

The increase in alcohol-related cancer incidence was dose dependent: Those who changed from nondrinking to mild, moderate, or heavy drinking were at increasingly higher risk for alcohol-related cancer, compared with those who remained nondrinkers (adjusted hazard ratios [aHRs], 1.03, 1.10, and 1.34, respectively).

Participants who were mild drinkers at baseline and who quit drinking were at lower risk of alcohol-related cancer, compared with those whose drinking level was sustained (aHR, 0.96). Those with moderate or heavy drinking levels who quit drinking were at higher overall cancer risk than were those who sustained their drinking levels. However, this difference was negated when quitting was sustained, the authors noted.

For heavy drinkers who reduced their drinking levels, cancer incidence was reduced, compared with those who sustained heavy drinking levels. This was true for those who changed from heavy to moderate drinking (aHR, 0.91 for alcohol-related cancers; 0.96 for alcohol-related cancers) and those who changed from heavy to mild drinking (aHR, 0.92 for alcohol-related cancers and all cancers).

“Alcohol cessation and reduction should be reinforced for the prevention of cancer,” concluded the authors.
 

Implications and future directions

The editorialists noted that the study is limited by several factors, such as a short interval between assessments and relatively short follow-up. There is also no information on participants’ alcohol consumption earlier in life or about other healthy lifestyle changes during the study period. In addition, there is no mention of a genetic variant affecting aldehyde dehydrogenase that leads to alcohol-induced flushing, which is common among East Asians.

Despite of these limitations, the study provides “important new findings about the potential role of changes in alcohol consumption in cancer risk,” Dr. Freedman and Dr. Abnet noted. Future studies should examine the association between alcohol intake and cancer risk in other populations and use longer intervals between assessments, they suggested.

“Such studies are needed to move the field forward and inform public health guidance on cancer prevention,” the editorialists concluded.

The authors of the study and the editorialists have disclosed no relevant financial relationships.

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

Alcohol is a major preventable risk factor for cancer. New data suggest that reducing alcohol intake reduces the risk of developing an alcohol-related cancer.

The findings, from a large population-based study conducted in Korea, underscore the importance of encouraging individuals to quit drinking or to reduce alcohol consumption to help reduce cancer risk, the authors noted.

The study was published online in JAMA Network Open.

It provides evidence “suggesting that cancer risk can be meaningfully altered by changing the amount of alcoholic beverages consumed,” wrote the authors of an accompanying editorial, Neal D. Freedman, PhD, and Christian C. Abnet, PhD, of the division of cancer epidemiology and genetics at the National Cancer Institute, Rockville, Md.

“Alcohol consumption is an important cancer risk factor,” they wrote, adding that a “well examined dose-response association has been reported, with highest risks observed among people who drink 3 alcoholic beverages per day and higher.”

The new study shows that a “reduction in use was associated with lower risk, particularly among participants who started drinking at a heavy level,” they noted.

Previous studies have estimated that alcohol use accounts for nearly 4% of newly diagnosed cancers worldwide and nearly 5% of U.S. cancer cases overall.

But the figures are much higher for some specific cancers. That same U.S. study found that alcohol accounts for at least 45% of oral cavity/pharyngeal cancers and at least 25% of laryngeal cancers, as well as 12.1% of female breast cancers, 11.1% of colorectal cancers, 10.5% of liver cancers, and 7.7% of esophageal cancers, as previously reported by this news organization.
 

New findings on reducing intake

This latest study involved an analysis of data on 4.5 million individuals who were adult beneficiaries of the Korean National Health Insurance Service. The median age of the participants was 53.6 years, and they underwent a national health screening in 2009 and 2011.

During median follow-up of 6.4 years, the cancer incidence rate was 7.7 per 1,000 person-years.

Information on alcohol consumption was collected from self-administered questionnaires completed during the health screenings. Participants were categorized on the basis of alcohol consumption: none (0 g/d), mild ( less than 15 g/d), moderate (15-29.9 g/d), and heavy (30 or more g/d).

Compared with those who sustained their alcohol consumption level during the study period, those who increased their level were at higher risk of alcohol-related cancers and all cancers, the investigators found.

The increase in alcohol-related cancer incidence was dose dependent: Those who changed from nondrinking to mild, moderate, or heavy drinking were at increasingly higher risk for alcohol-related cancer, compared with those who remained nondrinkers (adjusted hazard ratios [aHRs], 1.03, 1.10, and 1.34, respectively).

Participants who were mild drinkers at baseline and who quit drinking were at lower risk of alcohol-related cancer, compared with those whose drinking level was sustained (aHR, 0.96). Those with moderate or heavy drinking levels who quit drinking were at higher overall cancer risk than were those who sustained their drinking levels. However, this difference was negated when quitting was sustained, the authors noted.

For heavy drinkers who reduced their drinking levels, cancer incidence was reduced, compared with those who sustained heavy drinking levels. This was true for those who changed from heavy to moderate drinking (aHR, 0.91 for alcohol-related cancers; 0.96 for alcohol-related cancers) and those who changed from heavy to mild drinking (aHR, 0.92 for alcohol-related cancers and all cancers).

“Alcohol cessation and reduction should be reinforced for the prevention of cancer,” concluded the authors.
 

Implications and future directions

The editorialists noted that the study is limited by several factors, such as a short interval between assessments and relatively short follow-up. There is also no information on participants’ alcohol consumption earlier in life or about other healthy lifestyle changes during the study period. In addition, there is no mention of a genetic variant affecting aldehyde dehydrogenase that leads to alcohol-induced flushing, which is common among East Asians.

Despite of these limitations, the study provides “important new findings about the potential role of changes in alcohol consumption in cancer risk,” Dr. Freedman and Dr. Abnet noted. Future studies should examine the association between alcohol intake and cancer risk in other populations and use longer intervals between assessments, they suggested.

“Such studies are needed to move the field forward and inform public health guidance on cancer prevention,” the editorialists concluded.

The authors of the study and the editorialists have disclosed no relevant financial relationships.

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

Alcohol is a major preventable risk factor for cancer. New data suggest that reducing alcohol intake reduces the risk of developing an alcohol-related cancer.

The findings, from a large population-based study conducted in Korea, underscore the importance of encouraging individuals to quit drinking or to reduce alcohol consumption to help reduce cancer risk, the authors noted.

The study was published online in JAMA Network Open.

It provides evidence “suggesting that cancer risk can be meaningfully altered by changing the amount of alcoholic beverages consumed,” wrote the authors of an accompanying editorial, Neal D. Freedman, PhD, and Christian C. Abnet, PhD, of the division of cancer epidemiology and genetics at the National Cancer Institute, Rockville, Md.

“Alcohol consumption is an important cancer risk factor,” they wrote, adding that a “well examined dose-response association has been reported, with highest risks observed among people who drink 3 alcoholic beverages per day and higher.”

The new study shows that a “reduction in use was associated with lower risk, particularly among participants who started drinking at a heavy level,” they noted.

Previous studies have estimated that alcohol use accounts for nearly 4% of newly diagnosed cancers worldwide and nearly 5% of U.S. cancer cases overall.

But the figures are much higher for some specific cancers. That same U.S. study found that alcohol accounts for at least 45% of oral cavity/pharyngeal cancers and at least 25% of laryngeal cancers, as well as 12.1% of female breast cancers, 11.1% of colorectal cancers, 10.5% of liver cancers, and 7.7% of esophageal cancers, as previously reported by this news organization.
 

New findings on reducing intake

This latest study involved an analysis of data on 4.5 million individuals who were adult beneficiaries of the Korean National Health Insurance Service. The median age of the participants was 53.6 years, and they underwent a national health screening in 2009 and 2011.

During median follow-up of 6.4 years, the cancer incidence rate was 7.7 per 1,000 person-years.

Information on alcohol consumption was collected from self-administered questionnaires completed during the health screenings. Participants were categorized on the basis of alcohol consumption: none (0 g/d), mild ( less than 15 g/d), moderate (15-29.9 g/d), and heavy (30 or more g/d).

Compared with those who sustained their alcohol consumption level during the study period, those who increased their level were at higher risk of alcohol-related cancers and all cancers, the investigators found.

The increase in alcohol-related cancer incidence was dose dependent: Those who changed from nondrinking to mild, moderate, or heavy drinking were at increasingly higher risk for alcohol-related cancer, compared with those who remained nondrinkers (adjusted hazard ratios [aHRs], 1.03, 1.10, and 1.34, respectively).

Participants who were mild drinkers at baseline and who quit drinking were at lower risk of alcohol-related cancer, compared with those whose drinking level was sustained (aHR, 0.96). Those with moderate or heavy drinking levels who quit drinking were at higher overall cancer risk than were those who sustained their drinking levels. However, this difference was negated when quitting was sustained, the authors noted.

For heavy drinkers who reduced their drinking levels, cancer incidence was reduced, compared with those who sustained heavy drinking levels. This was true for those who changed from heavy to moderate drinking (aHR, 0.91 for alcohol-related cancers; 0.96 for alcohol-related cancers) and those who changed from heavy to mild drinking (aHR, 0.92 for alcohol-related cancers and all cancers).

“Alcohol cessation and reduction should be reinforced for the prevention of cancer,” concluded the authors.
 

Implications and future directions

The editorialists noted that the study is limited by several factors, such as a short interval between assessments and relatively short follow-up. There is also no information on participants’ alcohol consumption earlier in life or about other healthy lifestyle changes during the study period. In addition, there is no mention of a genetic variant affecting aldehyde dehydrogenase that leads to alcohol-induced flushing, which is common among East Asians.

Despite of these limitations, the study provides “important new findings about the potential role of changes in alcohol consumption in cancer risk,” Dr. Freedman and Dr. Abnet noted. Future studies should examine the association between alcohol intake and cancer risk in other populations and use longer intervals between assessments, they suggested.

“Such studies are needed to move the field forward and inform public health guidance on cancer prevention,” the editorialists concluded.

The authors of the study and the editorialists have disclosed no relevant financial relationships.

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

Adults aged 85 years and older who logged an hour or more of walking each week had a 40% reduced risk of all-cause mortality compared with less active peers, according to data from more than 7,000 individuals.

“Aging is accompanied by reduced physical activity and increased sedentary behavior, and reduced physical activity is associated with decreased life expectancy,” Moo-Nyun Jin, MD, of Inje University Sanggye Paik Hospital, Seoul, South Korea, said in an interview.

Reduced physical activity was especially likely in the elderly during the COVID-19 pandemic, he added.

oneinchpunch/Thinkstock

“Promoting walking may be a simple way to help older adults avoid inactivity and encourage an active lifestyle for all-cause and cardiovascular mortality risk reduction,” Dr. Jin said.

Although walking is generally an easy form of exercise for the older adult population, the specific benefit of walking on reducing mortality has not been well studied, according to Dr. Jin and colleagues.

For adults of any age, current guidelines recommend at least 150 minutes per week of moderate activity or 75 minutes per week of vigorous activity, but the amount of physical activity tends to decline with age, and activity recommendations are more difficult to meet, the authors wrote in a press release accompanying their study.

In the study, to be presented at the European Society of Cardiology Congress on Aug. 28 (Abstract 85643), the researchers reviewed data from 7,047 adults aged 85 years and older who participated in the Korean National Health Screening Program. The average age of the study population was 87 years, and 68% were women. Participants completed questionnaires about the amount of time spent in leisure time activities each week, including walking at a slow pace, moderate activity (such as cycling or brisk walking), and vigorous activity (such as running).

Those who walked at a slow pace for at least 1 hour per week had a 40% reduced risk of all-cause mortality and a 39% reduced risk of cardiovascular mortality, compared with inactive participants.

The proportions of participants who reported walking, moderate activity,­ and vigorous ­intensity physical activity were 42.5%, 14.7%, and 11.0%, respectively. Roughly one-third (33%) of those who reported slow walking each week also reported moderate or vigorous physical activity.

However, walking for 1 hour per week significantly reduced the risk for all-cause mortality and cardiovascular mortality among individuals who reported walking only, without other moderate or vigorous physical activity (hazard ratio, 0.50 and 0.46, respectively).

“Walking was linked with a lower likelihood of dying in older adults, regardless of whether or not they did any moderate to vigorous intensity physical activity,” Dr. Jin told this news organization. “Our study indicates that walking even just 1 hour every week is advantageous to those aged 85 years and older compared to being inactive.”

The hour of walking need not be in long bouts, 10 minutes each day will do, Dr. Jin added.

The participants were divided into five groups based on reported amount of weekly walking. More than half (57.5%) reported no slow walking, 8.5% walked less than 1 hour per week, 12.0% walked 1-2 hours, 8.7% walked 2-3 hours, and 13.3% walked more than 3 hours.

Although the study was limited by the reliance on self-reports, the results were strengthened by the large sample size and support the value of easy walking for adults aged 85 years and older compared to being inactive.

“Walking may present an opportunity for promoting physical activity among the elderly population, offering a simple way to avoid inactivity and increase physical activity,” said Dr. Jin. However, more research is needed to evaluate the association between mortality and walking by objective measurement of walking levels, using a device such as a smart watch, he noted.

 

Results are preliminary

“This is an observational study, not an experiment, so it means causality cannot be presumed,” said Maria Fiatarone Singh, MD, a geriatrician with a focus on exercise physiology at the University of Sydney, in an interview. “In other words, it is possible that diseases resulting in mortality prevented people from walking rather than the other way around,” she noted. The only published experimental study on exercise and mortality in older adults was conducted by Dr. Fiatarone Singh and colleagues in Norway. In that study, published in the British Medical Journal in 2020, high-intensity training programs were associated with reduced all-cause mortality compared with inactive controls and individuals who engaged in moderate intensity exercise.

The current study “would have needed to control for many factors related to mortality, such as cardiovascular disease, hypertension, diabetes, malnutrition, and dementia to see what residual benefit might be related to walking,” Dr. Fiatarone Singh said.

“Although walking seems easy and safe, in fact people who are frail, sarcopenic, osteoporotic, or have fallen are recommended to do resistance and balance training rather than walking, and add walking later when they are able to do it safely,” she emphasized.

The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Fiatarone Singh had no financial conflicts to disclose.

Adults aged 85 years and older who logged an hour or more of walking each week had a 40% reduced risk of all-cause mortality compared with less active peers, according to data from more than 7,000 individuals.

“Aging is accompanied by reduced physical activity and increased sedentary behavior, and reduced physical activity is associated with decreased life expectancy,” Moo-Nyun Jin, MD, of Inje University Sanggye Paik Hospital, Seoul, South Korea, said in an interview.

Reduced physical activity was especially likely in the elderly during the COVID-19 pandemic, he added.

oneinchpunch/Thinkstock

“Promoting walking may be a simple way to help older adults avoid inactivity and encourage an active lifestyle for all-cause and cardiovascular mortality risk reduction,” Dr. Jin said.

Although walking is generally an easy form of exercise for the older adult population, the specific benefit of walking on reducing mortality has not been well studied, according to Dr. Jin and colleagues.

For adults of any age, current guidelines recommend at least 150 minutes per week of moderate activity or 75 minutes per week of vigorous activity, but the amount of physical activity tends to decline with age, and activity recommendations are more difficult to meet, the authors wrote in a press release accompanying their study.

In the study, to be presented at the European Society of Cardiology Congress on Aug. 28 (Abstract 85643), the researchers reviewed data from 7,047 adults aged 85 years and older who participated in the Korean National Health Screening Program. The average age of the study population was 87 years, and 68% were women. Participants completed questionnaires about the amount of time spent in leisure time activities each week, including walking at a slow pace, moderate activity (such as cycling or brisk walking), and vigorous activity (such as running).

Those who walked at a slow pace for at least 1 hour per week had a 40% reduced risk of all-cause mortality and a 39% reduced risk of cardiovascular mortality, compared with inactive participants.

The proportions of participants who reported walking, moderate activity,­ and vigorous ­intensity physical activity were 42.5%, 14.7%, and 11.0%, respectively. Roughly one-third (33%) of those who reported slow walking each week also reported moderate or vigorous physical activity.

However, walking for 1 hour per week significantly reduced the risk for all-cause mortality and cardiovascular mortality among individuals who reported walking only, without other moderate or vigorous physical activity (hazard ratio, 0.50 and 0.46, respectively).

“Walking was linked with a lower likelihood of dying in older adults, regardless of whether or not they did any moderate to vigorous intensity physical activity,” Dr. Jin told this news organization. “Our study indicates that walking even just 1 hour every week is advantageous to those aged 85 years and older compared to being inactive.”

The hour of walking need not be in long bouts, 10 minutes each day will do, Dr. Jin added.

The participants were divided into five groups based on reported amount of weekly walking. More than half (57.5%) reported no slow walking, 8.5% walked less than 1 hour per week, 12.0% walked 1-2 hours, 8.7% walked 2-3 hours, and 13.3% walked more than 3 hours.

Although the study was limited by the reliance on self-reports, the results were strengthened by the large sample size and support the value of easy walking for adults aged 85 years and older compared to being inactive.

“Walking may present an opportunity for promoting physical activity among the elderly population, offering a simple way to avoid inactivity and increase physical activity,” said Dr. Jin. However, more research is needed to evaluate the association between mortality and walking by objective measurement of walking levels, using a device such as a smart watch, he noted.

 

Results are preliminary

“This is an observational study, not an experiment, so it means causality cannot be presumed,” said Maria Fiatarone Singh, MD, a geriatrician with a focus on exercise physiology at the University of Sydney, in an interview. “In other words, it is possible that diseases resulting in mortality prevented people from walking rather than the other way around,” she noted. The only published experimental study on exercise and mortality in older adults was conducted by Dr. Fiatarone Singh and colleagues in Norway. In that study, published in the British Medical Journal in 2020, high-intensity training programs were associated with reduced all-cause mortality compared with inactive controls and individuals who engaged in moderate intensity exercise.

The current study “would have needed to control for many factors related to mortality, such as cardiovascular disease, hypertension, diabetes, malnutrition, and dementia to see what residual benefit might be related to walking,” Dr. Fiatarone Singh said.

“Although walking seems easy and safe, in fact people who are frail, sarcopenic, osteoporotic, or have fallen are recommended to do resistance and balance training rather than walking, and add walking later when they are able to do it safely,” she emphasized.

The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Fiatarone Singh had no financial conflicts to disclose.

Adults aged 85 years and older who logged an hour or more of walking each week had a 40% reduced risk of all-cause mortality compared with less active peers, according to data from more than 7,000 individuals.

“Aging is accompanied by reduced physical activity and increased sedentary behavior, and reduced physical activity is associated with decreased life expectancy,” Moo-Nyun Jin, MD, of Inje University Sanggye Paik Hospital, Seoul, South Korea, said in an interview.

Reduced physical activity was especially likely in the elderly during the COVID-19 pandemic, he added.

oneinchpunch/Thinkstock

“Promoting walking may be a simple way to help older adults avoid inactivity and encourage an active lifestyle for all-cause and cardiovascular mortality risk reduction,” Dr. Jin said.

Although walking is generally an easy form of exercise for the older adult population, the specific benefit of walking on reducing mortality has not been well studied, according to Dr. Jin and colleagues.

For adults of any age, current guidelines recommend at least 150 minutes per week of moderate activity or 75 minutes per week of vigorous activity, but the amount of physical activity tends to decline with age, and activity recommendations are more difficult to meet, the authors wrote in a press release accompanying their study.

In the study, to be presented at the European Society of Cardiology Congress on Aug. 28 (Abstract 85643), the researchers reviewed data from 7,047 adults aged 85 years and older who participated in the Korean National Health Screening Program. The average age of the study population was 87 years, and 68% were women. Participants completed questionnaires about the amount of time spent in leisure time activities each week, including walking at a slow pace, moderate activity (such as cycling or brisk walking), and vigorous activity (such as running).

Those who walked at a slow pace for at least 1 hour per week had a 40% reduced risk of all-cause mortality and a 39% reduced risk of cardiovascular mortality, compared with inactive participants.

The proportions of participants who reported walking, moderate activity,­ and vigorous ­intensity physical activity were 42.5%, 14.7%, and 11.0%, respectively. Roughly one-third (33%) of those who reported slow walking each week also reported moderate or vigorous physical activity.

However, walking for 1 hour per week significantly reduced the risk for all-cause mortality and cardiovascular mortality among individuals who reported walking only, without other moderate or vigorous physical activity (hazard ratio, 0.50 and 0.46, respectively).

“Walking was linked with a lower likelihood of dying in older adults, regardless of whether or not they did any moderate to vigorous intensity physical activity,” Dr. Jin told this news organization. “Our study indicates that walking even just 1 hour every week is advantageous to those aged 85 years and older compared to being inactive.”

The hour of walking need not be in long bouts, 10 minutes each day will do, Dr. Jin added.

The participants were divided into five groups based on reported amount of weekly walking. More than half (57.5%) reported no slow walking, 8.5% walked less than 1 hour per week, 12.0% walked 1-2 hours, 8.7% walked 2-3 hours, and 13.3% walked more than 3 hours.

Although the study was limited by the reliance on self-reports, the results were strengthened by the large sample size and support the value of easy walking for adults aged 85 years and older compared to being inactive.

“Walking may present an opportunity for promoting physical activity among the elderly population, offering a simple way to avoid inactivity and increase physical activity,” said Dr. Jin. However, more research is needed to evaluate the association between mortality and walking by objective measurement of walking levels, using a device such as a smart watch, he noted.

 

Results are preliminary

“This is an observational study, not an experiment, so it means causality cannot be presumed,” said Maria Fiatarone Singh, MD, a geriatrician with a focus on exercise physiology at the University of Sydney, in an interview. “In other words, it is possible that diseases resulting in mortality prevented people from walking rather than the other way around,” she noted. The only published experimental study on exercise and mortality in older adults was conducted by Dr. Fiatarone Singh and colleagues in Norway. In that study, published in the British Medical Journal in 2020, high-intensity training programs were associated with reduced all-cause mortality compared with inactive controls and individuals who engaged in moderate intensity exercise.

The current study “would have needed to control for many factors related to mortality, such as cardiovascular disease, hypertension, diabetes, malnutrition, and dementia to see what residual benefit might be related to walking,” Dr. Fiatarone Singh said.

“Although walking seems easy and safe, in fact people who are frail, sarcopenic, osteoporotic, or have fallen are recommended to do resistance and balance training rather than walking, and add walking later when they are able to do it safely,” she emphasized.

The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Fiatarone Singh had no financial conflicts to disclose.

Cholesterol levels in American adults have improved over the previous decade, but a large cross-sectional analysis of more than 30,000 U.S. adults has found notable disparities in cholesterol control, particularly among Asian adults, lower lipid control rates among Black and other Hispanic adults compared to Whites, and no appreciable improvements for people taking statins.

“We found that total cholesterol improved significantly among U.S. adults from 2008 to 2018,” senior study author Rishi Wadhera, MD, of Beth Israel Deaconess Medical Center in Boston, said in an interview. “When we looked at rates of lipid control among adults treated with statins, we found no significant improvements from 2008 through 2018.”

He noted the patterns for lipid control were consistent for women and men, adding, “In contrast to all other racial and ethnic groups, Mexican American and Black adults did experience significant improvements in cholesterol control. Despite this progress, rates of cholesterol control still remained significantly lower in Black adults compared to White adults.”

The study analyzed lipid concentrations from 33,040 adults ages 20 and older from the National Health and Nutrition Examination Surveys (NHANES), using 2007-2008 as the baseline and 2017-2018 as the endpoint. With lipid control defined as total cholesterol of 200 mg/dL or less, the analysis showed that total cholesterol improved in the overall population from 197 to 189 mg/dL in that time (95% confidence interval, –12.2 to –4.9 mg/dL; P < .001).

The study analyzed lipid trends in several demographic categories. Age-adjusted total cholesterol for women improved significantly, from 199 to 192 mg/dL (95% confidence interval [CI], –11.6 to –3.6 mg/dL; P < .001), but improved slightly more for men, from 195 to 185 mg/dL (95% CI, –14 to –5.1 mg/dL; P < .001).

Overall, age-adjusted total cholesterol improved significantly for Blacks (–7.8 mg/dL), Mexican Americans (–11.3 mg/dL), other Hispanic adults (–8 mg/dL) and Whites (–8.8 mg/dL; P < .001 for all), but not for Asian adults, measured from 2011-2012 to 2017-2018: –.2 mg/dL (95% CI, –6.5 to 6.2 mg/dL; P = .9).

The study found that LDL cholesterol, on an age-adjusted basis, improved significantly overall, from 116 mg/dL in 2007-2008 to 111 mg/dL in 2017-2018 (95% CI, –8.3 to –1.4 mg/dL; P = .001). However, unlike total cholesterol, this improvement didn’t carry over to most ethnic groups. Mexican American adults (–8 mg/dL; P = .01) and Whites (–5.9 mg/dL; P = .001) showed significant improvements, but Asian, Black or other Hispanic adults didn’t.

The study also evaluated lipid control in people taking statins and found that, overall, it didn’t change significantly: from 78.5% in 2007-2008 to 79.5% in 2017-2018 (P = .27). Mexican American adults were the only ethnic group that showed significant improvement in lipid control, going from 73% in 2007-2008 to 86.5% in 2017-2018 (P = .008).

Disparities in lipid control

Women had notably lower lipid control rates than men, with an odds ratio of .52 in 2007-2010 (P < .001), with similar patterns found in 2011-2014 (OR, 0.48) and 2015-2018 (OR, 0.54, P < .001 for both).

Lipid control worsened over time for Black and other Hispanic adults compared to Whites. In 2007-2010, lipid control rates among the studied ethnic groups were similar, a trend that carried over to the 2011-2014 study interval and included Asian adults. However, in 2015-2018, Blacks had lower rates of lipid control compared to Whites (OR, 0.66; 95% CI, .47-.94; P = .03), as did other Hispanic adults (OR, 0.59; 95% CI, .37-.95; P = .04).

These disparities between sexes and ethnic groups warrant further investigation, Dr. Wadhera said. “We were surprised that women had significantly lower rates of cholesterol control than men,” he said. “We need to better understand whether gaps in care, such barriers in access, less frequent lab monitoring of cholesterol, or less intensive prescribing of important treatments, contribute to these differences.”

He called the lower lipid control rates in Black and Hispanic adults “concerning, especially because rates of heart attacks and strokes remain high in these groups. ... Efforts to identify gaps in care and increase and intensify medical therapy are needed, as treatment rates in these populations are low.”

While the study collected data before the COVID-19 pandemic, Dr. Wadhera acknowledged that the management of cardiovascular risk factors may have worsened because of it. “Monitoring cholesterol levels and control rates in the U.S. population as we emerge from the pandemic will be critically important,” he said.

In an accompanying editorial, Hermes Florez, MD, PhD, of the Medical University of South Carolina in Charleston, and colleagues called for adequately powered studies to further investigate the disparities in the Asian and Hispanic populations. “Worse rates of cholesterol control observed in women and in minority populations deserve special attention,” they wrote.

They noted that future studies should consider the impact of guidelines and recommendations that emerged since the study started, namely from the American College of Cardiology/American Heart Association 2013 guidelines, Healthy People 2030, and the U.S. Preventive Services Task Force (JAMA. 2022 Aug 23. doi: 10.1001/jama.2022.13044).

“More important, future work must focus on how to effectively eliminate those disparities and better control modifiable risk factors to enhance outcomes for all individuals regardless of race and ethnicity,” Dr. Florez and colleagues wrote.

The study received funding from the National Heart, Lung, and Blood Institute. Dr. Wadhera disclosed relationships with CVS Health and Abbott. Dr. Florez and colleagues have no disclosures.

Cholesterol levels in American adults have improved over the previous decade, but a large cross-sectional analysis of more than 30,000 U.S. adults has found notable disparities in cholesterol control, particularly among Asian adults, lower lipid control rates among Black and other Hispanic adults compared to Whites, and no appreciable improvements for people taking statins.

“We found that total cholesterol improved significantly among U.S. adults from 2008 to 2018,” senior study author Rishi Wadhera, MD, of Beth Israel Deaconess Medical Center in Boston, said in an interview. “When we looked at rates of lipid control among adults treated with statins, we found no significant improvements from 2008 through 2018.”

He noted the patterns for lipid control were consistent for women and men, adding, “In contrast to all other racial and ethnic groups, Mexican American and Black adults did experience significant improvements in cholesterol control. Despite this progress, rates of cholesterol control still remained significantly lower in Black adults compared to White adults.”

The study analyzed lipid concentrations from 33,040 adults ages 20 and older from the National Health and Nutrition Examination Surveys (NHANES), using 2007-2008 as the baseline and 2017-2018 as the endpoint. With lipid control defined as total cholesterol of 200 mg/dL or less, the analysis showed that total cholesterol improved in the overall population from 197 to 189 mg/dL in that time (95% confidence interval, –12.2 to –4.9 mg/dL; P < .001).

The study analyzed lipid trends in several demographic categories. Age-adjusted total cholesterol for women improved significantly, from 199 to 192 mg/dL (95% confidence interval [CI], –11.6 to –3.6 mg/dL; P < .001), but improved slightly more for men, from 195 to 185 mg/dL (95% CI, –14 to –5.1 mg/dL; P < .001).

Overall, age-adjusted total cholesterol improved significantly for Blacks (–7.8 mg/dL), Mexican Americans (–11.3 mg/dL), other Hispanic adults (–8 mg/dL) and Whites (–8.8 mg/dL; P < .001 for all), but not for Asian adults, measured from 2011-2012 to 2017-2018: –.2 mg/dL (95% CI, –6.5 to 6.2 mg/dL; P = .9).

The study found that LDL cholesterol, on an age-adjusted basis, improved significantly overall, from 116 mg/dL in 2007-2008 to 111 mg/dL in 2017-2018 (95% CI, –8.3 to –1.4 mg/dL; P = .001). However, unlike total cholesterol, this improvement didn’t carry over to most ethnic groups. Mexican American adults (–8 mg/dL; P = .01) and Whites (–5.9 mg/dL; P = .001) showed significant improvements, but Asian, Black or other Hispanic adults didn’t.

The study also evaluated lipid control in people taking statins and found that, overall, it didn’t change significantly: from 78.5% in 2007-2008 to 79.5% in 2017-2018 (P = .27). Mexican American adults were the only ethnic group that showed significant improvement in lipid control, going from 73% in 2007-2008 to 86.5% in 2017-2018 (P = .008).

Disparities in lipid control

Women had notably lower lipid control rates than men, with an odds ratio of .52 in 2007-2010 (P < .001), with similar patterns found in 2011-2014 (OR, 0.48) and 2015-2018 (OR, 0.54, P < .001 for both).

Lipid control worsened over time for Black and other Hispanic adults compared to Whites. In 2007-2010, lipid control rates among the studied ethnic groups were similar, a trend that carried over to the 2011-2014 study interval and included Asian adults. However, in 2015-2018, Blacks had lower rates of lipid control compared to Whites (OR, 0.66; 95% CI, .47-.94; P = .03), as did other Hispanic adults (OR, 0.59; 95% CI, .37-.95; P = .04).

These disparities between sexes and ethnic groups warrant further investigation, Dr. Wadhera said. “We were surprised that women had significantly lower rates of cholesterol control than men,” he said. “We need to better understand whether gaps in care, such barriers in access, less frequent lab monitoring of cholesterol, or less intensive prescribing of important treatments, contribute to these differences.”

He called the lower lipid control rates in Black and Hispanic adults “concerning, especially because rates of heart attacks and strokes remain high in these groups. ... Efforts to identify gaps in care and increase and intensify medical therapy are needed, as treatment rates in these populations are low.”

While the study collected data before the COVID-19 pandemic, Dr. Wadhera acknowledged that the management of cardiovascular risk factors may have worsened because of it. “Monitoring cholesterol levels and control rates in the U.S. population as we emerge from the pandemic will be critically important,” he said.

In an accompanying editorial, Hermes Florez, MD, PhD, of the Medical University of South Carolina in Charleston, and colleagues called for adequately powered studies to further investigate the disparities in the Asian and Hispanic populations. “Worse rates of cholesterol control observed in women and in minority populations deserve special attention,” they wrote.

They noted that future studies should consider the impact of guidelines and recommendations that emerged since the study started, namely from the American College of Cardiology/American Heart Association 2013 guidelines, Healthy People 2030, and the U.S. Preventive Services Task Force (JAMA. 2022 Aug 23. doi: 10.1001/jama.2022.13044).

“More important, future work must focus on how to effectively eliminate those disparities and better control modifiable risk factors to enhance outcomes for all individuals regardless of race and ethnicity,” Dr. Florez and colleagues wrote.

The study received funding from the National Heart, Lung, and Blood Institute. Dr. Wadhera disclosed relationships with CVS Health and Abbott. Dr. Florez and colleagues have no disclosures.

Cholesterol levels in American adults have improved over the previous decade, but a large cross-sectional analysis of more than 30,000 U.S. adults has found notable disparities in cholesterol control, particularly among Asian adults, lower lipid control rates among Black and other Hispanic adults compared to Whites, and no appreciable improvements for people taking statins.

“We found that total cholesterol improved significantly among U.S. adults from 2008 to 2018,” senior study author Rishi Wadhera, MD, of Beth Israel Deaconess Medical Center in Boston, said in an interview. “When we looked at rates of lipid control among adults treated with statins, we found no significant improvements from 2008 through 2018.”

He noted the patterns for lipid control were consistent for women and men, adding, “In contrast to all other racial and ethnic groups, Mexican American and Black adults did experience significant improvements in cholesterol control. Despite this progress, rates of cholesterol control still remained significantly lower in Black adults compared to White adults.”

The study analyzed lipid concentrations from 33,040 adults ages 20 and older from the National Health and Nutrition Examination Surveys (NHANES), using 2007-2008 as the baseline and 2017-2018 as the endpoint. With lipid control defined as total cholesterol of 200 mg/dL or less, the analysis showed that total cholesterol improved in the overall population from 197 to 189 mg/dL in that time (95% confidence interval, –12.2 to –4.9 mg/dL; P < .001).

The study analyzed lipid trends in several demographic categories. Age-adjusted total cholesterol for women improved significantly, from 199 to 192 mg/dL (95% confidence interval [CI], –11.6 to –3.6 mg/dL; P < .001), but improved slightly more for men, from 195 to 185 mg/dL (95% CI, –14 to –5.1 mg/dL; P < .001).

Overall, age-adjusted total cholesterol improved significantly for Blacks (–7.8 mg/dL), Mexican Americans (–11.3 mg/dL), other Hispanic adults (–8 mg/dL) and Whites (–8.8 mg/dL; P < .001 for all), but not for Asian adults, measured from 2011-2012 to 2017-2018: –.2 mg/dL (95% CI, –6.5 to 6.2 mg/dL; P = .9).

The study found that LDL cholesterol, on an age-adjusted basis, improved significantly overall, from 116 mg/dL in 2007-2008 to 111 mg/dL in 2017-2018 (95% CI, –8.3 to –1.4 mg/dL; P = .001). However, unlike total cholesterol, this improvement didn’t carry over to most ethnic groups. Mexican American adults (–8 mg/dL; P = .01) and Whites (–5.9 mg/dL; P = .001) showed significant improvements, but Asian, Black or other Hispanic adults didn’t.

The study also evaluated lipid control in people taking statins and found that, overall, it didn’t change significantly: from 78.5% in 2007-2008 to 79.5% in 2017-2018 (P = .27). Mexican American adults were the only ethnic group that showed significant improvement in lipid control, going from 73% in 2007-2008 to 86.5% in 2017-2018 (P = .008).

Disparities in lipid control

Women had notably lower lipid control rates than men, with an odds ratio of .52 in 2007-2010 (P < .001), with similar patterns found in 2011-2014 (OR, 0.48) and 2015-2018 (OR, 0.54, P < .001 for both).

Lipid control worsened over time for Black and other Hispanic adults compared to Whites. In 2007-2010, lipid control rates among the studied ethnic groups were similar, a trend that carried over to the 2011-2014 study interval and included Asian adults. However, in 2015-2018, Blacks had lower rates of lipid control compared to Whites (OR, 0.66; 95% CI, .47-.94; P = .03), as did other Hispanic adults (OR, 0.59; 95% CI, .37-.95; P = .04).

These disparities between sexes and ethnic groups warrant further investigation, Dr. Wadhera said. “We were surprised that women had significantly lower rates of cholesterol control than men,” he said. “We need to better understand whether gaps in care, such barriers in access, less frequent lab monitoring of cholesterol, or less intensive prescribing of important treatments, contribute to these differences.”

He called the lower lipid control rates in Black and Hispanic adults “concerning, especially because rates of heart attacks and strokes remain high in these groups. ... Efforts to identify gaps in care and increase and intensify medical therapy are needed, as treatment rates in these populations are low.”

While the study collected data before the COVID-19 pandemic, Dr. Wadhera acknowledged that the management of cardiovascular risk factors may have worsened because of it. “Monitoring cholesterol levels and control rates in the U.S. population as we emerge from the pandemic will be critically important,” he said.

In an accompanying editorial, Hermes Florez, MD, PhD, of the Medical University of South Carolina in Charleston, and colleagues called for adequately powered studies to further investigate the disparities in the Asian and Hispanic populations. “Worse rates of cholesterol control observed in women and in minority populations deserve special attention,” they wrote.

They noted that future studies should consider the impact of guidelines and recommendations that emerged since the study started, namely from the American College of Cardiology/American Heart Association 2013 guidelines, Healthy People 2030, and the U.S. Preventive Services Task Force (JAMA. 2022 Aug 23. doi: 10.1001/jama.2022.13044).

“More important, future work must focus on how to effectively eliminate those disparities and better control modifiable risk factors to enhance outcomes for all individuals regardless of race and ethnicity,” Dr. Florez and colleagues wrote.

The study received funding from the National Heart, Lung, and Blood Institute. Dr. Wadhera disclosed relationships with CVS Health and Abbott. Dr. Florez and colleagues have no disclosures.

Two biomarkers present in blood measured on the day of traumatic brain injury (TBI) can accurately predict a patient’s risk for death or severe disability 6 months later, new research suggests.

In new data from the TRACK-TBI study group, high levels of glial fibrillary acidic protein (GFAP) and ubiquitin carboxy-terminal hydrolase L1 (UCH-L1) proteins found in glial cells and neurons, respectively, correlated with death and severe injury. Investigators note that measuring these biomarkers may give a more accurate assessment of a patient’s prognosis following TBI.

This study is the “first report of the accuracy of a blood test that can be obtained rapidly on the day of injury to predict neurological recovery at 6 months after injury,” lead author Frederick Korley, MD, PhD, associate professor of emergency medicine at the University of Michigan, Ann Arbor, said in a news release.

The findings were published online in the Lancet Neurology.
 

Added value

The researchers measured GFAP and UCH-L1 in blood samples taken from 1,696 patients with TBI on the day of their injury, and they assessed patient recovery 6 months later.

The markers were measured using the i-STAT TBI Plasma test (Abbott Labs). The test was approved in 2021 by the U.S. Food and Drug Administration to determine which patients with mild TBI should undergo computed tomography scans.

About two-thirds of the study population were men, and the average age was 39 years. All patients were evaluated at Level I trauma centers for injuries caused primarily by traffic accidents or falls.

Six months following injury, 7% of the patients had died and 14% had an unfavorable outcome, ranging from vegetative state to severe disability requiring daily support. In addition, 67% had incomplete recovery, ranging from moderate disabilities requiring assistance outside of the home to minor disabling neurological or psychological deficits.

Day-of-injury GFAP and UCH-L1 levels had a high probability of predicting death (87% for GFAP and 89% for UCH-L1) and severe disability (86% for both GFAP and UCH-L1) at 6 months, the investigators reported.

The biomarkers were less accurate in predicting incomplete recovery (62% for GFAP and 61% for UCH-L1).

The researchers also assessed the added value of combining the blood biomarkers to current TBI prognostic models that take into account variables such as age, motor score, pupil reactivity, and CT characteristics.

In patients with a Glasgow Coma Scale (GCS) score of 3-12, adding GFAP and UCH-L1 alone or combined to each of the three International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) models significantly increased their accuracy for predicting death (range, 90%-94%) and unfavorable outcome (range, 83%-89%).

In patients with milder TBI (GCS score, 13-15), adding GFAP and UCH-L1 to the UPFRONT prognostic model modestly increased accuracy for predicting incomplete recovery (69%).
 

‘Important’ findings

Commenting on the study, Cyrus A. Raji, MD, PhD, assistant professor of radiology and neurology, Washington University, St. Louis, said this “critical” study shows that these biomarkers can “predict key outcomes,” including mortality and severe disability. “Thus, in conjunction with clinical evaluations and related data such as neuroimaging, these tests may warrant translation to broader clinical practice, particularly in acute settings,” said Dr. Raji, who was not involved in the research.

Also weighing in, Heidi Fusco, MD, assistant director of the traumatic brain injury program at NYU Langone Rusk Rehabilitation, said the findings are “important.”

“Prognosis after brain injury often is based on the initial presentation, ongoing clinical exams, and neuroimaging; and the addition of biomarkers would contribute to creating a more objective prognostic model,” Dr. Fusco said.

She noted “it’s unclear” whether clinical hospital laboratories would be able to accommodate this type of laboratory drawing.

“It is imperative that clinicians still use the patient history [and] clinical and radiological exam when making clinical decisions for a patient and not just lab values. It would be best to incorporate the GFAP and UCH-L1 into a preexisting prognostic model,” Dr. Fusco said.

The study was funded by the U.S. National Institutes of Health, the National Institute of Neurologic Disorders and Stroke, the U.S. Department of Defense, One Mind, and U.S. Army Medical Research and Development Command. Dr. Korley reported having previously consulted for Abbott Laboratories and has received research funding from Abbott Laboratories, which makes the assays used in the study. Dr. Raji is a consultant for Brainreader ApS and Neurevolution. Dr. Fusco has reported no relevant financial relationships.

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

Two biomarkers present in blood measured on the day of traumatic brain injury (TBI) can accurately predict a patient’s risk for death or severe disability 6 months later, new research suggests.

In new data from the TRACK-TBI study group, high levels of glial fibrillary acidic protein (GFAP) and ubiquitin carboxy-terminal hydrolase L1 (UCH-L1) proteins found in glial cells and neurons, respectively, correlated with death and severe injury. Investigators note that measuring these biomarkers may give a more accurate assessment of a patient’s prognosis following TBI.

This study is the “first report of the accuracy of a blood test that can be obtained rapidly on the day of injury to predict neurological recovery at 6 months after injury,” lead author Frederick Korley, MD, PhD, associate professor of emergency medicine at the University of Michigan, Ann Arbor, said in a news release.

The findings were published online in the Lancet Neurology.
 

Added value

The researchers measured GFAP and UCH-L1 in blood samples taken from 1,696 patients with TBI on the day of their injury, and they assessed patient recovery 6 months later.

The markers were measured using the i-STAT TBI Plasma test (Abbott Labs). The test was approved in 2021 by the U.S. Food and Drug Administration to determine which patients with mild TBI should undergo computed tomography scans.

About two-thirds of the study population were men, and the average age was 39 years. All patients were evaluated at Level I trauma centers for injuries caused primarily by traffic accidents or falls.

Six months following injury, 7% of the patients had died and 14% had an unfavorable outcome, ranging from vegetative state to severe disability requiring daily support. In addition, 67% had incomplete recovery, ranging from moderate disabilities requiring assistance outside of the home to minor disabling neurological or psychological deficits.

Day-of-injury GFAP and UCH-L1 levels had a high probability of predicting death (87% for GFAP and 89% for UCH-L1) and severe disability (86% for both GFAP and UCH-L1) at 6 months, the investigators reported.

The biomarkers were less accurate in predicting incomplete recovery (62% for GFAP and 61% for UCH-L1).

The researchers also assessed the added value of combining the blood biomarkers to current TBI prognostic models that take into account variables such as age, motor score, pupil reactivity, and CT characteristics.

In patients with a Glasgow Coma Scale (GCS) score of 3-12, adding GFAP and UCH-L1 alone or combined to each of the three International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) models significantly increased their accuracy for predicting death (range, 90%-94%) and unfavorable outcome (range, 83%-89%).

In patients with milder TBI (GCS score, 13-15), adding GFAP and UCH-L1 to the UPFRONT prognostic model modestly increased accuracy for predicting incomplete recovery (69%).
 

‘Important’ findings

Commenting on the study, Cyrus A. Raji, MD, PhD, assistant professor of radiology and neurology, Washington University, St. Louis, said this “critical” study shows that these biomarkers can “predict key outcomes,” including mortality and severe disability. “Thus, in conjunction with clinical evaluations and related data such as neuroimaging, these tests may warrant translation to broader clinical practice, particularly in acute settings,” said Dr. Raji, who was not involved in the research.

Also weighing in, Heidi Fusco, MD, assistant director of the traumatic brain injury program at NYU Langone Rusk Rehabilitation, said the findings are “important.”

“Prognosis after brain injury often is based on the initial presentation, ongoing clinical exams, and neuroimaging; and the addition of biomarkers would contribute to creating a more objective prognostic model,” Dr. Fusco said.

She noted “it’s unclear” whether clinical hospital laboratories would be able to accommodate this type of laboratory drawing.

“It is imperative that clinicians still use the patient history [and] clinical and radiological exam when making clinical decisions for a patient and not just lab values. It would be best to incorporate the GFAP and UCH-L1 into a preexisting prognostic model,” Dr. Fusco said.

The study was funded by the U.S. National Institutes of Health, the National Institute of Neurologic Disorders and Stroke, the U.S. Department of Defense, One Mind, and U.S. Army Medical Research and Development Command. Dr. Korley reported having previously consulted for Abbott Laboratories and has received research funding from Abbott Laboratories, which makes the assays used in the study. Dr. Raji is a consultant for Brainreader ApS and Neurevolution. Dr. Fusco has reported no relevant financial relationships.

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

Two biomarkers present in blood measured on the day of traumatic brain injury (TBI) can accurately predict a patient’s risk for death or severe disability 6 months later, new research suggests.

In new data from the TRACK-TBI study group, high levels of glial fibrillary acidic protein (GFAP) and ubiquitin carboxy-terminal hydrolase L1 (UCH-L1) proteins found in glial cells and neurons, respectively, correlated with death and severe injury. Investigators note that measuring these biomarkers may give a more accurate assessment of a patient’s prognosis following TBI.

This study is the “first report of the accuracy of a blood test that can be obtained rapidly on the day of injury to predict neurological recovery at 6 months after injury,” lead author Frederick Korley, MD, PhD, associate professor of emergency medicine at the University of Michigan, Ann Arbor, said in a news release.

The findings were published online in the Lancet Neurology.
 

Added value

The researchers measured GFAP and UCH-L1 in blood samples taken from 1,696 patients with TBI on the day of their injury, and they assessed patient recovery 6 months later.

The markers were measured using the i-STAT TBI Plasma test (Abbott Labs). The test was approved in 2021 by the U.S. Food and Drug Administration to determine which patients with mild TBI should undergo computed tomography scans.

About two-thirds of the study population were men, and the average age was 39 years. All patients were evaluated at Level I trauma centers for injuries caused primarily by traffic accidents or falls.

Six months following injury, 7% of the patients had died and 14% had an unfavorable outcome, ranging from vegetative state to severe disability requiring daily support. In addition, 67% had incomplete recovery, ranging from moderate disabilities requiring assistance outside of the home to minor disabling neurological or psychological deficits.

Day-of-injury GFAP and UCH-L1 levels had a high probability of predicting death (87% for GFAP and 89% for UCH-L1) and severe disability (86% for both GFAP and UCH-L1) at 6 months, the investigators reported.

The biomarkers were less accurate in predicting incomplete recovery (62% for GFAP and 61% for UCH-L1).

The researchers also assessed the added value of combining the blood biomarkers to current TBI prognostic models that take into account variables such as age, motor score, pupil reactivity, and CT characteristics.

In patients with a Glasgow Coma Scale (GCS) score of 3-12, adding GFAP and UCH-L1 alone or combined to each of the three International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) models significantly increased their accuracy for predicting death (range, 90%-94%) and unfavorable outcome (range, 83%-89%).

In patients with milder TBI (GCS score, 13-15), adding GFAP and UCH-L1 to the UPFRONT prognostic model modestly increased accuracy for predicting incomplete recovery (69%).
 

‘Important’ findings

Commenting on the study, Cyrus A. Raji, MD, PhD, assistant professor of radiology and neurology, Washington University, St. Louis, said this “critical” study shows that these biomarkers can “predict key outcomes,” including mortality and severe disability. “Thus, in conjunction with clinical evaluations and related data such as neuroimaging, these tests may warrant translation to broader clinical practice, particularly in acute settings,” said Dr. Raji, who was not involved in the research.

Also weighing in, Heidi Fusco, MD, assistant director of the traumatic brain injury program at NYU Langone Rusk Rehabilitation, said the findings are “important.”

“Prognosis after brain injury often is based on the initial presentation, ongoing clinical exams, and neuroimaging; and the addition of biomarkers would contribute to creating a more objective prognostic model,” Dr. Fusco said.

She noted “it’s unclear” whether clinical hospital laboratories would be able to accommodate this type of laboratory drawing.

“It is imperative that clinicians still use the patient history [and] clinical and radiological exam when making clinical decisions for a patient and not just lab values. It would be best to incorporate the GFAP and UCH-L1 into a preexisting prognostic model,” Dr. Fusco said.

The study was funded by the U.S. National Institutes of Health, the National Institute of Neurologic Disorders and Stroke, the U.S. Department of Defense, One Mind, and U.S. Army Medical Research and Development Command. Dr. Korley reported having previously consulted for Abbott Laboratories and has received research funding from Abbott Laboratories, which makes the assays used in the study. Dr. Raji is a consultant for Brainreader ApS and Neurevolution. Dr. Fusco has reported no relevant financial relationships.

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

Many dermatopathologists offering a second opinion about melanocytic skin lesions prefer to have access to the first diagnostic report, but a controlled trial demonstrates that this has a powerful influence on perception, diminishing the value and accuracy of an independent analysis.

In a novel effort to determine whether previous interpretations sway second opinions, 149 dermatopathologists were asked to read melanocytic skin biopsy specimens without access to the initial pathology report. A year or more later they read them again but now with access to the initial reading.

The study showed that the participants, independent of many variables, such as years of experience or frequency with which they offered second options, were more likely to upgrade or downgrade the severity of the specimens in accordance with the initial report even if their original reading was correct.

If the goal of a second dermatopathologist opinion is to obtain an independent diagnostic opinion, the message from this study is that they “should be blinded to first opinions,” according to the authors of this study, led by Joann G. Elmore, MD, professor of medicine, University of California, Los Angeles. The study was published online in JAMA Dermatology.
 

Two-phase study has 1-year washout

The study was conducted in two phases. In phase 1, a nationally representative sample of volunteer dermatopathologists performed 878 interpretations. In phase 2, conducted after a washout period of 12 months or more, the dermatopathologists read a random subset of the same cases evaluated in phase 1, but this time, unlike the first, they were first exposed to prior pathology reports.

Ultimately, “the dermatologists provided more than 5,000 interpretations of study cases, which was a big contribution of time,” Dr. Elmore said in an interview. Grateful for their critical contribution, she speculated that they were driven by the importance of the question being asked.

When categorized by the Melanocytic Pathology Assessment Tool (MPAT), which rates specimens from benign (class 1) to pT1b invasive melanoma (class 4), the influence of the prior report went in both directions, so that the likelihood of upgrading or downgrading went in accordance with the grading in the original dermatopathology report.

As a result, the risk of a less severe interpretation on the second relative to the first reading was 38% greater if the initial dermatopathology report had a lower grade (relative risk, 1.38; 95% confidence interval [CI], 1.19-1.59). The risk of upgrading the second report if the initial pathology report had a higher grade was increased by more than 50% (RR, 1.52; 95% CI, 1.34-1.73).

The greater likelihood of upgrading than downgrading is “understandable,” Dr. Elmore said. “I think this is consistent with the concern about missing something,” she explained.

According to Dr. Elmore, one of the greatest concerns regarding the bias imposed by the original pathology report is that the switch of opinions often went from one that was accurate to one that was inaccurate.

If the phase 1 diagnosis was accurate but upgraded in the phase 2 diagnosis, the risk of inaccuracy was almost doubled (RR, 1.96; 95% CI, 1.31-2.93). If the phase 1 report was inaccurate, the relative risk of changing the phase 2 diagnosis was still high but lower than if it was accurate (RR, 1.46; 95% CI, 1.27-1.68).

“That is, even when the phase 1 diagnoses agreed with the consensus reference diagnosis, they were swayed away from the correct diagnosis in phase 2 [when the initial pathology report characterized the specimen as higher grade],” Dr. Elmore reported.

Conversely, the risk of downgrading was about the same whether the phase 1 evaluation was accurate (RR, 1.37; 95% CI, 1.14-1.64) or inaccurate (RR 1.32; 95% CI, 1.07-1.64).

Downward and upward shifts in severity from an accurate diagnosis are concerning because of the likelihood they will lead to overtreatment or undertreatment. The problem, according to data from this study, is that dermatologists making a second opinion cannot judge their own susceptibility to being swayed by the original report.
 

Pathologists might be unaware of bias

At baseline, the participants were asked whether they thought they were influenced by the first interpretation when providing a second opinion. Although 69% acknowledged that they might be “somewhat influenced,” 31% maintained that they do not take initial reports into consideration. When the two groups were compared, the risk of downgrading was nearly identical. The risk of upgrading was lower in those claiming to disregard initial reports (RR, 1.29) relative to those who said they were “somewhat influenced” by a previous diagnosis (RR, 1.64), but the difference was not significant.

The actual risk of bias incurred by prior pathology reports might be greater than that captured in this study for several reasons, according to the investigators. They pointed out that all participants were experienced and board-certified and might therefore be expected to be more confident in their interpretations than an unselected group of dermatopathologists. In addition, participants might have been more careful in their interpretations knowing they were participating in a study.

“There are a lot of data to support the value of second opinions [in dermatopathology and other areas], but we need to consider the process of how they are being obtained,” Dr. Elmore said. “There needs to be a greater emphasis on providing an independent analysis.”

More than 60% of the dermatologists participating in this study reported that they agreed or strongly agreed with the premise that they prefer to have the original dermatopathology report when they offer a second opinion. Dr. Elmore said that the desire of those offering a second opinion to have as much information in front of them as possible is understandable, but the bias imposed by the original report weakens the value of the second opinion.
 

Blind reading of pathology reports needed

“These data suggest that seeing the original report sways opinions and that includes swaying opinions away from an accurate reading,” Dr. Elmore said. She thinks that for dermatopathologists to render a valuable and independent second opinion, the specimens should be examined “at least initially” without access to the first report.

The results of this study were not surprising to Vishal Anil Patel, MD, director of the Cutaneous Oncology Program, George Washington University Cancer Center, Washington. He made the point that physicians “are human first and foremost and not perfect machines.” As a result, he suggested bias and error are inevitable.

Although strategies to avoid bias are likely to offer some protection against inaccuracy, he said that diagnostic support tools such as artificial intelligence might be the right direction for improving inter- and intra-rater reliability.

Ruifeng Guo, MD, PhD, a consultant in the division of anatomic pathology at the Mayo Clinic, Rochester, Minn., agreed with the basic premise of the study, but he cautioned that restricting access to the initial pathology report might not always be the right approach.

It is true that “dermatopathologists providing a second opinion in diagnosing cutaneous melanoma are mostly unaware of the risk of bias if they read the initial pathology report,” said Dr. Guo, but restricting access comes with risks.

“There are also times critical information may be contained in the initial pathology report that needs to be considered when providing a second opinion consultation,” he noted. Ultimately, the decision to read or not read the initial report should be decided “on an individual basis.”

The study was funded by grants from the National Cancer Institute. Dr. Elmore, Dr. Patel, and Dr. Guo reported no relevant financial relationships. 

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

Many dermatopathologists offering a second opinion about melanocytic skin lesions prefer to have access to the first diagnostic report, but a controlled trial demonstrates that this has a powerful influence on perception, diminishing the value and accuracy of an independent analysis.

In a novel effort to determine whether previous interpretations sway second opinions, 149 dermatopathologists were asked to read melanocytic skin biopsy specimens without access to the initial pathology report. A year or more later they read them again but now with access to the initial reading.

The study showed that the participants, independent of many variables, such as years of experience or frequency with which they offered second options, were more likely to upgrade or downgrade the severity of the specimens in accordance with the initial report even if their original reading was correct.

If the goal of a second dermatopathologist opinion is to obtain an independent diagnostic opinion, the message from this study is that they “should be blinded to first opinions,” according to the authors of this study, led by Joann G. Elmore, MD, professor of medicine, University of California, Los Angeles. The study was published online in JAMA Dermatology.
 

Two-phase study has 1-year washout

The study was conducted in two phases. In phase 1, a nationally representative sample of volunteer dermatopathologists performed 878 interpretations. In phase 2, conducted after a washout period of 12 months or more, the dermatopathologists read a random subset of the same cases evaluated in phase 1, but this time, unlike the first, they were first exposed to prior pathology reports.

Ultimately, “the dermatologists provided more than 5,000 interpretations of study cases, which was a big contribution of time,” Dr. Elmore said in an interview. Grateful for their critical contribution, she speculated that they were driven by the importance of the question being asked.

When categorized by the Melanocytic Pathology Assessment Tool (MPAT), which rates specimens from benign (class 1) to pT1b invasive melanoma (class 4), the influence of the prior report went in both directions, so that the likelihood of upgrading or downgrading went in accordance with the grading in the original dermatopathology report.

As a result, the risk of a less severe interpretation on the second relative to the first reading was 38% greater if the initial dermatopathology report had a lower grade (relative risk, 1.38; 95% confidence interval [CI], 1.19-1.59). The risk of upgrading the second report if the initial pathology report had a higher grade was increased by more than 50% (RR, 1.52; 95% CI, 1.34-1.73).

The greater likelihood of upgrading than downgrading is “understandable,” Dr. Elmore said. “I think this is consistent with the concern about missing something,” she explained.

According to Dr. Elmore, one of the greatest concerns regarding the bias imposed by the original pathology report is that the switch of opinions often went from one that was accurate to one that was inaccurate.

If the phase 1 diagnosis was accurate but upgraded in the phase 2 diagnosis, the risk of inaccuracy was almost doubled (RR, 1.96; 95% CI, 1.31-2.93). If the phase 1 report was inaccurate, the relative risk of changing the phase 2 diagnosis was still high but lower than if it was accurate (RR, 1.46; 95% CI, 1.27-1.68).

“That is, even when the phase 1 diagnoses agreed with the consensus reference diagnosis, they were swayed away from the correct diagnosis in phase 2 [when the initial pathology report characterized the specimen as higher grade],” Dr. Elmore reported.

Conversely, the risk of downgrading was about the same whether the phase 1 evaluation was accurate (RR, 1.37; 95% CI, 1.14-1.64) or inaccurate (RR 1.32; 95% CI, 1.07-1.64).

Downward and upward shifts in severity from an accurate diagnosis are concerning because of the likelihood they will lead to overtreatment or undertreatment. The problem, according to data from this study, is that dermatologists making a second opinion cannot judge their own susceptibility to being swayed by the original report.
 

Pathologists might be unaware of bias

At baseline, the participants were asked whether they thought they were influenced by the first interpretation when providing a second opinion. Although 69% acknowledged that they might be “somewhat influenced,” 31% maintained that they do not take initial reports into consideration. When the two groups were compared, the risk of downgrading was nearly identical. The risk of upgrading was lower in those claiming to disregard initial reports (RR, 1.29) relative to those who said they were “somewhat influenced” by a previous diagnosis (RR, 1.64), but the difference was not significant.

The actual risk of bias incurred by prior pathology reports might be greater than that captured in this study for several reasons, according to the investigators. They pointed out that all participants were experienced and board-certified and might therefore be expected to be more confident in their interpretations than an unselected group of dermatopathologists. In addition, participants might have been more careful in their interpretations knowing they were participating in a study.

“There are a lot of data to support the value of second opinions [in dermatopathology and other areas], but we need to consider the process of how they are being obtained,” Dr. Elmore said. “There needs to be a greater emphasis on providing an independent analysis.”

More than 60% of the dermatologists participating in this study reported that they agreed or strongly agreed with the premise that they prefer to have the original dermatopathology report when they offer a second opinion. Dr. Elmore said that the desire of those offering a second opinion to have as much information in front of them as possible is understandable, but the bias imposed by the original report weakens the value of the second opinion.
 

Blind reading of pathology reports needed

“These data suggest that seeing the original report sways opinions and that includes swaying opinions away from an accurate reading,” Dr. Elmore said. She thinks that for dermatopathologists to render a valuable and independent second opinion, the specimens should be examined “at least initially” without access to the first report.

The results of this study were not surprising to Vishal Anil Patel, MD, director of the Cutaneous Oncology Program, George Washington University Cancer Center, Washington. He made the point that physicians “are human first and foremost and not perfect machines.” As a result, he suggested bias and error are inevitable.

Although strategies to avoid bias are likely to offer some protection against inaccuracy, he said that diagnostic support tools such as artificial intelligence might be the right direction for improving inter- and intra-rater reliability.

Ruifeng Guo, MD, PhD, a consultant in the division of anatomic pathology at the Mayo Clinic, Rochester, Minn., agreed with the basic premise of the study, but he cautioned that restricting access to the initial pathology report might not always be the right approach.

It is true that “dermatopathologists providing a second opinion in diagnosing cutaneous melanoma are mostly unaware of the risk of bias if they read the initial pathology report,” said Dr. Guo, but restricting access comes with risks.

“There are also times critical information may be contained in the initial pathology report that needs to be considered when providing a second opinion consultation,” he noted. Ultimately, the decision to read or not read the initial report should be decided “on an individual basis.”

The study was funded by grants from the National Cancer Institute. Dr. Elmore, Dr. Patel, and Dr. Guo reported no relevant financial relationships. 

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

Many dermatopathologists offering a second opinion about melanocytic skin lesions prefer to have access to the first diagnostic report, but a controlled trial demonstrates that this has a powerful influence on perception, diminishing the value and accuracy of an independent analysis.

In a novel effort to determine whether previous interpretations sway second opinions, 149 dermatopathologists were asked to read melanocytic skin biopsy specimens without access to the initial pathology report. A year or more later they read them again but now with access to the initial reading.

The study showed that the participants, independent of many variables, such as years of experience or frequency with which they offered second options, were more likely to upgrade or downgrade the severity of the specimens in accordance with the initial report even if their original reading was correct.

If the goal of a second dermatopathologist opinion is to obtain an independent diagnostic opinion, the message from this study is that they “should be blinded to first opinions,” according to the authors of this study, led by Joann G. Elmore, MD, professor of medicine, University of California, Los Angeles. The study was published online in JAMA Dermatology.
 

Two-phase study has 1-year washout

The study was conducted in two phases. In phase 1, a nationally representative sample of volunteer dermatopathologists performed 878 interpretations. In phase 2, conducted after a washout period of 12 months or more, the dermatopathologists read a random subset of the same cases evaluated in phase 1, but this time, unlike the first, they were first exposed to prior pathology reports.

Ultimately, “the dermatologists provided more than 5,000 interpretations of study cases, which was a big contribution of time,” Dr. Elmore said in an interview. Grateful for their critical contribution, she speculated that they were driven by the importance of the question being asked.

When categorized by the Melanocytic Pathology Assessment Tool (MPAT), which rates specimens from benign (class 1) to pT1b invasive melanoma (class 4), the influence of the prior report went in both directions, so that the likelihood of upgrading or downgrading went in accordance with the grading in the original dermatopathology report.

As a result, the risk of a less severe interpretation on the second relative to the first reading was 38% greater if the initial dermatopathology report had a lower grade (relative risk, 1.38; 95% confidence interval [CI], 1.19-1.59). The risk of upgrading the second report if the initial pathology report had a higher grade was increased by more than 50% (RR, 1.52; 95% CI, 1.34-1.73).

The greater likelihood of upgrading than downgrading is “understandable,” Dr. Elmore said. “I think this is consistent with the concern about missing something,” she explained.

According to Dr. Elmore, one of the greatest concerns regarding the bias imposed by the original pathology report is that the switch of opinions often went from one that was accurate to one that was inaccurate.

If the phase 1 diagnosis was accurate but upgraded in the phase 2 diagnosis, the risk of inaccuracy was almost doubled (RR, 1.96; 95% CI, 1.31-2.93). If the phase 1 report was inaccurate, the relative risk of changing the phase 2 diagnosis was still high but lower than if it was accurate (RR, 1.46; 95% CI, 1.27-1.68).

“That is, even when the phase 1 diagnoses agreed with the consensus reference diagnosis, they were swayed away from the correct diagnosis in phase 2 [when the initial pathology report characterized the specimen as higher grade],” Dr. Elmore reported.

Conversely, the risk of downgrading was about the same whether the phase 1 evaluation was accurate (RR, 1.37; 95% CI, 1.14-1.64) or inaccurate (RR 1.32; 95% CI, 1.07-1.64).

Downward and upward shifts in severity from an accurate diagnosis are concerning because of the likelihood they will lead to overtreatment or undertreatment. The problem, according to data from this study, is that dermatologists making a second opinion cannot judge their own susceptibility to being swayed by the original report.
 

Pathologists might be unaware of bias

At baseline, the participants were asked whether they thought they were influenced by the first interpretation when providing a second opinion. Although 69% acknowledged that they might be “somewhat influenced,” 31% maintained that they do not take initial reports into consideration. When the two groups were compared, the risk of downgrading was nearly identical. The risk of upgrading was lower in those claiming to disregard initial reports (RR, 1.29) relative to those who said they were “somewhat influenced” by a previous diagnosis (RR, 1.64), but the difference was not significant.

The actual risk of bias incurred by prior pathology reports might be greater than that captured in this study for several reasons, according to the investigators. They pointed out that all participants were experienced and board-certified and might therefore be expected to be more confident in their interpretations than an unselected group of dermatopathologists. In addition, participants might have been more careful in their interpretations knowing they were participating in a study.

“There are a lot of data to support the value of second opinions [in dermatopathology and other areas], but we need to consider the process of how they are being obtained,” Dr. Elmore said. “There needs to be a greater emphasis on providing an independent analysis.”

More than 60% of the dermatologists participating in this study reported that they agreed or strongly agreed with the premise that they prefer to have the original dermatopathology report when they offer a second opinion. Dr. Elmore said that the desire of those offering a second opinion to have as much information in front of them as possible is understandable, but the bias imposed by the original report weakens the value of the second opinion.
 

Blind reading of pathology reports needed

“These data suggest that seeing the original report sways opinions and that includes swaying opinions away from an accurate reading,” Dr. Elmore said. She thinks that for dermatopathologists to render a valuable and independent second opinion, the specimens should be examined “at least initially” without access to the first report.

The results of this study were not surprising to Vishal Anil Patel, MD, director of the Cutaneous Oncology Program, George Washington University Cancer Center, Washington. He made the point that physicians “are human first and foremost and not perfect machines.” As a result, he suggested bias and error are inevitable.

Although strategies to avoid bias are likely to offer some protection against inaccuracy, he said that diagnostic support tools such as artificial intelligence might be the right direction for improving inter- and intra-rater reliability.

Ruifeng Guo, MD, PhD, a consultant in the division of anatomic pathology at the Mayo Clinic, Rochester, Minn., agreed with the basic premise of the study, but he cautioned that restricting access to the initial pathology report might not always be the right approach.

It is true that “dermatopathologists providing a second opinion in diagnosing cutaneous melanoma are mostly unaware of the risk of bias if they read the initial pathology report,” said Dr. Guo, but restricting access comes with risks.

“There are also times critical information may be contained in the initial pathology report that needs to be considered when providing a second opinion consultation,” he noted. Ultimately, the decision to read or not read the initial report should be decided “on an individual basis.”

The study was funded by grants from the National Cancer Institute. Dr. Elmore, Dr. Patel, and Dr. Guo reported no relevant financial relationships. 

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

We are deeply saddened by the recent death of our friend and colleague, John Hickner. Although we are grieving, we consider ourselves fortunate to have had John in our lives and to be able to share a few of his many accomplishments and attributes. Anyone who knew John knew that he had many gifts. But above all, John was kind, generous, and thoughtful. Val, John’s wife of 48 years, and their family were at the center of John’s world. Everything John did was a reflection of his love for his family.

John was a small-town family physician, and this guided virtually all of his professional endeavors. He was a member of the faculty for the Michigan State University Department of Family Medicine in Escanaba, in Michigan’s Upper Peninsula. While in the Upper Peninsula, he helped establish 2 practice-based research networks: the statewide Michigan Research Network (MiRNet) and the regional Upper Peninsula Research Network (UPRNet). If you ever had the chance to attend the UPRNet meetings, you would have observed the entire practice staff included in planning research activities, sharing, and troubleshooting common practice hiccups. At the end of those meetings, John would conclude by reading a children’s story such as Goodnight Moon or play a song on his guitar and then give a final thoughtful message.

In 1999, John worked with the American Academy of Family Physicians to create the National Research Network, now composed of more than 870 practices and nearly 2400 members. His own interests in respiratory infections, stemming from his experiences with his own children, led to work with the North American Respiratory Infection Study Group and with the Centers for Disease Control and Prevention.

John’s interests in practice-based research paralleled his interests in evidence-based medicine, largely as a way to translate research into daily practice. This focus on evidence guided much of his work as Editor-in-Chief for The Journal of Family Practice, a title he held for a decade. He also worked with state Academies of Family Physicians for more than a decade to create a new conference series centered on short, practical clinical topics and based completely on summaries of recent research. Any listener of the Primary Care Update podcasts could hear his thoughtful questioning of current research and his wise approach to its integration into practice.

John was more than a thoughtful and kind clinician, an outstanding educator, and a gifted researcher; he was a natural leader. John had the capacity to understand the systems in which he worked and was able to skillfully guide teams to improve those systems. He served as the Chair of Family Medicine at the Cleveland Clinic and then at the University of Illinois Chicago (UIC), and mentored many faculty, residents, and students during his time at those institutions.

After retiring from UIC, John and Val moved back to Escanaba. At his retirement dinner, his children (Michael, Laura, Zach, Anna, and Olivia) gifted him a beautiful maple acoustic guitar with which he then serenaded the attendees. John was an avid tennis player and often would tell us he would have to skip meeting us for dinner while away at a conference because he had found a tennis opponent! Most of all, he loved to set out on his 35-foot sailboat on Big Bay de Noc or on Green Bay. We have fond memories of the days spent sailing with John and hope that he has found fair winds and following seas.

Henry C. Barry, MD, MS
Mark Ebell, MD, MS
Kate Rowland, MD, MS, FAAFP

We are deeply saddened by the recent death of our friend and colleague, John Hickner. Although we are grieving, we consider ourselves fortunate to have had John in our lives and to be able to share a few of his many accomplishments and attributes. Anyone who knew John knew that he had many gifts. But above all, John was kind, generous, and thoughtful. Val, John’s wife of 48 years, and their family were at the center of John’s world. Everything John did was a reflection of his love for his family.

John was a small-town family physician, and this guided virtually all of his professional endeavors. He was a member of the faculty for the Michigan State University Department of Family Medicine in Escanaba, in Michigan’s Upper Peninsula. While in the Upper Peninsula, he helped establish 2 practice-based research networks: the statewide Michigan Research Network (MiRNet) and the regional Upper Peninsula Research Network (UPRNet). If you ever had the chance to attend the UPRNet meetings, you would have observed the entire practice staff included in planning research activities, sharing, and troubleshooting common practice hiccups. At the end of those meetings, John would conclude by reading a children’s story such as Goodnight Moon or play a song on his guitar and then give a final thoughtful message.

In 1999, John worked with the American Academy of Family Physicians to create the National Research Network, now composed of more than 870 practices and nearly 2400 members. His own interests in respiratory infections, stemming from his experiences with his own children, led to work with the North American Respiratory Infection Study Group and with the Centers for Disease Control and Prevention.

John’s interests in practice-based research paralleled his interests in evidence-based medicine, largely as a way to translate research into daily practice. This focus on evidence guided much of his work as Editor-in-Chief for The Journal of Family Practice, a title he held for a decade. He also worked with state Academies of Family Physicians for more than a decade to create a new conference series centered on short, practical clinical topics and based completely on summaries of recent research. Any listener of the Primary Care Update podcasts could hear his thoughtful questioning of current research and his wise approach to its integration into practice.

John was more than a thoughtful and kind clinician, an outstanding educator, and a gifted researcher; he was a natural leader. John had the capacity to understand the systems in which he worked and was able to skillfully guide teams to improve those systems. He served as the Chair of Family Medicine at the Cleveland Clinic and then at the University of Illinois Chicago (UIC), and mentored many faculty, residents, and students during his time at those institutions.

After retiring from UIC, John and Val moved back to Escanaba. At his retirement dinner, his children (Michael, Laura, Zach, Anna, and Olivia) gifted him a beautiful maple acoustic guitar with which he then serenaded the attendees. John was an avid tennis player and often would tell us he would have to skip meeting us for dinner while away at a conference because he had found a tennis opponent! Most of all, he loved to set out on his 35-foot sailboat on Big Bay de Noc or on Green Bay. We have fond memories of the days spent sailing with John and hope that he has found fair winds and following seas.

Henry C. Barry, MD, MS
Mark Ebell, MD, MS
Kate Rowland, MD, MS, FAAFP

We are deeply saddened by the recent death of our friend and colleague, John Hickner. Although we are grieving, we consider ourselves fortunate to have had John in our lives and to be able to share a few of his many accomplishments and attributes. Anyone who knew John knew that he had many gifts. But above all, John was kind, generous, and thoughtful. Val, John’s wife of 48 years, and their family were at the center of John’s world. Everything John did was a reflection of his love for his family.

John was a small-town family physician, and this guided virtually all of his professional endeavors. He was a member of the faculty for the Michigan State University Department of Family Medicine in Escanaba, in Michigan’s Upper Peninsula. While in the Upper Peninsula, he helped establish 2 practice-based research networks: the statewide Michigan Research Network (MiRNet) and the regional Upper Peninsula Research Network (UPRNet). If you ever had the chance to attend the UPRNet meetings, you would have observed the entire practice staff included in planning research activities, sharing, and troubleshooting common practice hiccups. At the end of those meetings, John would conclude by reading a children’s story such as Goodnight Moon or play a song on his guitar and then give a final thoughtful message.

In 1999, John worked with the American Academy of Family Physicians to create the National Research Network, now composed of more than 870 practices and nearly 2400 members. His own interests in respiratory infections, stemming from his experiences with his own children, led to work with the North American Respiratory Infection Study Group and with the Centers for Disease Control and Prevention.

John’s interests in practice-based research paralleled his interests in evidence-based medicine, largely as a way to translate research into daily practice. This focus on evidence guided much of his work as Editor-in-Chief for The Journal of Family Practice, a title he held for a decade. He also worked with state Academies of Family Physicians for more than a decade to create a new conference series centered on short, practical clinical topics and based completely on summaries of recent research. Any listener of the Primary Care Update podcasts could hear his thoughtful questioning of current research and his wise approach to its integration into practice.

John was more than a thoughtful and kind clinician, an outstanding educator, and a gifted researcher; he was a natural leader. John had the capacity to understand the systems in which he worked and was able to skillfully guide teams to improve those systems. He served as the Chair of Family Medicine at the Cleveland Clinic and then at the University of Illinois Chicago (UIC), and mentored many faculty, residents, and students during his time at those institutions.

After retiring from UIC, John and Val moved back to Escanaba. At his retirement dinner, his children (Michael, Laura, Zach, Anna, and Olivia) gifted him a beautiful maple acoustic guitar with which he then serenaded the attendees. John was an avid tennis player and often would tell us he would have to skip meeting us for dinner while away at a conference because he had found a tennis opponent! Most of all, he loved to set out on his 35-foot sailboat on Big Bay de Noc or on Green Bay. We have fond memories of the days spent sailing with John and hope that he has found fair winds and following seas.

Henry C. Barry, MD, MS
Mark Ebell, MD, MS
Kate Rowland, MD, MS, FAAFP

Pfizer has sent an application to the Food and Drug Administration for emergency use authorization of its updated COVID-19 booster vaccine for the fall of 2022, the company announced on Aug. 22.

The vaccine, which is adapted for the BA.4 and BA.5 Omicron variants, would be meant for ages 12 and older. If authorized by the FDA, the doses could ship as soon as September.

“Having rapidly scaled up production, we are positioned to immediately begin distribution of the bivalent Omicron BA.4/BA.5 boosters, if authorized, to help protect individuals and families as we prepare for potential fall and winter surges,” Albert Bourla, PhD, Pfizer’s chairman and CEO, said in the statement.

Earlier this year, the FDA ordered vaccine makers such as Pfizer and Moderna to update their shots to target BA.4 and BA.5, which are better at escaping immunity from earlier vaccines and previous infections.

The United States has a contract to buy 105 million of the Pfizer doses and 66 million of the Moderna doses, according to The Associated Press. Moderna is expected to file its FDA application soon as well.

The new shots target both the original spike protein on the coronavirus and the spike mutations carried by BA.4 and BA.5. For now, BA.5 is causing 89% of new infections in the United States, followed by BA.4.6 with 6.3% and BA.4 with 4.3%, according to the latest Centers for Disease Control and Prevention data.

There’s no way to tell if BA.5 will still be the dominant strain this winter or if new variant will replace it, the AP reported. But public health officials have supported the updated boosters as a way to target the most recent strains and increase immunity again.

On Aug. 15, Great Britain became the first country to authorize another one of Moderna’s updated vaccines, which adds protection against BA.1, or the original Omicron strain that became dominant in the winter of 2021-2022. European regulators are considering this shot, the AP reported, but the United States opted not to use this version since new Omicron variants have become dominant.

To approve the latest Pfizer shot, the FDA will rely on scientific testing of prior updates to the vaccine, rather than the newest boosters, to decide whether to fast-track the updated shots for fall, the AP reported. This method is like how flu vaccines are updated each year without large studies that take months.

Previously, Pfizer announced results from a study that found the earlier Omicron update significantly boosted antibodies capable of fighting the BA.1 variant and provided some protection against BA.4 and BA.5. The company’s latest FDA application contains that data and animal testing on the newest booster, the AP reported.

Pfizer will start a trial using the BA.4/BA.5 booster in coming weeks to get more data on how well the latest shot works. Moderna has begun a similar study.

The full results from these studies won’t be available before a fall booster campaign, which is why the FDA and public health officials have called for an updated shot to be ready for distribution in September.

“It’s clear that none of these vaccines are going to completely prevent infection,” Rachel Presti, MD, a researcher with the Moderna trial and an infectious diseases specialist at Washington University in St. Louis, told the AP.

But previous studies of variant booster candidates have shown that “you still get a broader immune response giving a variant booster than giving the same booster,” she said.

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

Pfizer has sent an application to the Food and Drug Administration for emergency use authorization of its updated COVID-19 booster vaccine for the fall of 2022, the company announced on Aug. 22.

The vaccine, which is adapted for the BA.4 and BA.5 Omicron variants, would be meant for ages 12 and older. If authorized by the FDA, the doses could ship as soon as September.

“Having rapidly scaled up production, we are positioned to immediately begin distribution of the bivalent Omicron BA.4/BA.5 boosters, if authorized, to help protect individuals and families as we prepare for potential fall and winter surges,” Albert Bourla, PhD, Pfizer’s chairman and CEO, said in the statement.

Earlier this year, the FDA ordered vaccine makers such as Pfizer and Moderna to update their shots to target BA.4 and BA.5, which are better at escaping immunity from earlier vaccines and previous infections.

The United States has a contract to buy 105 million of the Pfizer doses and 66 million of the Moderna doses, according to The Associated Press. Moderna is expected to file its FDA application soon as well.

The new shots target both the original spike protein on the coronavirus and the spike mutations carried by BA.4 and BA.5. For now, BA.5 is causing 89% of new infections in the United States, followed by BA.4.6 with 6.3% and BA.4 with 4.3%, according to the latest Centers for Disease Control and Prevention data.

There’s no way to tell if BA.5 will still be the dominant strain this winter or if new variant will replace it, the AP reported. But public health officials have supported the updated boosters as a way to target the most recent strains and increase immunity again.

On Aug. 15, Great Britain became the first country to authorize another one of Moderna’s updated vaccines, which adds protection against BA.1, or the original Omicron strain that became dominant in the winter of 2021-2022. European regulators are considering this shot, the AP reported, but the United States opted not to use this version since new Omicron variants have become dominant.

To approve the latest Pfizer shot, the FDA will rely on scientific testing of prior updates to the vaccine, rather than the newest boosters, to decide whether to fast-track the updated shots for fall, the AP reported. This method is like how flu vaccines are updated each year without large studies that take months.

Previously, Pfizer announced results from a study that found the earlier Omicron update significantly boosted antibodies capable of fighting the BA.1 variant and provided some protection against BA.4 and BA.5. The company’s latest FDA application contains that data and animal testing on the newest booster, the AP reported.

Pfizer will start a trial using the BA.4/BA.5 booster in coming weeks to get more data on how well the latest shot works. Moderna has begun a similar study.

The full results from these studies won’t be available before a fall booster campaign, which is why the FDA and public health officials have called for an updated shot to be ready for distribution in September.

“It’s clear that none of these vaccines are going to completely prevent infection,” Rachel Presti, MD, a researcher with the Moderna trial and an infectious diseases specialist at Washington University in St. Louis, told the AP.

But previous studies of variant booster candidates have shown that “you still get a broader immune response giving a variant booster than giving the same booster,” she said.

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

Pfizer has sent an application to the Food and Drug Administration for emergency use authorization of its updated COVID-19 booster vaccine for the fall of 2022, the company announced on Aug. 22.

The vaccine, which is adapted for the BA.4 and BA.5 Omicron variants, would be meant for ages 12 and older. If authorized by the FDA, the doses could ship as soon as September.

“Having rapidly scaled up production, we are positioned to immediately begin distribution of the bivalent Omicron BA.4/BA.5 boosters, if authorized, to help protect individuals and families as we prepare for potential fall and winter surges,” Albert Bourla, PhD, Pfizer’s chairman and CEO, said in the statement.

Earlier this year, the FDA ordered vaccine makers such as Pfizer and Moderna to update their shots to target BA.4 and BA.5, which are better at escaping immunity from earlier vaccines and previous infections.

The United States has a contract to buy 105 million of the Pfizer doses and 66 million of the Moderna doses, according to The Associated Press. Moderna is expected to file its FDA application soon as well.

The new shots target both the original spike protein on the coronavirus and the spike mutations carried by BA.4 and BA.5. For now, BA.5 is causing 89% of new infections in the United States, followed by BA.4.6 with 6.3% and BA.4 with 4.3%, according to the latest Centers for Disease Control and Prevention data.

There’s no way to tell if BA.5 will still be the dominant strain this winter or if new variant will replace it, the AP reported. But public health officials have supported the updated boosters as a way to target the most recent strains and increase immunity again.

On Aug. 15, Great Britain became the first country to authorize another one of Moderna’s updated vaccines, which adds protection against BA.1, or the original Omicron strain that became dominant in the winter of 2021-2022. European regulators are considering this shot, the AP reported, but the United States opted not to use this version since new Omicron variants have become dominant.

To approve the latest Pfizer shot, the FDA will rely on scientific testing of prior updates to the vaccine, rather than the newest boosters, to decide whether to fast-track the updated shots for fall, the AP reported. This method is like how flu vaccines are updated each year without large studies that take months.

Previously, Pfizer announced results from a study that found the earlier Omicron update significantly boosted antibodies capable of fighting the BA.1 variant and provided some protection against BA.4 and BA.5. The company’s latest FDA application contains that data and animal testing on the newest booster, the AP reported.

Pfizer will start a trial using the BA.4/BA.5 booster in coming weeks to get more data on how well the latest shot works. Moderna has begun a similar study.

The full results from these studies won’t be available before a fall booster campaign, which is why the FDA and public health officials have called for an updated shot to be ready for distribution in September.

“It’s clear that none of these vaccines are going to completely prevent infection,” Rachel Presti, MD, a researcher with the Moderna trial and an infectious diseases specialist at Washington University in St. Louis, told the AP.

But previous studies of variant booster candidates have shown that “you still get a broader immune response giving a variant booster than giving the same booster,” she said.

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