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Summer campers spread COVID at home, follow-up finds
In a report published online in The New England Journal of Medicine, researchers found that campers spread COVID to household members after returning home – but transmission was more likely from some than others. Distancing and masking helped reduce the risk.
Victoria T. Chu, MD, MPH, with the Centers for Disease Control and Prevention, Atlanta, and colleagues with the agency and the Georgia Department of Health followed up with 224 camp attendees, aged 7 to 19 years, who had evidence of SARS-CoV-2 infection on laboratory testing.
These index patients – 88% of whom had symptoms – had 526 household contacts, mainly parents and siblings. Of 377 household contacts who underwent testing, 46 (12%) tested positive. Another two cases in household contacts were identified using clinical and epidemiologic criteria.
Family members hospitalized
Of the 41 adult household contacts who were infected, four (about 10%) were hospitalized. Their hospital stays ranged from 5 to 11 days. Of the seven infected household contacts who were younger than 18 years, none were hospitalized.
The four hospitalized adults were parents and grandparents aged 45 to 80 years, Dr. Chu said. Two of the four had underlying conditions. None of the household contacts died.
In an adjusted analysis, campers who had practiced physical distancing were less likely to transmit the virus at home, compared with those who had not practiced physical distancing (adjusted odds ratio, 0.4). Household members who had had close or direct contact with the index patients were more than 5 times more likely to become infected, compared with family members with minimal or no contact, analyses showed.
“This retrospective study showed that the efficient transmission of SARS-CoV-2 from school-age children and adolescents to household members led to the hospitalization of adults with secondary cases of COVID-19,” the researchers write. “In households in which transmission occurred, half the household contacts were infected.”
The secondary attack rates in this report may be an underestimate because testing was voluntary and participants reported the results themselves, the authors note. It is possible that infected household contacts spread the virus further, but this study did not address that question, Dr. Chu said.
For the study, investigators interviewed all camp attendees and their parents or guardians by phone between July 17, 2020 and Aug. 24, 2020, to collect information about demographic and clinical characteristics, SARS-CoV-2 testing, and preventive measures. The researchers’ analysis excluded households in which illness onset in a household contact occurred before or less than 2 days after a camper became sick.
About a third of the index patients began to have symptoms while still at camp. These campers may have been less infectious by the time they got home, compared with those whose symptoms started after they returned.
Two-thirds of the index patients adopted physical distancing at home, which “probably reduced the transmission of SARS-CoV-2 in the household,” Dr. Chu and colleagues wrote.
“Children who have had a known COVID-19 exposure should quarantine and obtain testing if they develop symptoms within the 14 days of returning home,” Dr. Chu advised. “If a child develops COVID-19, the child should be cared for and monitored using the proper combination of physical distancing, isolation when feasible, and mask use to prevent household transmission as much as possible. In addition, any person over the age of 12 is now eligible for vaccination in the United States. If eligible, children attending camp and their family members should get vaccinated to protect themselves and others, as vaccinations are our most effective public health prevention strategy.”
Mitigation can help
Another report regarding four overnight camps in Maine – in which three campers tested positive after they arrived last summer – shows that “aggressive mitigation strategies can be effective” in limiting transmission of the virus, William T. Basco Jr., MD, writes in a commentary for this news organization.
This summer, a range of factors, including vaccination rates at the camp, may influence transmission dynamics, Dr. Chu said in an interview. In July, the Associated Press reported outbreaks tied to summer camps in several states.
“Transmission dynamics will probably vary from summer camp to summer camp depending on many factors, such as vaccination rates of camp attendees, the mitigation measures in place, and the number of individual introductions during camp,” Dr. Chu said. “We would expect that a camp with a low vaccination rate among attendees and no enforcement of mitigation measures” still may experience a large outbreak.
“On the other hand, a large proportion of vaccinated individuals and appropriate implementation of multiple mitigation measures, such as wearing masks, may be quite effective at keeping their transmission rates low,” Dr. Chu added. “For camps with younger children who are not currently eligible for vaccination, implementing layered prevention strategies (e.g., mask use, physical distancing, and encouraging outdoor activities when feasible) is important to prevent transmission.”
Although COVID-19 transmission from children to adults, potentially leading to hospitalization, is not a new phenomenon, “data on the extent of transmission driven by children and adolescents in different settings are still quite sparse,” Dr. Chu said. “A better understanding of their impact on household and community transmission to help guide public health recommendations is particularly important, as most children are still not eligible for vaccination, and in-person schools will be reopening this fall.”
A version of this article first appeared on Medscape.com.
In a report published online in The New England Journal of Medicine, researchers found that campers spread COVID to household members after returning home – but transmission was more likely from some than others. Distancing and masking helped reduce the risk.
Victoria T. Chu, MD, MPH, with the Centers for Disease Control and Prevention, Atlanta, and colleagues with the agency and the Georgia Department of Health followed up with 224 camp attendees, aged 7 to 19 years, who had evidence of SARS-CoV-2 infection on laboratory testing.
These index patients – 88% of whom had symptoms – had 526 household contacts, mainly parents and siblings. Of 377 household contacts who underwent testing, 46 (12%) tested positive. Another two cases in household contacts were identified using clinical and epidemiologic criteria.
Family members hospitalized
Of the 41 adult household contacts who were infected, four (about 10%) were hospitalized. Their hospital stays ranged from 5 to 11 days. Of the seven infected household contacts who were younger than 18 years, none were hospitalized.
The four hospitalized adults were parents and grandparents aged 45 to 80 years, Dr. Chu said. Two of the four had underlying conditions. None of the household contacts died.
In an adjusted analysis, campers who had practiced physical distancing were less likely to transmit the virus at home, compared with those who had not practiced physical distancing (adjusted odds ratio, 0.4). Household members who had had close or direct contact with the index patients were more than 5 times more likely to become infected, compared with family members with minimal or no contact, analyses showed.
“This retrospective study showed that the efficient transmission of SARS-CoV-2 from school-age children and adolescents to household members led to the hospitalization of adults with secondary cases of COVID-19,” the researchers write. “In households in which transmission occurred, half the household contacts were infected.”
The secondary attack rates in this report may be an underestimate because testing was voluntary and participants reported the results themselves, the authors note. It is possible that infected household contacts spread the virus further, but this study did not address that question, Dr. Chu said.
For the study, investigators interviewed all camp attendees and their parents or guardians by phone between July 17, 2020 and Aug. 24, 2020, to collect information about demographic and clinical characteristics, SARS-CoV-2 testing, and preventive measures. The researchers’ analysis excluded households in which illness onset in a household contact occurred before or less than 2 days after a camper became sick.
About a third of the index patients began to have symptoms while still at camp. These campers may have been less infectious by the time they got home, compared with those whose symptoms started after they returned.
Two-thirds of the index patients adopted physical distancing at home, which “probably reduced the transmission of SARS-CoV-2 in the household,” Dr. Chu and colleagues wrote.
“Children who have had a known COVID-19 exposure should quarantine and obtain testing if they develop symptoms within the 14 days of returning home,” Dr. Chu advised. “If a child develops COVID-19, the child should be cared for and monitored using the proper combination of physical distancing, isolation when feasible, and mask use to prevent household transmission as much as possible. In addition, any person over the age of 12 is now eligible for vaccination in the United States. If eligible, children attending camp and their family members should get vaccinated to protect themselves and others, as vaccinations are our most effective public health prevention strategy.”
Mitigation can help
Another report regarding four overnight camps in Maine – in which three campers tested positive after they arrived last summer – shows that “aggressive mitigation strategies can be effective” in limiting transmission of the virus, William T. Basco Jr., MD, writes in a commentary for this news organization.
This summer, a range of factors, including vaccination rates at the camp, may influence transmission dynamics, Dr. Chu said in an interview. In July, the Associated Press reported outbreaks tied to summer camps in several states.
“Transmission dynamics will probably vary from summer camp to summer camp depending on many factors, such as vaccination rates of camp attendees, the mitigation measures in place, and the number of individual introductions during camp,” Dr. Chu said. “We would expect that a camp with a low vaccination rate among attendees and no enforcement of mitigation measures” still may experience a large outbreak.
“On the other hand, a large proportion of vaccinated individuals and appropriate implementation of multiple mitigation measures, such as wearing masks, may be quite effective at keeping their transmission rates low,” Dr. Chu added. “For camps with younger children who are not currently eligible for vaccination, implementing layered prevention strategies (e.g., mask use, physical distancing, and encouraging outdoor activities when feasible) is important to prevent transmission.”
Although COVID-19 transmission from children to adults, potentially leading to hospitalization, is not a new phenomenon, “data on the extent of transmission driven by children and adolescents in different settings are still quite sparse,” Dr. Chu said. “A better understanding of their impact on household and community transmission to help guide public health recommendations is particularly important, as most children are still not eligible for vaccination, and in-person schools will be reopening this fall.”
A version of this article first appeared on Medscape.com.
In a report published online in The New England Journal of Medicine, researchers found that campers spread COVID to household members after returning home – but transmission was more likely from some than others. Distancing and masking helped reduce the risk.
Victoria T. Chu, MD, MPH, with the Centers for Disease Control and Prevention, Atlanta, and colleagues with the agency and the Georgia Department of Health followed up with 224 camp attendees, aged 7 to 19 years, who had evidence of SARS-CoV-2 infection on laboratory testing.
These index patients – 88% of whom had symptoms – had 526 household contacts, mainly parents and siblings. Of 377 household contacts who underwent testing, 46 (12%) tested positive. Another two cases in household contacts were identified using clinical and epidemiologic criteria.
Family members hospitalized
Of the 41 adult household contacts who were infected, four (about 10%) were hospitalized. Their hospital stays ranged from 5 to 11 days. Of the seven infected household contacts who were younger than 18 years, none were hospitalized.
The four hospitalized adults were parents and grandparents aged 45 to 80 years, Dr. Chu said. Two of the four had underlying conditions. None of the household contacts died.
In an adjusted analysis, campers who had practiced physical distancing were less likely to transmit the virus at home, compared with those who had not practiced physical distancing (adjusted odds ratio, 0.4). Household members who had had close or direct contact with the index patients were more than 5 times more likely to become infected, compared with family members with minimal or no contact, analyses showed.
“This retrospective study showed that the efficient transmission of SARS-CoV-2 from school-age children and adolescents to household members led to the hospitalization of adults with secondary cases of COVID-19,” the researchers write. “In households in which transmission occurred, half the household contacts were infected.”
The secondary attack rates in this report may be an underestimate because testing was voluntary and participants reported the results themselves, the authors note. It is possible that infected household contacts spread the virus further, but this study did not address that question, Dr. Chu said.
For the study, investigators interviewed all camp attendees and their parents or guardians by phone between July 17, 2020 and Aug. 24, 2020, to collect information about demographic and clinical characteristics, SARS-CoV-2 testing, and preventive measures. The researchers’ analysis excluded households in which illness onset in a household contact occurred before or less than 2 days after a camper became sick.
About a third of the index patients began to have symptoms while still at camp. These campers may have been less infectious by the time they got home, compared with those whose symptoms started after they returned.
Two-thirds of the index patients adopted physical distancing at home, which “probably reduced the transmission of SARS-CoV-2 in the household,” Dr. Chu and colleagues wrote.
“Children who have had a known COVID-19 exposure should quarantine and obtain testing if they develop symptoms within the 14 days of returning home,” Dr. Chu advised. “If a child develops COVID-19, the child should be cared for and monitored using the proper combination of physical distancing, isolation when feasible, and mask use to prevent household transmission as much as possible. In addition, any person over the age of 12 is now eligible for vaccination in the United States. If eligible, children attending camp and their family members should get vaccinated to protect themselves and others, as vaccinations are our most effective public health prevention strategy.”
Mitigation can help
Another report regarding four overnight camps in Maine – in which three campers tested positive after they arrived last summer – shows that “aggressive mitigation strategies can be effective” in limiting transmission of the virus, William T. Basco Jr., MD, writes in a commentary for this news organization.
This summer, a range of factors, including vaccination rates at the camp, may influence transmission dynamics, Dr. Chu said in an interview. In July, the Associated Press reported outbreaks tied to summer camps in several states.
“Transmission dynamics will probably vary from summer camp to summer camp depending on many factors, such as vaccination rates of camp attendees, the mitigation measures in place, and the number of individual introductions during camp,” Dr. Chu said. “We would expect that a camp with a low vaccination rate among attendees and no enforcement of mitigation measures” still may experience a large outbreak.
“On the other hand, a large proportion of vaccinated individuals and appropriate implementation of multiple mitigation measures, such as wearing masks, may be quite effective at keeping their transmission rates low,” Dr. Chu added. “For camps with younger children who are not currently eligible for vaccination, implementing layered prevention strategies (e.g., mask use, physical distancing, and encouraging outdoor activities when feasible) is important to prevent transmission.”
Although COVID-19 transmission from children to adults, potentially leading to hospitalization, is not a new phenomenon, “data on the extent of transmission driven by children and adolescents in different settings are still quite sparse,” Dr. Chu said. “A better understanding of their impact on household and community transmission to help guide public health recommendations is particularly important, as most children are still not eligible for vaccination, and in-person schools will be reopening this fall.”
A version of this article first appeared on Medscape.com.
IBD risk rises with higher ultraprocessed food intake
Individuals who consumed more ultraprocessed foods had a significantly increased risk of developing inflammatory bowel disease (IBD) than those who consumed less, according to data from more than 100,000 adults.
“Diet alters the microbiome and modifies the intestinal immune response and so could play a role in the pathogenesis of IBD,” Neeraj Narula, MD, of McMaster University, Hamilton, Ont., and colleagues wrote. Although previous studies have investigated the impact of dietary risk factors on IBD, an association with ultraprocessed foods (defined as foods containing additives and preservatives) in particular has not been examined, they wrote.
In a study published in BMJ, the researchers examined data from 116,087 adults aged 35-70 years from 21 countries between 2003 and 2016 who were part of the large Prospective Urban Rural Epidemiology (PURE) Cohort. Participants completed baseline food frequency questionnaires and were followed at least every 3 years; the median follow-up time was 9.7 years. The primary outcome was the development of Crohn’s disease or ulcerative colitis. In this study, ultraprocessed food included all packaged and formulated foods and beverages that contained food additives, artificial flavors or colors, or other chemical ingredients.
The categories of ultraprocessed foods included processed meat, cold breakfast cereal, various sauces, soft drinks, and fruit drinks, and refined sweetened foods such as candy, chocolate, jam, jelly, and brownies.
Overall, 467 participants developed IBD, including 90 with Crohn’s disease and 377 with ulcerative colitis.
After controlling for confounding factors, the investigators found that increased consumption of ultraprocessed foods was significantly associated with an increased risk of incident IBD. Compared with individuals who consumed less than 1 serving per day of ultraprocessed foods, the hazard ratio was 1.82 for those who consumed 5 or more servings and 1.67 for those who consumed 1-4 servings daily (P = .006).
“The pattern of increased ultraprocessed food intake and higher risk of IBD persisted within each of the regions examined, and effect estimates were generally similar, with overlapping confidence intervals and no significant heterogeneity,” the researchers noted.
The risk of IBD increased among individuals who consumed 1 serving per week or more of processed meat, compared with those who consumed less than 1 serving per week, and the risk increased with the amount consumed (HR, 2.07 for 1 or more servings per day). Similarly, IBD risk was higher among individuals who consumed 100 g/day or more of refined sweetened foods compared with no intake of these foods (HR, 2.58).
Individuals who consumed at least one serving of fried foods per day had the highest risk of IBD (HR, 3.02), the researchers noted. The reason for the association is uncertain, but may occur not only because many fried foods are also processed but also because the action of frying food and the processing of oil, as well as type and quality of oil, might modify the nutrients.
In the subgroup analysis, higher consumption of salty snacks and soft drinks also was associated with higher risk for IBD. However, the researchers found no association between increased risk of IBD and consumption of white meat, unprocessed red meat, dairy, starchy foods, and fruit/vegetables/legumes.
The study findings were limited by several factors including the relatively small number of individuals with Crohn’s disease, potential lack of generalizability to those who develop IBD in childhood or young adulthood, and possible confounding from unmeasured variables. The study also did not account for dietary changes over time, the investigators reported. However, the longitudinal design allowed them “to focus on people with incident IBD and to use medical record review and central adjudication to validate a sample of the diagnoses.”
The results suggest that the way food is processed or ultraprocessed, rather than the food itself, may be what confers the risk for IBD, given the lack of association between IBD and other food categories such as unprocessed red meat and dairy, the researchers concluded.
Next steps: Pin down driving factors
“There is significant interest in the apparent increase in the incidence and prevalence of IBD, particularly in previously low incidence areas,” Edward L. Barnes, MD, MPH, of the University of North Carolina at Chapel Hill said in an interview.
“Many research groups and clinicians suspect that environmental exposures, including dietary exposures, may play a critical role in these trends,” said Dr. Barnes. “This study utilized a large, multinational prospective cohort design to assess the influence of diet on the risk of developing IBD,” which is particularly important considering the potential for processed foods and food additives to impact the gastrointestinal tract.
“The strong associations demonstrated by the authors were impressive, particularly given that the authors performed multiple subanalyses, including evaluations by participant age and evaluations of particular food groups/types [e.g., processed meat, soft drinks, and refined sweet foods],” he noted. Dr. Barnes also found the lack of association with intake of white meat and unprocessed red meat interesting. “In my opinion, these subanalyses strengthen the overall associations demonstrated by the authors given their prospective study design and their attention to evaluating all potential associations that may be driving the relationships present in this cohort.
“At this point, the take-home message for clinicians treating patients with Crohn’s disease and ulcerative colitis should be that this association exists,” said Dr. Barnes. “One question that remains is whether the same risk factors that are present for developing disease also influence the disease course, given that the primary outcome of this study was the development of IBD. Given that much of our data with regard to the interplay between diet and IBD are still emerging, physicians treating patients with IBD can make patients aware of these associations and the potential benefit of limiting ultraprocessed foods in their diet.”
For these important results to become actionable, “further research is likely necessary to identify the factors that are driving this association,” Dr. Barnes explained. “This would likely build on prior animal models that have demonstrated an association between food additives such as emulsifiers and changes in the gastrointestinal tract that could ultimately lead to increased inflammation and the development of IBD.” Such information about specific drivers “would then allow clinicians to determine which population would benefit most from dietary changes/recommendations.”
The overall PURE study was supported by the Population Health Research Institute, Hamilton Health Sciences Research Institute, Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, CIHR’s Strategy for Patient Oriented Research through the Ontario SPOR Support Unit, and the Ontario Ministry of Health and Long-term Care. PURE also was supported in part by unrestricted grants from several pharmaceutical companies, notably AstraZeneca, Sanofi-Aventis, Boehringer Ingelheim, Servier, and GlaxoSmithKline. The researchers had no relevant financial conflicts to disclose. Dr. Barnes disclosed serving as a consultant for AbbVie, Gilead, Pfizer, Takeda, and Target RWE.
Individuals who consumed more ultraprocessed foods had a significantly increased risk of developing inflammatory bowel disease (IBD) than those who consumed less, according to data from more than 100,000 adults.
“Diet alters the microbiome and modifies the intestinal immune response and so could play a role in the pathogenesis of IBD,” Neeraj Narula, MD, of McMaster University, Hamilton, Ont., and colleagues wrote. Although previous studies have investigated the impact of dietary risk factors on IBD, an association with ultraprocessed foods (defined as foods containing additives and preservatives) in particular has not been examined, they wrote.
In a study published in BMJ, the researchers examined data from 116,087 adults aged 35-70 years from 21 countries between 2003 and 2016 who were part of the large Prospective Urban Rural Epidemiology (PURE) Cohort. Participants completed baseline food frequency questionnaires and were followed at least every 3 years; the median follow-up time was 9.7 years. The primary outcome was the development of Crohn’s disease or ulcerative colitis. In this study, ultraprocessed food included all packaged and formulated foods and beverages that contained food additives, artificial flavors or colors, or other chemical ingredients.
The categories of ultraprocessed foods included processed meat, cold breakfast cereal, various sauces, soft drinks, and fruit drinks, and refined sweetened foods such as candy, chocolate, jam, jelly, and brownies.
Overall, 467 participants developed IBD, including 90 with Crohn’s disease and 377 with ulcerative colitis.
After controlling for confounding factors, the investigators found that increased consumption of ultraprocessed foods was significantly associated with an increased risk of incident IBD. Compared with individuals who consumed less than 1 serving per day of ultraprocessed foods, the hazard ratio was 1.82 for those who consumed 5 or more servings and 1.67 for those who consumed 1-4 servings daily (P = .006).
“The pattern of increased ultraprocessed food intake and higher risk of IBD persisted within each of the regions examined, and effect estimates were generally similar, with overlapping confidence intervals and no significant heterogeneity,” the researchers noted.
The risk of IBD increased among individuals who consumed 1 serving per week or more of processed meat, compared with those who consumed less than 1 serving per week, and the risk increased with the amount consumed (HR, 2.07 for 1 or more servings per day). Similarly, IBD risk was higher among individuals who consumed 100 g/day or more of refined sweetened foods compared with no intake of these foods (HR, 2.58).
Individuals who consumed at least one serving of fried foods per day had the highest risk of IBD (HR, 3.02), the researchers noted. The reason for the association is uncertain, but may occur not only because many fried foods are also processed but also because the action of frying food and the processing of oil, as well as type and quality of oil, might modify the nutrients.
In the subgroup analysis, higher consumption of salty snacks and soft drinks also was associated with higher risk for IBD. However, the researchers found no association between increased risk of IBD and consumption of white meat, unprocessed red meat, dairy, starchy foods, and fruit/vegetables/legumes.
The study findings were limited by several factors including the relatively small number of individuals with Crohn’s disease, potential lack of generalizability to those who develop IBD in childhood or young adulthood, and possible confounding from unmeasured variables. The study also did not account for dietary changes over time, the investigators reported. However, the longitudinal design allowed them “to focus on people with incident IBD and to use medical record review and central adjudication to validate a sample of the diagnoses.”
The results suggest that the way food is processed or ultraprocessed, rather than the food itself, may be what confers the risk for IBD, given the lack of association between IBD and other food categories such as unprocessed red meat and dairy, the researchers concluded.
Next steps: Pin down driving factors
“There is significant interest in the apparent increase in the incidence and prevalence of IBD, particularly in previously low incidence areas,” Edward L. Barnes, MD, MPH, of the University of North Carolina at Chapel Hill said in an interview.
“Many research groups and clinicians suspect that environmental exposures, including dietary exposures, may play a critical role in these trends,” said Dr. Barnes. “This study utilized a large, multinational prospective cohort design to assess the influence of diet on the risk of developing IBD,” which is particularly important considering the potential for processed foods and food additives to impact the gastrointestinal tract.
“The strong associations demonstrated by the authors were impressive, particularly given that the authors performed multiple subanalyses, including evaluations by participant age and evaluations of particular food groups/types [e.g., processed meat, soft drinks, and refined sweet foods],” he noted. Dr. Barnes also found the lack of association with intake of white meat and unprocessed red meat interesting. “In my opinion, these subanalyses strengthen the overall associations demonstrated by the authors given their prospective study design and their attention to evaluating all potential associations that may be driving the relationships present in this cohort.
“At this point, the take-home message for clinicians treating patients with Crohn’s disease and ulcerative colitis should be that this association exists,” said Dr. Barnes. “One question that remains is whether the same risk factors that are present for developing disease also influence the disease course, given that the primary outcome of this study was the development of IBD. Given that much of our data with regard to the interplay between diet and IBD are still emerging, physicians treating patients with IBD can make patients aware of these associations and the potential benefit of limiting ultraprocessed foods in their diet.”
For these important results to become actionable, “further research is likely necessary to identify the factors that are driving this association,” Dr. Barnes explained. “This would likely build on prior animal models that have demonstrated an association between food additives such as emulsifiers and changes in the gastrointestinal tract that could ultimately lead to increased inflammation and the development of IBD.” Such information about specific drivers “would then allow clinicians to determine which population would benefit most from dietary changes/recommendations.”
The overall PURE study was supported by the Population Health Research Institute, Hamilton Health Sciences Research Institute, Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, CIHR’s Strategy for Patient Oriented Research through the Ontario SPOR Support Unit, and the Ontario Ministry of Health and Long-term Care. PURE also was supported in part by unrestricted grants from several pharmaceutical companies, notably AstraZeneca, Sanofi-Aventis, Boehringer Ingelheim, Servier, and GlaxoSmithKline. The researchers had no relevant financial conflicts to disclose. Dr. Barnes disclosed serving as a consultant for AbbVie, Gilead, Pfizer, Takeda, and Target RWE.
Individuals who consumed more ultraprocessed foods had a significantly increased risk of developing inflammatory bowel disease (IBD) than those who consumed less, according to data from more than 100,000 adults.
“Diet alters the microbiome and modifies the intestinal immune response and so could play a role in the pathogenesis of IBD,” Neeraj Narula, MD, of McMaster University, Hamilton, Ont., and colleagues wrote. Although previous studies have investigated the impact of dietary risk factors on IBD, an association with ultraprocessed foods (defined as foods containing additives and preservatives) in particular has not been examined, they wrote.
In a study published in BMJ, the researchers examined data from 116,087 adults aged 35-70 years from 21 countries between 2003 and 2016 who were part of the large Prospective Urban Rural Epidemiology (PURE) Cohort. Participants completed baseline food frequency questionnaires and were followed at least every 3 years; the median follow-up time was 9.7 years. The primary outcome was the development of Crohn’s disease or ulcerative colitis. In this study, ultraprocessed food included all packaged and formulated foods and beverages that contained food additives, artificial flavors or colors, or other chemical ingredients.
The categories of ultraprocessed foods included processed meat, cold breakfast cereal, various sauces, soft drinks, and fruit drinks, and refined sweetened foods such as candy, chocolate, jam, jelly, and brownies.
Overall, 467 participants developed IBD, including 90 with Crohn’s disease and 377 with ulcerative colitis.
After controlling for confounding factors, the investigators found that increased consumption of ultraprocessed foods was significantly associated with an increased risk of incident IBD. Compared with individuals who consumed less than 1 serving per day of ultraprocessed foods, the hazard ratio was 1.82 for those who consumed 5 or more servings and 1.67 for those who consumed 1-4 servings daily (P = .006).
“The pattern of increased ultraprocessed food intake and higher risk of IBD persisted within each of the regions examined, and effect estimates were generally similar, with overlapping confidence intervals and no significant heterogeneity,” the researchers noted.
The risk of IBD increased among individuals who consumed 1 serving per week or more of processed meat, compared with those who consumed less than 1 serving per week, and the risk increased with the amount consumed (HR, 2.07 for 1 or more servings per day). Similarly, IBD risk was higher among individuals who consumed 100 g/day or more of refined sweetened foods compared with no intake of these foods (HR, 2.58).
Individuals who consumed at least one serving of fried foods per day had the highest risk of IBD (HR, 3.02), the researchers noted. The reason for the association is uncertain, but may occur not only because many fried foods are also processed but also because the action of frying food and the processing of oil, as well as type and quality of oil, might modify the nutrients.
In the subgroup analysis, higher consumption of salty snacks and soft drinks also was associated with higher risk for IBD. However, the researchers found no association between increased risk of IBD and consumption of white meat, unprocessed red meat, dairy, starchy foods, and fruit/vegetables/legumes.
The study findings were limited by several factors including the relatively small number of individuals with Crohn’s disease, potential lack of generalizability to those who develop IBD in childhood or young adulthood, and possible confounding from unmeasured variables. The study also did not account for dietary changes over time, the investigators reported. However, the longitudinal design allowed them “to focus on people with incident IBD and to use medical record review and central adjudication to validate a sample of the diagnoses.”
The results suggest that the way food is processed or ultraprocessed, rather than the food itself, may be what confers the risk for IBD, given the lack of association between IBD and other food categories such as unprocessed red meat and dairy, the researchers concluded.
Next steps: Pin down driving factors
“There is significant interest in the apparent increase in the incidence and prevalence of IBD, particularly in previously low incidence areas,” Edward L. Barnes, MD, MPH, of the University of North Carolina at Chapel Hill said in an interview.
“Many research groups and clinicians suspect that environmental exposures, including dietary exposures, may play a critical role in these trends,” said Dr. Barnes. “This study utilized a large, multinational prospective cohort design to assess the influence of diet on the risk of developing IBD,” which is particularly important considering the potential for processed foods and food additives to impact the gastrointestinal tract.
“The strong associations demonstrated by the authors were impressive, particularly given that the authors performed multiple subanalyses, including evaluations by participant age and evaluations of particular food groups/types [e.g., processed meat, soft drinks, and refined sweet foods],” he noted. Dr. Barnes also found the lack of association with intake of white meat and unprocessed red meat interesting. “In my opinion, these subanalyses strengthen the overall associations demonstrated by the authors given their prospective study design and their attention to evaluating all potential associations that may be driving the relationships present in this cohort.
“At this point, the take-home message for clinicians treating patients with Crohn’s disease and ulcerative colitis should be that this association exists,” said Dr. Barnes. “One question that remains is whether the same risk factors that are present for developing disease also influence the disease course, given that the primary outcome of this study was the development of IBD. Given that much of our data with regard to the interplay between diet and IBD are still emerging, physicians treating patients with IBD can make patients aware of these associations and the potential benefit of limiting ultraprocessed foods in their diet.”
For these important results to become actionable, “further research is likely necessary to identify the factors that are driving this association,” Dr. Barnes explained. “This would likely build on prior animal models that have demonstrated an association between food additives such as emulsifiers and changes in the gastrointestinal tract that could ultimately lead to increased inflammation and the development of IBD.” Such information about specific drivers “would then allow clinicians to determine which population would benefit most from dietary changes/recommendations.”
The overall PURE study was supported by the Population Health Research Institute, Hamilton Health Sciences Research Institute, Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, CIHR’s Strategy for Patient Oriented Research through the Ontario SPOR Support Unit, and the Ontario Ministry of Health and Long-term Care. PURE also was supported in part by unrestricted grants from several pharmaceutical companies, notably AstraZeneca, Sanofi-Aventis, Boehringer Ingelheim, Servier, and GlaxoSmithKline. The researchers had no relevant financial conflicts to disclose. Dr. Barnes disclosed serving as a consultant for AbbVie, Gilead, Pfizer, Takeda, and Target RWE.
FROM THE BMJ
Long COVID symptoms rare but real in some kids
School-aged children with SARS-CoV-2 infection had only a few mild symptoms and typically recovered in 6 days, with more than 98% recovering in 8 weeks, a large U.K. study of smartphone data reassuringly reports.
In a small proportion (4.4%), however, COVID-19 symptoms such as fatigue, headache, or loss of smell persisted beyond a month, highlighting the need for ongoing pediatric care, according to Erika Molteni, PhD, a research fellow at King’s College, London, and colleagues.
The results, published online in The Lancet Child & Adolescent Health, also indicated that some children who had non-COVID infections were also susceptible to prolonged symptoms. “Our data highlight that other illnesses, such as colds and flu, can also have prolonged symptoms in children and it is important to consider this when planning for pediatric health services during the pandemic and beyond,” Michael Absoud, PhD, a senior coauthor and a King’s College consultant and senior lecturer, said in a news release. “All children who have persistent symptoms – from any illness – need timely multidisciplinary support linked with education, to enable them to find their individual pathway to recovery.”
Using a “citizen science” approach, the study extracted data from a smartphone app for tracking COVID symptoms in the ZOE COVID Study. The researchers looked at 258,790 children aged 5-17 years whose details were reported by adult proxies such as parents and carers from March 24, 2020, to Feb. 22, 2021. Of these, 75,529 had undergone a valid SARS-CoV-2 test.
The study also assessed symptoms in a randomly selected, age- and sex-matched cohort of 1,734 children in the app database who tested negative for COVID-19 but may have had other illnesses such as colds or flu.
In the 1,734 children testing positive for COVID-19 (approximately 50% each boys and girls), the most common symptoms were headache (62.2%) and fatigue (55.0%). More than 10% of the entire cohort had underlying asthma, but other comorbidities were very rare.
To assess the effect of age, the children were assessed in two groups: 5-11 years (n = 588) and 12-17 years (n = 1,146).
While unable to cross-check app reporting against actual medical records, the study suggested that illness lasted longer in COVID-positive than COVID-negative children, with a median of 6 days (interquartile range, 3-11) versus 3 days (IQR, 2-7). Furthermore, illness duration was positively associated with age: older children (median, 7 days; IQR, 3-12) versus younger children (median, 5 days; IQR, 2-9).
In 77 (4.4%) of the 1,734 COVID-positive children, illness persisted for at least 28 days, again more often in older than younger children: 5.1% of older children versus 3.1% of younger children (P = .046).
In addition, those with COVID-19 were more likely than children with non-COVID illness to be sick for more than 4 weeks: 4.4% versus 0.9%. At 4 weeks, however, the few children with other illnesses tended to have more symptoms, exhibiting a median of five symptoms versus two symptoms in the COVID-positive group.
“I tend to agree with the U.K. findings. COVID-19 in most school-age children is asymptomatic or a brief, self-limiting illness,” Sindhu Mohandas, MD, a pediatric infectious disease specialist at the Children’s Hospital Los Angeles, said in an interview. “The few children who need hospitalization have also mostly fully recovered by the time they are seen for their first outpatient clinic follow-up visit.”
Dr. Mohandas, who was not involved in the U.K. study, added that in her experience a small percentage, particularly adolescents, have some lingering symptoms after infection including fatigue, loss of appetite, and changes in smell and taste. “Identifying children with persistent illness and providing support and multidisciplinary care based on their symptomatology can make a positive impact on patients and their families.”
Recent research has suggested that long symptoms can persist for 3 months in 6% of children with COVID-19. And data from China have indicated that the prevalence of coinfection may be higher than in older patients.
In an accompanying comment, Dana Mahr, PhD, and Bruno J. Strasser, PhD, researchers in the faculty of science at the University of Geneva, said the app-based study “illustrates the potential and challenges of what has been called citizenship science,” in which projects rely on data input from nonscientists.
But while potentially democratizing participation in medical research, this subjective approach has the inherent bias of self-reporting (and in the case of the current study, proxy reporting), and can introduce potential conflicts of interest owing to the politicization of certain diseases.
In the case of the current study, Dr. Mahr and Dr. Strasser argued that, since the COVID-19 test result is known to participants, a pediatrician using objective criteria is better positioned to control for reporting biases than a parent asking a child about symptoms. “Entering data on a smartphone app is not equivalent to discussing with a pediatrician or health care worker who can answer further questions and concerns of participants, an especially important factor for underserved communities,” they wrote. “Citizen science will continue to require a close interaction with professional medical researchers to turn unique illness experiences into research data.”
This study was funded by Zoe Limited, the U.K. Government Department of Health and Social Care, Wellcome Trust, the U.K. Engineering and Physical Sciences Research Council, the U.K. Research and Innovation London Medical Imaging and Artificial Intelligence Centre for Value Based Healthcare, the U.K. National Institute for Health Research, the U.K. Medical Research Council, the British Heart Foundation, and the Alzheimer’s Society. Several study authors have disclosed support from various research-funding agencies and Zoe Limited supported all aspects of building and running the symptom-tracking application. Dr. Mahr and Dr. Strasser declared no competing interests. Dr. Mohandas disclosed no competing interests with regard to her comments.
School-aged children with SARS-CoV-2 infection had only a few mild symptoms and typically recovered in 6 days, with more than 98% recovering in 8 weeks, a large U.K. study of smartphone data reassuringly reports.
In a small proportion (4.4%), however, COVID-19 symptoms such as fatigue, headache, or loss of smell persisted beyond a month, highlighting the need for ongoing pediatric care, according to Erika Molteni, PhD, a research fellow at King’s College, London, and colleagues.
The results, published online in The Lancet Child & Adolescent Health, also indicated that some children who had non-COVID infections were also susceptible to prolonged symptoms. “Our data highlight that other illnesses, such as colds and flu, can also have prolonged symptoms in children and it is important to consider this when planning for pediatric health services during the pandemic and beyond,” Michael Absoud, PhD, a senior coauthor and a King’s College consultant and senior lecturer, said in a news release. “All children who have persistent symptoms – from any illness – need timely multidisciplinary support linked with education, to enable them to find their individual pathway to recovery.”
Using a “citizen science” approach, the study extracted data from a smartphone app for tracking COVID symptoms in the ZOE COVID Study. The researchers looked at 258,790 children aged 5-17 years whose details were reported by adult proxies such as parents and carers from March 24, 2020, to Feb. 22, 2021. Of these, 75,529 had undergone a valid SARS-CoV-2 test.
The study also assessed symptoms in a randomly selected, age- and sex-matched cohort of 1,734 children in the app database who tested negative for COVID-19 but may have had other illnesses such as colds or flu.
In the 1,734 children testing positive for COVID-19 (approximately 50% each boys and girls), the most common symptoms were headache (62.2%) and fatigue (55.0%). More than 10% of the entire cohort had underlying asthma, but other comorbidities were very rare.
To assess the effect of age, the children were assessed in two groups: 5-11 years (n = 588) and 12-17 years (n = 1,146).
While unable to cross-check app reporting against actual medical records, the study suggested that illness lasted longer in COVID-positive than COVID-negative children, with a median of 6 days (interquartile range, 3-11) versus 3 days (IQR, 2-7). Furthermore, illness duration was positively associated with age: older children (median, 7 days; IQR, 3-12) versus younger children (median, 5 days; IQR, 2-9).
In 77 (4.4%) of the 1,734 COVID-positive children, illness persisted for at least 28 days, again more often in older than younger children: 5.1% of older children versus 3.1% of younger children (P = .046).
In addition, those with COVID-19 were more likely than children with non-COVID illness to be sick for more than 4 weeks: 4.4% versus 0.9%. At 4 weeks, however, the few children with other illnesses tended to have more symptoms, exhibiting a median of five symptoms versus two symptoms in the COVID-positive group.
“I tend to agree with the U.K. findings. COVID-19 in most school-age children is asymptomatic or a brief, self-limiting illness,” Sindhu Mohandas, MD, a pediatric infectious disease specialist at the Children’s Hospital Los Angeles, said in an interview. “The few children who need hospitalization have also mostly fully recovered by the time they are seen for their first outpatient clinic follow-up visit.”
Dr. Mohandas, who was not involved in the U.K. study, added that in her experience a small percentage, particularly adolescents, have some lingering symptoms after infection including fatigue, loss of appetite, and changes in smell and taste. “Identifying children with persistent illness and providing support and multidisciplinary care based on their symptomatology can make a positive impact on patients and their families.”
Recent research has suggested that long symptoms can persist for 3 months in 6% of children with COVID-19. And data from China have indicated that the prevalence of coinfection may be higher than in older patients.
In an accompanying comment, Dana Mahr, PhD, and Bruno J. Strasser, PhD, researchers in the faculty of science at the University of Geneva, said the app-based study “illustrates the potential and challenges of what has been called citizenship science,” in which projects rely on data input from nonscientists.
But while potentially democratizing participation in medical research, this subjective approach has the inherent bias of self-reporting (and in the case of the current study, proxy reporting), and can introduce potential conflicts of interest owing to the politicization of certain diseases.
In the case of the current study, Dr. Mahr and Dr. Strasser argued that, since the COVID-19 test result is known to participants, a pediatrician using objective criteria is better positioned to control for reporting biases than a parent asking a child about symptoms. “Entering data on a smartphone app is not equivalent to discussing with a pediatrician or health care worker who can answer further questions and concerns of participants, an especially important factor for underserved communities,” they wrote. “Citizen science will continue to require a close interaction with professional medical researchers to turn unique illness experiences into research data.”
This study was funded by Zoe Limited, the U.K. Government Department of Health and Social Care, Wellcome Trust, the U.K. Engineering and Physical Sciences Research Council, the U.K. Research and Innovation London Medical Imaging and Artificial Intelligence Centre for Value Based Healthcare, the U.K. National Institute for Health Research, the U.K. Medical Research Council, the British Heart Foundation, and the Alzheimer’s Society. Several study authors have disclosed support from various research-funding agencies and Zoe Limited supported all aspects of building and running the symptom-tracking application. Dr. Mahr and Dr. Strasser declared no competing interests. Dr. Mohandas disclosed no competing interests with regard to her comments.
School-aged children with SARS-CoV-2 infection had only a few mild symptoms and typically recovered in 6 days, with more than 98% recovering in 8 weeks, a large U.K. study of smartphone data reassuringly reports.
In a small proportion (4.4%), however, COVID-19 symptoms such as fatigue, headache, or loss of smell persisted beyond a month, highlighting the need for ongoing pediatric care, according to Erika Molteni, PhD, a research fellow at King’s College, London, and colleagues.
The results, published online in The Lancet Child & Adolescent Health, also indicated that some children who had non-COVID infections were also susceptible to prolonged symptoms. “Our data highlight that other illnesses, such as colds and flu, can also have prolonged symptoms in children and it is important to consider this when planning for pediatric health services during the pandemic and beyond,” Michael Absoud, PhD, a senior coauthor and a King’s College consultant and senior lecturer, said in a news release. “All children who have persistent symptoms – from any illness – need timely multidisciplinary support linked with education, to enable them to find their individual pathway to recovery.”
Using a “citizen science” approach, the study extracted data from a smartphone app for tracking COVID symptoms in the ZOE COVID Study. The researchers looked at 258,790 children aged 5-17 years whose details were reported by adult proxies such as parents and carers from March 24, 2020, to Feb. 22, 2021. Of these, 75,529 had undergone a valid SARS-CoV-2 test.
The study also assessed symptoms in a randomly selected, age- and sex-matched cohort of 1,734 children in the app database who tested negative for COVID-19 but may have had other illnesses such as colds or flu.
In the 1,734 children testing positive for COVID-19 (approximately 50% each boys and girls), the most common symptoms were headache (62.2%) and fatigue (55.0%). More than 10% of the entire cohort had underlying asthma, but other comorbidities were very rare.
To assess the effect of age, the children were assessed in two groups: 5-11 years (n = 588) and 12-17 years (n = 1,146).
While unable to cross-check app reporting against actual medical records, the study suggested that illness lasted longer in COVID-positive than COVID-negative children, with a median of 6 days (interquartile range, 3-11) versus 3 days (IQR, 2-7). Furthermore, illness duration was positively associated with age: older children (median, 7 days; IQR, 3-12) versus younger children (median, 5 days; IQR, 2-9).
In 77 (4.4%) of the 1,734 COVID-positive children, illness persisted for at least 28 days, again more often in older than younger children: 5.1% of older children versus 3.1% of younger children (P = .046).
In addition, those with COVID-19 were more likely than children with non-COVID illness to be sick for more than 4 weeks: 4.4% versus 0.9%. At 4 weeks, however, the few children with other illnesses tended to have more symptoms, exhibiting a median of five symptoms versus two symptoms in the COVID-positive group.
“I tend to agree with the U.K. findings. COVID-19 in most school-age children is asymptomatic or a brief, self-limiting illness,” Sindhu Mohandas, MD, a pediatric infectious disease specialist at the Children’s Hospital Los Angeles, said in an interview. “The few children who need hospitalization have also mostly fully recovered by the time they are seen for their first outpatient clinic follow-up visit.”
Dr. Mohandas, who was not involved in the U.K. study, added that in her experience a small percentage, particularly adolescents, have some lingering symptoms after infection including fatigue, loss of appetite, and changes in smell and taste. “Identifying children with persistent illness and providing support and multidisciplinary care based on their symptomatology can make a positive impact on patients and their families.”
Recent research has suggested that long symptoms can persist for 3 months in 6% of children with COVID-19. And data from China have indicated that the prevalence of coinfection may be higher than in older patients.
In an accompanying comment, Dana Mahr, PhD, and Bruno J. Strasser, PhD, researchers in the faculty of science at the University of Geneva, said the app-based study “illustrates the potential and challenges of what has been called citizenship science,” in which projects rely on data input from nonscientists.
But while potentially democratizing participation in medical research, this subjective approach has the inherent bias of self-reporting (and in the case of the current study, proxy reporting), and can introduce potential conflicts of interest owing to the politicization of certain diseases.
In the case of the current study, Dr. Mahr and Dr. Strasser argued that, since the COVID-19 test result is known to participants, a pediatrician using objective criteria is better positioned to control for reporting biases than a parent asking a child about symptoms. “Entering data on a smartphone app is not equivalent to discussing with a pediatrician or health care worker who can answer further questions and concerns of participants, an especially important factor for underserved communities,” they wrote. “Citizen science will continue to require a close interaction with professional medical researchers to turn unique illness experiences into research data.”
This study was funded by Zoe Limited, the U.K. Government Department of Health and Social Care, Wellcome Trust, the U.K. Engineering and Physical Sciences Research Council, the U.K. Research and Innovation London Medical Imaging and Artificial Intelligence Centre for Value Based Healthcare, the U.K. National Institute for Health Research, the U.K. Medical Research Council, the British Heart Foundation, and the Alzheimer’s Society. Several study authors have disclosed support from various research-funding agencies and Zoe Limited supported all aspects of building and running the symptom-tracking application. Dr. Mahr and Dr. Strasser declared no competing interests. Dr. Mohandas disclosed no competing interests with regard to her comments.
FROM THE LANCET CHILD & ADOLESCENT HEALTH
Pruritic welts
The patient’s history and the classic morphology of raised plaques was consistent with chronic spontaneous urticaria. Erythema may be subtle or not visible in patients with skin of color.
Individual urticarial lesions last less than 24 hours with itching and burning. Angioedema also occurs, and manifests as a deeper edema with itching, burning, and pain. Symptoms typically last for 2 to 3 days and involve the eyelids, lips, and tongue.
Chronic urticaria (CU) is defined as episodes of spontaneous wheals or angioedema lasting for more than 6 weeks and is subdivided into chronic spontaneous urticaria or inducible urticaria (if there is a known cause). Triggers include infection, emotional stressors, or medications (eg, angiotensin-converting enzyme inhibitors, nonsteroidal anti-inflammatory drugs). Autoimmunity is seen in one-third of CU patients.1
Only a limited routine-diagnostic work-up is necessary for CU and it may include a complete blood count with differential and erythrocyte sedimentation rate and C-reactive protein testing. Further diagnostic testing is based on history and may include functional autoantibodies, thyroid stimulating hormone, and thyroid autoantibodies.
The initial step in treatment involves identification and elimination of triggers. If this is not possible, first-line therapy includes second-generation antihistamines. If symptoms persist beyond 2 weeks, the dose of the antihistamine is increased up to 4-fold. Patients should be counseled that the lowest necessary dose needs to be taken habitually to prevent urticaria. If symptoms persist, omalizumab, a recombinant humanized IgG monoclonal antibody against serum IgE, cyclosporine, or montelukast, may be added. Leukotriene-receptor antagonists such as montelukast were previously second-line therapy, but they have had mixed results in randomized controlled trials. With a much lower cost than omalizumab, leukotriene-receptor antagonists are a reasonable alternative for patients who are refractory to antihistamines.1
This patient was given high-dose nonsedating antihistamines; she experienced sedation and inadequate relief. A prior authorization was successfully obtained, and she was prescribed omalizumab.
Image courtesy of Kriti Mishra, MD, Department of Dermatology, University of New Mexico School of Medicine, Albuquerque. Text courtesy of Kriti Mishra, MD, and Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.
1. Antia C, Baquerizo K, Korman A, et al. Urticaria: a comprehensive review: treatment of chronic urticaria, special populations, and disease outcomes. J Am Acad Dermatol. 2018;79:617-633. doi: 10.1016/j.jaad.2018.01.023
The patient’s history and the classic morphology of raised plaques was consistent with chronic spontaneous urticaria. Erythema may be subtle or not visible in patients with skin of color.
Individual urticarial lesions last less than 24 hours with itching and burning. Angioedema also occurs, and manifests as a deeper edema with itching, burning, and pain. Symptoms typically last for 2 to 3 days and involve the eyelids, lips, and tongue.
Chronic urticaria (CU) is defined as episodes of spontaneous wheals or angioedema lasting for more than 6 weeks and is subdivided into chronic spontaneous urticaria or inducible urticaria (if there is a known cause). Triggers include infection, emotional stressors, or medications (eg, angiotensin-converting enzyme inhibitors, nonsteroidal anti-inflammatory drugs). Autoimmunity is seen in one-third of CU patients.1
Only a limited routine-diagnostic work-up is necessary for CU and it may include a complete blood count with differential and erythrocyte sedimentation rate and C-reactive protein testing. Further diagnostic testing is based on history and may include functional autoantibodies, thyroid stimulating hormone, and thyroid autoantibodies.
The initial step in treatment involves identification and elimination of triggers. If this is not possible, first-line therapy includes second-generation antihistamines. If symptoms persist beyond 2 weeks, the dose of the antihistamine is increased up to 4-fold. Patients should be counseled that the lowest necessary dose needs to be taken habitually to prevent urticaria. If symptoms persist, omalizumab, a recombinant humanized IgG monoclonal antibody against serum IgE, cyclosporine, or montelukast, may be added. Leukotriene-receptor antagonists such as montelukast were previously second-line therapy, but they have had mixed results in randomized controlled trials. With a much lower cost than omalizumab, leukotriene-receptor antagonists are a reasonable alternative for patients who are refractory to antihistamines.1
This patient was given high-dose nonsedating antihistamines; she experienced sedation and inadequate relief. A prior authorization was successfully obtained, and she was prescribed omalizumab.
Image courtesy of Kriti Mishra, MD, Department of Dermatology, University of New Mexico School of Medicine, Albuquerque. Text courtesy of Kriti Mishra, MD, and Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.
The patient’s history and the classic morphology of raised plaques was consistent with chronic spontaneous urticaria. Erythema may be subtle or not visible in patients with skin of color.
Individual urticarial lesions last less than 24 hours with itching and burning. Angioedema also occurs, and manifests as a deeper edema with itching, burning, and pain. Symptoms typically last for 2 to 3 days and involve the eyelids, lips, and tongue.
Chronic urticaria (CU) is defined as episodes of spontaneous wheals or angioedema lasting for more than 6 weeks and is subdivided into chronic spontaneous urticaria or inducible urticaria (if there is a known cause). Triggers include infection, emotional stressors, or medications (eg, angiotensin-converting enzyme inhibitors, nonsteroidal anti-inflammatory drugs). Autoimmunity is seen in one-third of CU patients.1
Only a limited routine-diagnostic work-up is necessary for CU and it may include a complete blood count with differential and erythrocyte sedimentation rate and C-reactive protein testing. Further diagnostic testing is based on history and may include functional autoantibodies, thyroid stimulating hormone, and thyroid autoantibodies.
The initial step in treatment involves identification and elimination of triggers. If this is not possible, first-line therapy includes second-generation antihistamines. If symptoms persist beyond 2 weeks, the dose of the antihistamine is increased up to 4-fold. Patients should be counseled that the lowest necessary dose needs to be taken habitually to prevent urticaria. If symptoms persist, omalizumab, a recombinant humanized IgG monoclonal antibody against serum IgE, cyclosporine, or montelukast, may be added. Leukotriene-receptor antagonists such as montelukast were previously second-line therapy, but they have had mixed results in randomized controlled trials. With a much lower cost than omalizumab, leukotriene-receptor antagonists are a reasonable alternative for patients who are refractory to antihistamines.1
This patient was given high-dose nonsedating antihistamines; she experienced sedation and inadequate relief. A prior authorization was successfully obtained, and she was prescribed omalizumab.
Image courtesy of Kriti Mishra, MD, Department of Dermatology, University of New Mexico School of Medicine, Albuquerque. Text courtesy of Kriti Mishra, MD, and Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.
1. Antia C, Baquerizo K, Korman A, et al. Urticaria: a comprehensive review: treatment of chronic urticaria, special populations, and disease outcomes. J Am Acad Dermatol. 2018;79:617-633. doi: 10.1016/j.jaad.2018.01.023
1. Antia C, Baquerizo K, Korman A, et al. Urticaria: a comprehensive review: treatment of chronic urticaria, special populations, and disease outcomes. J Am Acad Dermatol. 2018;79:617-633. doi: 10.1016/j.jaad.2018.01.023
Isolated Scrotal Granular Parakeratosis: An Atypical Clinical Presentation
To the Editor:
Granular parakeratosis is a rare condition with an unclear etiology that results from a myriad of factors, including exposure to irritants, friction, moisture, and heat. The diagnosis is made based on a distinct histologic reaction pattern that may be protective against the triggers. We present a case of isolated scrotal granular parakeratosis in a patient with compensatory hyperhidrosis after endoscopic thoracic sympathectomy.
A 52-year-old man presented with a 5-year history of a recurrent rash affecting the scrotum. He experienced monthly flares that were exacerbated by inguinal hyperhidrosis. His symptoms included a burning sensation and pruritus followed by superficial desquamation, with gradual yet temporary improvement. His medical history was remarkable for primary axillary and palmoplantar hyperhidrosis, with compensatory inguinal hyperhidrosis after endoscopic thoracic sympathectomy 8 years prior to presentation.
Physical examination revealed a well-demarcated, scaly, erythematous plaque affecting the scrotal skin with sparing of the median raphe, penis, and inguinal folds (Figure 1). There were no other lesions noted in the axillary region or other skin folds.
Prior treatments prescribed by other providers included topical pimecrolimus, antifungal creams, topical corticosteroids, zinc oxide ointment, and daily application of an over-the-counter medicated powder with no resolution.
A punch biopsy performed at the current presentation showed psoriasiform hyperplasia of the epidermis with only a focally diminished granular layer. There was overlying thick parakeratosis and retention of keratohyalin granules (Figure 2). Grocott-Gomori methenamine- silver staining was negative for fungal elements in the sections examined. Clinical history, morphology of the eruption, and histologic features were consistent with granular parakeratosis.
Since the first reported incident of granular parakeratosis of the axilla in 1991,1 granular parakeratosis has been reported in other intertriginous areas, including the inframammary folds, inguinal folds, genitalia, perianal skin, and beneath the abdominal pannus.2 One case study in 1998 reported a patient with isolated involvement of the inguinal region3; however, this presentation is rare.4 This condition has been reported in both sexes and all age groups, including children.5
Granular parakeratosis classically presents as erythematous to brown hyperkeratotic papules that coalesce into plaques.6 It is thought to be a reactive inflammatory condition secondary to aggravating factors such as exposure to heat,7 moisture, and friction; skin occlusion; repeated washing; irritation from external agents; antiperspirants; and use of depilatory creams.8 Histopathology is characteristic and consists of retained nuclei and keratohyalin granules within the stratum corneum, beneath which there is a retained stratum granulosum. Epidermal changes may be varied and include atrophy or hyperplasia.
Murine models have postulated that granular parakeratosis may result from a deficiency in caspase 14, a protease vital to the formation of a well-functioning skin barrier.9 A cornified envelope often is noted in granular parakeratotic cells with no defects in desmosomes and cell membranes, suggesting that the pathogenesis lies within processing of profilaggrin to filaggrin, resulting in a failure to degrade keratohyalin granules and aggregation of keratin filaments.10 Granular parakeratosis is not known to be associated with other medical conditions, but it has been observed in patients receiving chemotherapy for breast11 and ovarian12 carcinomas. In infants with atopic dermatitis, granular parakeratosis was reported in 5 out of 7 cases.6 In our patient with secondary inguinal hyperhidrosis after thoracic sympathectomy, granular parakeratosis may be reactive to excess sweating and friction in the scrotal area.
Granular parakeratosis follows a waxing and waning pattern that may spontaneously resolve without any treatment; it also can follow a protracted course, as in a case with associated facial papules that persisted for 20 years.13 Topical corticosteroids alone or in combination with topical antifungal agents have been used for the treatment of granular parakeratosis with the goal of accelerating resolution.2,14 However, the efficacy of these therapeutic interventions is limited, and no controlled trials are underway. Topical vitamin D analogues15,16 and topical retinoids17 also have been reported with successful outcomes. Spontaneous resolution also has been observed in 2 different cases after previously being unresponsive to topical treatment.18,19 Treatment with Clostridium botulinum toxin A resulted in complete remission of the disease observed at 6-month follow-up. The pharmacologic action of the neurotoxin disrupts the stimulation of eccrine sweat glands, resulting in decreased sweating, a known exacerbating factor of granular parakeratosis.20
In summary, our case represents a unique clinical presentation of granular parakeratosis with classic histopathologic features. A high index of suspicion and a biopsy are vital to arriving at the correct diagnosis.
- Northcutt AD, Nelson DM, Tschen JA. Axillary granular parakeratosis. J Am Acad Dermatol. 1991;24:541-544.
- Burford C. Granular parakeratosis of multiple intertriginous areas. Australas J Dermatol. 2008;49:35-38.
- Mehregan DA, Thomas JE, Mehregan DR. Intertriginous granular parakeratosis. J Am Acad Dermatol. 1998;39:495-496.
- Leclerc-Mercier S, Prost-Squarcioni C, Hamel-Teillac D, et al. A case of congenital granular parakeratosis. Am J Dermatopathol. 2011;33:531-533.
- Scheinfeld NS, Mones J. Granular parakeratosis: pathologic and clinical correlation of 18 cases of granular parakeratosis. J Am Acad Dermatol. 2005;52:863-867.
- Akkaya AD, Oram Y, Aydin O. Infantile granular parakeratosis: cytologic examination of superficial scrapings as an aid to diagnosis. Pediatr Dermatol. 2015;32:392-396.
- Rodríguez G. Axillary granular parakeratosis [in Spanish]. Biomedica. 2002;22:519-523.
- Samrao A, Reis M, Niedt G, et al. Granular parakeratosis: response to calcipotriene and brief review of current therapeutic options. Skinmed. 2010;8:357-359.
- Hoste E, Denecker G, Gilbert B, et al. Caspase-14-deficient mice are more prone to the development of parakeratosis. J Invest Dermatol. 2013;133:742-750.
- Metze D, Rutten A. Granular parakeratosis—a unique acquired disorder of keratinization. J Cutan Pathol. 1999;26:339-352.
- Wallace CA, Pichardo RO, Yosipovitch G, et al. Granular parakeratosis: a case report and literature review. J Cutan Pathol. 2003;30:332-335.
- Jaconelli L, Doebelin B, Kanitakis J, et al. Granular parakeratosis in a patient treated with liposomal doxorubicin for ovarian carcinoma. J Am Acad Dermatol. 2008;58(5 suppl 1):S84-S87.
- Reddy IS, Swarnalata G, Mody T. Intertriginous granular parakeratosis persisting for 20 years. Indian J Dermatol Venereol Leprol. 2008;74:405-407.
- Dearden C, al-Nakib W, Andries K, et al. Drug resistant rhinoviruses from the nose of experimentally treated volunteers. Arch Virol. 1989;109:71-81.
- Patel U, Patel T, Skinner RB Jr. Resolution of granular parakeratosis with topical calcitriol. Arch Dermatol. 2011;147:997-998.
- Contreras ME, Gottfried LC, Bang RH, et al. Axillary intertriginous granular parakeratosis responsive to topical calcipotriene and ammonium lactate. Int J Dermatol. 2003;42:382-383.
- Brown SK, Heilman ER. Granular parakeratosis: resolution with topical tretinoin. J Am Acad Dermatol. 2002;47(5 suppl):S279-S280.
- Compton AK, Jackson JM. Isotretinoin as a treatment for axillary granular parakeratosis. Cutis. 2007;80:55-56.
- Webster CG, Resnik KS, Webster GF. Axillary granular parakeratosis: response to isotretinoin. J Am Acad Dermatol. 1997; 37:789-790.
- Ravitskiy L, Heymann WR. Botulinum toxin-induced resolution of axillary granular parakeratosis. Skinmed. 2005;4:118-120.
To the Editor:
Granular parakeratosis is a rare condition with an unclear etiology that results from a myriad of factors, including exposure to irritants, friction, moisture, and heat. The diagnosis is made based on a distinct histologic reaction pattern that may be protective against the triggers. We present a case of isolated scrotal granular parakeratosis in a patient with compensatory hyperhidrosis after endoscopic thoracic sympathectomy.
A 52-year-old man presented with a 5-year history of a recurrent rash affecting the scrotum. He experienced monthly flares that were exacerbated by inguinal hyperhidrosis. His symptoms included a burning sensation and pruritus followed by superficial desquamation, with gradual yet temporary improvement. His medical history was remarkable for primary axillary and palmoplantar hyperhidrosis, with compensatory inguinal hyperhidrosis after endoscopic thoracic sympathectomy 8 years prior to presentation.
Physical examination revealed a well-demarcated, scaly, erythematous plaque affecting the scrotal skin with sparing of the median raphe, penis, and inguinal folds (Figure 1). There were no other lesions noted in the axillary region or other skin folds.
Prior treatments prescribed by other providers included topical pimecrolimus, antifungal creams, topical corticosteroids, zinc oxide ointment, and daily application of an over-the-counter medicated powder with no resolution.
A punch biopsy performed at the current presentation showed psoriasiform hyperplasia of the epidermis with only a focally diminished granular layer. There was overlying thick parakeratosis and retention of keratohyalin granules (Figure 2). Grocott-Gomori methenamine- silver staining was negative for fungal elements in the sections examined. Clinical history, morphology of the eruption, and histologic features were consistent with granular parakeratosis.
Since the first reported incident of granular parakeratosis of the axilla in 1991,1 granular parakeratosis has been reported in other intertriginous areas, including the inframammary folds, inguinal folds, genitalia, perianal skin, and beneath the abdominal pannus.2 One case study in 1998 reported a patient with isolated involvement of the inguinal region3; however, this presentation is rare.4 This condition has been reported in both sexes and all age groups, including children.5
Granular parakeratosis classically presents as erythematous to brown hyperkeratotic papules that coalesce into plaques.6 It is thought to be a reactive inflammatory condition secondary to aggravating factors such as exposure to heat,7 moisture, and friction; skin occlusion; repeated washing; irritation from external agents; antiperspirants; and use of depilatory creams.8 Histopathology is characteristic and consists of retained nuclei and keratohyalin granules within the stratum corneum, beneath which there is a retained stratum granulosum. Epidermal changes may be varied and include atrophy or hyperplasia.
Murine models have postulated that granular parakeratosis may result from a deficiency in caspase 14, a protease vital to the formation of a well-functioning skin barrier.9 A cornified envelope often is noted in granular parakeratotic cells with no defects in desmosomes and cell membranes, suggesting that the pathogenesis lies within processing of profilaggrin to filaggrin, resulting in a failure to degrade keratohyalin granules and aggregation of keratin filaments.10 Granular parakeratosis is not known to be associated with other medical conditions, but it has been observed in patients receiving chemotherapy for breast11 and ovarian12 carcinomas. In infants with atopic dermatitis, granular parakeratosis was reported in 5 out of 7 cases.6 In our patient with secondary inguinal hyperhidrosis after thoracic sympathectomy, granular parakeratosis may be reactive to excess sweating and friction in the scrotal area.
Granular parakeratosis follows a waxing and waning pattern that may spontaneously resolve without any treatment; it also can follow a protracted course, as in a case with associated facial papules that persisted for 20 years.13 Topical corticosteroids alone or in combination with topical antifungal agents have been used for the treatment of granular parakeratosis with the goal of accelerating resolution.2,14 However, the efficacy of these therapeutic interventions is limited, and no controlled trials are underway. Topical vitamin D analogues15,16 and topical retinoids17 also have been reported with successful outcomes. Spontaneous resolution also has been observed in 2 different cases after previously being unresponsive to topical treatment.18,19 Treatment with Clostridium botulinum toxin A resulted in complete remission of the disease observed at 6-month follow-up. The pharmacologic action of the neurotoxin disrupts the stimulation of eccrine sweat glands, resulting in decreased sweating, a known exacerbating factor of granular parakeratosis.20
In summary, our case represents a unique clinical presentation of granular parakeratosis with classic histopathologic features. A high index of suspicion and a biopsy are vital to arriving at the correct diagnosis.
To the Editor:
Granular parakeratosis is a rare condition with an unclear etiology that results from a myriad of factors, including exposure to irritants, friction, moisture, and heat. The diagnosis is made based on a distinct histologic reaction pattern that may be protective against the triggers. We present a case of isolated scrotal granular parakeratosis in a patient with compensatory hyperhidrosis after endoscopic thoracic sympathectomy.
A 52-year-old man presented with a 5-year history of a recurrent rash affecting the scrotum. He experienced monthly flares that were exacerbated by inguinal hyperhidrosis. His symptoms included a burning sensation and pruritus followed by superficial desquamation, with gradual yet temporary improvement. His medical history was remarkable for primary axillary and palmoplantar hyperhidrosis, with compensatory inguinal hyperhidrosis after endoscopic thoracic sympathectomy 8 years prior to presentation.
Physical examination revealed a well-demarcated, scaly, erythematous plaque affecting the scrotal skin with sparing of the median raphe, penis, and inguinal folds (Figure 1). There were no other lesions noted in the axillary region or other skin folds.
Prior treatments prescribed by other providers included topical pimecrolimus, antifungal creams, topical corticosteroids, zinc oxide ointment, and daily application of an over-the-counter medicated powder with no resolution.
A punch biopsy performed at the current presentation showed psoriasiform hyperplasia of the epidermis with only a focally diminished granular layer. There was overlying thick parakeratosis and retention of keratohyalin granules (Figure 2). Grocott-Gomori methenamine- silver staining was negative for fungal elements in the sections examined. Clinical history, morphology of the eruption, and histologic features were consistent with granular parakeratosis.
Since the first reported incident of granular parakeratosis of the axilla in 1991,1 granular parakeratosis has been reported in other intertriginous areas, including the inframammary folds, inguinal folds, genitalia, perianal skin, and beneath the abdominal pannus.2 One case study in 1998 reported a patient with isolated involvement of the inguinal region3; however, this presentation is rare.4 This condition has been reported in both sexes and all age groups, including children.5
Granular parakeratosis classically presents as erythematous to brown hyperkeratotic papules that coalesce into plaques.6 It is thought to be a reactive inflammatory condition secondary to aggravating factors such as exposure to heat,7 moisture, and friction; skin occlusion; repeated washing; irritation from external agents; antiperspirants; and use of depilatory creams.8 Histopathology is characteristic and consists of retained nuclei and keratohyalin granules within the stratum corneum, beneath which there is a retained stratum granulosum. Epidermal changes may be varied and include atrophy or hyperplasia.
Murine models have postulated that granular parakeratosis may result from a deficiency in caspase 14, a protease vital to the formation of a well-functioning skin barrier.9 A cornified envelope often is noted in granular parakeratotic cells with no defects in desmosomes and cell membranes, suggesting that the pathogenesis lies within processing of profilaggrin to filaggrin, resulting in a failure to degrade keratohyalin granules and aggregation of keratin filaments.10 Granular parakeratosis is not known to be associated with other medical conditions, but it has been observed in patients receiving chemotherapy for breast11 and ovarian12 carcinomas. In infants with atopic dermatitis, granular parakeratosis was reported in 5 out of 7 cases.6 In our patient with secondary inguinal hyperhidrosis after thoracic sympathectomy, granular parakeratosis may be reactive to excess sweating and friction in the scrotal area.
Granular parakeratosis follows a waxing and waning pattern that may spontaneously resolve without any treatment; it also can follow a protracted course, as in a case with associated facial papules that persisted for 20 years.13 Topical corticosteroids alone or in combination with topical antifungal agents have been used for the treatment of granular parakeratosis with the goal of accelerating resolution.2,14 However, the efficacy of these therapeutic interventions is limited, and no controlled trials are underway. Topical vitamin D analogues15,16 and topical retinoids17 also have been reported with successful outcomes. Spontaneous resolution also has been observed in 2 different cases after previously being unresponsive to topical treatment.18,19 Treatment with Clostridium botulinum toxin A resulted in complete remission of the disease observed at 6-month follow-up. The pharmacologic action of the neurotoxin disrupts the stimulation of eccrine sweat glands, resulting in decreased sweating, a known exacerbating factor of granular parakeratosis.20
In summary, our case represents a unique clinical presentation of granular parakeratosis with classic histopathologic features. A high index of suspicion and a biopsy are vital to arriving at the correct diagnosis.
- Northcutt AD, Nelson DM, Tschen JA. Axillary granular parakeratosis. J Am Acad Dermatol. 1991;24:541-544.
- Burford C. Granular parakeratosis of multiple intertriginous areas. Australas J Dermatol. 2008;49:35-38.
- Mehregan DA, Thomas JE, Mehregan DR. Intertriginous granular parakeratosis. J Am Acad Dermatol. 1998;39:495-496.
- Leclerc-Mercier S, Prost-Squarcioni C, Hamel-Teillac D, et al. A case of congenital granular parakeratosis. Am J Dermatopathol. 2011;33:531-533.
- Scheinfeld NS, Mones J. Granular parakeratosis: pathologic and clinical correlation of 18 cases of granular parakeratosis. J Am Acad Dermatol. 2005;52:863-867.
- Akkaya AD, Oram Y, Aydin O. Infantile granular parakeratosis: cytologic examination of superficial scrapings as an aid to diagnosis. Pediatr Dermatol. 2015;32:392-396.
- Rodríguez G. Axillary granular parakeratosis [in Spanish]. Biomedica. 2002;22:519-523.
- Samrao A, Reis M, Niedt G, et al. Granular parakeratosis: response to calcipotriene and brief review of current therapeutic options. Skinmed. 2010;8:357-359.
- Hoste E, Denecker G, Gilbert B, et al. Caspase-14-deficient mice are more prone to the development of parakeratosis. J Invest Dermatol. 2013;133:742-750.
- Metze D, Rutten A. Granular parakeratosis—a unique acquired disorder of keratinization. J Cutan Pathol. 1999;26:339-352.
- Wallace CA, Pichardo RO, Yosipovitch G, et al. Granular parakeratosis: a case report and literature review. J Cutan Pathol. 2003;30:332-335.
- Jaconelli L, Doebelin B, Kanitakis J, et al. Granular parakeratosis in a patient treated with liposomal doxorubicin for ovarian carcinoma. J Am Acad Dermatol. 2008;58(5 suppl 1):S84-S87.
- Reddy IS, Swarnalata G, Mody T. Intertriginous granular parakeratosis persisting for 20 years. Indian J Dermatol Venereol Leprol. 2008;74:405-407.
- Dearden C, al-Nakib W, Andries K, et al. Drug resistant rhinoviruses from the nose of experimentally treated volunteers. Arch Virol. 1989;109:71-81.
- Patel U, Patel T, Skinner RB Jr. Resolution of granular parakeratosis with topical calcitriol. Arch Dermatol. 2011;147:997-998.
- Contreras ME, Gottfried LC, Bang RH, et al. Axillary intertriginous granular parakeratosis responsive to topical calcipotriene and ammonium lactate. Int J Dermatol. 2003;42:382-383.
- Brown SK, Heilman ER. Granular parakeratosis: resolution with topical tretinoin. J Am Acad Dermatol. 2002;47(5 suppl):S279-S280.
- Compton AK, Jackson JM. Isotretinoin as a treatment for axillary granular parakeratosis. Cutis. 2007;80:55-56.
- Webster CG, Resnik KS, Webster GF. Axillary granular parakeratosis: response to isotretinoin. J Am Acad Dermatol. 1997; 37:789-790.
- Ravitskiy L, Heymann WR. Botulinum toxin-induced resolution of axillary granular parakeratosis. Skinmed. 2005;4:118-120.
- Northcutt AD, Nelson DM, Tschen JA. Axillary granular parakeratosis. J Am Acad Dermatol. 1991;24:541-544.
- Burford C. Granular parakeratosis of multiple intertriginous areas. Australas J Dermatol. 2008;49:35-38.
- Mehregan DA, Thomas JE, Mehregan DR. Intertriginous granular parakeratosis. J Am Acad Dermatol. 1998;39:495-496.
- Leclerc-Mercier S, Prost-Squarcioni C, Hamel-Teillac D, et al. A case of congenital granular parakeratosis. Am J Dermatopathol. 2011;33:531-533.
- Scheinfeld NS, Mones J. Granular parakeratosis: pathologic and clinical correlation of 18 cases of granular parakeratosis. J Am Acad Dermatol. 2005;52:863-867.
- Akkaya AD, Oram Y, Aydin O. Infantile granular parakeratosis: cytologic examination of superficial scrapings as an aid to diagnosis. Pediatr Dermatol. 2015;32:392-396.
- Rodríguez G. Axillary granular parakeratosis [in Spanish]. Biomedica. 2002;22:519-523.
- Samrao A, Reis M, Niedt G, et al. Granular parakeratosis: response to calcipotriene and brief review of current therapeutic options. Skinmed. 2010;8:357-359.
- Hoste E, Denecker G, Gilbert B, et al. Caspase-14-deficient mice are more prone to the development of parakeratosis. J Invest Dermatol. 2013;133:742-750.
- Metze D, Rutten A. Granular parakeratosis—a unique acquired disorder of keratinization. J Cutan Pathol. 1999;26:339-352.
- Wallace CA, Pichardo RO, Yosipovitch G, et al. Granular parakeratosis: a case report and literature review. J Cutan Pathol. 2003;30:332-335.
- Jaconelli L, Doebelin B, Kanitakis J, et al. Granular parakeratosis in a patient treated with liposomal doxorubicin for ovarian carcinoma. J Am Acad Dermatol. 2008;58(5 suppl 1):S84-S87.
- Reddy IS, Swarnalata G, Mody T. Intertriginous granular parakeratosis persisting for 20 years. Indian J Dermatol Venereol Leprol. 2008;74:405-407.
- Dearden C, al-Nakib W, Andries K, et al. Drug resistant rhinoviruses from the nose of experimentally treated volunteers. Arch Virol. 1989;109:71-81.
- Patel U, Patel T, Skinner RB Jr. Resolution of granular parakeratosis with topical calcitriol. Arch Dermatol. 2011;147:997-998.
- Contreras ME, Gottfried LC, Bang RH, et al. Axillary intertriginous granular parakeratosis responsive to topical calcipotriene and ammonium lactate. Int J Dermatol. 2003;42:382-383.
- Brown SK, Heilman ER. Granular parakeratosis: resolution with topical tretinoin. J Am Acad Dermatol. 2002;47(5 suppl):S279-S280.
- Compton AK, Jackson JM. Isotretinoin as a treatment for axillary granular parakeratosis. Cutis. 2007;80:55-56.
- Webster CG, Resnik KS, Webster GF. Axillary granular parakeratosis: response to isotretinoin. J Am Acad Dermatol. 1997; 37:789-790.
- Ravitskiy L, Heymann WR. Botulinum toxin-induced resolution of axillary granular parakeratosis. Skinmed. 2005;4:118-120.
Practice Points
- Granular parakeratosis can occur in response to triggers such as irritants, friction, hyperhidrosis, and heat.
- Granular parakeratosis can have an atypical presentation; therefore, a high index of suspicion and punch biopsy are vital to arrive at the correct diagnosis.
- Classic histopathology demonstrates retained nuclei and keratohyalin granules within the stratum corneum beneath which there is a retained stratum granulosum.
Please interrupt me, but don't heat your fish
Bother me, I’m working
Although some of us have been comfortably functioning in a virtual work environment, others are now trickling back into the office. And you know what that means? People come to your desk to show you pictures of their cat or tell you about their kid’s birthday party. You may sneer at the interruption, but a study shows you actually like it.
A team of researchers at the University of Cincinnati surveyed 111 full-time employees twice a day for 3 weeks about their work experience. They asked about mental exhaustion, workplace interruptions, sense of belonging, and overall job satisfaction. They found that employees had a higher sense of belonging and job satisfaction when interrupted with a social versus work interruption.
“Interruptions can actually benefit individuals from an interpersonal perspective – people feel like they belong when others come and talk to them or ask them questions, even while being distracted from their tasks,” said Heather C. Vough, senior investigator and a former university faculty member.
Chitchatting at work is often seen as a distraction, but this study suggests that it’s not like heating up fish in the breakroom microwave.
So the next time someone hits you with the “Hey, do you have a sec?,” do yourself a favor and enjoy the interruption.
A smorgasbord of science
It’s probably difficult to recruit patients for some medical trials. Try this new drug and potentially get all sorts of interesting and unpleasant side effects. Pass. We suggest the approach a group of researchers from the University of Kansas took for a recent study into weight gain: Invite a bunch of 20-something adults to an all-you-can-eat buffet. They’ll be beating down your door in no time.
Their study, published in Appetite, focused on hyperpalatable food – the sort of food you can keep eating – and compared it with high-energy-dense food and ultra processed food. The test patients had their body composition measured, were let loose on the buffet, and were measured again a year later.
The patients who favored salty/carbohydrate-filled hyperpalatable food (such as pretzels or popcorn) were much more likely to gain weight, compared with those who focused on salty/fat-filled food of any variety. As a matter of fact, those who stuck to fatty food during the buffet had no change in weight over the 1-year study period. The researchers noted that those who ate the carb-filled food tended more toward hedonic eating, or the act of eating simply for pleasure.
The study is no doubt helpful in the long battle against obesity and overeating, but it’s also a very helpful guide to getting the most bang for your buck at the buffet. Stay away from the cheap salty snack food. Go for the steak and seafood. Get your money’s worth. In the long run you won’t even gain any weight. No promises about tomorrow though.
There’s a cheat code for that
For a large percentage of kids and young adults, and maybe even older adults (we don’t judge), a storm warning means a cozy night in playing video games. Staying inside is probably the safest bet when there’s a storm, and the weatherman never says to avoid playing video games when there’s lightning.
Maybe he should, though, since a man from Tennessee reportedly got struck by lightning through his game controller. Emergency crews determined that lightning either hit the man’s house or struck near it and went through the controller. The type of console was not revealed, even though some people may want to know the specifics before playing during the next storm.
Luckily, the man was not seriously hurt and did not need to go to the hospital. This is apparently not unheard of, as a professional gamer was shocked through a wired controller last year, causing burns on her hands and a broken controller.
This might be our cue to do less electrical types of activities during thunderstorms, like knitting or reading by candlelight.
Freeze, squeeze, and enjoy … cramping
As you were ingesting last week’s installment of the never-ending buffet that is LOTME, you probably wondered: What’s going on? Where’s the latest bodily insult being perpetuated by the gang over at TikTok?
Have no fear, good readers. We would never make you go 2 straight weeks without serving up some hyperpalatable TikTok tidbits.
Our bodily insult du jour is frozen honey, and it’s exploding all over TikTok … and a few other places. “The hashtag ‘#FrozenHoney’ has been viewed nearly 600 million times, and the hashtag ‘#FrozenHoneyChallenge’ has been viewed more than 80 million times,” NBC News recently reported.
After a few hours in the freezer, honey can be squeezed out of a plastic bottle as a semisolid, toothpastelike goo – it’s stiff enough to rise out of a container that’s pointed straight up – and bitten off in large chunks. And therein lies the problem.
Some people are overdoing it. “Honey is great, but having it in small amounts to sweeten is really a healthy relationship with food, and using it to get a lot of followers and a lot of attention and having it in excess amounts is crazy,” Kristin Kirkpatrick, a registered dietitian at the Cleveland Clinic, told NBC.
Besides the possible weight gain from eating massive amounts of sugar, experts warned that “gobbling up bottles of frozen honey” could lead to stomach cramping, bloating, and diarrhea. Some TikTokers, NBC noted, said that they “were running for the bathroom.”
As we said, it’s a trend that is exploding.
Be sure to tune in next week, when we learn how TikTokers use ground meat as a skin moisturizer.
Bother me, I’m working
Although some of us have been comfortably functioning in a virtual work environment, others are now trickling back into the office. And you know what that means? People come to your desk to show you pictures of their cat or tell you about their kid’s birthday party. You may sneer at the interruption, but a study shows you actually like it.
A team of researchers at the University of Cincinnati surveyed 111 full-time employees twice a day for 3 weeks about their work experience. They asked about mental exhaustion, workplace interruptions, sense of belonging, and overall job satisfaction. They found that employees had a higher sense of belonging and job satisfaction when interrupted with a social versus work interruption.
“Interruptions can actually benefit individuals from an interpersonal perspective – people feel like they belong when others come and talk to them or ask them questions, even while being distracted from their tasks,” said Heather C. Vough, senior investigator and a former university faculty member.
Chitchatting at work is often seen as a distraction, but this study suggests that it’s not like heating up fish in the breakroom microwave.
So the next time someone hits you with the “Hey, do you have a sec?,” do yourself a favor and enjoy the interruption.
A smorgasbord of science
It’s probably difficult to recruit patients for some medical trials. Try this new drug and potentially get all sorts of interesting and unpleasant side effects. Pass. We suggest the approach a group of researchers from the University of Kansas took for a recent study into weight gain: Invite a bunch of 20-something adults to an all-you-can-eat buffet. They’ll be beating down your door in no time.
Their study, published in Appetite, focused on hyperpalatable food – the sort of food you can keep eating – and compared it with high-energy-dense food and ultra processed food. The test patients had their body composition measured, were let loose on the buffet, and were measured again a year later.
The patients who favored salty/carbohydrate-filled hyperpalatable food (such as pretzels or popcorn) were much more likely to gain weight, compared with those who focused on salty/fat-filled food of any variety. As a matter of fact, those who stuck to fatty food during the buffet had no change in weight over the 1-year study period. The researchers noted that those who ate the carb-filled food tended more toward hedonic eating, or the act of eating simply for pleasure.
The study is no doubt helpful in the long battle against obesity and overeating, but it’s also a very helpful guide to getting the most bang for your buck at the buffet. Stay away from the cheap salty snack food. Go for the steak and seafood. Get your money’s worth. In the long run you won’t even gain any weight. No promises about tomorrow though.
There’s a cheat code for that
For a large percentage of kids and young adults, and maybe even older adults (we don’t judge), a storm warning means a cozy night in playing video games. Staying inside is probably the safest bet when there’s a storm, and the weatherman never says to avoid playing video games when there’s lightning.
Maybe he should, though, since a man from Tennessee reportedly got struck by lightning through his game controller. Emergency crews determined that lightning either hit the man’s house or struck near it and went through the controller. The type of console was not revealed, even though some people may want to know the specifics before playing during the next storm.
Luckily, the man was not seriously hurt and did not need to go to the hospital. This is apparently not unheard of, as a professional gamer was shocked through a wired controller last year, causing burns on her hands and a broken controller.
This might be our cue to do less electrical types of activities during thunderstorms, like knitting or reading by candlelight.
Freeze, squeeze, and enjoy … cramping
As you were ingesting last week’s installment of the never-ending buffet that is LOTME, you probably wondered: What’s going on? Where’s the latest bodily insult being perpetuated by the gang over at TikTok?
Have no fear, good readers. We would never make you go 2 straight weeks without serving up some hyperpalatable TikTok tidbits.
Our bodily insult du jour is frozen honey, and it’s exploding all over TikTok … and a few other places. “The hashtag ‘#FrozenHoney’ has been viewed nearly 600 million times, and the hashtag ‘#FrozenHoneyChallenge’ has been viewed more than 80 million times,” NBC News recently reported.
After a few hours in the freezer, honey can be squeezed out of a plastic bottle as a semisolid, toothpastelike goo – it’s stiff enough to rise out of a container that’s pointed straight up – and bitten off in large chunks. And therein lies the problem.
Some people are overdoing it. “Honey is great, but having it in small amounts to sweeten is really a healthy relationship with food, and using it to get a lot of followers and a lot of attention and having it in excess amounts is crazy,” Kristin Kirkpatrick, a registered dietitian at the Cleveland Clinic, told NBC.
Besides the possible weight gain from eating massive amounts of sugar, experts warned that “gobbling up bottles of frozen honey” could lead to stomach cramping, bloating, and diarrhea. Some TikTokers, NBC noted, said that they “were running for the bathroom.”
As we said, it’s a trend that is exploding.
Be sure to tune in next week, when we learn how TikTokers use ground meat as a skin moisturizer.
Bother me, I’m working
Although some of us have been comfortably functioning in a virtual work environment, others are now trickling back into the office. And you know what that means? People come to your desk to show you pictures of their cat or tell you about their kid’s birthday party. You may sneer at the interruption, but a study shows you actually like it.
A team of researchers at the University of Cincinnati surveyed 111 full-time employees twice a day for 3 weeks about their work experience. They asked about mental exhaustion, workplace interruptions, sense of belonging, and overall job satisfaction. They found that employees had a higher sense of belonging and job satisfaction when interrupted with a social versus work interruption.
“Interruptions can actually benefit individuals from an interpersonal perspective – people feel like they belong when others come and talk to them or ask them questions, even while being distracted from their tasks,” said Heather C. Vough, senior investigator and a former university faculty member.
Chitchatting at work is often seen as a distraction, but this study suggests that it’s not like heating up fish in the breakroom microwave.
So the next time someone hits you with the “Hey, do you have a sec?,” do yourself a favor and enjoy the interruption.
A smorgasbord of science
It’s probably difficult to recruit patients for some medical trials. Try this new drug and potentially get all sorts of interesting and unpleasant side effects. Pass. We suggest the approach a group of researchers from the University of Kansas took for a recent study into weight gain: Invite a bunch of 20-something adults to an all-you-can-eat buffet. They’ll be beating down your door in no time.
Their study, published in Appetite, focused on hyperpalatable food – the sort of food you can keep eating – and compared it with high-energy-dense food and ultra processed food. The test patients had their body composition measured, were let loose on the buffet, and were measured again a year later.
The patients who favored salty/carbohydrate-filled hyperpalatable food (such as pretzels or popcorn) were much more likely to gain weight, compared with those who focused on salty/fat-filled food of any variety. As a matter of fact, those who stuck to fatty food during the buffet had no change in weight over the 1-year study period. The researchers noted that those who ate the carb-filled food tended more toward hedonic eating, or the act of eating simply for pleasure.
The study is no doubt helpful in the long battle against obesity and overeating, but it’s also a very helpful guide to getting the most bang for your buck at the buffet. Stay away from the cheap salty snack food. Go for the steak and seafood. Get your money’s worth. In the long run you won’t even gain any weight. No promises about tomorrow though.
There’s a cheat code for that
For a large percentage of kids and young adults, and maybe even older adults (we don’t judge), a storm warning means a cozy night in playing video games. Staying inside is probably the safest bet when there’s a storm, and the weatherman never says to avoid playing video games when there’s lightning.
Maybe he should, though, since a man from Tennessee reportedly got struck by lightning through his game controller. Emergency crews determined that lightning either hit the man’s house or struck near it and went through the controller. The type of console was not revealed, even though some people may want to know the specifics before playing during the next storm.
Luckily, the man was not seriously hurt and did not need to go to the hospital. This is apparently not unheard of, as a professional gamer was shocked through a wired controller last year, causing burns on her hands and a broken controller.
This might be our cue to do less electrical types of activities during thunderstorms, like knitting or reading by candlelight.
Freeze, squeeze, and enjoy … cramping
As you were ingesting last week’s installment of the never-ending buffet that is LOTME, you probably wondered: What’s going on? Where’s the latest bodily insult being perpetuated by the gang over at TikTok?
Have no fear, good readers. We would never make you go 2 straight weeks without serving up some hyperpalatable TikTok tidbits.
Our bodily insult du jour is frozen honey, and it’s exploding all over TikTok … and a few other places. “The hashtag ‘#FrozenHoney’ has been viewed nearly 600 million times, and the hashtag ‘#FrozenHoneyChallenge’ has been viewed more than 80 million times,” NBC News recently reported.
After a few hours in the freezer, honey can be squeezed out of a plastic bottle as a semisolid, toothpastelike goo – it’s stiff enough to rise out of a container that’s pointed straight up – and bitten off in large chunks. And therein lies the problem.
Some people are overdoing it. “Honey is great, but having it in small amounts to sweeten is really a healthy relationship with food, and using it to get a lot of followers and a lot of attention and having it in excess amounts is crazy,” Kristin Kirkpatrick, a registered dietitian at the Cleveland Clinic, told NBC.
Besides the possible weight gain from eating massive amounts of sugar, experts warned that “gobbling up bottles of frozen honey” could lead to stomach cramping, bloating, and diarrhea. Some TikTokers, NBC noted, said that they “were running for the bathroom.”
As we said, it’s a trend that is exploding.
Be sure to tune in next week, when we learn how TikTokers use ground meat as a skin moisturizer.
Reckoning with America’s alarming rise in anti-Asian hate
On March 16, the world was witness to a horrific act of violence when a gunman killed six Asian American women and two others at spas in the Atlanta, Georgia area. The attack prompted a national outcry and protests against the rising levels of hate and violence directed at Asian Americans and Pacific Islanders (AAPI), a community that has experienced a profound and disturbing legacy of racism in American history.
Despite this fact, my own understanding and awareness of the hate and racism experienced by the AAPI community, then and now, would be described as limited at best. Was I aware on some level? Perhaps. But if I’m being honest, I have not fully appreciated the unique experiences of AAPI colleagues, friends, and students.
That changed when I attended a White Coats Against Asian Hate & Racism rally, held by the George Washington University School of Medicine and Health Sciences 2 months after the Atlanta killings. Hearing my colleagues speak of their personal experiences, I quickly realized my lack of education on the subject of how systemic racism has long affected Asian Americans in this country.
Measuring the alarming rise in anti-Asian hate
The data supporting a rise in anti-Asian hate crimes have been staring us in the face for decades but have drawn increasing attention since the beginning of the COVID-19 pandemic, when these already distressingly high numbers experienced a steep rise.
Before looking at these figures, though, we must begin by defining what is considered a hate crime versus a hate incident. The National Asian Pacific American Bar Association and Asian & Pacific Islander American Health Forum have produced a beneficial summary document on precisely what separates these terms:
- A hate crime is a crime committed on the basis of the victim’s perceived or actual race, color, religion, national origin, sexual orientation, gender identity, or disability. It differs from “regular” crime in that its victims include the immediate crime target and others like them. Hate crimes affect families, communities, and, at times, an entire nation.
- A hate incident describes acts of prejudice that are not crimes and do not involve violence, threats, or property damage. The most common examples are isolated forms of speech, such as racial slurs.
Stop AAPI Hate (SAH) was founded in March 2020 as a coalition to track and analyze incidents of hate against this community. SAH’s 2020-2021 national report details 3,795 hate incidents that occurred from March 19, 2020, to Feb. 28, 2021. In a notable parallel to the Georgia killings, SAH found that Asian American women reported hate incidents 2.3 times more often than men and that businesses were the primary site of discrimination.
This rise in hate incidents has occurred in parallel with an increase in Asian American hate crimes. Recently, the Center for the Study of Hate and Extremism (CSUSB) released its Report to the Nation: Anti-Asian Prejudice & Hate Crime. I re-read that data point multiple times, thinking it must be in error. If you’re asking exactly why I was having difficulty accepting this data, you have to appreciate these two critical points:
- Per the CSUSB, anti-Asian hate crimes were already surging by 146% in 2020.
- This surge occurred while overall hate crimes dropped by 7%.
So, if 2020 was a surge, the first quarter of 2021 is a hurricane. What’s perhaps most concerning is that these data only capture reported cases and therefore are a fraction of the total.
Undoubtedly, we are living through an unprecedented rise in anti-Asian hate incidents and hate crimes since the start of the pandemic. This rise in hate-related events paralleled the many pandemic-related stressors (disease, isolation, economics, mental health, etc.). Should anyone have been surprised when this most recent deadly spike of anti-Asian hate occurred in the first quarter of 2021?
Hate’s toll on mental health
As a psychiatrist, I’ve spent my entire career working with dedicated teams to treat patients with mental health disorders. Currently, hate is not classified by the Diagnostic and Statistical Manual of Mental Disorders as a mental illness. However, I can’t think of another emotion that is a better candidate for further research and scientific instigation, if for no other reason than to better understand when prejudice and bias transform into hatred and crime.
Surprisingly, there has been relatively little research on the topic of hate in the fields of psychology and psychiatry. I’d be willing to wager that if you asked a typical graduating class of medical students to give you an actual working definition of the emotion of hate, most would be at a loss for words.
Dr. Fischer and Dr. Halperin published a helpful article that gives a functional perspective on hate. The authors cover a great deal of research on hate and offer the following four starting points valuable in considering it:
- “Hate is different from anger because an anger target is appraised as someone whose behavior can be influenced and changed.”
- “A hate target, on the contrary, implies appraisals of the other’s malevolent nature and malicious intent.”
- “Hate is characterized by appraisals that imply a stable perception of a person or group and thus the incapability to change the extremely negative characteristics attributed to the target of hate.”
- “Everyday observations also suggest that hate is so powerful that it does, not just temporarily but permanently, destroy relations between individuals or groups.”
When I view hate with these insights in mind, it completely changes how I choose to utilize the word or concept. Hate is an emotion whose goal/action tendency is to eliminate groups (not just people or obstacles) and destroy any current or future relationships. We can take this a step further in noting that hate spreads, not only to the intended targets but potentially my “own” group. Similar to secondhand smoke, there is no risk-free exposure to hate or racism.
In the past decade, a robust body of evidence has emerged that clearly illustrates the negative health impacts of racism. Dr. Paradies and colleagues performed a systematic meta-analysis explicitly focused on racism as a determinant of health, finding that it was associated with poorer mental health, including depression, anxiety, and psychological distress. Over the past two decades, researchers have increasingly looked at the effects of racial discrimination on the AAPI community. In their 2009 review article, Dr. Gee and colleagues identified 62 empirical articles assessing the relation between discrimination and health among Asian Americans. Most of the studies found that discrimination was associated with poorer health. Of the 40 studies focused on mental health, 37 reported that discrimination was associated with poorer outcomes.
SAH recently released its very illuminating Mental Health Report. Among several key findings, two in particular caught my attention. First, Asian Americans who have experienced racism are more stressed by anti-Asian hate than the pandemic itself. Second, one in five Asian Americans who have experienced racism display racial trauma, the psychological and emotional harm caused by racism. Given the rise in hate crimes, there must be concern regarding the level of trauma being inflicted upon the Asian American community.
A complete review of the health effects of racism is beyond this article’s scope. Still, the previously mentioned studies further support the need to treat racism in general, and specifically anti-Asian hate, as the urgent public health concern that it truly is. The U.S. government recently outlined an action plan to respond to anti-Asian violence, xenophobia, and bias. These are helpful first steps, but much more is required on a societal and individual level, given the mental health disparities faced by the AAPI community.
Determining the best ways to address this urgent public health concern can be overwhelming, exhausting, and outright demoralizing. The bottom line is that if we do nothing, communities and groups will continue to suffer the effects of racial hatred. These consequences are severe and transgenerational.
But we must start somewhere. For me, that begins by gaining a better understanding of the emotion of hate and my role in either facilitating or stopping it, and by listening, listening, and listening some more to AAPI colleagues, friends, and family about their lived experience with anti-Asian hate.
A version of this article first appeared on Medscape.com.
On March 16, the world was witness to a horrific act of violence when a gunman killed six Asian American women and two others at spas in the Atlanta, Georgia area. The attack prompted a national outcry and protests against the rising levels of hate and violence directed at Asian Americans and Pacific Islanders (AAPI), a community that has experienced a profound and disturbing legacy of racism in American history.
Despite this fact, my own understanding and awareness of the hate and racism experienced by the AAPI community, then and now, would be described as limited at best. Was I aware on some level? Perhaps. But if I’m being honest, I have not fully appreciated the unique experiences of AAPI colleagues, friends, and students.
That changed when I attended a White Coats Against Asian Hate & Racism rally, held by the George Washington University School of Medicine and Health Sciences 2 months after the Atlanta killings. Hearing my colleagues speak of their personal experiences, I quickly realized my lack of education on the subject of how systemic racism has long affected Asian Americans in this country.
Measuring the alarming rise in anti-Asian hate
The data supporting a rise in anti-Asian hate crimes have been staring us in the face for decades but have drawn increasing attention since the beginning of the COVID-19 pandemic, when these already distressingly high numbers experienced a steep rise.
Before looking at these figures, though, we must begin by defining what is considered a hate crime versus a hate incident. The National Asian Pacific American Bar Association and Asian & Pacific Islander American Health Forum have produced a beneficial summary document on precisely what separates these terms:
- A hate crime is a crime committed on the basis of the victim’s perceived or actual race, color, religion, national origin, sexual orientation, gender identity, or disability. It differs from “regular” crime in that its victims include the immediate crime target and others like them. Hate crimes affect families, communities, and, at times, an entire nation.
- A hate incident describes acts of prejudice that are not crimes and do not involve violence, threats, or property damage. The most common examples are isolated forms of speech, such as racial slurs.
Stop AAPI Hate (SAH) was founded in March 2020 as a coalition to track and analyze incidents of hate against this community. SAH’s 2020-2021 national report details 3,795 hate incidents that occurred from March 19, 2020, to Feb. 28, 2021. In a notable parallel to the Georgia killings, SAH found that Asian American women reported hate incidents 2.3 times more often than men and that businesses were the primary site of discrimination.
This rise in hate incidents has occurred in parallel with an increase in Asian American hate crimes. Recently, the Center for the Study of Hate and Extremism (CSUSB) released its Report to the Nation: Anti-Asian Prejudice & Hate Crime. I re-read that data point multiple times, thinking it must be in error. If you’re asking exactly why I was having difficulty accepting this data, you have to appreciate these two critical points:
- Per the CSUSB, anti-Asian hate crimes were already surging by 146% in 2020.
- This surge occurred while overall hate crimes dropped by 7%.
So, if 2020 was a surge, the first quarter of 2021 is a hurricane. What’s perhaps most concerning is that these data only capture reported cases and therefore are a fraction of the total.
Undoubtedly, we are living through an unprecedented rise in anti-Asian hate incidents and hate crimes since the start of the pandemic. This rise in hate-related events paralleled the many pandemic-related stressors (disease, isolation, economics, mental health, etc.). Should anyone have been surprised when this most recent deadly spike of anti-Asian hate occurred in the first quarter of 2021?
Hate’s toll on mental health
As a psychiatrist, I’ve spent my entire career working with dedicated teams to treat patients with mental health disorders. Currently, hate is not classified by the Diagnostic and Statistical Manual of Mental Disorders as a mental illness. However, I can’t think of another emotion that is a better candidate for further research and scientific instigation, if for no other reason than to better understand when prejudice and bias transform into hatred and crime.
Surprisingly, there has been relatively little research on the topic of hate in the fields of psychology and psychiatry. I’d be willing to wager that if you asked a typical graduating class of medical students to give you an actual working definition of the emotion of hate, most would be at a loss for words.
Dr. Fischer and Dr. Halperin published a helpful article that gives a functional perspective on hate. The authors cover a great deal of research on hate and offer the following four starting points valuable in considering it:
- “Hate is different from anger because an anger target is appraised as someone whose behavior can be influenced and changed.”
- “A hate target, on the contrary, implies appraisals of the other’s malevolent nature and malicious intent.”
- “Hate is characterized by appraisals that imply a stable perception of a person or group and thus the incapability to change the extremely negative characteristics attributed to the target of hate.”
- “Everyday observations also suggest that hate is so powerful that it does, not just temporarily but permanently, destroy relations between individuals or groups.”
When I view hate with these insights in mind, it completely changes how I choose to utilize the word or concept. Hate is an emotion whose goal/action tendency is to eliminate groups (not just people or obstacles) and destroy any current or future relationships. We can take this a step further in noting that hate spreads, not only to the intended targets but potentially my “own” group. Similar to secondhand smoke, there is no risk-free exposure to hate or racism.
In the past decade, a robust body of evidence has emerged that clearly illustrates the negative health impacts of racism. Dr. Paradies and colleagues performed a systematic meta-analysis explicitly focused on racism as a determinant of health, finding that it was associated with poorer mental health, including depression, anxiety, and psychological distress. Over the past two decades, researchers have increasingly looked at the effects of racial discrimination on the AAPI community. In their 2009 review article, Dr. Gee and colleagues identified 62 empirical articles assessing the relation between discrimination and health among Asian Americans. Most of the studies found that discrimination was associated with poorer health. Of the 40 studies focused on mental health, 37 reported that discrimination was associated with poorer outcomes.
SAH recently released its very illuminating Mental Health Report. Among several key findings, two in particular caught my attention. First, Asian Americans who have experienced racism are more stressed by anti-Asian hate than the pandemic itself. Second, one in five Asian Americans who have experienced racism display racial trauma, the psychological and emotional harm caused by racism. Given the rise in hate crimes, there must be concern regarding the level of trauma being inflicted upon the Asian American community.
A complete review of the health effects of racism is beyond this article’s scope. Still, the previously mentioned studies further support the need to treat racism in general, and specifically anti-Asian hate, as the urgent public health concern that it truly is. The U.S. government recently outlined an action plan to respond to anti-Asian violence, xenophobia, and bias. These are helpful first steps, but much more is required on a societal and individual level, given the mental health disparities faced by the AAPI community.
Determining the best ways to address this urgent public health concern can be overwhelming, exhausting, and outright demoralizing. The bottom line is that if we do nothing, communities and groups will continue to suffer the effects of racial hatred. These consequences are severe and transgenerational.
But we must start somewhere. For me, that begins by gaining a better understanding of the emotion of hate and my role in either facilitating or stopping it, and by listening, listening, and listening some more to AAPI colleagues, friends, and family about their lived experience with anti-Asian hate.
A version of this article first appeared on Medscape.com.
On March 16, the world was witness to a horrific act of violence when a gunman killed six Asian American women and two others at spas in the Atlanta, Georgia area. The attack prompted a national outcry and protests against the rising levels of hate and violence directed at Asian Americans and Pacific Islanders (AAPI), a community that has experienced a profound and disturbing legacy of racism in American history.
Despite this fact, my own understanding and awareness of the hate and racism experienced by the AAPI community, then and now, would be described as limited at best. Was I aware on some level? Perhaps. But if I’m being honest, I have not fully appreciated the unique experiences of AAPI colleagues, friends, and students.
That changed when I attended a White Coats Against Asian Hate & Racism rally, held by the George Washington University School of Medicine and Health Sciences 2 months after the Atlanta killings. Hearing my colleagues speak of their personal experiences, I quickly realized my lack of education on the subject of how systemic racism has long affected Asian Americans in this country.
Measuring the alarming rise in anti-Asian hate
The data supporting a rise in anti-Asian hate crimes have been staring us in the face for decades but have drawn increasing attention since the beginning of the COVID-19 pandemic, when these already distressingly high numbers experienced a steep rise.
Before looking at these figures, though, we must begin by defining what is considered a hate crime versus a hate incident. The National Asian Pacific American Bar Association and Asian & Pacific Islander American Health Forum have produced a beneficial summary document on precisely what separates these terms:
- A hate crime is a crime committed on the basis of the victim’s perceived or actual race, color, religion, national origin, sexual orientation, gender identity, or disability. It differs from “regular” crime in that its victims include the immediate crime target and others like them. Hate crimes affect families, communities, and, at times, an entire nation.
- A hate incident describes acts of prejudice that are not crimes and do not involve violence, threats, or property damage. The most common examples are isolated forms of speech, such as racial slurs.
Stop AAPI Hate (SAH) was founded in March 2020 as a coalition to track and analyze incidents of hate against this community. SAH’s 2020-2021 national report details 3,795 hate incidents that occurred from March 19, 2020, to Feb. 28, 2021. In a notable parallel to the Georgia killings, SAH found that Asian American women reported hate incidents 2.3 times more often than men and that businesses were the primary site of discrimination.
This rise in hate incidents has occurred in parallel with an increase in Asian American hate crimes. Recently, the Center for the Study of Hate and Extremism (CSUSB) released its Report to the Nation: Anti-Asian Prejudice & Hate Crime. I re-read that data point multiple times, thinking it must be in error. If you’re asking exactly why I was having difficulty accepting this data, you have to appreciate these two critical points:
- Per the CSUSB, anti-Asian hate crimes were already surging by 146% in 2020.
- This surge occurred while overall hate crimes dropped by 7%.
So, if 2020 was a surge, the first quarter of 2021 is a hurricane. What’s perhaps most concerning is that these data only capture reported cases and therefore are a fraction of the total.
Undoubtedly, we are living through an unprecedented rise in anti-Asian hate incidents and hate crimes since the start of the pandemic. This rise in hate-related events paralleled the many pandemic-related stressors (disease, isolation, economics, mental health, etc.). Should anyone have been surprised when this most recent deadly spike of anti-Asian hate occurred in the first quarter of 2021?
Hate’s toll on mental health
As a psychiatrist, I’ve spent my entire career working with dedicated teams to treat patients with mental health disorders. Currently, hate is not classified by the Diagnostic and Statistical Manual of Mental Disorders as a mental illness. However, I can’t think of another emotion that is a better candidate for further research and scientific instigation, if for no other reason than to better understand when prejudice and bias transform into hatred and crime.
Surprisingly, there has been relatively little research on the topic of hate in the fields of psychology and psychiatry. I’d be willing to wager that if you asked a typical graduating class of medical students to give you an actual working definition of the emotion of hate, most would be at a loss for words.
Dr. Fischer and Dr. Halperin published a helpful article that gives a functional perspective on hate. The authors cover a great deal of research on hate and offer the following four starting points valuable in considering it:
- “Hate is different from anger because an anger target is appraised as someone whose behavior can be influenced and changed.”
- “A hate target, on the contrary, implies appraisals of the other’s malevolent nature and malicious intent.”
- “Hate is characterized by appraisals that imply a stable perception of a person or group and thus the incapability to change the extremely negative characteristics attributed to the target of hate.”
- “Everyday observations also suggest that hate is so powerful that it does, not just temporarily but permanently, destroy relations between individuals or groups.”
When I view hate with these insights in mind, it completely changes how I choose to utilize the word or concept. Hate is an emotion whose goal/action tendency is to eliminate groups (not just people or obstacles) and destroy any current or future relationships. We can take this a step further in noting that hate spreads, not only to the intended targets but potentially my “own” group. Similar to secondhand smoke, there is no risk-free exposure to hate or racism.
In the past decade, a robust body of evidence has emerged that clearly illustrates the negative health impacts of racism. Dr. Paradies and colleagues performed a systematic meta-analysis explicitly focused on racism as a determinant of health, finding that it was associated with poorer mental health, including depression, anxiety, and psychological distress. Over the past two decades, researchers have increasingly looked at the effects of racial discrimination on the AAPI community. In their 2009 review article, Dr. Gee and colleagues identified 62 empirical articles assessing the relation between discrimination and health among Asian Americans. Most of the studies found that discrimination was associated with poorer health. Of the 40 studies focused on mental health, 37 reported that discrimination was associated with poorer outcomes.
SAH recently released its very illuminating Mental Health Report. Among several key findings, two in particular caught my attention. First, Asian Americans who have experienced racism are more stressed by anti-Asian hate than the pandemic itself. Second, one in five Asian Americans who have experienced racism display racial trauma, the psychological and emotional harm caused by racism. Given the rise in hate crimes, there must be concern regarding the level of trauma being inflicted upon the Asian American community.
A complete review of the health effects of racism is beyond this article’s scope. Still, the previously mentioned studies further support the need to treat racism in general, and specifically anti-Asian hate, as the urgent public health concern that it truly is. The U.S. government recently outlined an action plan to respond to anti-Asian violence, xenophobia, and bias. These are helpful first steps, but much more is required on a societal and individual level, given the mental health disparities faced by the AAPI community.
Determining the best ways to address this urgent public health concern can be overwhelming, exhausting, and outright demoralizing. The bottom line is that if we do nothing, communities and groups will continue to suffer the effects of racial hatred. These consequences are severe and transgenerational.
But we must start somewhere. For me, that begins by gaining a better understanding of the emotion of hate and my role in either facilitating or stopping it, and by listening, listening, and listening some more to AAPI colleagues, friends, and family about their lived experience with anti-Asian hate.
A version of this article first appeared on Medscape.com.
Certain gut bacteria tied to lower risk of diabetes
Having more diverse gut bacteria (greater microbiome richness) and specifically a greater abundance of 12 types of butyrate-producing bacteria were both associated with less insulin resistance and less type 2 diabetes, in a population-based observational study from the Netherlands.
Several studies have reported that there is less microbiome diversity in type 2 diabetes, Zhangling Chen, MD, PhD, of Erasmus Medical Center, Rotterdam, the Netherlands, and colleagues note.
Their study also identified a dozen types of bacteria that ferment dietary fiber (undigested carbohydrates) in the gut to produce butyrate, a short-chain fatty acid, which may play a role in protection against type 2 diabetes.
“The current study is the first, to our knowledge, to comprehensively investigate the associations between gut microbiome composition [and] type 2 diabetes in a large population-based sample … which we adjusted for a series of key confounders,” the researchers write.
“These findings suggest that higher gut microbial diversity, along with specifically more butyrate-producing bacteria, may play a role in the development of type 2 diabetes, which may help guide future prevention and treatment strategies,” they conclude in their study published online July 29 in JAMA Network Open.
Confirmation of previous work, plus some new findings
The study confirms what many smaller ones have repeatedly shown – that low gut microbiome diversity is associated with increased risks of obesity and type 2 diabetes, Nanette I. Steinle, MD, RDN, who was not involved in the research, said in an interview.
A diet rich in fiber and prebiotics promotes gut biome diversity, added Dr. Steinle, chief of the endocrinology and diabetes section at Maryland Veterans Affairs Medical Center in Baltimore.
The findings add to other research, she noted, such as a prospective trial in which a high-fiber diet induced changes in the gut microbe that were linked to better glycemic regulation (Science. 2018;359:1151-6) and a study of a promising probiotic formula to treat diabetes.
“An important next step,” according to Dr. Steinle, “is to provide interventions like healthy diet or specific fiber types to see what can be done to produce lasting shifts in the gut microbiome and if these shifts result in improved metabolic health.”
Natalia Shulzhenko, MD, PhD, said: “Some of associations of taxa [bacteria groupings] with type 2 diabetes reported by this study are new.”
Dr. Shulzhenko and colleagues recently published a review of the role of gut microbiota in type 2 diabetes pathophysiology that summarized evidence from 42 human studies as well as preclinical studies and clinical trials of probiotic treatments (EBioMedicine. 2020;51:102590).
“Besides adding new microbes to the list of potential pathobionts [organisms that can cause harm] and beneficial microbes for type 2 diabetes,” the findings by Dr. Chen and colleagues “support a notion that different members of the gut microbial community may have similar effects on type 2 diabetes in different individuals,” commonly known as “functional redundancy,” Dr. Shulzhenko, associate professor, Carlson College of Veterinary Medicine, Oregon State University, Corvallis, pointed out in an email.
Also “in line with previous studies,” the study shows that butyrate-producing bacteria are associated with type 2 diabetes.
She speculated that “these results will probably contribute to the body of knowledge that is needed to develop microbiota-based therapy and diagnostics.”
Which gut bacteria are linked with diabetes?
It is unclear which gut bacteria are associated with the development of type 2 diabetes, Dr. Chen and colleagues write.
To investigate this, they identified 1,418 participants from the Rotterdam Study and 748 participants from the LifeLines-DEEP study enrolled from January 2018 to December 2020. Of these participants, 193 had type 2 diabetes.
The participants provided stool samples that were used to measure gut microbiome composition using the 16S ribosomal RNA method. They also had blood tests to measure glucose and insulin, and researchers collected other demographic and medical data.
Participants in the Rotterdam study were older than in the LifeLines Deep study (mean age, 62 vs. 45 years). Both cohorts included slightly more men than women (58%).
Dr. Chen and colleagues identified 126 (bacteria) genera in the gut microbiome in the Rotterdam study and 184 genera in the LifeLines Deep study.
After correcting for age, sex, smoking, education, physical activity, alcohol intake, daily calories, body mass index, and use of lipid-lowering medication or proton pump inhibitors, higher microbiome diversity was associated with lower insulin resistance and a lower prevalence of type 2 diabetes.
A higher abundance of each of seven types of butyrate-producing bacteria – Christensenellaceae, Christensenellaceae R7 group, Marvinbryantia, Ruminococcaceae UCG-005, Ruminococcaceae UCG-008, Ruminococcaceae UCG-010, and Ruminococcaceae NK4A214 group – was associated with lower insulin resistance, after adjusting for confounders such as diet and medications (all P < .001).
And a higher abundance of each of five other types of butyrate-producing bacteria – Clostridiaceae 1, Peptostreptococcaceae, Clostridium sensu stricto 1, Intestinibacter, and Romboutsia – was associated with less type 2 diabetes (all P < .001).
Study limitations include that gut microbiome composition was determined from stool (fecal) samples, whereas the actual composition varies in different locations along the intestine, and the study also lacked information about butyrate concentrations in stool or blood, the researchers note.
They call for “future research [to] validate the hypothesis of butyrate-producing bacteria affecting glucose metabolism and diabetes risk via production of butyrate.”
The authors and Dr. Shulzhenko have reported no relevant financial relationships. Dr. Steinle has reported receiving funding from the National Institutes of Health and conducting a study funded by Kowa through the VA.
A version of this article first appeared on Medscape.com.
Having more diverse gut bacteria (greater microbiome richness) and specifically a greater abundance of 12 types of butyrate-producing bacteria were both associated with less insulin resistance and less type 2 diabetes, in a population-based observational study from the Netherlands.
Several studies have reported that there is less microbiome diversity in type 2 diabetes, Zhangling Chen, MD, PhD, of Erasmus Medical Center, Rotterdam, the Netherlands, and colleagues note.
Their study also identified a dozen types of bacteria that ferment dietary fiber (undigested carbohydrates) in the gut to produce butyrate, a short-chain fatty acid, which may play a role in protection against type 2 diabetes.
“The current study is the first, to our knowledge, to comprehensively investigate the associations between gut microbiome composition [and] type 2 diabetes in a large population-based sample … which we adjusted for a series of key confounders,” the researchers write.
“These findings suggest that higher gut microbial diversity, along with specifically more butyrate-producing bacteria, may play a role in the development of type 2 diabetes, which may help guide future prevention and treatment strategies,” they conclude in their study published online July 29 in JAMA Network Open.
Confirmation of previous work, plus some new findings
The study confirms what many smaller ones have repeatedly shown – that low gut microbiome diversity is associated with increased risks of obesity and type 2 diabetes, Nanette I. Steinle, MD, RDN, who was not involved in the research, said in an interview.
A diet rich in fiber and prebiotics promotes gut biome diversity, added Dr. Steinle, chief of the endocrinology and diabetes section at Maryland Veterans Affairs Medical Center in Baltimore.
The findings add to other research, she noted, such as a prospective trial in which a high-fiber diet induced changes in the gut microbe that were linked to better glycemic regulation (Science. 2018;359:1151-6) and a study of a promising probiotic formula to treat diabetes.
“An important next step,” according to Dr. Steinle, “is to provide interventions like healthy diet or specific fiber types to see what can be done to produce lasting shifts in the gut microbiome and if these shifts result in improved metabolic health.”
Natalia Shulzhenko, MD, PhD, said: “Some of associations of taxa [bacteria groupings] with type 2 diabetes reported by this study are new.”
Dr. Shulzhenko and colleagues recently published a review of the role of gut microbiota in type 2 diabetes pathophysiology that summarized evidence from 42 human studies as well as preclinical studies and clinical trials of probiotic treatments (EBioMedicine. 2020;51:102590).
“Besides adding new microbes to the list of potential pathobionts [organisms that can cause harm] and beneficial microbes for type 2 diabetes,” the findings by Dr. Chen and colleagues “support a notion that different members of the gut microbial community may have similar effects on type 2 diabetes in different individuals,” commonly known as “functional redundancy,” Dr. Shulzhenko, associate professor, Carlson College of Veterinary Medicine, Oregon State University, Corvallis, pointed out in an email.
Also “in line with previous studies,” the study shows that butyrate-producing bacteria are associated with type 2 diabetes.
She speculated that “these results will probably contribute to the body of knowledge that is needed to develop microbiota-based therapy and diagnostics.”
Which gut bacteria are linked with diabetes?
It is unclear which gut bacteria are associated with the development of type 2 diabetes, Dr. Chen and colleagues write.
To investigate this, they identified 1,418 participants from the Rotterdam Study and 748 participants from the LifeLines-DEEP study enrolled from January 2018 to December 2020. Of these participants, 193 had type 2 diabetes.
The participants provided stool samples that were used to measure gut microbiome composition using the 16S ribosomal RNA method. They also had blood tests to measure glucose and insulin, and researchers collected other demographic and medical data.
Participants in the Rotterdam study were older than in the LifeLines Deep study (mean age, 62 vs. 45 years). Both cohorts included slightly more men than women (58%).
Dr. Chen and colleagues identified 126 (bacteria) genera in the gut microbiome in the Rotterdam study and 184 genera in the LifeLines Deep study.
After correcting for age, sex, smoking, education, physical activity, alcohol intake, daily calories, body mass index, and use of lipid-lowering medication or proton pump inhibitors, higher microbiome diversity was associated with lower insulin resistance and a lower prevalence of type 2 diabetes.
A higher abundance of each of seven types of butyrate-producing bacteria – Christensenellaceae, Christensenellaceae R7 group, Marvinbryantia, Ruminococcaceae UCG-005, Ruminococcaceae UCG-008, Ruminococcaceae UCG-010, and Ruminococcaceae NK4A214 group – was associated with lower insulin resistance, after adjusting for confounders such as diet and medications (all P < .001).
And a higher abundance of each of five other types of butyrate-producing bacteria – Clostridiaceae 1, Peptostreptococcaceae, Clostridium sensu stricto 1, Intestinibacter, and Romboutsia – was associated with less type 2 diabetes (all P < .001).
Study limitations include that gut microbiome composition was determined from stool (fecal) samples, whereas the actual composition varies in different locations along the intestine, and the study also lacked information about butyrate concentrations in stool or blood, the researchers note.
They call for “future research [to] validate the hypothesis of butyrate-producing bacteria affecting glucose metabolism and diabetes risk via production of butyrate.”
The authors and Dr. Shulzhenko have reported no relevant financial relationships. Dr. Steinle has reported receiving funding from the National Institutes of Health and conducting a study funded by Kowa through the VA.
A version of this article first appeared on Medscape.com.
Having more diverse gut bacteria (greater microbiome richness) and specifically a greater abundance of 12 types of butyrate-producing bacteria were both associated with less insulin resistance and less type 2 diabetes, in a population-based observational study from the Netherlands.
Several studies have reported that there is less microbiome diversity in type 2 diabetes, Zhangling Chen, MD, PhD, of Erasmus Medical Center, Rotterdam, the Netherlands, and colleagues note.
Their study also identified a dozen types of bacteria that ferment dietary fiber (undigested carbohydrates) in the gut to produce butyrate, a short-chain fatty acid, which may play a role in protection against type 2 diabetes.
“The current study is the first, to our knowledge, to comprehensively investigate the associations between gut microbiome composition [and] type 2 diabetes in a large population-based sample … which we adjusted for a series of key confounders,” the researchers write.
“These findings suggest that higher gut microbial diversity, along with specifically more butyrate-producing bacteria, may play a role in the development of type 2 diabetes, which may help guide future prevention and treatment strategies,” they conclude in their study published online July 29 in JAMA Network Open.
Confirmation of previous work, plus some new findings
The study confirms what many smaller ones have repeatedly shown – that low gut microbiome diversity is associated with increased risks of obesity and type 2 diabetes, Nanette I. Steinle, MD, RDN, who was not involved in the research, said in an interview.
A diet rich in fiber and prebiotics promotes gut biome diversity, added Dr. Steinle, chief of the endocrinology and diabetes section at Maryland Veterans Affairs Medical Center in Baltimore.
The findings add to other research, she noted, such as a prospective trial in which a high-fiber diet induced changes in the gut microbe that were linked to better glycemic regulation (Science. 2018;359:1151-6) and a study of a promising probiotic formula to treat diabetes.
“An important next step,” according to Dr. Steinle, “is to provide interventions like healthy diet or specific fiber types to see what can be done to produce lasting shifts in the gut microbiome and if these shifts result in improved metabolic health.”
Natalia Shulzhenko, MD, PhD, said: “Some of associations of taxa [bacteria groupings] with type 2 diabetes reported by this study are new.”
Dr. Shulzhenko and colleagues recently published a review of the role of gut microbiota in type 2 diabetes pathophysiology that summarized evidence from 42 human studies as well as preclinical studies and clinical trials of probiotic treatments (EBioMedicine. 2020;51:102590).
“Besides adding new microbes to the list of potential pathobionts [organisms that can cause harm] and beneficial microbes for type 2 diabetes,” the findings by Dr. Chen and colleagues “support a notion that different members of the gut microbial community may have similar effects on type 2 diabetes in different individuals,” commonly known as “functional redundancy,” Dr. Shulzhenko, associate professor, Carlson College of Veterinary Medicine, Oregon State University, Corvallis, pointed out in an email.
Also “in line with previous studies,” the study shows that butyrate-producing bacteria are associated with type 2 diabetes.
She speculated that “these results will probably contribute to the body of knowledge that is needed to develop microbiota-based therapy and diagnostics.”
Which gut bacteria are linked with diabetes?
It is unclear which gut bacteria are associated with the development of type 2 diabetes, Dr. Chen and colleagues write.
To investigate this, they identified 1,418 participants from the Rotterdam Study and 748 participants from the LifeLines-DEEP study enrolled from January 2018 to December 2020. Of these participants, 193 had type 2 diabetes.
The participants provided stool samples that were used to measure gut microbiome composition using the 16S ribosomal RNA method. They also had blood tests to measure glucose and insulin, and researchers collected other demographic and medical data.
Participants in the Rotterdam study were older than in the LifeLines Deep study (mean age, 62 vs. 45 years). Both cohorts included slightly more men than women (58%).
Dr. Chen and colleagues identified 126 (bacteria) genera in the gut microbiome in the Rotterdam study and 184 genera in the LifeLines Deep study.
After correcting for age, sex, smoking, education, physical activity, alcohol intake, daily calories, body mass index, and use of lipid-lowering medication or proton pump inhibitors, higher microbiome diversity was associated with lower insulin resistance and a lower prevalence of type 2 diabetes.
A higher abundance of each of seven types of butyrate-producing bacteria – Christensenellaceae, Christensenellaceae R7 group, Marvinbryantia, Ruminococcaceae UCG-005, Ruminococcaceae UCG-008, Ruminococcaceae UCG-010, and Ruminococcaceae NK4A214 group – was associated with lower insulin resistance, after adjusting for confounders such as diet and medications (all P < .001).
And a higher abundance of each of five other types of butyrate-producing bacteria – Clostridiaceae 1, Peptostreptococcaceae, Clostridium sensu stricto 1, Intestinibacter, and Romboutsia – was associated with less type 2 diabetes (all P < .001).
Study limitations include that gut microbiome composition was determined from stool (fecal) samples, whereas the actual composition varies in different locations along the intestine, and the study also lacked information about butyrate concentrations in stool or blood, the researchers note.
They call for “future research [to] validate the hypothesis of butyrate-producing bacteria affecting glucose metabolism and diabetes risk via production of butyrate.”
The authors and Dr. Shulzhenko have reported no relevant financial relationships. Dr. Steinle has reported receiving funding from the National Institutes of Health and conducting a study funded by Kowa through the VA.
A version of this article first appeared on Medscape.com.
Fulminant Hemorrhagic Bullae of the Upper Extremities Arising in the Setting of IV Placement During Severe COVID-19 Infection: Observations From a Major Consultative Practice
To the Editor:
A range of dermatologic manifestations of COVID-19 have been reported, including nonspecific maculopapular exanthems, urticaria, and varicellalike eruptions.1 Additionally, there have been sporadic accounts of cutaneous vasculopathic signs such as perniolike lesions, acro-ischemia, livedo reticularis, and retiform purpura.2 We describe exuberant hemorrhagic bullae occurring on the extremities of 2 critically ill patients with COVID-19. We hypothesized that the bullae were vasculopathic in nature and possibly exacerbated by peripheral intravenous (IV)–related injury.
A 62-year-old woman with a history of diabetes mellitus and chronic obstructive pulmonary disease was admitted to the intensive care unit for acute hypoxemic respiratory failure secondary to COVID-19 infection. Dermatology was consulted for evaluation of blisters on the right arm. A new peripheral IV line was inserted into the patient’s right forearm for treatment of secondary methicillin-resistant Staphylococcus aureus pneumonia. The peripheral IV was inserted into the right proximal forearm for 2 days prior to development of ecchymosis and blisters. Intravenous medications included vancomycin, cefepime, methylprednisolone, and famotidine, as well as maintenance fluids (normal saline). Physical examination revealed extensive confluent ecchymoses with overlying tense bullae (Figure 1). Notable laboratory findings included an elevated D-dimer (peak of 8.67 μg/mL fibrinogen-equivalent units [FEUs], reference range <0.5 μg/mL FEU) and fibrinogen (789 mg/dL, reference range 200–400 mg/dL) levels. Three days later she developed worsening edema of the right arm, accompanied by more extensive bullae formation (Figure 2). Computed tomography of the right arm showed extensive subcutaneous stranding and subcutaneous edema. An orthopedic consultation determined that there was no compartment syndrome, and surgical intervention was not recommended. The patient’s course was complicated by multiorgan failure, and she died 18 days after admission.
A 67-year-old man with coronary artery disease, diabetes mellitus, and hemiparesis secondary to stroke was admitted to the intensive care unit due to hypoxemia secondary to COVID-19 pneumonia. Dermatology was consulted for the evaluation of blisters on both arms. The right forearm peripheral IV line was used for 4 days prior to the development of cutaneous symptoms. Intravenous medications included cefepime, famotidine, and methylprednisolone. The left forearm peripheral IV line was in place for 1 day prior to the development of blisters and was used for the infusion of maintenance fluids (lactated Ringer’s solution). On the first day of the eruption, small bullae were noted at sites of prior peripheral IV lines (Figure 3). On day 3 of admission, the eruption progressed to larger and more confluent tense bullae with ecchymosis (Figure 4). Additionally, laboratory test results were notable for an elevated D-dimer (peak of >20.00 ug/mL FEU) and fibrinogen (748 mg/dL) levels. Computed tomography of the arms showed extensive subcutaneous stranding and fluid along the fascial planes of the arms, with no gas or abscess formation. Surgical intervention was not recommended following an orthopedic consultation. The patient’s course was complicated by acute kidney injury and rhabdomyolysis; he was later discharged to a skilled nursing facility in stable condition.
Reports from China indicate that approximately 50% of COVID-19 patients have elevated D-dimer levels and are at risk for thrombosis.3 We hypothesize that the exuberant hemorrhagic bullous eruptions in our 2 cases may be mediated in part by a hypercoagulable state secondary to COVID-19 infection combined with IV-related trauma or extravasation injury. However, a direct cytotoxic effect of the virus cannot be entirely excluded as a potential inciting factor. Other entities considered in the differential for localized bullae included trauma-induced bullous pemphigoid as well as bullous cellulitis. Both patients were treated with high-dose steroids as well as broad-spectrum antibiotics, which were expected to lead to improvement in symptoms of bullous pemphigoid and cellulitis, respectively; however, they did not lead to symptom improvement.
Extravasation injury results from unintentional administration of potentially vesicant substances into tissues surrounding the intended vascular channel.4 The mechanism of action of these injuries is postulated to arise from direct tissue injury from cytotoxic substances, elevated osmotic pressure, and reduced blood supply if vasoconstrictive substances are infused.5 In our patients, these injuries also may have promoted vascular occlusion leading to the brisk reaction observed. Although ecchymoses typically are associated with hypocoagulable states, both of our patients were noted to have normal platelet levels throughout hospitalization. Additionally, findings of elevated D-dimer and fibrinogen levels point to a hypercoagulable state. However, there is a possibility of platelet dysfunction leading to the observed cutaneous findings of ecchymoses. Thrombocytopenia is a common finding in patients with COVID-19 and is found to be associated with increased in-hospital mortality.6 Additional study of these reactions is needed given the propensity for multiorgan failure and death in patients with COVID-19 from suspected diffuse microvascular damage.3
- Recalcati S. Cutaneous manifestations in COVID-19: a first perspective [published online March 26, 2020]. J Eur Acad Dermatol Venereol. doi:10.1111/jdv.16387
- Zhang Y, Cao W, Xiao M, et al. Clinical and coagulation characteristics of 7 patients with critical COVID-19 pneumonia and acro-ischemia [in Chinese][published online March 28, 2020]. Zhonghua Xue Ye Xue Za Zhi. 2020;41:E006.
- Mei H, Hu Y. Characteristics, causes, diagnosis and treatment of coagulation dysfunction in patients with COVID-19 [in Chinese][published online March 14, 2020]. Zhonghua Xue Ye Xue Za Zhi. 2020;41:E002.
- Sauerland C, Engelking C, Wickham R, et al. Vesicant extravasation part I: mechanisms, pathogenesis, and nursing care to reduce risk. Oncol Nurs Forum. 2006;33:1134-1141.
- Reynolds PM, MacLaren R, Mueller SW, et al. Management of extravasation injuries: a focused evaluation of noncytotoxic medications. Pharmacotherapy. 2014;34:617-632.
- Yang X, Yang Q, Wang Y, et al. Thrombocytopenia and its association with mortality in patients with COVID-19. J Thromb Haemost. 2020;18:1469‐1472.
To the Editor:
A range of dermatologic manifestations of COVID-19 have been reported, including nonspecific maculopapular exanthems, urticaria, and varicellalike eruptions.1 Additionally, there have been sporadic accounts of cutaneous vasculopathic signs such as perniolike lesions, acro-ischemia, livedo reticularis, and retiform purpura.2 We describe exuberant hemorrhagic bullae occurring on the extremities of 2 critically ill patients with COVID-19. We hypothesized that the bullae were vasculopathic in nature and possibly exacerbated by peripheral intravenous (IV)–related injury.
A 62-year-old woman with a history of diabetes mellitus and chronic obstructive pulmonary disease was admitted to the intensive care unit for acute hypoxemic respiratory failure secondary to COVID-19 infection. Dermatology was consulted for evaluation of blisters on the right arm. A new peripheral IV line was inserted into the patient’s right forearm for treatment of secondary methicillin-resistant Staphylococcus aureus pneumonia. The peripheral IV was inserted into the right proximal forearm for 2 days prior to development of ecchymosis and blisters. Intravenous medications included vancomycin, cefepime, methylprednisolone, and famotidine, as well as maintenance fluids (normal saline). Physical examination revealed extensive confluent ecchymoses with overlying tense bullae (Figure 1). Notable laboratory findings included an elevated D-dimer (peak of 8.67 μg/mL fibrinogen-equivalent units [FEUs], reference range <0.5 μg/mL FEU) and fibrinogen (789 mg/dL, reference range 200–400 mg/dL) levels. Three days later she developed worsening edema of the right arm, accompanied by more extensive bullae formation (Figure 2). Computed tomography of the right arm showed extensive subcutaneous stranding and subcutaneous edema. An orthopedic consultation determined that there was no compartment syndrome, and surgical intervention was not recommended. The patient’s course was complicated by multiorgan failure, and she died 18 days after admission.
A 67-year-old man with coronary artery disease, diabetes mellitus, and hemiparesis secondary to stroke was admitted to the intensive care unit due to hypoxemia secondary to COVID-19 pneumonia. Dermatology was consulted for the evaluation of blisters on both arms. The right forearm peripheral IV line was used for 4 days prior to the development of cutaneous symptoms. Intravenous medications included cefepime, famotidine, and methylprednisolone. The left forearm peripheral IV line was in place for 1 day prior to the development of blisters and was used for the infusion of maintenance fluids (lactated Ringer’s solution). On the first day of the eruption, small bullae were noted at sites of prior peripheral IV lines (Figure 3). On day 3 of admission, the eruption progressed to larger and more confluent tense bullae with ecchymosis (Figure 4). Additionally, laboratory test results were notable for an elevated D-dimer (peak of >20.00 ug/mL FEU) and fibrinogen (748 mg/dL) levels. Computed tomography of the arms showed extensive subcutaneous stranding and fluid along the fascial planes of the arms, with no gas or abscess formation. Surgical intervention was not recommended following an orthopedic consultation. The patient’s course was complicated by acute kidney injury and rhabdomyolysis; he was later discharged to a skilled nursing facility in stable condition.
Reports from China indicate that approximately 50% of COVID-19 patients have elevated D-dimer levels and are at risk for thrombosis.3 We hypothesize that the exuberant hemorrhagic bullous eruptions in our 2 cases may be mediated in part by a hypercoagulable state secondary to COVID-19 infection combined with IV-related trauma or extravasation injury. However, a direct cytotoxic effect of the virus cannot be entirely excluded as a potential inciting factor. Other entities considered in the differential for localized bullae included trauma-induced bullous pemphigoid as well as bullous cellulitis. Both patients were treated with high-dose steroids as well as broad-spectrum antibiotics, which were expected to lead to improvement in symptoms of bullous pemphigoid and cellulitis, respectively; however, they did not lead to symptom improvement.
Extravasation injury results from unintentional administration of potentially vesicant substances into tissues surrounding the intended vascular channel.4 The mechanism of action of these injuries is postulated to arise from direct tissue injury from cytotoxic substances, elevated osmotic pressure, and reduced blood supply if vasoconstrictive substances are infused.5 In our patients, these injuries also may have promoted vascular occlusion leading to the brisk reaction observed. Although ecchymoses typically are associated with hypocoagulable states, both of our patients were noted to have normal platelet levels throughout hospitalization. Additionally, findings of elevated D-dimer and fibrinogen levels point to a hypercoagulable state. However, there is a possibility of platelet dysfunction leading to the observed cutaneous findings of ecchymoses. Thrombocytopenia is a common finding in patients with COVID-19 and is found to be associated with increased in-hospital mortality.6 Additional study of these reactions is needed given the propensity for multiorgan failure and death in patients with COVID-19 from suspected diffuse microvascular damage.3
To the Editor:
A range of dermatologic manifestations of COVID-19 have been reported, including nonspecific maculopapular exanthems, urticaria, and varicellalike eruptions.1 Additionally, there have been sporadic accounts of cutaneous vasculopathic signs such as perniolike lesions, acro-ischemia, livedo reticularis, and retiform purpura.2 We describe exuberant hemorrhagic bullae occurring on the extremities of 2 critically ill patients with COVID-19. We hypothesized that the bullae were vasculopathic in nature and possibly exacerbated by peripheral intravenous (IV)–related injury.
A 62-year-old woman with a history of diabetes mellitus and chronic obstructive pulmonary disease was admitted to the intensive care unit for acute hypoxemic respiratory failure secondary to COVID-19 infection. Dermatology was consulted for evaluation of blisters on the right arm. A new peripheral IV line was inserted into the patient’s right forearm for treatment of secondary methicillin-resistant Staphylococcus aureus pneumonia. The peripheral IV was inserted into the right proximal forearm for 2 days prior to development of ecchymosis and blisters. Intravenous medications included vancomycin, cefepime, methylprednisolone, and famotidine, as well as maintenance fluids (normal saline). Physical examination revealed extensive confluent ecchymoses with overlying tense bullae (Figure 1). Notable laboratory findings included an elevated D-dimer (peak of 8.67 μg/mL fibrinogen-equivalent units [FEUs], reference range <0.5 μg/mL FEU) and fibrinogen (789 mg/dL, reference range 200–400 mg/dL) levels. Three days later she developed worsening edema of the right arm, accompanied by more extensive bullae formation (Figure 2). Computed tomography of the right arm showed extensive subcutaneous stranding and subcutaneous edema. An orthopedic consultation determined that there was no compartment syndrome, and surgical intervention was not recommended. The patient’s course was complicated by multiorgan failure, and she died 18 days after admission.
A 67-year-old man with coronary artery disease, diabetes mellitus, and hemiparesis secondary to stroke was admitted to the intensive care unit due to hypoxemia secondary to COVID-19 pneumonia. Dermatology was consulted for the evaluation of blisters on both arms. The right forearm peripheral IV line was used for 4 days prior to the development of cutaneous symptoms. Intravenous medications included cefepime, famotidine, and methylprednisolone. The left forearm peripheral IV line was in place for 1 day prior to the development of blisters and was used for the infusion of maintenance fluids (lactated Ringer’s solution). On the first day of the eruption, small bullae were noted at sites of prior peripheral IV lines (Figure 3). On day 3 of admission, the eruption progressed to larger and more confluent tense bullae with ecchymosis (Figure 4). Additionally, laboratory test results were notable for an elevated D-dimer (peak of >20.00 ug/mL FEU) and fibrinogen (748 mg/dL) levels. Computed tomography of the arms showed extensive subcutaneous stranding and fluid along the fascial planes of the arms, with no gas or abscess formation. Surgical intervention was not recommended following an orthopedic consultation. The patient’s course was complicated by acute kidney injury and rhabdomyolysis; he was later discharged to a skilled nursing facility in stable condition.
Reports from China indicate that approximately 50% of COVID-19 patients have elevated D-dimer levels and are at risk for thrombosis.3 We hypothesize that the exuberant hemorrhagic bullous eruptions in our 2 cases may be mediated in part by a hypercoagulable state secondary to COVID-19 infection combined with IV-related trauma or extravasation injury. However, a direct cytotoxic effect of the virus cannot be entirely excluded as a potential inciting factor. Other entities considered in the differential for localized bullae included trauma-induced bullous pemphigoid as well as bullous cellulitis. Both patients were treated with high-dose steroids as well as broad-spectrum antibiotics, which were expected to lead to improvement in symptoms of bullous pemphigoid and cellulitis, respectively; however, they did not lead to symptom improvement.
Extravasation injury results from unintentional administration of potentially vesicant substances into tissues surrounding the intended vascular channel.4 The mechanism of action of these injuries is postulated to arise from direct tissue injury from cytotoxic substances, elevated osmotic pressure, and reduced blood supply if vasoconstrictive substances are infused.5 In our patients, these injuries also may have promoted vascular occlusion leading to the brisk reaction observed. Although ecchymoses typically are associated with hypocoagulable states, both of our patients were noted to have normal platelet levels throughout hospitalization. Additionally, findings of elevated D-dimer and fibrinogen levels point to a hypercoagulable state. However, there is a possibility of platelet dysfunction leading to the observed cutaneous findings of ecchymoses. Thrombocytopenia is a common finding in patients with COVID-19 and is found to be associated with increased in-hospital mortality.6 Additional study of these reactions is needed given the propensity for multiorgan failure and death in patients with COVID-19 from suspected diffuse microvascular damage.3
- Recalcati S. Cutaneous manifestations in COVID-19: a first perspective [published online March 26, 2020]. J Eur Acad Dermatol Venereol. doi:10.1111/jdv.16387
- Zhang Y, Cao W, Xiao M, et al. Clinical and coagulation characteristics of 7 patients with critical COVID-19 pneumonia and acro-ischemia [in Chinese][published online March 28, 2020]. Zhonghua Xue Ye Xue Za Zhi. 2020;41:E006.
- Mei H, Hu Y. Characteristics, causes, diagnosis and treatment of coagulation dysfunction in patients with COVID-19 [in Chinese][published online March 14, 2020]. Zhonghua Xue Ye Xue Za Zhi. 2020;41:E002.
- Sauerland C, Engelking C, Wickham R, et al. Vesicant extravasation part I: mechanisms, pathogenesis, and nursing care to reduce risk. Oncol Nurs Forum. 2006;33:1134-1141.
- Reynolds PM, MacLaren R, Mueller SW, et al. Management of extravasation injuries: a focused evaluation of noncytotoxic medications. Pharmacotherapy. 2014;34:617-632.
- Yang X, Yang Q, Wang Y, et al. Thrombocytopenia and its association with mortality in patients with COVID-19. J Thromb Haemost. 2020;18:1469‐1472.
- Recalcati S. Cutaneous manifestations in COVID-19: a first perspective [published online March 26, 2020]. J Eur Acad Dermatol Venereol. doi:10.1111/jdv.16387
- Zhang Y, Cao W, Xiao M, et al. Clinical and coagulation characteristics of 7 patients with critical COVID-19 pneumonia and acro-ischemia [in Chinese][published online March 28, 2020]. Zhonghua Xue Ye Xue Za Zhi. 2020;41:E006.
- Mei H, Hu Y. Characteristics, causes, diagnosis and treatment of coagulation dysfunction in patients with COVID-19 [in Chinese][published online March 14, 2020]. Zhonghua Xue Ye Xue Za Zhi. 2020;41:E002.
- Sauerland C, Engelking C, Wickham R, et al. Vesicant extravasation part I: mechanisms, pathogenesis, and nursing care to reduce risk. Oncol Nurs Forum. 2006;33:1134-1141.
- Reynolds PM, MacLaren R, Mueller SW, et al. Management of extravasation injuries: a focused evaluation of noncytotoxic medications. Pharmacotherapy. 2014;34:617-632.
- Yang X, Yang Q, Wang Y, et al. Thrombocytopenia and its association with mortality in patients with COVID-19. J Thromb Haemost. 2020;18:1469‐1472.
Practice Points
- Hemorrhagic bullae are an uncommon cutaneous manifestation of COVID-19 infection in hospitalized individuals.
- Although there is no reported treatment for COVID-19–associated hemorrhagic bullae, we recommend supportive care and management of underlying etiology.
Shorter HCC screening intervals benefit high-risk patients
Ultrasonography screening intervals of less than 6-12 months were associated with early detection of hepatocellular carcinoma, as well as increased life expectancy and quality of life, according to data from a nationwide comparative effectiveness study of nearly 60,000 patients in Taiwan.
Many international societies, including the American Association for the Study of Liver Diseases, the Asian Pacific Association for the Study of the Liver, and the European Association for the Study of the Liver, recommend abdominal ultrasonography screening for hepatocellular carcinoma (HCC) with or without alpha-fetoprotein every 6 months for patients at increased risk for HCC, wrote Shih-Chiang Kuo, MD, of National Cheng Kung University, Tainan, Taiwan, and colleagues.
However, some studies do not support this recommendation, and data suggest that “adherence to regular screenings by high-risk patients has been inadequate, leading to reduced overall benefits of ultrasonography screening in real-world practice,” and the impact of screening schedules on quality of life has not been assessed, they said.
In a study published in JAMA Network Open, the researchers identified adults with newly diagnosed HCC from 2002 through 2015 using data from the Taiwan National Cancer Registry. Barcelona Clinic Liver Cancer (BCLC) staging information was available for 42,081 men and 17,113 women; the average age was 62 years for men and 69 years for women. The patients were divided into five cohorts based on the time between their last ultrasonography screening and an index date of 90 days before their HCC diagnosis. These groups were 6 months (0-6 months), 12 months (7-12 months), 24 months (13-24 months), 36 months (25-36 months), and longer than 36 months.
“For both sexes, the proportions of patients with HCC classified as being in earlier stages (stage 0 and A) were higher in subcohorts with shorter screening intervals since the most recent ultrasonography,” the researchers wrote.
The researchers also assessed quality of life measures using the European Quality of Life Five-Dimensions in 807 men (3,370 repeated assessments) and 252 women (1,044 repeated assessments). Among men, the loss of quality of life expectancy in terms of quality of life years (QALYs) was 10.0, 11.1, 12.1, 13.1, and 14.6 for screening intervals of 6 months, 12 months, 24 months, 36 months, and beyond 36 months, respectively. The corresponding QALYs for women at the same screening intervals were 9.0, 9.7, 10.3, 10.7, and 11.4, respectively.
In a subgroup analysis according to underlying liver disease, patients with underlying hepatitis B virus infection or cirrhosis showed the greatest benefits from shorter screening intervals. For those with hepatitis B virus infection, abdominal ultrasonography screening 6 months or less prior to diagnosis of HCC was associated with an additional 4.8 QALYs for men and 2.8 QALYs for women, compared with screening longer than 36 months prior to diagnosis. The corresponding savings in QALY for men and women with underlying cirrhosis was 4.8 QALYs and 2.4 QALYs. Patients with no underlying liver disease also benefited from shorter intervals, with potential savings of 3.2 QALYs for men and 1.6 QALYs for women in the 6-month screening groups, compared with the longer than 36 months groups.
However, less than half of the men overall underwent screening withing 6 months or 12 months before diagnosis (31.4% and 39.3%, respectively); for women, 42.2% received screening within 6 months of diagnosis and 51.9% received screening within 12 months.
The study findings were limited by several factors including the use of only the last screening before diagnosis, which allows the possibility that patients in the 6- or 12-month groups did not have regular screening, the researchers noted. In addition, the lack of data on quality of life for women with BCLC stage D might have caused an underestimation of quality of life loss, they said. However, the results were strengthened by the use of a national database and long follow-up period, they said.
The results support intervals of 6-12 months or less for regular ultrasonography screening as a way to improve early detection of HCC, “and may save lives and improve utility for patients with HCC from a lifetime perspective,” the researchers emphasized. “Because people with underlying risk factors (including hepatitis B virus or hepatitis C virus infection, cirrhosis, and alcoholic liver disease) showed only slightly more frequent ultrasonography screening than those without underlying risk factors, we recommend improving this clinical practice,” they concluded.
Impact of identifying risk
“This study is important because HCC remains the third leading cause of cancer deaths, and the 5-year survival rate is low,” said Atsushi Sakuraba, MD, of the University of Chicago, in an interview.
Dr. Sakuraba said that he was not surprised by any of the study findings. “Earlier diagnosis of cancer is often associated with improved outcome in many cancers,” he noted.
However, “Overutilization of resources may lead to increased health care costs, so correct identification of high-risk populations is needed,” Dr. Sakuraba said.
Additional research is warranted in several areas in order to make an impact on clinical practice, Dr. Sakuraba said, notably, “confirmation in other countries and ethnicities where the incidence of viral hepatitis varies.” Comparison to other tests, such as tumor markers, CT, and MRI, is needed as well, he concluded.
The study was supported by the Taiwan Ministry of Science and Technology. The researchers had no financial conflicts to disclose. Dr. Sakuraba had no financial conflicts to disclose.
Ultrasonography screening intervals of less than 6-12 months were associated with early detection of hepatocellular carcinoma, as well as increased life expectancy and quality of life, according to data from a nationwide comparative effectiveness study of nearly 60,000 patients in Taiwan.
Many international societies, including the American Association for the Study of Liver Diseases, the Asian Pacific Association for the Study of the Liver, and the European Association for the Study of the Liver, recommend abdominal ultrasonography screening for hepatocellular carcinoma (HCC) with or without alpha-fetoprotein every 6 months for patients at increased risk for HCC, wrote Shih-Chiang Kuo, MD, of National Cheng Kung University, Tainan, Taiwan, and colleagues.
However, some studies do not support this recommendation, and data suggest that “adherence to regular screenings by high-risk patients has been inadequate, leading to reduced overall benefits of ultrasonography screening in real-world practice,” and the impact of screening schedules on quality of life has not been assessed, they said.
In a study published in JAMA Network Open, the researchers identified adults with newly diagnosed HCC from 2002 through 2015 using data from the Taiwan National Cancer Registry. Barcelona Clinic Liver Cancer (BCLC) staging information was available for 42,081 men and 17,113 women; the average age was 62 years for men and 69 years for women. The patients were divided into five cohorts based on the time between their last ultrasonography screening and an index date of 90 days before their HCC diagnosis. These groups were 6 months (0-6 months), 12 months (7-12 months), 24 months (13-24 months), 36 months (25-36 months), and longer than 36 months.
“For both sexes, the proportions of patients with HCC classified as being in earlier stages (stage 0 and A) were higher in subcohorts with shorter screening intervals since the most recent ultrasonography,” the researchers wrote.
The researchers also assessed quality of life measures using the European Quality of Life Five-Dimensions in 807 men (3,370 repeated assessments) and 252 women (1,044 repeated assessments). Among men, the loss of quality of life expectancy in terms of quality of life years (QALYs) was 10.0, 11.1, 12.1, 13.1, and 14.6 for screening intervals of 6 months, 12 months, 24 months, 36 months, and beyond 36 months, respectively. The corresponding QALYs for women at the same screening intervals were 9.0, 9.7, 10.3, 10.7, and 11.4, respectively.
In a subgroup analysis according to underlying liver disease, patients with underlying hepatitis B virus infection or cirrhosis showed the greatest benefits from shorter screening intervals. For those with hepatitis B virus infection, abdominal ultrasonography screening 6 months or less prior to diagnosis of HCC was associated with an additional 4.8 QALYs for men and 2.8 QALYs for women, compared with screening longer than 36 months prior to diagnosis. The corresponding savings in QALY for men and women with underlying cirrhosis was 4.8 QALYs and 2.4 QALYs. Patients with no underlying liver disease also benefited from shorter intervals, with potential savings of 3.2 QALYs for men and 1.6 QALYs for women in the 6-month screening groups, compared with the longer than 36 months groups.
However, less than half of the men overall underwent screening withing 6 months or 12 months before diagnosis (31.4% and 39.3%, respectively); for women, 42.2% received screening within 6 months of diagnosis and 51.9% received screening within 12 months.
The study findings were limited by several factors including the use of only the last screening before diagnosis, which allows the possibility that patients in the 6- or 12-month groups did not have regular screening, the researchers noted. In addition, the lack of data on quality of life for women with BCLC stage D might have caused an underestimation of quality of life loss, they said. However, the results were strengthened by the use of a national database and long follow-up period, they said.
The results support intervals of 6-12 months or less for regular ultrasonography screening as a way to improve early detection of HCC, “and may save lives and improve utility for patients with HCC from a lifetime perspective,” the researchers emphasized. “Because people with underlying risk factors (including hepatitis B virus or hepatitis C virus infection, cirrhosis, and alcoholic liver disease) showed only slightly more frequent ultrasonography screening than those without underlying risk factors, we recommend improving this clinical practice,” they concluded.
Impact of identifying risk
“This study is important because HCC remains the third leading cause of cancer deaths, and the 5-year survival rate is low,” said Atsushi Sakuraba, MD, of the University of Chicago, in an interview.
Dr. Sakuraba said that he was not surprised by any of the study findings. “Earlier diagnosis of cancer is often associated with improved outcome in many cancers,” he noted.
However, “Overutilization of resources may lead to increased health care costs, so correct identification of high-risk populations is needed,” Dr. Sakuraba said.
Additional research is warranted in several areas in order to make an impact on clinical practice, Dr. Sakuraba said, notably, “confirmation in other countries and ethnicities where the incidence of viral hepatitis varies.” Comparison to other tests, such as tumor markers, CT, and MRI, is needed as well, he concluded.
The study was supported by the Taiwan Ministry of Science and Technology. The researchers had no financial conflicts to disclose. Dr. Sakuraba had no financial conflicts to disclose.
Ultrasonography screening intervals of less than 6-12 months were associated with early detection of hepatocellular carcinoma, as well as increased life expectancy and quality of life, according to data from a nationwide comparative effectiveness study of nearly 60,000 patients in Taiwan.
Many international societies, including the American Association for the Study of Liver Diseases, the Asian Pacific Association for the Study of the Liver, and the European Association for the Study of the Liver, recommend abdominal ultrasonography screening for hepatocellular carcinoma (HCC) with or without alpha-fetoprotein every 6 months for patients at increased risk for HCC, wrote Shih-Chiang Kuo, MD, of National Cheng Kung University, Tainan, Taiwan, and colleagues.
However, some studies do not support this recommendation, and data suggest that “adherence to regular screenings by high-risk patients has been inadequate, leading to reduced overall benefits of ultrasonography screening in real-world practice,” and the impact of screening schedules on quality of life has not been assessed, they said.
In a study published in JAMA Network Open, the researchers identified adults with newly diagnosed HCC from 2002 through 2015 using data from the Taiwan National Cancer Registry. Barcelona Clinic Liver Cancer (BCLC) staging information was available for 42,081 men and 17,113 women; the average age was 62 years for men and 69 years for women. The patients were divided into five cohorts based on the time between their last ultrasonography screening and an index date of 90 days before their HCC diagnosis. These groups were 6 months (0-6 months), 12 months (7-12 months), 24 months (13-24 months), 36 months (25-36 months), and longer than 36 months.
“For both sexes, the proportions of patients with HCC classified as being in earlier stages (stage 0 and A) were higher in subcohorts with shorter screening intervals since the most recent ultrasonography,” the researchers wrote.
The researchers also assessed quality of life measures using the European Quality of Life Five-Dimensions in 807 men (3,370 repeated assessments) and 252 women (1,044 repeated assessments). Among men, the loss of quality of life expectancy in terms of quality of life years (QALYs) was 10.0, 11.1, 12.1, 13.1, and 14.6 for screening intervals of 6 months, 12 months, 24 months, 36 months, and beyond 36 months, respectively. The corresponding QALYs for women at the same screening intervals were 9.0, 9.7, 10.3, 10.7, and 11.4, respectively.
In a subgroup analysis according to underlying liver disease, patients with underlying hepatitis B virus infection or cirrhosis showed the greatest benefits from shorter screening intervals. For those with hepatitis B virus infection, abdominal ultrasonography screening 6 months or less prior to diagnosis of HCC was associated with an additional 4.8 QALYs for men and 2.8 QALYs for women, compared with screening longer than 36 months prior to diagnosis. The corresponding savings in QALY for men and women with underlying cirrhosis was 4.8 QALYs and 2.4 QALYs. Patients with no underlying liver disease also benefited from shorter intervals, with potential savings of 3.2 QALYs for men and 1.6 QALYs for women in the 6-month screening groups, compared with the longer than 36 months groups.
However, less than half of the men overall underwent screening withing 6 months or 12 months before diagnosis (31.4% and 39.3%, respectively); for women, 42.2% received screening within 6 months of diagnosis and 51.9% received screening within 12 months.
The study findings were limited by several factors including the use of only the last screening before diagnosis, which allows the possibility that patients in the 6- or 12-month groups did not have regular screening, the researchers noted. In addition, the lack of data on quality of life for women with BCLC stage D might have caused an underestimation of quality of life loss, they said. However, the results were strengthened by the use of a national database and long follow-up period, they said.
The results support intervals of 6-12 months or less for regular ultrasonography screening as a way to improve early detection of HCC, “and may save lives and improve utility for patients with HCC from a lifetime perspective,” the researchers emphasized. “Because people with underlying risk factors (including hepatitis B virus or hepatitis C virus infection, cirrhosis, and alcoholic liver disease) showed only slightly more frequent ultrasonography screening than those without underlying risk factors, we recommend improving this clinical practice,” they concluded.
Impact of identifying risk
“This study is important because HCC remains the third leading cause of cancer deaths, and the 5-year survival rate is low,” said Atsushi Sakuraba, MD, of the University of Chicago, in an interview.
Dr. Sakuraba said that he was not surprised by any of the study findings. “Earlier diagnosis of cancer is often associated with improved outcome in many cancers,” he noted.
However, “Overutilization of resources may lead to increased health care costs, so correct identification of high-risk populations is needed,” Dr. Sakuraba said.
Additional research is warranted in several areas in order to make an impact on clinical practice, Dr. Sakuraba said, notably, “confirmation in other countries and ethnicities where the incidence of viral hepatitis varies.” Comparison to other tests, such as tumor markers, CT, and MRI, is needed as well, he concluded.
The study was supported by the Taiwan Ministry of Science and Technology. The researchers had no financial conflicts to disclose. Dr. Sakuraba had no financial conflicts to disclose.
FROM JAMA NETWORK OPEN