I don’t rightly remember when I first learned of restless legs syndrome (RLS). It was many decades ago, and I recognized that once in a while, I would be restless during sleep, tossing and turning, seeking a favorable sleeping position. I felt like I just needed to move my legs around; my gastrocnemii and hamstrings might cramp; and my torso skin might strangely “crawl” a bit, but then normal sleep would return. I never sought medical care for it and used no treatment, except moving my legs when indicated.

My trusty LLM (large language model), Bard, tells me that there are about 53,000 articles about RLS in English, of which, some 20,000 are in the primary source, peer reviewed literature. Count this as one more article. Will it make a difference? Read on and see.

For many centuries (since Sir Thomas Willis in 1672), the symptoms now grouped and categorized as RLS have been recognized and reported but were often dismissed as bizarre and unexplained. The name was applied in 1948 by Dr Karl-Axel Ekborn.

In the 1960s, in sleep labs, RLS became better studied and characterized.

Mayo Clinic describes RLS as “… compelling, unpleasant sensations in the legs or feet ... both sides of the body ... within the limb rather than on the skin ... crawling, creeping, pulling, throbbing, aching, itching, electric ... difficult to explain …” Not numbness, but a consistent desire to move the legs.

When I read about it many decades ago, I realized that I may have RLS. But then many months would pass with no recurrence, so I dismissed it as just another of those “symptoms of unknown origin” that my late friend Clifton Meador has written about so eloquently.

I am sure that a lot of people experience this, don’t understand it, and don’t consider it important enough to do anything about. Between 1% and 15% (a wide range) of Americans are believed to be affected by RLS. The cause is unknown, but it seems to run in families. It may be autosomal dominant, but no causative genes have been confirmed.
 

Treatment of RLS

Many pharmacologic and physical treatments have been tried with some success for some patients, but over time, these treatments have mostly failed.

We know how Big Pharma often operates. A company owns a drug, preferably under patent protection, but without an apparent profitable indication. They need to find a medical condition, ideally one with troublesome symptoms, that the drug might ameliorate to some degree. Armed with a plausible candidate symptom, the company embarks upon a campaign to find people who might want to take the drug. Mass communications, such as direct-to-consumer advertising, can identify large numbers of people who match to pretty much any symptoms, although many of these people never suspected they had a disease, much less a treatable one.

I figured long ago that RLS was just another of those nonspecific entities experienced by many people, making them good candidates for disease mongering.

In 2005, the marketing of GlaxoSmithKline’s (GSK’s) dopamine agonist drug Requip (ropinirole) was approved by the FDA. GSK had already undertaken an intensive promotional campaign for Requip, issuing press releases, advertising to doctors in medical journals, and advertising directly to consumers. To increase general awareness of RLS, GSK’s campaign told consumers that a “new survey reveals that a common yet underrecognized disorder-restless legs syndrome—is keeping Americans awake at night.” GSK was accused of “disease mongering,” trying to turn ordinary people into patients who needed specific drugs.

Within a year, sales of the drug had doubled, climbing from $165 million in 2005 to nearly $330 million in 2006. Soon, 4.4 million prescriptions were written annually for the drug, with sales reported to be nearly $491 million. However, the focus on RLS faded rapidly as the Requip television commercials were pulled from the airwaves following approval of generic ropinirole.

And Requip had competition. Boehringer Ingelheim manufactures pramipexole (brand name Mirapex) another dopamine agonist. Gabapentin enacarbil (marketed as Horizant by UCB Pharma) is also approved for RLS, and Pfizer’s pregabalin (brand name Lyrica) is used off-label to manage symptoms of RLS. Janssen Pharmaceuticals manufactures rotigotine, (brand name Neupro), a dopamine agonist delivered via a transdermal patch.

It is safe to say that RLS is a real clinical entity composed of clearly recognizable symptoms, with no cure and no ending, unless it is associated with iron-deficiency anemia. However, as a disease, it seems to lack etiology, pathology, pathogenesis, pathophysiology, diagnostic findings on physical examination, laboratory tests, or imaging, and any clear strategy for prevention.

Pharmacologic treatments include dopaminergic agents, benzodiazepines, opioids, anticonvulsants, alpha 2–adrenergic agonists and iron salts. Yes, you read that right; RLS is treated with a broad array of different drugs, which is usually a sign that nothing works very well. Some agents work for a while, but none seem to be the definitive solution.

Same for the physical interventions: sleep hygiene, exercise, hot or cold bathing, limb massage, vibratory or electrical stimulation of the feet, stopping caffeine before bedtime. Try everything and see if something works.
 

Taking the Sugar Challenge

Could the culprit be sugar?

Lacking clarity of scientific understanding of RLS or its treatment from an extensive clinical literature, after ascertaining that RLS is real, one might look for real-world evidence, including well-performed N-of-1 trials.

I am an antisugar guy. Read my prior Medscape columns. I practice what I preach, but sugar does taste good.

Early in November 2023, after a healthy, conservative dinner at home with some wine, I enjoyed a mini Dove bar for dessert. But I didn’t stop there.

Mini Dove bars contain 11 grams sugar. It was also just a few days after Halloween. Having had fewer trick-or-treaters than expected, we had leftovers. Snickers, Milky Ways, Twix mini bars, each with at least 20 grams of sugar.

I ate several of these not long before bedtime. Lo and behold, in the dark of that night, and continuing off and on for a few fitful hours, I had bad RLS. Shifting, tossing, turning, compulsively seeking a new sleeping position only to have to soon move again. Plus, I had repetitive leg cramps and that creepy-crawly skin sensation. An altogether unpleasant experience. Sound sleep eventually arrived, and there were no recurrences over subsequent weeks.

The classic way to determine whether a drug is causing a reaction, condition, or disease is to apply the challenge-dechallenge-rechallenge testing method.

Give the drug, the patient demonstrates the disease finding. Remove the drug, the problem disappears. Rinse and repeat three times. We pathologists first worked this out for drug-induced liver disease, such as steatosis, in the late 1960s. Blinding or double blinding in these N-of-1 situations would be nice but often not practical.

Siwert de Groot, in the Netherlands, published a very convincing use of this technique in 2023: Big-time sugar consumption for a week, then low intake of sugar for the following week, repeated three times on one patient.

Very elaborate RLS symptom reporting. I’m pretty convinced from my unintentional challenge and single dechallenge that my unusually high sugar intake resulted in RLS. I will not undergo a rechallenge, although it might be fun to binge on sucrose and see what happens.

If you are serious about identifying or treating RLS, I suggest that you incorporate the International Restless Legs Study Group Severity Rating Scale into your practice, and begin the systematic use of the dechallenge-rechallenge exclusion process for your patients with RLS. Start with sugar and see what happens. Keep records and let the world know what you discover. Be your own clinical investigator. Social media offers you abundant opportunity to share your results, whatever they may be.

How many millions of dollars would Big Pharma lose if patients with RLS just said no to sugar and it worked? Of course, humans being humans, many would probably prefer to continue to gorge on sugar, gain weight, develop diabetes, and then take medications to control their RLS symptoms. But patients ought to at least be given an informed choice.

I will be watching for your reports.

Dr. Lundberg had no disclosures.

A version of this article appeared on Medscape.com.

I don’t rightly remember when I first learned of restless legs syndrome (RLS). It was many decades ago, and I recognized that once in a while, I would be restless during sleep, tossing and turning, seeking a favorable sleeping position. I felt like I just needed to move my legs around; my gastrocnemii and hamstrings might cramp; and my torso skin might strangely “crawl” a bit, but then normal sleep would return. I never sought medical care for it and used no treatment, except moving my legs when indicated.

My trusty LLM (large language model), Bard, tells me that there are about 53,000 articles about RLS in English, of which, some 20,000 are in the primary source, peer reviewed literature. Count this as one more article. Will it make a difference? Read on and see.

For many centuries (since Sir Thomas Willis in 1672), the symptoms now grouped and categorized as RLS have been recognized and reported but were often dismissed as bizarre and unexplained. The name was applied in 1948 by Dr Karl-Axel Ekborn.

In the 1960s, in sleep labs, RLS became better studied and characterized.

Mayo Clinic describes RLS as “… compelling, unpleasant sensations in the legs or feet ... both sides of the body ... within the limb rather than on the skin ... crawling, creeping, pulling, throbbing, aching, itching, electric ... difficult to explain …” Not numbness, but a consistent desire to move the legs.

When I read about it many decades ago, I realized that I may have RLS. But then many months would pass with no recurrence, so I dismissed it as just another of those “symptoms of unknown origin” that my late friend Clifton Meador has written about so eloquently.

I am sure that a lot of people experience this, don’t understand it, and don’t consider it important enough to do anything about. Between 1% and 15% (a wide range) of Americans are believed to be affected by RLS. The cause is unknown, but it seems to run in families. It may be autosomal dominant, but no causative genes have been confirmed.
 

Treatment of RLS

Many pharmacologic and physical treatments have been tried with some success for some patients, but over time, these treatments have mostly failed.

We know how Big Pharma often operates. A company owns a drug, preferably under patent protection, but without an apparent profitable indication. They need to find a medical condition, ideally one with troublesome symptoms, that the drug might ameliorate to some degree. Armed with a plausible candidate symptom, the company embarks upon a campaign to find people who might want to take the drug. Mass communications, such as direct-to-consumer advertising, can identify large numbers of people who match to pretty much any symptoms, although many of these people never suspected they had a disease, much less a treatable one.

I figured long ago that RLS was just another of those nonspecific entities experienced by many people, making them good candidates for disease mongering.

In 2005, the marketing of GlaxoSmithKline’s (GSK’s) dopamine agonist drug Requip (ropinirole) was approved by the FDA. GSK had already undertaken an intensive promotional campaign for Requip, issuing press releases, advertising to doctors in medical journals, and advertising directly to consumers. To increase general awareness of RLS, GSK’s campaign told consumers that a “new survey reveals that a common yet underrecognized disorder-restless legs syndrome—is keeping Americans awake at night.” GSK was accused of “disease mongering,” trying to turn ordinary people into patients who needed specific drugs.

Within a year, sales of the drug had doubled, climbing from $165 million in 2005 to nearly $330 million in 2006. Soon, 4.4 million prescriptions were written annually for the drug, with sales reported to be nearly $491 million. However, the focus on RLS faded rapidly as the Requip television commercials were pulled from the airwaves following approval of generic ropinirole.

And Requip had competition. Boehringer Ingelheim manufactures pramipexole (brand name Mirapex) another dopamine agonist. Gabapentin enacarbil (marketed as Horizant by UCB Pharma) is also approved for RLS, and Pfizer’s pregabalin (brand name Lyrica) is used off-label to manage symptoms of RLS. Janssen Pharmaceuticals manufactures rotigotine, (brand name Neupro), a dopamine agonist delivered via a transdermal patch.

It is safe to say that RLS is a real clinical entity composed of clearly recognizable symptoms, with no cure and no ending, unless it is associated with iron-deficiency anemia. However, as a disease, it seems to lack etiology, pathology, pathogenesis, pathophysiology, diagnostic findings on physical examination, laboratory tests, or imaging, and any clear strategy for prevention.

Pharmacologic treatments include dopaminergic agents, benzodiazepines, opioids, anticonvulsants, alpha 2–adrenergic agonists and iron salts. Yes, you read that right; RLS is treated with a broad array of different drugs, which is usually a sign that nothing works very well. Some agents work for a while, but none seem to be the definitive solution.

Same for the physical interventions: sleep hygiene, exercise, hot or cold bathing, limb massage, vibratory or electrical stimulation of the feet, stopping caffeine before bedtime. Try everything and see if something works.
 

Taking the Sugar Challenge

Could the culprit be sugar?

Lacking clarity of scientific understanding of RLS or its treatment from an extensive clinical literature, after ascertaining that RLS is real, one might look for real-world evidence, including well-performed N-of-1 trials.

I am an antisugar guy. Read my prior Medscape columns. I practice what I preach, but sugar does taste good.

Early in November 2023, after a healthy, conservative dinner at home with some wine, I enjoyed a mini Dove bar for dessert. But I didn’t stop there.

Mini Dove bars contain 11 grams sugar. It was also just a few days after Halloween. Having had fewer trick-or-treaters than expected, we had leftovers. Snickers, Milky Ways, Twix mini bars, each with at least 20 grams of sugar.

I ate several of these not long before bedtime. Lo and behold, in the dark of that night, and continuing off and on for a few fitful hours, I had bad RLS. Shifting, tossing, turning, compulsively seeking a new sleeping position only to have to soon move again. Plus, I had repetitive leg cramps and that creepy-crawly skin sensation. An altogether unpleasant experience. Sound sleep eventually arrived, and there were no recurrences over subsequent weeks.

The classic way to determine whether a drug is causing a reaction, condition, or disease is to apply the challenge-dechallenge-rechallenge testing method.

Give the drug, the patient demonstrates the disease finding. Remove the drug, the problem disappears. Rinse and repeat three times. We pathologists first worked this out for drug-induced liver disease, such as steatosis, in the late 1960s. Blinding or double blinding in these N-of-1 situations would be nice but often not practical.

Siwert de Groot, in the Netherlands, published a very convincing use of this technique in 2023: Big-time sugar consumption for a week, then low intake of sugar for the following week, repeated three times on one patient.

Very elaborate RLS symptom reporting. I’m pretty convinced from my unintentional challenge and single dechallenge that my unusually high sugar intake resulted in RLS. I will not undergo a rechallenge, although it might be fun to binge on sucrose and see what happens.

If you are serious about identifying or treating RLS, I suggest that you incorporate the International Restless Legs Study Group Severity Rating Scale into your practice, and begin the systematic use of the dechallenge-rechallenge exclusion process for your patients with RLS. Start with sugar and see what happens. Keep records and let the world know what you discover. Be your own clinical investigator. Social media offers you abundant opportunity to share your results, whatever they may be.

How many millions of dollars would Big Pharma lose if patients with RLS just said no to sugar and it worked? Of course, humans being humans, many would probably prefer to continue to gorge on sugar, gain weight, develop diabetes, and then take medications to control their RLS symptoms. But patients ought to at least be given an informed choice.

I will be watching for your reports.

Dr. Lundberg had no disclosures.

A version of this article appeared on Medscape.com.

I don’t rightly remember when I first learned of restless legs syndrome (RLS). It was many decades ago, and I recognized that once in a while, I would be restless during sleep, tossing and turning, seeking a favorable sleeping position. I felt like I just needed to move my legs around; my gastrocnemii and hamstrings might cramp; and my torso skin might strangely “crawl” a bit, but then normal sleep would return. I never sought medical care for it and used no treatment, except moving my legs when indicated.

My trusty LLM (large language model), Bard, tells me that there are about 53,000 articles about RLS in English, of which, some 20,000 are in the primary source, peer reviewed literature. Count this as one more article. Will it make a difference? Read on and see.

For many centuries (since Sir Thomas Willis in 1672), the symptoms now grouped and categorized as RLS have been recognized and reported but were often dismissed as bizarre and unexplained. The name was applied in 1948 by Dr Karl-Axel Ekborn.

In the 1960s, in sleep labs, RLS became better studied and characterized.

Mayo Clinic describes RLS as “… compelling, unpleasant sensations in the legs or feet ... both sides of the body ... within the limb rather than on the skin ... crawling, creeping, pulling, throbbing, aching, itching, electric ... difficult to explain …” Not numbness, but a consistent desire to move the legs.

When I read about it many decades ago, I realized that I may have RLS. But then many months would pass with no recurrence, so I dismissed it as just another of those “symptoms of unknown origin” that my late friend Clifton Meador has written about so eloquently.

I am sure that a lot of people experience this, don’t understand it, and don’t consider it important enough to do anything about. Between 1% and 15% (a wide range) of Americans are believed to be affected by RLS. The cause is unknown, but it seems to run in families. It may be autosomal dominant, but no causative genes have been confirmed.
 

Treatment of RLS

Many pharmacologic and physical treatments have been tried with some success for some patients, but over time, these treatments have mostly failed.

We know how Big Pharma often operates. A company owns a drug, preferably under patent protection, but without an apparent profitable indication. They need to find a medical condition, ideally one with troublesome symptoms, that the drug might ameliorate to some degree. Armed with a plausible candidate symptom, the company embarks upon a campaign to find people who might want to take the drug. Mass communications, such as direct-to-consumer advertising, can identify large numbers of people who match to pretty much any symptoms, although many of these people never suspected they had a disease, much less a treatable one.

I figured long ago that RLS was just another of those nonspecific entities experienced by many people, making them good candidates for disease mongering.

In 2005, the marketing of GlaxoSmithKline’s (GSK’s) dopamine agonist drug Requip (ropinirole) was approved by the FDA. GSK had already undertaken an intensive promotional campaign for Requip, issuing press releases, advertising to doctors in medical journals, and advertising directly to consumers. To increase general awareness of RLS, GSK’s campaign told consumers that a “new survey reveals that a common yet underrecognized disorder-restless legs syndrome—is keeping Americans awake at night.” GSK was accused of “disease mongering,” trying to turn ordinary people into patients who needed specific drugs.

Within a year, sales of the drug had doubled, climbing from $165 million in 2005 to nearly $330 million in 2006. Soon, 4.4 million prescriptions were written annually for the drug, with sales reported to be nearly $491 million. However, the focus on RLS faded rapidly as the Requip television commercials were pulled from the airwaves following approval of generic ropinirole.

And Requip had competition. Boehringer Ingelheim manufactures pramipexole (brand name Mirapex) another dopamine agonist. Gabapentin enacarbil (marketed as Horizant by UCB Pharma) is also approved for RLS, and Pfizer’s pregabalin (brand name Lyrica) is used off-label to manage symptoms of RLS. Janssen Pharmaceuticals manufactures rotigotine, (brand name Neupro), a dopamine agonist delivered via a transdermal patch.

It is safe to say that RLS is a real clinical entity composed of clearly recognizable symptoms, with no cure and no ending, unless it is associated with iron-deficiency anemia. However, as a disease, it seems to lack etiology, pathology, pathogenesis, pathophysiology, diagnostic findings on physical examination, laboratory tests, or imaging, and any clear strategy for prevention.

Pharmacologic treatments include dopaminergic agents, benzodiazepines, opioids, anticonvulsants, alpha 2–adrenergic agonists and iron salts. Yes, you read that right; RLS is treated with a broad array of different drugs, which is usually a sign that nothing works very well. Some agents work for a while, but none seem to be the definitive solution.

Same for the physical interventions: sleep hygiene, exercise, hot or cold bathing, limb massage, vibratory or electrical stimulation of the feet, stopping caffeine before bedtime. Try everything and see if something works.
 

Taking the Sugar Challenge

Could the culprit be sugar?

Lacking clarity of scientific understanding of RLS or its treatment from an extensive clinical literature, after ascertaining that RLS is real, one might look for real-world evidence, including well-performed N-of-1 trials.

I am an antisugar guy. Read my prior Medscape columns. I practice what I preach, but sugar does taste good.

Early in November 2023, after a healthy, conservative dinner at home with some wine, I enjoyed a mini Dove bar for dessert. But I didn’t stop there.

Mini Dove bars contain 11 grams sugar. It was also just a few days after Halloween. Having had fewer trick-or-treaters than expected, we had leftovers. Snickers, Milky Ways, Twix mini bars, each with at least 20 grams of sugar.

I ate several of these not long before bedtime. Lo and behold, in the dark of that night, and continuing off and on for a few fitful hours, I had bad RLS. Shifting, tossing, turning, compulsively seeking a new sleeping position only to have to soon move again. Plus, I had repetitive leg cramps and that creepy-crawly skin sensation. An altogether unpleasant experience. Sound sleep eventually arrived, and there were no recurrences over subsequent weeks.

The classic way to determine whether a drug is causing a reaction, condition, or disease is to apply the challenge-dechallenge-rechallenge testing method.

Give the drug, the patient demonstrates the disease finding. Remove the drug, the problem disappears. Rinse and repeat three times. We pathologists first worked this out for drug-induced liver disease, such as steatosis, in the late 1960s. Blinding or double blinding in these N-of-1 situations would be nice but often not practical.

Siwert de Groot, in the Netherlands, published a very convincing use of this technique in 2023: Big-time sugar consumption for a week, then low intake of sugar for the following week, repeated three times on one patient.

Very elaborate RLS symptom reporting. I’m pretty convinced from my unintentional challenge and single dechallenge that my unusually high sugar intake resulted in RLS. I will not undergo a rechallenge, although it might be fun to binge on sucrose and see what happens.

If you are serious about identifying or treating RLS, I suggest that you incorporate the International Restless Legs Study Group Severity Rating Scale into your practice, and begin the systematic use of the dechallenge-rechallenge exclusion process for your patients with RLS. Start with sugar and see what happens. Keep records and let the world know what you discover. Be your own clinical investigator. Social media offers you abundant opportunity to share your results, whatever they may be.

How many millions of dollars would Big Pharma lose if patients with RLS just said no to sugar and it worked? Of course, humans being humans, many would probably prefer to continue to gorge on sugar, gain weight, develop diabetes, and then take medications to control their RLS symptoms. But patients ought to at least be given an informed choice.

I will be watching for your reports.

Dr. Lundberg had no disclosures.

A version of this article appeared on Medscape.com.

Certain patients with irritable bowel syndrome (IBS) may benefit from treatment with mesalamine, although the quality of evidence supporting this strategy remains low, according to a recent systematic literature review and meta-analysis.

Global IBS symptoms improved significantly across the entire population, however, a subgroup analysis suggested that mesalamine may be most beneficial for patients who present with diarrhea, providing support for a large clinical trial in this patient population, reported lead author Vivek C. Goodoory, MBChB, of St. James’s University Hospital, Leeds, United Kingdom, and colleagues.

Some patients with IBS may present with low-grade inflammation in the intestine, offering theoretical grounds for prescribing mesalamine, which is typically used for treating ulcerative colitis, the investigators wrote in Clinical Gastroenterology and Hepatology. Yet previous randomized controlled trials (RCTs) evaluating mesalamine for IBS have yielded mixed results, and a meta-analysis showed that mesalamine offered no benefit.

According to Dr. Goodoory and colleagues, however, that meta-analysis fell short since it “only pooled mean symptom scores, rather than the proportion of patients in each trial experiencing an improvement in symptoms, and did not appear to include data from all available RCTs.” Furthermore, they noted that this prior study lacked subgroup analyses conducted based on IBS subtype or postinfection status.

“We, therefore, conducted a contemporaneous meta-analysis to examine the efficacy and safety of mesalamine in IBS addressing these deficits in knowledge,” the investigators wrote.

Their meta-analysis included 820 patients from 8 RCTs published between 2009 and 2022. Efficacy and safety were evaluated via dichotomous assessments of global IBS symptoms, bowel habit or stool frequency, abdominal pain, and adverse events. Two subgroup analyses were planned to evaluate responses based on post-infection status and predominant stool pattern.

Unlike the previous meta-analysis, Dr. Goodoory and colleagues detected a potential signal for efficacy.

Across all patients, mesalamine was associated with significant improvement in global IBS symptoms, compared with placebo (relative risk [RR], 0.86; 95% CI, 0.79-0.95). However, no significant improvements were detected for abdominal pain or bowel habit/stool frequency.

A subgroup analysis of patients exhibiting IBS with diarrhea showed significantly greater improvements in global IBS symptoms for mesalamine versus placebo (RR, 0.88; 95% CI, 0.79-0.99). This subgroup showed no improvements in abdominal pain or bowel habit/stool frequency.

Subgroup analyses for patients with constipation or mixed bowel habits, or based on postinfection status, revealed no significant differences, although the investigators noted that relevant data were limited.

Mesalamine appeared to be well tolerated. Across five studies reporting adverse events, 43.5% of patients receiving mesalamine reported any adverse event, compared with 41.4% of patients on placebo. The RR of experiencing an adverse event in those taking mesalamine was 1.20 (95% CI, 0.89-1.63), which was not statistically significant.

“There was no evidence of heterogeneity between studies in most of our analyses, but only one trial was at low risk of bias across all domains, and there were insufficient studies to assess for funnel plot asymmetry,” Dr. Goodoory and colleagues wrote. “Based on these limitations of the evidence,” they continued, “our confidence in the results of the meta-analysis would be low, and further large trials at low risk of bias would be informative.”

Specifically, the investigators suggested an RCT recruiting only patients with IBS with diarrhea, and reporting efficacy according to postinfection status.

One coauthor reported research funding from Tillotts Pharma and Dr Falk Pharma UK. The remaining authors reported no conflicts.

Certain patients with irritable bowel syndrome (IBS) may benefit from treatment with mesalamine, although the quality of evidence supporting this strategy remains low, according to a recent systematic literature review and meta-analysis.

Global IBS symptoms improved significantly across the entire population, however, a subgroup analysis suggested that mesalamine may be most beneficial for patients who present with diarrhea, providing support for a large clinical trial in this patient population, reported lead author Vivek C. Goodoory, MBChB, of St. James’s University Hospital, Leeds, United Kingdom, and colleagues.

Some patients with IBS may present with low-grade inflammation in the intestine, offering theoretical grounds for prescribing mesalamine, which is typically used for treating ulcerative colitis, the investigators wrote in Clinical Gastroenterology and Hepatology. Yet previous randomized controlled trials (RCTs) evaluating mesalamine for IBS have yielded mixed results, and a meta-analysis showed that mesalamine offered no benefit.

According to Dr. Goodoory and colleagues, however, that meta-analysis fell short since it “only pooled mean symptom scores, rather than the proportion of patients in each trial experiencing an improvement in symptoms, and did not appear to include data from all available RCTs.” Furthermore, they noted that this prior study lacked subgroup analyses conducted based on IBS subtype or postinfection status.

“We, therefore, conducted a contemporaneous meta-analysis to examine the efficacy and safety of mesalamine in IBS addressing these deficits in knowledge,” the investigators wrote.

Their meta-analysis included 820 patients from 8 RCTs published between 2009 and 2022. Efficacy and safety were evaluated via dichotomous assessments of global IBS symptoms, bowel habit or stool frequency, abdominal pain, and adverse events. Two subgroup analyses were planned to evaluate responses based on post-infection status and predominant stool pattern.

Unlike the previous meta-analysis, Dr. Goodoory and colleagues detected a potential signal for efficacy.

Across all patients, mesalamine was associated with significant improvement in global IBS symptoms, compared with placebo (relative risk [RR], 0.86; 95% CI, 0.79-0.95). However, no significant improvements were detected for abdominal pain or bowel habit/stool frequency.

A subgroup analysis of patients exhibiting IBS with diarrhea showed significantly greater improvements in global IBS symptoms for mesalamine versus placebo (RR, 0.88; 95% CI, 0.79-0.99). This subgroup showed no improvements in abdominal pain or bowel habit/stool frequency.

Subgroup analyses for patients with constipation or mixed bowel habits, or based on postinfection status, revealed no significant differences, although the investigators noted that relevant data were limited.

Mesalamine appeared to be well tolerated. Across five studies reporting adverse events, 43.5% of patients receiving mesalamine reported any adverse event, compared with 41.4% of patients on placebo. The RR of experiencing an adverse event in those taking mesalamine was 1.20 (95% CI, 0.89-1.63), which was not statistically significant.

“There was no evidence of heterogeneity between studies in most of our analyses, but only one trial was at low risk of bias across all domains, and there were insufficient studies to assess for funnel plot asymmetry,” Dr. Goodoory and colleagues wrote. “Based on these limitations of the evidence,” they continued, “our confidence in the results of the meta-analysis would be low, and further large trials at low risk of bias would be informative.”

Specifically, the investigators suggested an RCT recruiting only patients with IBS with diarrhea, and reporting efficacy according to postinfection status.

One coauthor reported research funding from Tillotts Pharma and Dr Falk Pharma UK. The remaining authors reported no conflicts.

Certain patients with irritable bowel syndrome (IBS) may benefit from treatment with mesalamine, although the quality of evidence supporting this strategy remains low, according to a recent systematic literature review and meta-analysis.

Global IBS symptoms improved significantly across the entire population, however, a subgroup analysis suggested that mesalamine may be most beneficial for patients who present with diarrhea, providing support for a large clinical trial in this patient population, reported lead author Vivek C. Goodoory, MBChB, of St. James’s University Hospital, Leeds, United Kingdom, and colleagues.

Some patients with IBS may present with low-grade inflammation in the intestine, offering theoretical grounds for prescribing mesalamine, which is typically used for treating ulcerative colitis, the investigators wrote in Clinical Gastroenterology and Hepatology. Yet previous randomized controlled trials (RCTs) evaluating mesalamine for IBS have yielded mixed results, and a meta-analysis showed that mesalamine offered no benefit.

According to Dr. Goodoory and colleagues, however, that meta-analysis fell short since it “only pooled mean symptom scores, rather than the proportion of patients in each trial experiencing an improvement in symptoms, and did not appear to include data from all available RCTs.” Furthermore, they noted that this prior study lacked subgroup analyses conducted based on IBS subtype or postinfection status.

“We, therefore, conducted a contemporaneous meta-analysis to examine the efficacy and safety of mesalamine in IBS addressing these deficits in knowledge,” the investigators wrote.

Their meta-analysis included 820 patients from 8 RCTs published between 2009 and 2022. Efficacy and safety were evaluated via dichotomous assessments of global IBS symptoms, bowel habit or stool frequency, abdominal pain, and adverse events. Two subgroup analyses were planned to evaluate responses based on post-infection status and predominant stool pattern.

Unlike the previous meta-analysis, Dr. Goodoory and colleagues detected a potential signal for efficacy.

Across all patients, mesalamine was associated with significant improvement in global IBS symptoms, compared with placebo (relative risk [RR], 0.86; 95% CI, 0.79-0.95). However, no significant improvements were detected for abdominal pain or bowel habit/stool frequency.

A subgroup analysis of patients exhibiting IBS with diarrhea showed significantly greater improvements in global IBS symptoms for mesalamine versus placebo (RR, 0.88; 95% CI, 0.79-0.99). This subgroup showed no improvements in abdominal pain or bowel habit/stool frequency.

Subgroup analyses for patients with constipation or mixed bowel habits, or based on postinfection status, revealed no significant differences, although the investigators noted that relevant data were limited.

Mesalamine appeared to be well tolerated. Across five studies reporting adverse events, 43.5% of patients receiving mesalamine reported any adverse event, compared with 41.4% of patients on placebo. The RR of experiencing an adverse event in those taking mesalamine was 1.20 (95% CI, 0.89-1.63), which was not statistically significant.

“There was no evidence of heterogeneity between studies in most of our analyses, but only one trial was at low risk of bias across all domains, and there were insufficient studies to assess for funnel plot asymmetry,” Dr. Goodoory and colleagues wrote. “Based on these limitations of the evidence,” they continued, “our confidence in the results of the meta-analysis would be low, and further large trials at low risk of bias would be informative.”

Specifically, the investigators suggested an RCT recruiting only patients with IBS with diarrhea, and reporting efficacy according to postinfection status.

One coauthor reported research funding from Tillotts Pharma and Dr Falk Pharma UK. The remaining authors reported no conflicts.

Non–Lyme disease, tick-borne illnesses — such as spotted fever group rickettsiosis (SFGR), ehrlichiosis, and alpha-gal syndrome (AGS) — are emerging public health threats, but whether prior tick exposures are responsible for long-term complications, such as musculoskeletal symptoms or osteoarthritis, has been unclear.

Many patients attribute their nonspecific long-term symptoms, such as musculoskeletal pain, to previous illnesses from tick bites, note authors of a study published in JAMA Network Open. But the researchers, led by Diana L. Zychowski, MD, MPH, with the Division of Infectious Diseases at the University of North Carolina at Chapel Hill, found that Ehrlichia or Rickettsia seropositivity was not associated with chronic musculoskeletal symptoms, though they write that “further investigation into the pathogenesis of [alpha-gal] syndrome is needed.”
 

Tick-Borne Illness Cases Multiplying

Cases of tick-borne illness (TBD) in the United States have multiplied in recent years. More than 50,000 cases of TBD in the United States were reported in 2019, which doubled the number of cases over the previous 2 decades, the authors note.

Most of the cases are Lyme disease, but others — including SFGR and ehrlichiosis — represent an important public health threat, especially in southeastern states, the authors write. Cases of ehrlichiosis, for example, transmitted by the lone star tick, soared more than 10-fold since 2000.

The goal of this study was to evaluate whether there was an association between prior exposure to TBDs endemic to the southeastern United States and chronic musculoskeletal symptoms and radiographic measures of osteoarthritis.

Researchers analyzed 488 blood samples from the fourth visit (2017-2018) of the Johnston County Osteoarthritis (JoCo OA) project, an ongoing population-based study in Johnston County, North Carolina. JoCo OA participants include noninstitutionalized White and Black Johnston County residents 45 years old or older with osteoarthritis.

They measured seroprevalence of Rickettsia- and Ehrlichia-specific immunoglobulin G (IgG) as well as alpha-gal immunoglobulin E (IgE) in patient samples. Only alpha-gal IgE was linked in the study with knee pain, aching, or stiffness. Antibodies to Rickettsia, Ehrlichia, and alpha-gal were not associated with radiographic, symptomatic knee osteoarthritis.

“To our knowledge,” the authors write, “this study was the first population-based seroprevalence study of SFGR, Ehrlichia, and [alpha]-gal.”

The study also found a high prevalence of TBD exposure in the cohort. More than a third (36.5%) had either an alpha-gal IgE level greater than 0.1 IU/mL, a positive test for SFGR IgG antibodies, or a positive test for Ehrlichia IgG antibodies.

Given that not every tick carries an infectious pathogen, the findings show human-tick interactions are common, they write.

“These findings suggest that substantial investment is required to examine the pathogenesis of these TBDs and interventions to reduce human-tick interactions,” the authors conclude.

This study was funded by a Creativity Hub Award from the University of North Carolina Office of the Vice Chancellor for Research. The JoCo OA project is supported in part by grants from the Association of Schools of Public Health/Centers for Disease Control and Prevention (CDC); and grants from the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Authors reported grants from the National Institutes of Health, the CDC, and several pharmaceutical companies.

Non–Lyme disease, tick-borne illnesses — such as spotted fever group rickettsiosis (SFGR), ehrlichiosis, and alpha-gal syndrome (AGS) — are emerging public health threats, but whether prior tick exposures are responsible for long-term complications, such as musculoskeletal symptoms or osteoarthritis, has been unclear.

Many patients attribute their nonspecific long-term symptoms, such as musculoskeletal pain, to previous illnesses from tick bites, note authors of a study published in JAMA Network Open. But the researchers, led by Diana L. Zychowski, MD, MPH, with the Division of Infectious Diseases at the University of North Carolina at Chapel Hill, found that Ehrlichia or Rickettsia seropositivity was not associated with chronic musculoskeletal symptoms, though they write that “further investigation into the pathogenesis of [alpha-gal] syndrome is needed.”
 

Tick-Borne Illness Cases Multiplying

Cases of tick-borne illness (TBD) in the United States have multiplied in recent years. More than 50,000 cases of TBD in the United States were reported in 2019, which doubled the number of cases over the previous 2 decades, the authors note.

Most of the cases are Lyme disease, but others — including SFGR and ehrlichiosis — represent an important public health threat, especially in southeastern states, the authors write. Cases of ehrlichiosis, for example, transmitted by the lone star tick, soared more than 10-fold since 2000.

The goal of this study was to evaluate whether there was an association between prior exposure to TBDs endemic to the southeastern United States and chronic musculoskeletal symptoms and radiographic measures of osteoarthritis.

Researchers analyzed 488 blood samples from the fourth visit (2017-2018) of the Johnston County Osteoarthritis (JoCo OA) project, an ongoing population-based study in Johnston County, North Carolina. JoCo OA participants include noninstitutionalized White and Black Johnston County residents 45 years old or older with osteoarthritis.

They measured seroprevalence of Rickettsia- and Ehrlichia-specific immunoglobulin G (IgG) as well as alpha-gal immunoglobulin E (IgE) in patient samples. Only alpha-gal IgE was linked in the study with knee pain, aching, or stiffness. Antibodies to Rickettsia, Ehrlichia, and alpha-gal were not associated with radiographic, symptomatic knee osteoarthritis.

“To our knowledge,” the authors write, “this study was the first population-based seroprevalence study of SFGR, Ehrlichia, and [alpha]-gal.”

The study also found a high prevalence of TBD exposure in the cohort. More than a third (36.5%) had either an alpha-gal IgE level greater than 0.1 IU/mL, a positive test for SFGR IgG antibodies, or a positive test for Ehrlichia IgG antibodies.

Given that not every tick carries an infectious pathogen, the findings show human-tick interactions are common, they write.

“These findings suggest that substantial investment is required to examine the pathogenesis of these TBDs and interventions to reduce human-tick interactions,” the authors conclude.

This study was funded by a Creativity Hub Award from the University of North Carolina Office of the Vice Chancellor for Research. The JoCo OA project is supported in part by grants from the Association of Schools of Public Health/Centers for Disease Control and Prevention (CDC); and grants from the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Authors reported grants from the National Institutes of Health, the CDC, and several pharmaceutical companies.

Non–Lyme disease, tick-borne illnesses — such as spotted fever group rickettsiosis (SFGR), ehrlichiosis, and alpha-gal syndrome (AGS) — are emerging public health threats, but whether prior tick exposures are responsible for long-term complications, such as musculoskeletal symptoms or osteoarthritis, has been unclear.

Many patients attribute their nonspecific long-term symptoms, such as musculoskeletal pain, to previous illnesses from tick bites, note authors of a study published in JAMA Network Open. But the researchers, led by Diana L. Zychowski, MD, MPH, with the Division of Infectious Diseases at the University of North Carolina at Chapel Hill, found that Ehrlichia or Rickettsia seropositivity was not associated with chronic musculoskeletal symptoms, though they write that “further investigation into the pathogenesis of [alpha-gal] syndrome is needed.”
 

Tick-Borne Illness Cases Multiplying

Cases of tick-borne illness (TBD) in the United States have multiplied in recent years. More than 50,000 cases of TBD in the United States were reported in 2019, which doubled the number of cases over the previous 2 decades, the authors note.

Most of the cases are Lyme disease, but others — including SFGR and ehrlichiosis — represent an important public health threat, especially in southeastern states, the authors write. Cases of ehrlichiosis, for example, transmitted by the lone star tick, soared more than 10-fold since 2000.

The goal of this study was to evaluate whether there was an association between prior exposure to TBDs endemic to the southeastern United States and chronic musculoskeletal symptoms and radiographic measures of osteoarthritis.

Researchers analyzed 488 blood samples from the fourth visit (2017-2018) of the Johnston County Osteoarthritis (JoCo OA) project, an ongoing population-based study in Johnston County, North Carolina. JoCo OA participants include noninstitutionalized White and Black Johnston County residents 45 years old or older with osteoarthritis.

They measured seroprevalence of Rickettsia- and Ehrlichia-specific immunoglobulin G (IgG) as well as alpha-gal immunoglobulin E (IgE) in patient samples. Only alpha-gal IgE was linked in the study with knee pain, aching, or stiffness. Antibodies to Rickettsia, Ehrlichia, and alpha-gal were not associated with radiographic, symptomatic knee osteoarthritis.

“To our knowledge,” the authors write, “this study was the first population-based seroprevalence study of SFGR, Ehrlichia, and [alpha]-gal.”

The study also found a high prevalence of TBD exposure in the cohort. More than a third (36.5%) had either an alpha-gal IgE level greater than 0.1 IU/mL, a positive test for SFGR IgG antibodies, or a positive test for Ehrlichia IgG antibodies.

Given that not every tick carries an infectious pathogen, the findings show human-tick interactions are common, they write.

“These findings suggest that substantial investment is required to examine the pathogenesis of these TBDs and interventions to reduce human-tick interactions,” the authors conclude.

This study was funded by a Creativity Hub Award from the University of North Carolina Office of the Vice Chancellor for Research. The JoCo OA project is supported in part by grants from the Association of Schools of Public Health/Centers for Disease Control and Prevention (CDC); and grants from the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Authors reported grants from the National Institutes of Health, the CDC, and several pharmaceutical companies.

How might you discuss a suicidal ideation, an anxiety-provoking topic, with your patients and their parents? After a positive screen, there will be times when you decide your patient should go to an emergency department for an urgent evaluation. However, most of the time you will be able to help the family identify strategies to lower risk and improve safety and resilience, while waiting for a thorough psychiatric evaluation.

Bring in the Parents: Modeling Validation, Structure, and Optimism

If you have identified some degree of suicide risk in your patient, either with a screening instrument or in your clinical interview, ask your patient if you can bring their parents into the conversation. They may resist, and if so, find out why they are hesitant. Are they worried about causing their parents some distress? Are they concerned their parents will be surprised? Disappointed? Scared? Angry? Acknowledge how hard it can be to find a way to talk about such emotional material with parents. What is their communication like with their parents usually? Do they talk every night at dinner or rarely? Are their interactions usually lighthearted or playful? Brief? Irritable and angry? Have they talked about or managed difficult times before as a family? How did that go? Did they feel they ended up supporting an anxious or depressed single parent? Was their parent harsh and punitive? Since involving the parent is essential, if you become concerned that a conversation with the parent would truly increase the risk of suicide, perhaps because of reports of violence at home, then you may need to send your patient to the emergency department so they can be assessed in a safe setting where a clinical team can evaluate your patient while involving more (or different) members of the family.

Most of the time, your patient will describe a situation that will simply be uncomfortable or stressful for their parent. Don’t be dismissive of their concerns. Instead, acknowledge that talking about their inner life will feel hard. Validate that their parents will be sad, worried, and stressed to hear about what they are feeling. Then offer that parents always prefer to know what is happening with their child so they can help, even if that means only being present to bear it alongside them. You can remind them that you will be there, too, to reassure their parents that this is a common problem and that you can face it and help it to get better together. Find out if they would like you to take the lead in speaking about it, but do not let them wait in the waiting room. Discussing the topic with you with both parents and patient in the room will help even those families that are not great communicators to begin to be more connected, even if you do most of the talking. While you need to bring their symptoms and suicidality to their parents’ attention, find out if there are any details they would rather not share. Perhaps they are struggling with questions of gender identity or sexual orientation, or are thinking of giving up an activity their parents may be very invested in. While any future treatment will prioritize honest communication within the family, communication about their emerging identity should not be rushed, and especially not in the setting of concerns about suicide risk.

With the information you do gather, there are often steps you can take to lower the stress level. The parents’ awareness of their suffering, perhaps acknowledging a broken heart, excessive academic pressure, or a major disappointment may suggest steps to lower the stress level. A mental health referral might introduce a sense of hope. A reminder of their meaningful connection to a parent, a team, a religion, or an activity may also remind the adolescent of a positive view of their future.
 

Introducing the Topic

When you bring parents into the room, let them know that there is something important and difficult that you need to discuss with them together. Ask if they have noted any changes in their child’s behavior, school performance, or demeanor. Have they had any worries about their teenager? If they have, affirm that they are picking up on something real, and ask more about it. If they have not, offer that their child has been doing a valiant job of soldiering through their days while managing some strong and difficult thoughts and feelings. Walk them through some of what you have learned from your patient, always inviting your patient to affirm or add to what you are detailing. Most parents are keenly aware of the prevalence of suicidal thoughts during adolescence. Bring it into the open, and offer that the next steps are going to be to add more adults to their child’s orbit to help diagnose and treat any underlying psychiatric illness. Reassure them that you are confident that psychiatric illnesses are treatable, even curable. Reassure them that one of the best safety measures is good communication and connectedness with parents.

Help Parents to Be Good Listeners

Some parents may respond with heightened anxiety and need for reassurance from their child. Others may try to talk their child out of their suicidal thoughts. But your year is going so well! You got a great grade in calculus! Gently model validation: Acknowledge to the parents that it is understandable to feel worried or to look for a rational argument against suicide. Offer that feelings don’t usually respond to logic, but do improve with support and time. It may be better for everyone to treat this topic more like the weather so it is easier to talk about and manage. No one gets defensive or distressed if it’s raining, they just put on the right gear. Has the parent ever felt depressed? Did they ever have suicidal ideation growing up? Can they agree to check in at regular times? Could the child speak up if they are feeling badly? Can all agree that parents should check in if their child seems more down? Help them to acknowledge how hard it is to bear strong feelings, but that it is always better together.

Identify Coping Strategies

In front of parents, ask your patient if anything helps when they are feeling at their worst. If they can’t identify anything, offer some possibilities: a walk outside together? making art or music? being out in nature? snuggling with a beloved pet? a set of jumping jacks to get their heart rate up? a favorite playlist? Talking to a particular friend or relative? Make a list. Prioritize activities that are healthy and connect them to others when they are feeling their worst.

Focus on the Basics

Make a concrete and practical plan for steps they can all take to improve well-being. Start with strategies to ensure restful sleep at night, regular exercise, and healthy nutrition. Depression and anxiety often interfere with these functions, so families can work together to support them even while waiting for assessment by a psychiatrist. Help them identify modest rules or routines (consistent bedtime, no screens in the bedroom, a daily walk after dinner) that parents can set that will make a difference.

Set Up Speed Bumps

Talk together about setting up some speed bumps to support their child’s safety. Find out if there are firearms in the home. Be crystal clear that they should be locked, preferably with ammunition, in a separate secure place. Their child should have no knowledge of how to access them, or they should be stored out of the home for the time being.

Parents should lock any medications that could be dangerous in overdose (including in homes if the adolescent will be visiting). Educate them about Tylenol and any prescription medications in their home that should be locked. This part of a conversation is always stressful. Acknowledge that, and remind everyone that, these are important strategies. It should be always be easier to ask their parent for help if they are feeling terrible than it is to access something dangerous.
 

Acknowledge the Strain

Finally, it is important to acknowledge how hard it is for your patient to bear these feelings, and that speaking up about them may feel like the last thing they want to do. Applaud them for their strength while reminding them that they need to share if they feel worse. Likewise, model for parents that feeling stressed and worried in this circumstance is normal. They should think about how to take good care of themselves. The same well-being strategies you reviewed for their child can work for them too! They may want to focus on sleep or exercise, enhance their nourishing social connections, protect time for beloved hobbies. Everyone should hear that they should never worry alone. If someone feels more worried, bring it to their parent, therapist, psychiatrist, spouse, or to you. They should trust their instincts if they think it is time to go to the emergency department. With supportive open communication, they will strengthen the protective connections which in turn will see the family through the course of the treatable illnesses that cause suicidal thoughts.

Lastly, this is difficult work for any physician. As psychiatrists, we worry about higher-risk teenagers when we decide that hospitalization carries a bigger risk than benefit. Pediatricians see many more teenagers with suicidal ideation and even though the statistical risk is very low, no one knows how to predict any individual teenager’s behavior. Therefore, pediatricians face the direct stress of the clinical work and the deeper stress of knowing there is always some uncertainty in medicine.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].

How might you discuss a suicidal ideation, an anxiety-provoking topic, with your patients and their parents? After a positive screen, there will be times when you decide your patient should go to an emergency department for an urgent evaluation. However, most of the time you will be able to help the family identify strategies to lower risk and improve safety and resilience, while waiting for a thorough psychiatric evaluation.

Bring in the Parents: Modeling Validation, Structure, and Optimism

If you have identified some degree of suicide risk in your patient, either with a screening instrument or in your clinical interview, ask your patient if you can bring their parents into the conversation. They may resist, and if so, find out why they are hesitant. Are they worried about causing their parents some distress? Are they concerned their parents will be surprised? Disappointed? Scared? Angry? Acknowledge how hard it can be to find a way to talk about such emotional material with parents. What is their communication like with their parents usually? Do they talk every night at dinner or rarely? Are their interactions usually lighthearted or playful? Brief? Irritable and angry? Have they talked about or managed difficult times before as a family? How did that go? Did they feel they ended up supporting an anxious or depressed single parent? Was their parent harsh and punitive? Since involving the parent is essential, if you become concerned that a conversation with the parent would truly increase the risk of suicide, perhaps because of reports of violence at home, then you may need to send your patient to the emergency department so they can be assessed in a safe setting where a clinical team can evaluate your patient while involving more (or different) members of the family.

Most of the time, your patient will describe a situation that will simply be uncomfortable or stressful for their parent. Don’t be dismissive of their concerns. Instead, acknowledge that talking about their inner life will feel hard. Validate that their parents will be sad, worried, and stressed to hear about what they are feeling. Then offer that parents always prefer to know what is happening with their child so they can help, even if that means only being present to bear it alongside them. You can remind them that you will be there, too, to reassure their parents that this is a common problem and that you can face it and help it to get better together. Find out if they would like you to take the lead in speaking about it, but do not let them wait in the waiting room. Discussing the topic with you with both parents and patient in the room will help even those families that are not great communicators to begin to be more connected, even if you do most of the talking. While you need to bring their symptoms and suicidality to their parents’ attention, find out if there are any details they would rather not share. Perhaps they are struggling with questions of gender identity or sexual orientation, or are thinking of giving up an activity their parents may be very invested in. While any future treatment will prioritize honest communication within the family, communication about their emerging identity should not be rushed, and especially not in the setting of concerns about suicide risk.

With the information you do gather, there are often steps you can take to lower the stress level. The parents’ awareness of their suffering, perhaps acknowledging a broken heart, excessive academic pressure, or a major disappointment may suggest steps to lower the stress level. A mental health referral might introduce a sense of hope. A reminder of their meaningful connection to a parent, a team, a religion, or an activity may also remind the adolescent of a positive view of their future.
 

Introducing the Topic

When you bring parents into the room, let them know that there is something important and difficult that you need to discuss with them together. Ask if they have noted any changes in their child’s behavior, school performance, or demeanor. Have they had any worries about their teenager? If they have, affirm that they are picking up on something real, and ask more about it. If they have not, offer that their child has been doing a valiant job of soldiering through their days while managing some strong and difficult thoughts and feelings. Walk them through some of what you have learned from your patient, always inviting your patient to affirm or add to what you are detailing. Most parents are keenly aware of the prevalence of suicidal thoughts during adolescence. Bring it into the open, and offer that the next steps are going to be to add more adults to their child’s orbit to help diagnose and treat any underlying psychiatric illness. Reassure them that you are confident that psychiatric illnesses are treatable, even curable. Reassure them that one of the best safety measures is good communication and connectedness with parents.

Help Parents to Be Good Listeners

Some parents may respond with heightened anxiety and need for reassurance from their child. Others may try to talk their child out of their suicidal thoughts. But your year is going so well! You got a great grade in calculus! Gently model validation: Acknowledge to the parents that it is understandable to feel worried or to look for a rational argument against suicide. Offer that feelings don’t usually respond to logic, but do improve with support and time. It may be better for everyone to treat this topic more like the weather so it is easier to talk about and manage. No one gets defensive or distressed if it’s raining, they just put on the right gear. Has the parent ever felt depressed? Did they ever have suicidal ideation growing up? Can they agree to check in at regular times? Could the child speak up if they are feeling badly? Can all agree that parents should check in if their child seems more down? Help them to acknowledge how hard it is to bear strong feelings, but that it is always better together.

Identify Coping Strategies

In front of parents, ask your patient if anything helps when they are feeling at their worst. If they can’t identify anything, offer some possibilities: a walk outside together? making art or music? being out in nature? snuggling with a beloved pet? a set of jumping jacks to get their heart rate up? a favorite playlist? Talking to a particular friend or relative? Make a list. Prioritize activities that are healthy and connect them to others when they are feeling their worst.

Focus on the Basics

Make a concrete and practical plan for steps they can all take to improve well-being. Start with strategies to ensure restful sleep at night, regular exercise, and healthy nutrition. Depression and anxiety often interfere with these functions, so families can work together to support them even while waiting for assessment by a psychiatrist. Help them identify modest rules or routines (consistent bedtime, no screens in the bedroom, a daily walk after dinner) that parents can set that will make a difference.

Set Up Speed Bumps

Talk together about setting up some speed bumps to support their child’s safety. Find out if there are firearms in the home. Be crystal clear that they should be locked, preferably with ammunition, in a separate secure place. Their child should have no knowledge of how to access them, or they should be stored out of the home for the time being.

Parents should lock any medications that could be dangerous in overdose (including in homes if the adolescent will be visiting). Educate them about Tylenol and any prescription medications in their home that should be locked. This part of a conversation is always stressful. Acknowledge that, and remind everyone that, these are important strategies. It should be always be easier to ask their parent for help if they are feeling terrible than it is to access something dangerous.
 

Acknowledge the Strain

Finally, it is important to acknowledge how hard it is for your patient to bear these feelings, and that speaking up about them may feel like the last thing they want to do. Applaud them for their strength while reminding them that they need to share if they feel worse. Likewise, model for parents that feeling stressed and worried in this circumstance is normal. They should think about how to take good care of themselves. The same well-being strategies you reviewed for their child can work for them too! They may want to focus on sleep or exercise, enhance their nourishing social connections, protect time for beloved hobbies. Everyone should hear that they should never worry alone. If someone feels more worried, bring it to their parent, therapist, psychiatrist, spouse, or to you. They should trust their instincts if they think it is time to go to the emergency department. With supportive open communication, they will strengthen the protective connections which in turn will see the family through the course of the treatable illnesses that cause suicidal thoughts.

Lastly, this is difficult work for any physician. As psychiatrists, we worry about higher-risk teenagers when we decide that hospitalization carries a bigger risk than benefit. Pediatricians see many more teenagers with suicidal ideation and even though the statistical risk is very low, no one knows how to predict any individual teenager’s behavior. Therefore, pediatricians face the direct stress of the clinical work and the deeper stress of knowing there is always some uncertainty in medicine.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].

How might you discuss a suicidal ideation, an anxiety-provoking topic, with your patients and their parents? After a positive screen, there will be times when you decide your patient should go to an emergency department for an urgent evaluation. However, most of the time you will be able to help the family identify strategies to lower risk and improve safety and resilience, while waiting for a thorough psychiatric evaluation.

Bring in the Parents: Modeling Validation, Structure, and Optimism

If you have identified some degree of suicide risk in your patient, either with a screening instrument or in your clinical interview, ask your patient if you can bring their parents into the conversation. They may resist, and if so, find out why they are hesitant. Are they worried about causing their parents some distress? Are they concerned their parents will be surprised? Disappointed? Scared? Angry? Acknowledge how hard it can be to find a way to talk about such emotional material with parents. What is their communication like with their parents usually? Do they talk every night at dinner or rarely? Are their interactions usually lighthearted or playful? Brief? Irritable and angry? Have they talked about or managed difficult times before as a family? How did that go? Did they feel they ended up supporting an anxious or depressed single parent? Was their parent harsh and punitive? Since involving the parent is essential, if you become concerned that a conversation with the parent would truly increase the risk of suicide, perhaps because of reports of violence at home, then you may need to send your patient to the emergency department so they can be assessed in a safe setting where a clinical team can evaluate your patient while involving more (or different) members of the family.

Most of the time, your patient will describe a situation that will simply be uncomfortable or stressful for their parent. Don’t be dismissive of their concerns. Instead, acknowledge that talking about their inner life will feel hard. Validate that their parents will be sad, worried, and stressed to hear about what they are feeling. Then offer that parents always prefer to know what is happening with their child so they can help, even if that means only being present to bear it alongside them. You can remind them that you will be there, too, to reassure their parents that this is a common problem and that you can face it and help it to get better together. Find out if they would like you to take the lead in speaking about it, but do not let them wait in the waiting room. Discussing the topic with you with both parents and patient in the room will help even those families that are not great communicators to begin to be more connected, even if you do most of the talking. While you need to bring their symptoms and suicidality to their parents’ attention, find out if there are any details they would rather not share. Perhaps they are struggling with questions of gender identity or sexual orientation, or are thinking of giving up an activity their parents may be very invested in. While any future treatment will prioritize honest communication within the family, communication about their emerging identity should not be rushed, and especially not in the setting of concerns about suicide risk.

With the information you do gather, there are often steps you can take to lower the stress level. The parents’ awareness of their suffering, perhaps acknowledging a broken heart, excessive academic pressure, or a major disappointment may suggest steps to lower the stress level. A mental health referral might introduce a sense of hope. A reminder of their meaningful connection to a parent, a team, a religion, or an activity may also remind the adolescent of a positive view of their future.
 

Introducing the Topic

When you bring parents into the room, let them know that there is something important and difficult that you need to discuss with them together. Ask if they have noted any changes in their child’s behavior, school performance, or demeanor. Have they had any worries about their teenager? If they have, affirm that they are picking up on something real, and ask more about it. If they have not, offer that their child has been doing a valiant job of soldiering through their days while managing some strong and difficult thoughts and feelings. Walk them through some of what you have learned from your patient, always inviting your patient to affirm or add to what you are detailing. Most parents are keenly aware of the prevalence of suicidal thoughts during adolescence. Bring it into the open, and offer that the next steps are going to be to add more adults to their child’s orbit to help diagnose and treat any underlying psychiatric illness. Reassure them that you are confident that psychiatric illnesses are treatable, even curable. Reassure them that one of the best safety measures is good communication and connectedness with parents.

Help Parents to Be Good Listeners

Some parents may respond with heightened anxiety and need for reassurance from their child. Others may try to talk their child out of their suicidal thoughts. But your year is going so well! You got a great grade in calculus! Gently model validation: Acknowledge to the parents that it is understandable to feel worried or to look for a rational argument against suicide. Offer that feelings don’t usually respond to logic, but do improve with support and time. It may be better for everyone to treat this topic more like the weather so it is easier to talk about and manage. No one gets defensive or distressed if it’s raining, they just put on the right gear. Has the parent ever felt depressed? Did they ever have suicidal ideation growing up? Can they agree to check in at regular times? Could the child speak up if they are feeling badly? Can all agree that parents should check in if their child seems more down? Help them to acknowledge how hard it is to bear strong feelings, but that it is always better together.

Identify Coping Strategies

In front of parents, ask your patient if anything helps when they are feeling at their worst. If they can’t identify anything, offer some possibilities: a walk outside together? making art or music? being out in nature? snuggling with a beloved pet? a set of jumping jacks to get their heart rate up? a favorite playlist? Talking to a particular friend or relative? Make a list. Prioritize activities that are healthy and connect them to others when they are feeling their worst.

Focus on the Basics

Make a concrete and practical plan for steps they can all take to improve well-being. Start with strategies to ensure restful sleep at night, regular exercise, and healthy nutrition. Depression and anxiety often interfere with these functions, so families can work together to support them even while waiting for assessment by a psychiatrist. Help them identify modest rules or routines (consistent bedtime, no screens in the bedroom, a daily walk after dinner) that parents can set that will make a difference.

Set Up Speed Bumps

Talk together about setting up some speed bumps to support their child’s safety. Find out if there are firearms in the home. Be crystal clear that they should be locked, preferably with ammunition, in a separate secure place. Their child should have no knowledge of how to access them, or they should be stored out of the home for the time being.

Parents should lock any medications that could be dangerous in overdose (including in homes if the adolescent will be visiting). Educate them about Tylenol and any prescription medications in their home that should be locked. This part of a conversation is always stressful. Acknowledge that, and remind everyone that, these are important strategies. It should be always be easier to ask their parent for help if they are feeling terrible than it is to access something dangerous.
 

Acknowledge the Strain

Finally, it is important to acknowledge how hard it is for your patient to bear these feelings, and that speaking up about them may feel like the last thing they want to do. Applaud them for their strength while reminding them that they need to share if they feel worse. Likewise, model for parents that feeling stressed and worried in this circumstance is normal. They should think about how to take good care of themselves. The same well-being strategies you reviewed for their child can work for them too! They may want to focus on sleep or exercise, enhance their nourishing social connections, protect time for beloved hobbies. Everyone should hear that they should never worry alone. If someone feels more worried, bring it to their parent, therapist, psychiatrist, spouse, or to you. They should trust their instincts if they think it is time to go to the emergency department. With supportive open communication, they will strengthen the protective connections which in turn will see the family through the course of the treatable illnesses that cause suicidal thoughts.

Lastly, this is difficult work for any physician. As psychiatrists, we worry about higher-risk teenagers when we decide that hospitalization carries a bigger risk than benefit. Pediatricians see many more teenagers with suicidal ideation and even though the statistical risk is very low, no one knows how to predict any individual teenager’s behavior. Therefore, pediatricians face the direct stress of the clinical work and the deeper stress of knowing there is always some uncertainty in medicine.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].

TOPLINE:

Routine clinical examination detects only 2.2% of second breast cancers during 10-year follow-up in women undergoing posttreatment surveillance after ductal carcinoma in situ (DCIS).

METHODOLOGY:

• National Comprehensive Cancer Network guidelines recommend DCIS surveillance with a physical exam every 6-12 months for 5 years and then annually with a mammogram every 12 months. Research, however, suggested clinical breast exams only detect 15% of second breast cancers.
• A retrospective cohort study of 1550 female members of Kaiser Permanente Northern California diagnosed with unilateral DCIS between January 1, 2008, and January 1, 2011, who were followed until 2021.
• Patients who developed a second breast cancer within 10 years of follow-up were identified from the electronic health records. The detection methods were categorized into three groups: Patient-detected, physician-detected, and imaging-detected.

TAKEAWAY:

• During follow-up, 11.5% of women developed a second breast cancer with a median time to diagnosis of 57 months. Among patients with second breast cancers, 43.0% were ipsilateral, 54.8% were contralateral, and 2.2% presented with distant metastases.
• Overall, patients had a median of five mammograms between years 1 and 6 of surveillance and a median of seven clinic visits with most providers completing a clinical examination during the visit.
• Second breast cancers were detected through imaging in 74.3% of cases compared with 20.1% detected by patients and only 2.2% detected by physicians during physical exams. The remaining 3.4% were detected incidentally from plastic surgery procedures unrelated to oncologic surveillance.
• Mammogram detected 99.2% of cases (132 of 133 cases) identified by imaging.

IN PRACTICE:

“Our findings highlight the importance of mammogram screening and patient education regarding self-detection and can inform future NCCN recommendations for DCIS survivorship care,” the authors concluded, adding that “decreasing the need for in-person breast examinations could allow for other effective methods of survivorship monitoring.”

SOURCE:

This study, led by Bethany T. Waites of Kaiser Permanente San Francisco Medical Center, San Francisco, California, was published online on December 28 in the Journal of the National Comprehensive Cancer Network.

LIMITATIONS:

The retrospective design may have introduced selection bias or confounding. The study’s follow-up period until 2021, including the initial 18 months of the COVID-19 pandemic, may have affected surveillance patterns.

DISCLOSURES:

This study was supported by the Kaiser Permanente Northern California Graduate Medical Education program. The authors declared no relevant financial relationships.

A version of this article appeared on Medscape.com.

TOPLINE:

Routine clinical examination detects only 2.2% of second breast cancers during 10-year follow-up in women undergoing posttreatment surveillance after ductal carcinoma in situ (DCIS).

METHODOLOGY:

• National Comprehensive Cancer Network guidelines recommend DCIS surveillance with a physical exam every 6-12 months for 5 years and then annually with a mammogram every 12 months. Research, however, suggested clinical breast exams only detect 15% of second breast cancers.
• A retrospective cohort study of 1550 female members of Kaiser Permanente Northern California diagnosed with unilateral DCIS between January 1, 2008, and January 1, 2011, who were followed until 2021.
• Patients who developed a second breast cancer within 10 years of follow-up were identified from the electronic health records. The detection methods were categorized into three groups: Patient-detected, physician-detected, and imaging-detected.

TAKEAWAY:

• During follow-up, 11.5% of women developed a second breast cancer with a median time to diagnosis of 57 months. Among patients with second breast cancers, 43.0% were ipsilateral, 54.8% were contralateral, and 2.2% presented with distant metastases.
• Overall, patients had a median of five mammograms between years 1 and 6 of surveillance and a median of seven clinic visits with most providers completing a clinical examination during the visit.
• Second breast cancers were detected through imaging in 74.3% of cases compared with 20.1% detected by patients and only 2.2% detected by physicians during physical exams. The remaining 3.4% were detected incidentally from plastic surgery procedures unrelated to oncologic surveillance.
• Mammogram detected 99.2% of cases (132 of 133 cases) identified by imaging.

IN PRACTICE:

“Our findings highlight the importance of mammogram screening and patient education regarding self-detection and can inform future NCCN recommendations for DCIS survivorship care,” the authors concluded, adding that “decreasing the need for in-person breast examinations could allow for other effective methods of survivorship monitoring.”

SOURCE:

This study, led by Bethany T. Waites of Kaiser Permanente San Francisco Medical Center, San Francisco, California, was published online on December 28 in the Journal of the National Comprehensive Cancer Network.

LIMITATIONS:

The retrospective design may have introduced selection bias or confounding. The study’s follow-up period until 2021, including the initial 18 months of the COVID-19 pandemic, may have affected surveillance patterns.

DISCLOSURES:

This study was supported by the Kaiser Permanente Northern California Graduate Medical Education program. The authors declared no relevant financial relationships.

A version of this article appeared on Medscape.com.

TOPLINE:

Routine clinical examination detects only 2.2% of second breast cancers during 10-year follow-up in women undergoing posttreatment surveillance after ductal carcinoma in situ (DCIS).

METHODOLOGY:

• National Comprehensive Cancer Network guidelines recommend DCIS surveillance with a physical exam every 6-12 months for 5 years and then annually with a mammogram every 12 months. Research, however, suggested clinical breast exams only detect 15% of second breast cancers.
• A retrospective cohort study of 1550 female members of Kaiser Permanente Northern California diagnosed with unilateral DCIS between January 1, 2008, and January 1, 2011, who were followed until 2021.
• Patients who developed a second breast cancer within 10 years of follow-up were identified from the electronic health records. The detection methods were categorized into three groups: Patient-detected, physician-detected, and imaging-detected.

TAKEAWAY:

• During follow-up, 11.5% of women developed a second breast cancer with a median time to diagnosis of 57 months. Among patients with second breast cancers, 43.0% were ipsilateral, 54.8% were contralateral, and 2.2% presented with distant metastases.
• Overall, patients had a median of five mammograms between years 1 and 6 of surveillance and a median of seven clinic visits with most providers completing a clinical examination during the visit.
• Second breast cancers were detected through imaging in 74.3% of cases compared with 20.1% detected by patients and only 2.2% detected by physicians during physical exams. The remaining 3.4% were detected incidentally from plastic surgery procedures unrelated to oncologic surveillance.
• Mammogram detected 99.2% of cases (132 of 133 cases) identified by imaging.

IN PRACTICE:

“Our findings highlight the importance of mammogram screening and patient education regarding self-detection and can inform future NCCN recommendations for DCIS survivorship care,” the authors concluded, adding that “decreasing the need for in-person breast examinations could allow for other effective methods of survivorship monitoring.”

SOURCE:

This study, led by Bethany T. Waites of Kaiser Permanente San Francisco Medical Center, San Francisco, California, was published online on December 28 in the Journal of the National Comprehensive Cancer Network.

LIMITATIONS:

The retrospective design may have introduced selection bias or confounding. The study’s follow-up period until 2021, including the initial 18 months of the COVID-19 pandemic, may have affected surveillance patterns.

DISCLOSURES:

This study was supported by the Kaiser Permanente Northern California Graduate Medical Education program. The authors declared no relevant financial relationships.

A version of this article appeared on Medscape.com.

TOPLINE:

After lung cancer screening (LCS), imaging, and invasive procedures were performed 31.9% and 2.8% of the time, respectively. Complications during invasive procedures occurred in 30.6% of cases. 

METHODOLOGY:

• Researchers analyzed data from 9266 patients aged 55-80 years who completed at least one LCS with low-dose CT (LDCT) between 2014 and 2018.
• This study used data from the PROSPR Lung Consortium.
• Results were compared with findings from the National Lung Screening Trial (NLST), a large study of smokers published in 2011.

TAKEAWAY:

• In total, 2956 patients (31.9%) underwent follow-up imaging, including CT, LDCT, MRI, or PET; 180 (0.02%) had invasive procedures, including needle biopsy, bronchoscopy, mediastinoscopy or mediastinotomy, or thoracoscopy.
• Within 30 days after an invasive diagnostic procedure, 55 of 180 patients (30.6%) experienced complications; 20.6% were major, 8.3% were intermediate, and 1.7% were minor.
• Complication rates after invasive procedures were higher in PROSPR than the NLST (30.6% vs 17.7%).
• Compared with all patients, those with an abnormal LCS were slightly older, more likely to currently smoke, reported more packs of cigarettes smoked daily, and had more comorbid conditions.
• In 2013, the US Preventive Services Task Force recommended annual LCS for certain people who smoke, on the basis of findings from the NLST.

IN PRACTICE:

“We observed higher rates of both invasive procedures and complications than those observed in NLST, highlighting the need for practice-based strategies to assess variations in the quality of care and to prioritize LCS among those patients most likely to receive a net benefit from screening in relation to potential complications and other harms,” the researchers wrote. 

SOURCE:

Katharine A. Rendle, PhD, MSW, MPH, with Perelman School of Medicine, University of Pennsylvania, is the study’s corresponding author. The study was published online in Annals of Internal Medicine.

LIMITATIONS:

This study was retrospective, and data were analyzed using procedural coding. In addition, the NLST based abnormal findings on different criteria from those used in clinical practice (Lung-RADS), making direct comparison of patients difficult. Patients in PROSPR were older, more likely to be currently smoking, and had higher rates of comorbid conditions compared with patients in the NLST. 

DISCLOSURES:

This study was supported by grants from the National Cancer Institute and the Gordon and Betty Moore Foundation.

TOPLINE:

After lung cancer screening (LCS), imaging, and invasive procedures were performed 31.9% and 2.8% of the time, respectively. Complications during invasive procedures occurred in 30.6% of cases. 

METHODOLOGY:

• Researchers analyzed data from 9266 patients aged 55-80 years who completed at least one LCS with low-dose CT (LDCT) between 2014 and 2018.
• This study used data from the PROSPR Lung Consortium.
• Results were compared with findings from the National Lung Screening Trial (NLST), a large study of smokers published in 2011.

TAKEAWAY:

• In total, 2956 patients (31.9%) underwent follow-up imaging, including CT, LDCT, MRI, or PET; 180 (0.02%) had invasive procedures, including needle biopsy, bronchoscopy, mediastinoscopy or mediastinotomy, or thoracoscopy.
• Within 30 days after an invasive diagnostic procedure, 55 of 180 patients (30.6%) experienced complications; 20.6% were major, 8.3% were intermediate, and 1.7% were minor.
• Complication rates after invasive procedures were higher in PROSPR than the NLST (30.6% vs 17.7%).
• Compared with all patients, those with an abnormal LCS were slightly older, more likely to currently smoke, reported more packs of cigarettes smoked daily, and had more comorbid conditions.
• In 2013, the US Preventive Services Task Force recommended annual LCS for certain people who smoke, on the basis of findings from the NLST.

IN PRACTICE:

“We observed higher rates of both invasive procedures and complications than those observed in NLST, highlighting the need for practice-based strategies to assess variations in the quality of care and to prioritize LCS among those patients most likely to receive a net benefit from screening in relation to potential complications and other harms,” the researchers wrote. 

SOURCE:

Katharine A. Rendle, PhD, MSW, MPH, with Perelman School of Medicine, University of Pennsylvania, is the study’s corresponding author. The study was published online in Annals of Internal Medicine.

LIMITATIONS:

This study was retrospective, and data were analyzed using procedural coding. In addition, the NLST based abnormal findings on different criteria from those used in clinical practice (Lung-RADS), making direct comparison of patients difficult. Patients in PROSPR were older, more likely to be currently smoking, and had higher rates of comorbid conditions compared with patients in the NLST. 

DISCLOSURES:

This study was supported by grants from the National Cancer Institute and the Gordon and Betty Moore Foundation.

TOPLINE:

After lung cancer screening (LCS), imaging, and invasive procedures were performed 31.9% and 2.8% of the time, respectively. Complications during invasive procedures occurred in 30.6% of cases. 

METHODOLOGY:

• Researchers analyzed data from 9266 patients aged 55-80 years who completed at least one LCS with low-dose CT (LDCT) between 2014 and 2018.
• This study used data from the PROSPR Lung Consortium.
• Results were compared with findings from the National Lung Screening Trial (NLST), a large study of smokers published in 2011.

TAKEAWAY:

• In total, 2956 patients (31.9%) underwent follow-up imaging, including CT, LDCT, MRI, or PET; 180 (0.02%) had invasive procedures, including needle biopsy, bronchoscopy, mediastinoscopy or mediastinotomy, or thoracoscopy.
• Within 30 days after an invasive diagnostic procedure, 55 of 180 patients (30.6%) experienced complications; 20.6% were major, 8.3% were intermediate, and 1.7% were minor.
• Complication rates after invasive procedures were higher in PROSPR than the NLST (30.6% vs 17.7%).
• Compared with all patients, those with an abnormal LCS were slightly older, more likely to currently smoke, reported more packs of cigarettes smoked daily, and had more comorbid conditions.
• In 2013, the US Preventive Services Task Force recommended annual LCS for certain people who smoke, on the basis of findings from the NLST.

IN PRACTICE:

“We observed higher rates of both invasive procedures and complications than those observed in NLST, highlighting the need for practice-based strategies to assess variations in the quality of care and to prioritize LCS among those patients most likely to receive a net benefit from screening in relation to potential complications and other harms,” the researchers wrote. 

SOURCE:

Katharine A. Rendle, PhD, MSW, MPH, with Perelman School of Medicine, University of Pennsylvania, is the study’s corresponding author. The study was published online in Annals of Internal Medicine.

LIMITATIONS:

This study was retrospective, and data were analyzed using procedural coding. In addition, the NLST based abnormal findings on different criteria from those used in clinical practice (Lung-RADS), making direct comparison of patients difficult. Patients in PROSPR were older, more likely to be currently smoking, and had higher rates of comorbid conditions compared with patients in the NLST. 

DISCLOSURES:

This study was supported by grants from the National Cancer Institute and the Gordon and Betty Moore Foundation.

Delivered at 34 weeks’ gestation, Baby “Alex” had an enlarged liver and spleen on his initial newborn exam, poor tone, and a diffuse, peeling rash. Baby “Aaliyah” was born at term and appeared healthy. By 1 month of age, she was gaining weight poorly and developed copious nasal drainage and a salmon-colored rash on the soles of her feet.

The connection? Both babies were ultimately diagnosed with congenital syphilis. Infections in both babies could have been prevented if their mothers had been tested for syphilis and treated during pregnancy. Alex’s mom had no prenatal care. Aaliyah’s mom had tested negative for syphilis during her first trimester but had not been re-tested, despite sharing with her health care provider that she had a new sexual partner.

Alex and Aaliyah are representative of what Centers for Disease Control and Prevention (CDC) Chief Medical Officer Debra Houry, MD, MPH, calls a “family tragedy.” Cases of congenital syphilis are rising rapidly in the United States, reaching a 30-year high in 2021.¹ Cases increased by 755% between 2012 and 2021, from 335 in 2012 to 2,865 in 2021. In 2022, cases rose again: 3,761 cases of congenital syphilis were reported, including 231 stillbirths and 51 infant deaths. Infants with congenital syphilis are at risk for lifelong complications, including deafness, blindness, and intellectual disability.

Most of these cases were preventable. Congenital syphilis is rare when pregnant people complete adequate treatment at least 30 days before delivery. In 2022, lack of testing or timely testing contributed to 36.8% of congenital syphilis cases. Nearly 40% of birth parents of infected babies received inadequate treatment during pregnancy, and 11.2% received no treatment or treatment was not documented.

Cases of congenital syphilis have increased in all demographic groups and all US Census Bureau regions, but racial and geographic disparities exist, suggesting ongoing barriers to care related to social determinants of health. In 2021, the highest rates of congenital syphilis were among babies born to individuals who were non-Hispanic American Indian or Alaska Native (384 cases per 100,000 live births), non-Hispanic Native Hawaiian or other Pacific Islander (192 cases per 100,000 live births), and non-Hispanic Black or African American (169 cases per 100,000 live births). Six states had rates of congenital syphilis that exceeded 160 cases per 100,000 population, including Arizona, New Mexico, Louisiana, Mississippi, Texas, and Oklahoma. That is more than twice the national rate of 77.9 cases/100,000.
 

Reducing the Risk

To reduce rates of congenital syphilis in all people, barriers to testing must be eliminated. The CDC recommends that all pregnant people be tested early in pregnancy, with repeat testing at 28 weeks and at delivery for those at increased risk for infection based on individual risk factors or residence in a high-prevalence community. Rapid syphilis testing and treatment during pregnancy is recommended in settings such as emergency departments, syringe service programs, prisons/jails, and maternal and child health programs to minimize missed opportunities for care.

While pediatric clinicians rarely care for pregnant patients, they also have an essential role to play in reducing the adverse health outcomes associated with congenital syphilis. No infant should be discharged from the newborn nursery without confirming that the birth parent was tested for syphilis at least once and was treated appropriately if positive. Appropriate treatment during pregnancy is a single dose of benzathine penicillin G for primary, secondary, or early latent syphilis. Late-latent syphilis or syphilis of unknown duration is treated with three doses of benzathine penicillin G spaced 7-9 days apart. If the doses are given further than 9 days apart, treatment is considered inadequate, and the series of doses must be restarted. Benzathine penicillin G remains in short supply in the United States, but is the only drug recommended to treat syphilis during pregnancy.

Collaboration between obstetrical and newborn care providers is essential. Those who care for newborns need easy access to birthing parents’ syphilis treatment results. As more health care facilities implement routine syphilis testing at delivery, rapid syphilis testing must be available to avoid prolonging newborn hospital stays.

Pediatricians need to maintain an index of suspicion for congenital syphilis, regardless of maternal history, because symptomatic congenital syphilis can mimic a variety of infectious and noninfectious conditions. Most infected infants look normal at birth. While the majority of cases of congenital syphilis are identified in the newborn period, a 2021 paper published in Pediatrics described 84 infants born between 2014 and 2018 who were diagnosed beyond a month of age.² These represented 2.2% of all infants born with congenital syphilis. Common symptoms included rash, snuffles, and hepatomegaly. Sixty-nine percent of infants who had long bone radiographs obtained had findings consistent with congenital syphilis. Typical imaging findings include periostitis and demineralization of the metaphysis and diaphysis of long bones, although fractures can also occur. Case reports describe infants who presented with fractures and were initially evaluated for nonaccidental trauma.³

Another critical approach is to treat syphilis in people of childbearing age before pregnancy occurs. The CDC recommends syphilis testing for sexually active females 18-44 years of age and living in communities with high rates of syphilis. County-specific specific rates of syphilis rates are available at https://www.cdc.gov/nchhstp/atlas/syphilis/. Point-of-care tests are now available for syphilis and may facilitate timely treatment. 

Additional resources describing syphilis testing and treatment are available from the CDC and the American Academy of Pediatrics.

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She is a member of the AAP’s Committee on Infectious Diseases and one of the lead authors of the AAP’s Recommendations for Prevention and Control of Influenza in Children, 2022-2023. The opinions expressed in this article are her own. Dr. Bryant discloses that she has served as an investigator on clinical trials funded by Pfizer, Enanta, and Gilead. Email her at [email protected]. (Also [email protected].)

References

1. McDonald R et al. Vital Signs: Missed Opportunities for Preventing Congenital Syphilis — United States, 2022. MMWR Morb Mortal Wkly Rep. 2023 Nov 17;72(46):1269-74. doi: 10.15585/mmwr.mm7246e1. 

2. Kimball A et al. Congenital Syphilis Diagnosed Beyond the Neonatal Period in the United States: 2014-2018. Pediatrics. 2021 Sep;148(3):e2020049080. doi: 10.1542/peds.2020-049080. 

3. Jacobs K et al. Congenital Syphilis Misdiagnosed as Suspected Nonaccidental Trauma. Pediatrics. 2019 Oct;144(4):e20191564. doi: 10.1542/peds.2019-1564. 

Delivered at 34 weeks’ gestation, Baby “Alex” had an enlarged liver and spleen on his initial newborn exam, poor tone, and a diffuse, peeling rash. Baby “Aaliyah” was born at term and appeared healthy. By 1 month of age, she was gaining weight poorly and developed copious nasal drainage and a salmon-colored rash on the soles of her feet.

The connection? Both babies were ultimately diagnosed with congenital syphilis. Infections in both babies could have been prevented if their mothers had been tested for syphilis and treated during pregnancy. Alex’s mom had no prenatal care. Aaliyah’s mom had tested negative for syphilis during her first trimester but had not been re-tested, despite sharing with her health care provider that she had a new sexual partner.

Alex and Aaliyah are representative of what Centers for Disease Control and Prevention (CDC) Chief Medical Officer Debra Houry, MD, MPH, calls a “family tragedy.” Cases of congenital syphilis are rising rapidly in the United States, reaching a 30-year high in 2021.¹ Cases increased by 755% between 2012 and 2021, from 335 in 2012 to 2,865 in 2021. In 2022, cases rose again: 3,761 cases of congenital syphilis were reported, including 231 stillbirths and 51 infant deaths. Infants with congenital syphilis are at risk for lifelong complications, including deafness, blindness, and intellectual disability.

Most of these cases were preventable. Congenital syphilis is rare when pregnant people complete adequate treatment at least 30 days before delivery. In 2022, lack of testing or timely testing contributed to 36.8% of congenital syphilis cases. Nearly 40% of birth parents of infected babies received inadequate treatment during pregnancy, and 11.2% received no treatment or treatment was not documented.

Cases of congenital syphilis have increased in all demographic groups and all US Census Bureau regions, but racial and geographic disparities exist, suggesting ongoing barriers to care related to social determinants of health. In 2021, the highest rates of congenital syphilis were among babies born to individuals who were non-Hispanic American Indian or Alaska Native (384 cases per 100,000 live births), non-Hispanic Native Hawaiian or other Pacific Islander (192 cases per 100,000 live births), and non-Hispanic Black or African American (169 cases per 100,000 live births). Six states had rates of congenital syphilis that exceeded 160 cases per 100,000 population, including Arizona, New Mexico, Louisiana, Mississippi, Texas, and Oklahoma. That is more than twice the national rate of 77.9 cases/100,000.
 

Reducing the Risk

To reduce rates of congenital syphilis in all people, barriers to testing must be eliminated. The CDC recommends that all pregnant people be tested early in pregnancy, with repeat testing at 28 weeks and at delivery for those at increased risk for infection based on individual risk factors or residence in a high-prevalence community. Rapid syphilis testing and treatment during pregnancy is recommended in settings such as emergency departments, syringe service programs, prisons/jails, and maternal and child health programs to minimize missed opportunities for care.

While pediatric clinicians rarely care for pregnant patients, they also have an essential role to play in reducing the adverse health outcomes associated with congenital syphilis. No infant should be discharged from the newborn nursery without confirming that the birth parent was tested for syphilis at least once and was treated appropriately if positive. Appropriate treatment during pregnancy is a single dose of benzathine penicillin G for primary, secondary, or early latent syphilis. Late-latent syphilis or syphilis of unknown duration is treated with three doses of benzathine penicillin G spaced 7-9 days apart. If the doses are given further than 9 days apart, treatment is considered inadequate, and the series of doses must be restarted. Benzathine penicillin G remains in short supply in the United States, but is the only drug recommended to treat syphilis during pregnancy.

Collaboration between obstetrical and newborn care providers is essential. Those who care for newborns need easy access to birthing parents’ syphilis treatment results. As more health care facilities implement routine syphilis testing at delivery, rapid syphilis testing must be available to avoid prolonging newborn hospital stays.

Pediatricians need to maintain an index of suspicion for congenital syphilis, regardless of maternal history, because symptomatic congenital syphilis can mimic a variety of infectious and noninfectious conditions. Most infected infants look normal at birth. While the majority of cases of congenital syphilis are identified in the newborn period, a 2021 paper published in Pediatrics described 84 infants born between 2014 and 2018 who were diagnosed beyond a month of age.² These represented 2.2% of all infants born with congenital syphilis. Common symptoms included rash, snuffles, and hepatomegaly. Sixty-nine percent of infants who had long bone radiographs obtained had findings consistent with congenital syphilis. Typical imaging findings include periostitis and demineralization of the metaphysis and diaphysis of long bones, although fractures can also occur. Case reports describe infants who presented with fractures and were initially evaluated for nonaccidental trauma.³

Another critical approach is to treat syphilis in people of childbearing age before pregnancy occurs. The CDC recommends syphilis testing for sexually active females 18-44 years of age and living in communities with high rates of syphilis. County-specific specific rates of syphilis rates are available at https://www.cdc.gov/nchhstp/atlas/syphilis/. Point-of-care tests are now available for syphilis and may facilitate timely treatment. 

Additional resources describing syphilis testing and treatment are available from the CDC and the American Academy of Pediatrics.

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She is a member of the AAP’s Committee on Infectious Diseases and one of the lead authors of the AAP’s Recommendations for Prevention and Control of Influenza in Children, 2022-2023. The opinions expressed in this article are her own. Dr. Bryant discloses that she has served as an investigator on clinical trials funded by Pfizer, Enanta, and Gilead. Email her at [email protected]. (Also [email protected].)

References

1. McDonald R et al. Vital Signs: Missed Opportunities for Preventing Congenital Syphilis — United States, 2022. MMWR Morb Mortal Wkly Rep. 2023 Nov 17;72(46):1269-74. doi: 10.15585/mmwr.mm7246e1. 

2. Kimball A et al. Congenital Syphilis Diagnosed Beyond the Neonatal Period in the United States: 2014-2018. Pediatrics. 2021 Sep;148(3):e2020049080. doi: 10.1542/peds.2020-049080. 

3. Jacobs K et al. Congenital Syphilis Misdiagnosed as Suspected Nonaccidental Trauma. Pediatrics. 2019 Oct;144(4):e20191564. doi: 10.1542/peds.2019-1564. 

Delivered at 34 weeks’ gestation, Baby “Alex” had an enlarged liver and spleen on his initial newborn exam, poor tone, and a diffuse, peeling rash. Baby “Aaliyah” was born at term and appeared healthy. By 1 month of age, she was gaining weight poorly and developed copious nasal drainage and a salmon-colored rash on the soles of her feet.

The connection? Both babies were ultimately diagnosed with congenital syphilis. Infections in both babies could have been prevented if their mothers had been tested for syphilis and treated during pregnancy. Alex’s mom had no prenatal care. Aaliyah’s mom had tested negative for syphilis during her first trimester but had not been re-tested, despite sharing with her health care provider that she had a new sexual partner.

Alex and Aaliyah are representative of what Centers for Disease Control and Prevention (CDC) Chief Medical Officer Debra Houry, MD, MPH, calls a “family tragedy.” Cases of congenital syphilis are rising rapidly in the United States, reaching a 30-year high in 2021.¹ Cases increased by 755% between 2012 and 2021, from 335 in 2012 to 2,865 in 2021. In 2022, cases rose again: 3,761 cases of congenital syphilis were reported, including 231 stillbirths and 51 infant deaths. Infants with congenital syphilis are at risk for lifelong complications, including deafness, blindness, and intellectual disability.

Most of these cases were preventable. Congenital syphilis is rare when pregnant people complete adequate treatment at least 30 days before delivery. In 2022, lack of testing or timely testing contributed to 36.8% of congenital syphilis cases. Nearly 40% of birth parents of infected babies received inadequate treatment during pregnancy, and 11.2% received no treatment or treatment was not documented.

Cases of congenital syphilis have increased in all demographic groups and all US Census Bureau regions, but racial and geographic disparities exist, suggesting ongoing barriers to care related to social determinants of health. In 2021, the highest rates of congenital syphilis were among babies born to individuals who were non-Hispanic American Indian or Alaska Native (384 cases per 100,000 live births), non-Hispanic Native Hawaiian or other Pacific Islander (192 cases per 100,000 live births), and non-Hispanic Black or African American (169 cases per 100,000 live births). Six states had rates of congenital syphilis that exceeded 160 cases per 100,000 population, including Arizona, New Mexico, Louisiana, Mississippi, Texas, and Oklahoma. That is more than twice the national rate of 77.9 cases/100,000.
 

Reducing the Risk

To reduce rates of congenital syphilis in all people, barriers to testing must be eliminated. The CDC recommends that all pregnant people be tested early in pregnancy, with repeat testing at 28 weeks and at delivery for those at increased risk for infection based on individual risk factors or residence in a high-prevalence community. Rapid syphilis testing and treatment during pregnancy is recommended in settings such as emergency departments, syringe service programs, prisons/jails, and maternal and child health programs to minimize missed opportunities for care.

While pediatric clinicians rarely care for pregnant patients, they also have an essential role to play in reducing the adverse health outcomes associated with congenital syphilis. No infant should be discharged from the newborn nursery without confirming that the birth parent was tested for syphilis at least once and was treated appropriately if positive. Appropriate treatment during pregnancy is a single dose of benzathine penicillin G for primary, secondary, or early latent syphilis. Late-latent syphilis or syphilis of unknown duration is treated with three doses of benzathine penicillin G spaced 7-9 days apart. If the doses are given further than 9 days apart, treatment is considered inadequate, and the series of doses must be restarted. Benzathine penicillin G remains in short supply in the United States, but is the only drug recommended to treat syphilis during pregnancy.

Collaboration between obstetrical and newborn care providers is essential. Those who care for newborns need easy access to birthing parents’ syphilis treatment results. As more health care facilities implement routine syphilis testing at delivery, rapid syphilis testing must be available to avoid prolonging newborn hospital stays.

Pediatricians need to maintain an index of suspicion for congenital syphilis, regardless of maternal history, because symptomatic congenital syphilis can mimic a variety of infectious and noninfectious conditions. Most infected infants look normal at birth. While the majority of cases of congenital syphilis are identified in the newborn period, a 2021 paper published in Pediatrics described 84 infants born between 2014 and 2018 who were diagnosed beyond a month of age.² These represented 2.2% of all infants born with congenital syphilis. Common symptoms included rash, snuffles, and hepatomegaly. Sixty-nine percent of infants who had long bone radiographs obtained had findings consistent with congenital syphilis. Typical imaging findings include periostitis and demineralization of the metaphysis and diaphysis of long bones, although fractures can also occur. Case reports describe infants who presented with fractures and were initially evaluated for nonaccidental trauma.³

Another critical approach is to treat syphilis in people of childbearing age before pregnancy occurs. The CDC recommends syphilis testing for sexually active females 18-44 years of age and living in communities with high rates of syphilis. County-specific specific rates of syphilis rates are available at https://www.cdc.gov/nchhstp/atlas/syphilis/. Point-of-care tests are now available for syphilis and may facilitate timely treatment. 

Additional resources describing syphilis testing and treatment are available from the CDC and the American Academy of Pediatrics.

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She is a member of the AAP’s Committee on Infectious Diseases and one of the lead authors of the AAP’s Recommendations for Prevention and Control of Influenza in Children, 2022-2023. The opinions expressed in this article are her own. Dr. Bryant discloses that she has served as an investigator on clinical trials funded by Pfizer, Enanta, and Gilead. Email her at [email protected]. (Also [email protected].)

References

1. McDonald R et al. Vital Signs: Missed Opportunities for Preventing Congenital Syphilis — United States, 2022. MMWR Morb Mortal Wkly Rep. 2023 Nov 17;72(46):1269-74. doi: 10.15585/mmwr.mm7246e1. 

2. Kimball A et al. Congenital Syphilis Diagnosed Beyond the Neonatal Period in the United States: 2014-2018. Pediatrics. 2021 Sep;148(3):e2020049080. doi: 10.1542/peds.2020-049080. 

3. Jacobs K et al. Congenital Syphilis Misdiagnosed as Suspected Nonaccidental Trauma. Pediatrics. 2019 Oct;144(4):e20191564. doi: 10.1542/peds.2019-1564. 

Key clinical point: A significant association was observed between atopic dermatitis (AD) and poorer cognitive function in men, and familial characteristics exerted a confounding effect on this association.

Major finding: After effectively controlling for familial environmental confounding factors and addressing genetic influences, AD in men was significantly associated with poorer cognitive function (regression coefficient −0.04; 95% CI −0.07 to −0.003).

Study details: This sibling-comparison study included 1,687,038 men who underwent a military conscription examination at 17-22 years of age, of which 25,995 were diagnosed with AD.

Disclosures: This study was sponsored by grants from the Swedish Research Council for Health, Working Life, and Welfare (Forte) and the UK Economic and Social Research Council. L von Kobyletzki declared being a consultant for and receiving research funding from various organizations. The other authors declared no conflicts of interest.

Source: Smith KA et al. Atopic dermatitis and cognitive function: A sibling comparison study among males in Sweden. Br J Dermatol. 2024 (Jan 3). doi: 10.1093/bjd/ljae004

Key clinical point: A significant association was observed between atopic dermatitis (AD) and poorer cognitive function in men, and familial characteristics exerted a confounding effect on this association.

Major finding: After effectively controlling for familial environmental confounding factors and addressing genetic influences, AD in men was significantly associated with poorer cognitive function (regression coefficient −0.04; 95% CI −0.07 to −0.003).

Study details: This sibling-comparison study included 1,687,038 men who underwent a military conscription examination at 17-22 years of age, of which 25,995 were diagnosed with AD.

Disclosures: This study was sponsored by grants from the Swedish Research Council for Health, Working Life, and Welfare (Forte) and the UK Economic and Social Research Council. L von Kobyletzki declared being a consultant for and receiving research funding from various organizations. The other authors declared no conflicts of interest.

Source: Smith KA et al. Atopic dermatitis and cognitive function: A sibling comparison study among males in Sweden. Br J Dermatol. 2024 (Jan 3). doi: 10.1093/bjd/ljae004

Key clinical point: A significant association was observed between atopic dermatitis (AD) and poorer cognitive function in men, and familial characteristics exerted a confounding effect on this association.

Major finding: After effectively controlling for familial environmental confounding factors and addressing genetic influences, AD in men was significantly associated with poorer cognitive function (regression coefficient −0.04; 95% CI −0.07 to −0.003).

Study details: This sibling-comparison study included 1,687,038 men who underwent a military conscription examination at 17-22 years of age, of which 25,995 were diagnosed with AD.

Disclosures: This study was sponsored by grants from the Swedish Research Council for Health, Working Life, and Welfare (Forte) and the UK Economic and Social Research Council. L von Kobyletzki declared being a consultant for and receiving research funding from various organizations. The other authors declared no conflicts of interest.

Source: Smith KA et al. Atopic dermatitis and cognitive function: A sibling comparison study among males in Sweden. Br J Dermatol. 2024 (Jan 3). doi: 10.1093/bjd/ljae004

Key clinical point: Patients with atopic dermatitis (AD), especially moderate-to-severe AD, had an increased prevalence of inflammatory bowel disease (IBD).

Major finding: A significant association was observed between IBD and AD (adjusted odds ratio [aOR] 3.89; P = .0169); however, when stratified by AD severity, only moderate-to-severe AD was found to be associated with IBD (aOR 4.45; P = .0102).

Study details: Findings are from a retrospective observational study including 364 patients with AD and 725 matched control individuals without AD.

Disclosures: This study was sponsored by an independent investigator grant from AbbVie. Two authors declared serving as investigators for or receiving honoraria or fees as consultants or advisory board members from various organizations, including AbbVie. The other authors declared no conflicts of interest.

Source: Rom H et al. The association between atopic dermatitis and inflammatory bowel disease in adults: A cross-sectional study in a specialized atopic dermatitis clinic. J Eur Acad Dermatol Venereol. 2023 (Dec 21). doi: 10.1111/jdv.19769

Key clinical point: Patients with atopic dermatitis (AD), especially moderate-to-severe AD, had an increased prevalence of inflammatory bowel disease (IBD).

Major finding: A significant association was observed between IBD and AD (adjusted odds ratio [aOR] 3.89; P = .0169); however, when stratified by AD severity, only moderate-to-severe AD was found to be associated with IBD (aOR 4.45; P = .0102).

Study details: Findings are from a retrospective observational study including 364 patients with AD and 725 matched control individuals without AD.

Disclosures: This study was sponsored by an independent investigator grant from AbbVie. Two authors declared serving as investigators for or receiving honoraria or fees as consultants or advisory board members from various organizations, including AbbVie. The other authors declared no conflicts of interest.

Source: Rom H et al. The association between atopic dermatitis and inflammatory bowel disease in adults: A cross-sectional study in a specialized atopic dermatitis clinic. J Eur Acad Dermatol Venereol. 2023 (Dec 21). doi: 10.1111/jdv.19769

Key clinical point: Patients with atopic dermatitis (AD), especially moderate-to-severe AD, had an increased prevalence of inflammatory bowel disease (IBD).

Major finding: A significant association was observed between IBD and AD (adjusted odds ratio [aOR] 3.89; P = .0169); however, when stratified by AD severity, only moderate-to-severe AD was found to be associated with IBD (aOR 4.45; P = .0102).

Study details: Findings are from a retrospective observational study including 364 patients with AD and 725 matched control individuals without AD.

Disclosures: This study was sponsored by an independent investigator grant from AbbVie. Two authors declared serving as investigators for or receiving honoraria or fees as consultants or advisory board members from various organizations, including AbbVie. The other authors declared no conflicts of interest.

Source: Rom H et al. The association between atopic dermatitis and inflammatory bowel disease in adults: A cross-sectional study in a specialized atopic dermatitis clinic. J Eur Acad Dermatol Venereol. 2023 (Dec 21). doi: 10.1111/jdv.19769

Key clinical point: The majority of tralokinumab-treated patients with moderate-to-severe atopic dermatitis (AD) attained physician- and patient-reported outcomes over 32 weeks of observation, highlighting the multidimensional efficacy of tralokinumab in real-world settings.

Major finding: The proportion of patients achieving a ≥75% improvement in the baseline Eczema Area and Severity Index (EASI) score increased significantly from 42% at week 4 to 76% at week 32 (P = .0075). A similar trend was observed for patient-reported outcomes. At week 16, at least one real-world therapeutic endpoint was achieved by 88% of patients treated with tralokinumab.

Study details: Findings are from a multicenter real-world retrospective cohort study including 194 patients with moderate-to-severe AD who were treated with tralokinumab for ≥16 weeks.

Disclosures: This study did not receive any funding. Several authors declared serving as speakers, consultants, or scientific advisors; receiving personal fees, speaker’s honoraria, or travel support, or having other ties with various pharmaceutical companies.

Source: Chiricozzi A et al for the MEDaCoTRA Study Group. Current treatment goals are achieved by the majority of patients with atopic dermatitis treated with tralokinumab: Results from a multicentric, multinational, retrospective, cohort study. Expert Opin Biol Ther. 2023;23(12):1307-1315 (Dec 18). doi: 10.1080/14712598.2023.2292627

Key clinical point: The majority of tralokinumab-treated patients with moderate-to-severe atopic dermatitis (AD) attained physician- and patient-reported outcomes over 32 weeks of observation, highlighting the multidimensional efficacy of tralokinumab in real-world settings.

Major finding: The proportion of patients achieving a ≥75% improvement in the baseline Eczema Area and Severity Index (EASI) score increased significantly from 42% at week 4 to 76% at week 32 (P = .0075). A similar trend was observed for patient-reported outcomes. At week 16, at least one real-world therapeutic endpoint was achieved by 88% of patients treated with tralokinumab.

Study details: Findings are from a multicenter real-world retrospective cohort study including 194 patients with moderate-to-severe AD who were treated with tralokinumab for ≥16 weeks.

Disclosures: This study did not receive any funding. Several authors declared serving as speakers, consultants, or scientific advisors; receiving personal fees, speaker’s honoraria, or travel support, or having other ties with various pharmaceutical companies.

Source: Chiricozzi A et al for the MEDaCoTRA Study Group. Current treatment goals are achieved by the majority of patients with atopic dermatitis treated with tralokinumab: Results from a multicentric, multinational, retrospective, cohort study. Expert Opin Biol Ther. 2023;23(12):1307-1315 (Dec 18). doi: 10.1080/14712598.2023.2292627

Key clinical point: The majority of tralokinumab-treated patients with moderate-to-severe atopic dermatitis (AD) attained physician- and patient-reported outcomes over 32 weeks of observation, highlighting the multidimensional efficacy of tralokinumab in real-world settings.

Major finding: The proportion of patients achieving a ≥75% improvement in the baseline Eczema Area and Severity Index (EASI) score increased significantly from 42% at week 4 to 76% at week 32 (P = .0075). A similar trend was observed for patient-reported outcomes. At week 16, at least one real-world therapeutic endpoint was achieved by 88% of patients treated with tralokinumab.

Study details: Findings are from a multicenter real-world retrospective cohort study including 194 patients with moderate-to-severe AD who were treated with tralokinumab for ≥16 weeks.

Disclosures: This study did not receive any funding. Several authors declared serving as speakers, consultants, or scientific advisors; receiving personal fees, speaker’s honoraria, or travel support, or having other ties with various pharmaceutical companies.

Source: Chiricozzi A et al for the MEDaCoTRA Study Group. Current treatment goals are achieved by the majority of patients with atopic dermatitis treated with tralokinumab: Results from a multicentric, multinational, retrospective, cohort study. Expert Opin Biol Ther. 2023;23(12):1307-1315 (Dec 18). doi: 10.1080/14712598.2023.2292627