A study investigating the effectiveness of a pilot program to educate barbers about pseudofolliculitis barbae (PFB) found that the barbers significantly improved their knowledge about the causes, prevention, and treatment of the condition after the educational intervention.

The results were published in a research letter in JAMA Dermatology. “Educating barbers on dermatologic conditions that disproportionately affect Black males and establishing referral services between barbers and dermatologists could serve as plausible interventions,” the authors wrote.

PFB — or “razor bumps” in layman’s terms — is a chronic, inflammatory follicular disorder, which can occur in any racial group, but primarily affects Black men, noted the corresponding author of the study, Xavier Rice, MD, a dermatology resident at Washington University in Saint Louis, Missouri. PFB manifests as bumps and pustules or nodules along the beard line and are painful, he said in an interview. “They tend to leave scars once they resolve,” and impair the ability to shave, he noted.

In some communities, Black men may see their barbers more often than primary care doctors or dermatologists, “so if you equip the barbers with the knowledge to recognize the disease, make recommendations on how to prevent and to treat, and also form some allyship with barbers and dermatologists, then we can get referrals for people, especially the ones with severe disease,” he said. A lot of the barbers in the study said that “they didn’t receive much education on how to properly address it [PFB] and they had a lot of miseducation about what actually caused it,” added Dr. Rice, who was a medical student at the University of Texas Medical Branch, Galveston, when the study was conducted.

Study involved 40 barbers

For the study, Dr. Rice and his coauthors surveyed 40 barbers in the Houston, Texas, area; 39 were Black and one was Hispanic; 75% were men and 25% were women. Most (90%) said that at least 60% of their clients were Black. Between January and April 2022, the barbers received questionnaires before and after participating in a session that involved a review of a comprehensive educational brochure with information on the recognition, cause, prevention, and treatment of PFB, which they then kept for reference and to provide to clients as needed. “Common myths and nuanced home remedies from barber experience were also addressed,” the authors wrote.

No more than 2 weeks after the information session, each barber completed a posttest questionnaire.

Based on their responses to pretest questions, 39 of the 40 barbers understood that Black men were the group most impacted by PFB and that a person with severe PFB should see a physician. In the pretest survey, 12 barbers (30%) correctly recognized a photo of PFB, which increased to 39 (97.5%) in the posttest survey. In the pretest survey, two barbers (5%) identified laser hair removal as the most effective treatment for PFB, compared with 37 (92.5%) in the posttest survey.

Overall, the mean percentage of correct scores out of 20 questions was 54.8% in the pretest survey, increasing to 91% in the posttest survey (P <.001).

Limitations of the studies included heterogeneity in the survey response options that potentially could have introduced bias, the authors wrote. Another was that since there is a lack of evidence for ideal treatment strategies for PFB, there may have been some uncertainty among the correct answers for the survey that might have contributed to variability in responses. “Further research and implementation of these interventions are needed in efforts to improve health outcomes,” they added.

“Barbers can serve as allies in referral services,” Dr. Rice said in the interview. “They can be the first line for a number of diseases that are related to hair.”

Part of his role as a dermatologist, he added, includes going into a community with “boots on the ground” and talking to people who will see these patients “because access to care, presentation to big hospital systems can be challenging.”

Dr. Rice and the other study authors had no not report any financial disclosures.

A study investigating the effectiveness of a pilot program to educate barbers about pseudofolliculitis barbae (PFB) found that the barbers significantly improved their knowledge about the causes, prevention, and treatment of the condition after the educational intervention.

The results were published in a research letter in JAMA Dermatology. “Educating barbers on dermatologic conditions that disproportionately affect Black males and establishing referral services between barbers and dermatologists could serve as plausible interventions,” the authors wrote.

PFB — or “razor bumps” in layman’s terms — is a chronic, inflammatory follicular disorder, which can occur in any racial group, but primarily affects Black men, noted the corresponding author of the study, Xavier Rice, MD, a dermatology resident at Washington University in Saint Louis, Missouri. PFB manifests as bumps and pustules or nodules along the beard line and are painful, he said in an interview. “They tend to leave scars once they resolve,” and impair the ability to shave, he noted.

In some communities, Black men may see their barbers more often than primary care doctors or dermatologists, “so if you equip the barbers with the knowledge to recognize the disease, make recommendations on how to prevent and to treat, and also form some allyship with barbers and dermatologists, then we can get referrals for people, especially the ones with severe disease,” he said. A lot of the barbers in the study said that “they didn’t receive much education on how to properly address it [PFB] and they had a lot of miseducation about what actually caused it,” added Dr. Rice, who was a medical student at the University of Texas Medical Branch, Galveston, when the study was conducted.

Study involved 40 barbers

For the study, Dr. Rice and his coauthors surveyed 40 barbers in the Houston, Texas, area; 39 were Black and one was Hispanic; 75% were men and 25% were women. Most (90%) said that at least 60% of their clients were Black. Between January and April 2022, the barbers received questionnaires before and after participating in a session that involved a review of a comprehensive educational brochure with information on the recognition, cause, prevention, and treatment of PFB, which they then kept for reference and to provide to clients as needed. “Common myths and nuanced home remedies from barber experience were also addressed,” the authors wrote.

No more than 2 weeks after the information session, each barber completed a posttest questionnaire.

Based on their responses to pretest questions, 39 of the 40 barbers understood that Black men were the group most impacted by PFB and that a person with severe PFB should see a physician. In the pretest survey, 12 barbers (30%) correctly recognized a photo of PFB, which increased to 39 (97.5%) in the posttest survey. In the pretest survey, two barbers (5%) identified laser hair removal as the most effective treatment for PFB, compared with 37 (92.5%) in the posttest survey.

Overall, the mean percentage of correct scores out of 20 questions was 54.8% in the pretest survey, increasing to 91% in the posttest survey (P <.001).

Limitations of the studies included heterogeneity in the survey response options that potentially could have introduced bias, the authors wrote. Another was that since there is a lack of evidence for ideal treatment strategies for PFB, there may have been some uncertainty among the correct answers for the survey that might have contributed to variability in responses. “Further research and implementation of these interventions are needed in efforts to improve health outcomes,” they added.

“Barbers can serve as allies in referral services,” Dr. Rice said in the interview. “They can be the first line for a number of diseases that are related to hair.”

Part of his role as a dermatologist, he added, includes going into a community with “boots on the ground” and talking to people who will see these patients “because access to care, presentation to big hospital systems can be challenging.”

Dr. Rice and the other study authors had no not report any financial disclosures.

A study investigating the effectiveness of a pilot program to educate barbers about pseudofolliculitis barbae (PFB) found that the barbers significantly improved their knowledge about the causes, prevention, and treatment of the condition after the educational intervention.

The results were published in a research letter in JAMA Dermatology. “Educating barbers on dermatologic conditions that disproportionately affect Black males and establishing referral services between barbers and dermatologists could serve as plausible interventions,” the authors wrote.

PFB — or “razor bumps” in layman’s terms — is a chronic, inflammatory follicular disorder, which can occur in any racial group, but primarily affects Black men, noted the corresponding author of the study, Xavier Rice, MD, a dermatology resident at Washington University in Saint Louis, Missouri. PFB manifests as bumps and pustules or nodules along the beard line and are painful, he said in an interview. “They tend to leave scars once they resolve,” and impair the ability to shave, he noted.

In some communities, Black men may see their barbers more often than primary care doctors or dermatologists, “so if you equip the barbers with the knowledge to recognize the disease, make recommendations on how to prevent and to treat, and also form some allyship with barbers and dermatologists, then we can get referrals for people, especially the ones with severe disease,” he said. A lot of the barbers in the study said that “they didn’t receive much education on how to properly address it [PFB] and they had a lot of miseducation about what actually caused it,” added Dr. Rice, who was a medical student at the University of Texas Medical Branch, Galveston, when the study was conducted.

Study involved 40 barbers

For the study, Dr. Rice and his coauthors surveyed 40 barbers in the Houston, Texas, area; 39 were Black and one was Hispanic; 75% were men and 25% were women. Most (90%) said that at least 60% of their clients were Black. Between January and April 2022, the barbers received questionnaires before and after participating in a session that involved a review of a comprehensive educational brochure with information on the recognition, cause, prevention, and treatment of PFB, which they then kept for reference and to provide to clients as needed. “Common myths and nuanced home remedies from barber experience were also addressed,” the authors wrote.

No more than 2 weeks after the information session, each barber completed a posttest questionnaire.

Based on their responses to pretest questions, 39 of the 40 barbers understood that Black men were the group most impacted by PFB and that a person with severe PFB should see a physician. In the pretest survey, 12 barbers (30%) correctly recognized a photo of PFB, which increased to 39 (97.5%) in the posttest survey. In the pretest survey, two barbers (5%) identified laser hair removal as the most effective treatment for PFB, compared with 37 (92.5%) in the posttest survey.

Overall, the mean percentage of correct scores out of 20 questions was 54.8% in the pretest survey, increasing to 91% in the posttest survey (P <.001).

Limitations of the studies included heterogeneity in the survey response options that potentially could have introduced bias, the authors wrote. Another was that since there is a lack of evidence for ideal treatment strategies for PFB, there may have been some uncertainty among the correct answers for the survey that might have contributed to variability in responses. “Further research and implementation of these interventions are needed in efforts to improve health outcomes,” they added.

“Barbers can serve as allies in referral services,” Dr. Rice said in the interview. “They can be the first line for a number of diseases that are related to hair.”

Part of his role as a dermatologist, he added, includes going into a community with “boots on the ground” and talking to people who will see these patients “because access to care, presentation to big hospital systems can be challenging.”

Dr. Rice and the other study authors had no not report any financial disclosures.

The increased risk of vitiligo found in recipients of stem cell and solid organ transplants, especially those who develop graft-versus-host disease (GVHD), requires careful monitoring, according to authors of a study published online in JAMA Dermatology December 13.

In the cohort study, the greatest risk occurred with hematopoietic stem cell transplants (HSCTs) and in cases involving GVHD. Kidney and liver transplants carried slight increases in risk.

“The findings suggest that early detection and management of vitiligo lesions can be improved by estimating the likelihood of its development in transplant recipients and implementing a multidisciplinary approach for monitoring,” wrote the authors, from the departments of dermatology and biostatistics, at the Catholic University of Korea, Seoul.

Using claims data from South Korea’s National Health Insurance Service database, the investigators compared vitiligo incidence among 23,829 patients who had undergone solid organ transplantation (SOT) or HSCT between 2010 and 2017 versus that of 119,145 age- and sex-matched controls. At a mean observation time of 4.79 years in the transplant group (and 5.12 years for controls), the adjusted hazard ratio (AHR) for vitiligo among patients who had undergone any transplant was 1.73. AHRs for HSCT, liver transplants, and kidney transplants were 12.69, 1.63, and 1.50, respectively.

Patients who had undergone allogeneic HSCT (AHR, 14.43) or autologous transplants (AHR, 5.71), as well as those with and without GVHD (24.09 and 8.21, respectively) had significantly higher vitiligo risk than the control group.

Among those with GVHD, HSCT recipients (AHR, 16.42) and those with allogeneic grafts (AHR, 16.81) had a higher vitiligo risk than that of control patients.

In a subgroup that included 10,355 transplant recipients who underwent posttransplant health checkups, investigators found the highest vitiligo risk — AHR, 25.09 versus controls — among HSCT recipients with comorbid GVHD. However, patients who underwent SOT, autologous HSCT, or HSCT without GVHD showed no increased vitiligo risk in this analysis. “The results of health checkup data analysis may differ from the initial analysis due to additional adjustments for lifestyle factors and inclusion of only patients who underwent a health checkup,” the authors wrote.

Asked to comment on the results, George Han, MD, PhD, who was not involved with the study, told this news organization, “this is an interesting paper where the primary difference from previous studies is the new association between GVHD in hematopoietic stem cell transplant recipients and vitiligo.” Prior research had shown higher rates of vitiligo in HSCT recipients without making the GVHD distinction. Dr. Han is associate professor of dermatology in the Hofstra/Northwell Department of Dermatology, Hyde Park, New York.

Although GVHD may not be top-of-mind for dermatologists in daily practice, he said, the study enhances their understanding of vitiligo risk in HSCT recipients. “In some ways,” Dr. Han added, “the association makes sense, as the activated T cells from the graft attacking the skin in the HSCT recipient follow many of the mechanisms of vitiligo, including upregulating interferon gamma and the CXCR3/CXCL10 axis.”

Presently, he said, dermatologists worry more about solid organ recipients than about HSCT recipients because the long-term immunosuppression required by SOT increases the risk of squamous cell carcinoma (SCC). “However, the risk of skin cancers also seems to be elevated in HSCT recipients, and in this case the basal cell carcinoma (BCC):SCC ratio is not necessarily reversed as we see in solid organ transplant recipients. So the mechanisms are a bit less clear. Interestingly, acute and chronic GVHD have both been associated with increased risks of BCC and SCC/BCC, respectively.”

Overall, Dr. Han said, any transplant recipient should undergo yearly skin checks not only for skin cancers, but also for other skin conditions such as vitiligo. “It would be nice to see this codified into official guidelines, which can vary considerably but are overall more consistent in solid organ transplant recipients than in HSCT recipients. No such guidelines seem to be available for HSCTs.”

The study was funded by the Basic Research in Science & Engineering program through the National Research Foundation of Korea, which is funded by the country’s Ministry of Education. The study authors had no disclosures. Dr. Han reports no relevant financial interests.

The increased risk of vitiligo found in recipients of stem cell and solid organ transplants, especially those who develop graft-versus-host disease (GVHD), requires careful monitoring, according to authors of a study published online in JAMA Dermatology December 13.

In the cohort study, the greatest risk occurred with hematopoietic stem cell transplants (HSCTs) and in cases involving GVHD. Kidney and liver transplants carried slight increases in risk.

“The findings suggest that early detection and management of vitiligo lesions can be improved by estimating the likelihood of its development in transplant recipients and implementing a multidisciplinary approach for monitoring,” wrote the authors, from the departments of dermatology and biostatistics, at the Catholic University of Korea, Seoul.

Using claims data from South Korea’s National Health Insurance Service database, the investigators compared vitiligo incidence among 23,829 patients who had undergone solid organ transplantation (SOT) or HSCT between 2010 and 2017 versus that of 119,145 age- and sex-matched controls. At a mean observation time of 4.79 years in the transplant group (and 5.12 years for controls), the adjusted hazard ratio (AHR) for vitiligo among patients who had undergone any transplant was 1.73. AHRs for HSCT, liver transplants, and kidney transplants were 12.69, 1.63, and 1.50, respectively.

Patients who had undergone allogeneic HSCT (AHR, 14.43) or autologous transplants (AHR, 5.71), as well as those with and without GVHD (24.09 and 8.21, respectively) had significantly higher vitiligo risk than the control group.

Among those with GVHD, HSCT recipients (AHR, 16.42) and those with allogeneic grafts (AHR, 16.81) had a higher vitiligo risk than that of control patients.

In a subgroup that included 10,355 transplant recipients who underwent posttransplant health checkups, investigators found the highest vitiligo risk — AHR, 25.09 versus controls — among HSCT recipients with comorbid GVHD. However, patients who underwent SOT, autologous HSCT, or HSCT without GVHD showed no increased vitiligo risk in this analysis. “The results of health checkup data analysis may differ from the initial analysis due to additional adjustments for lifestyle factors and inclusion of only patients who underwent a health checkup,” the authors wrote.

Asked to comment on the results, George Han, MD, PhD, who was not involved with the study, told this news organization, “this is an interesting paper where the primary difference from previous studies is the new association between GVHD in hematopoietic stem cell transplant recipients and vitiligo.” Prior research had shown higher rates of vitiligo in HSCT recipients without making the GVHD distinction. Dr. Han is associate professor of dermatology in the Hofstra/Northwell Department of Dermatology, Hyde Park, New York.

Although GVHD may not be top-of-mind for dermatologists in daily practice, he said, the study enhances their understanding of vitiligo risk in HSCT recipients. “In some ways,” Dr. Han added, “the association makes sense, as the activated T cells from the graft attacking the skin in the HSCT recipient follow many of the mechanisms of vitiligo, including upregulating interferon gamma and the CXCR3/CXCL10 axis.”

Presently, he said, dermatologists worry more about solid organ recipients than about HSCT recipients because the long-term immunosuppression required by SOT increases the risk of squamous cell carcinoma (SCC). “However, the risk of skin cancers also seems to be elevated in HSCT recipients, and in this case the basal cell carcinoma (BCC):SCC ratio is not necessarily reversed as we see in solid organ transplant recipients. So the mechanisms are a bit less clear. Interestingly, acute and chronic GVHD have both been associated with increased risks of BCC and SCC/BCC, respectively.”

Overall, Dr. Han said, any transplant recipient should undergo yearly skin checks not only for skin cancers, but also for other skin conditions such as vitiligo. “It would be nice to see this codified into official guidelines, which can vary considerably but are overall more consistent in solid organ transplant recipients than in HSCT recipients. No such guidelines seem to be available for HSCTs.”

The study was funded by the Basic Research in Science & Engineering program through the National Research Foundation of Korea, which is funded by the country’s Ministry of Education. The study authors had no disclosures. Dr. Han reports no relevant financial interests.

The increased risk of vitiligo found in recipients of stem cell and solid organ transplants, especially those who develop graft-versus-host disease (GVHD), requires careful monitoring, according to authors of a study published online in JAMA Dermatology December 13.

In the cohort study, the greatest risk occurred with hematopoietic stem cell transplants (HSCTs) and in cases involving GVHD. Kidney and liver transplants carried slight increases in risk.

“The findings suggest that early detection and management of vitiligo lesions can be improved by estimating the likelihood of its development in transplant recipients and implementing a multidisciplinary approach for monitoring,” wrote the authors, from the departments of dermatology and biostatistics, at the Catholic University of Korea, Seoul.

Using claims data from South Korea’s National Health Insurance Service database, the investigators compared vitiligo incidence among 23,829 patients who had undergone solid organ transplantation (SOT) or HSCT between 2010 and 2017 versus that of 119,145 age- and sex-matched controls. At a mean observation time of 4.79 years in the transplant group (and 5.12 years for controls), the adjusted hazard ratio (AHR) for vitiligo among patients who had undergone any transplant was 1.73. AHRs for HSCT, liver transplants, and kidney transplants were 12.69, 1.63, and 1.50, respectively.

Patients who had undergone allogeneic HSCT (AHR, 14.43) or autologous transplants (AHR, 5.71), as well as those with and without GVHD (24.09 and 8.21, respectively) had significantly higher vitiligo risk than the control group.

Among those with GVHD, HSCT recipients (AHR, 16.42) and those with allogeneic grafts (AHR, 16.81) had a higher vitiligo risk than that of control patients.

In a subgroup that included 10,355 transplant recipients who underwent posttransplant health checkups, investigators found the highest vitiligo risk — AHR, 25.09 versus controls — among HSCT recipients with comorbid GVHD. However, patients who underwent SOT, autologous HSCT, or HSCT without GVHD showed no increased vitiligo risk in this analysis. “The results of health checkup data analysis may differ from the initial analysis due to additional adjustments for lifestyle factors and inclusion of only patients who underwent a health checkup,” the authors wrote.

Asked to comment on the results, George Han, MD, PhD, who was not involved with the study, told this news organization, “this is an interesting paper where the primary difference from previous studies is the new association between GVHD in hematopoietic stem cell transplant recipients and vitiligo.” Prior research had shown higher rates of vitiligo in HSCT recipients without making the GVHD distinction. Dr. Han is associate professor of dermatology in the Hofstra/Northwell Department of Dermatology, Hyde Park, New York.

Although GVHD may not be top-of-mind for dermatologists in daily practice, he said, the study enhances their understanding of vitiligo risk in HSCT recipients. “In some ways,” Dr. Han added, “the association makes sense, as the activated T cells from the graft attacking the skin in the HSCT recipient follow many of the mechanisms of vitiligo, including upregulating interferon gamma and the CXCR3/CXCL10 axis.”

Presently, he said, dermatologists worry more about solid organ recipients than about HSCT recipients because the long-term immunosuppression required by SOT increases the risk of squamous cell carcinoma (SCC). “However, the risk of skin cancers also seems to be elevated in HSCT recipients, and in this case the basal cell carcinoma (BCC):SCC ratio is not necessarily reversed as we see in solid organ transplant recipients. So the mechanisms are a bit less clear. Interestingly, acute and chronic GVHD have both been associated with increased risks of BCC and SCC/BCC, respectively.”

Overall, Dr. Han said, any transplant recipient should undergo yearly skin checks not only for skin cancers, but also for other skin conditions such as vitiligo. “It would be nice to see this codified into official guidelines, which can vary considerably but are overall more consistent in solid organ transplant recipients than in HSCT recipients. No such guidelines seem to be available for HSCTs.”

The study was funded by the Basic Research in Science & Engineering program through the National Research Foundation of Korea, which is funded by the country’s Ministry of Education. The study authors had no disclosures. Dr. Han reports no relevant financial interests.

Children with obesity issues should undergo “comprehensive, intensive behavioral interventions,” including supervised physical activity sessions for up to a year, a federal task force said. 

The U.S. Preventive Services Task Force — a team of independent, volunteer experts in disease prevention who guide doctors’ decisions and influence insurance coverage — issued a draft recommendation statement outlining the interventions that should be taken when a child or teen has a high body mass index. 

Nearly 20% of children between 2 and 19 years old have what are considered high BMIs, according to Centers for Disease Control and Prevention data. While adults who have a BMI of 30 or higher are considered to have obesity, childhood obesity is determined if a child is at or above the 95th percentile of others their age and gender. 

Given the prevalence of the issue, the task force recommends behavioral interventions that include at least 26 hours of supervised physical activity sessions for up to a year. This differs from the task force’s previous recommendations on the topic, which emphasized the importance of screening for high BMIs rather than describing the right ways to intervene.

Some of the most effective interventions are targeted at both parents and their children, whether that be together, separately, or a combination of the two. Additionally, the task force recommends that children attend group sessions about healthy eating habits, how to read food labels, and exercise techniques. Ideally, these would be led and guided by people of various professional backgrounds like pediatricians, physical therapists, dietitians, psychologists, and social workers. Other medical organizations, namely the American Academy of Pediatrics, have recommended medication for some children with obesity; the task force, however, takes a more conservative approach. They noted that although the body of evidence shows weight loss medications and surgery are effective for many, there isn’t enough research to lean on regarding the use of these interventions in children, especially in the long term. 

“There are proven ways that clinicians can help the many children and teens who have a high BMI to manage their weight and stay healthy,” said Katrina Donahue, MD, MPH, a member of the task force and professor of family medicine at the University of North Carolina at Chapel Hill. “Intensive behavioral interventions are effective in helping children achieve a healthy weight while improving quality of life.”

The guidelines are still in the draft stage and are available for public comment until Jan. 16, 2024. 
 

A version of this article appeared on WebMD.com.

Children with obesity issues should undergo “comprehensive, intensive behavioral interventions,” including supervised physical activity sessions for up to a year, a federal task force said. 

The U.S. Preventive Services Task Force — a team of independent, volunteer experts in disease prevention who guide doctors’ decisions and influence insurance coverage — issued a draft recommendation statement outlining the interventions that should be taken when a child or teen has a high body mass index. 

Nearly 20% of children between 2 and 19 years old have what are considered high BMIs, according to Centers for Disease Control and Prevention data. While adults who have a BMI of 30 or higher are considered to have obesity, childhood obesity is determined if a child is at or above the 95th percentile of others their age and gender. 

Given the prevalence of the issue, the task force recommends behavioral interventions that include at least 26 hours of supervised physical activity sessions for up to a year. This differs from the task force’s previous recommendations on the topic, which emphasized the importance of screening for high BMIs rather than describing the right ways to intervene.

Some of the most effective interventions are targeted at both parents and their children, whether that be together, separately, or a combination of the two. Additionally, the task force recommends that children attend group sessions about healthy eating habits, how to read food labels, and exercise techniques. Ideally, these would be led and guided by people of various professional backgrounds like pediatricians, physical therapists, dietitians, psychologists, and social workers. Other medical organizations, namely the American Academy of Pediatrics, have recommended medication for some children with obesity; the task force, however, takes a more conservative approach. They noted that although the body of evidence shows weight loss medications and surgery are effective for many, there isn’t enough research to lean on regarding the use of these interventions in children, especially in the long term. 

“There are proven ways that clinicians can help the many children and teens who have a high BMI to manage their weight and stay healthy,” said Katrina Donahue, MD, MPH, a member of the task force and professor of family medicine at the University of North Carolina at Chapel Hill. “Intensive behavioral interventions are effective in helping children achieve a healthy weight while improving quality of life.”

The guidelines are still in the draft stage and are available for public comment until Jan. 16, 2024. 
 

A version of this article appeared on WebMD.com.

Children with obesity issues should undergo “comprehensive, intensive behavioral interventions,” including supervised physical activity sessions for up to a year, a federal task force said. 

The U.S. Preventive Services Task Force — a team of independent, volunteer experts in disease prevention who guide doctors’ decisions and influence insurance coverage — issued a draft recommendation statement outlining the interventions that should be taken when a child or teen has a high body mass index. 

Nearly 20% of children between 2 and 19 years old have what are considered high BMIs, according to Centers for Disease Control and Prevention data. While adults who have a BMI of 30 or higher are considered to have obesity, childhood obesity is determined if a child is at or above the 95th percentile of others their age and gender. 

Given the prevalence of the issue, the task force recommends behavioral interventions that include at least 26 hours of supervised physical activity sessions for up to a year. This differs from the task force’s previous recommendations on the topic, which emphasized the importance of screening for high BMIs rather than describing the right ways to intervene.

Some of the most effective interventions are targeted at both parents and their children, whether that be together, separately, or a combination of the two. Additionally, the task force recommends that children attend group sessions about healthy eating habits, how to read food labels, and exercise techniques. Ideally, these would be led and guided by people of various professional backgrounds like pediatricians, physical therapists, dietitians, psychologists, and social workers. Other medical organizations, namely the American Academy of Pediatrics, have recommended medication for some children with obesity; the task force, however, takes a more conservative approach. They noted that although the body of evidence shows weight loss medications and surgery are effective for many, there isn’t enough research to lean on regarding the use of these interventions in children, especially in the long term. 

“There are proven ways that clinicians can help the many children and teens who have a high BMI to manage their weight and stay healthy,” said Katrina Donahue, MD, MPH, a member of the task force and professor of family medicine at the University of North Carolina at Chapel Hill. “Intensive behavioral interventions are effective in helping children achieve a healthy weight while improving quality of life.”

The guidelines are still in the draft stage and are available for public comment until Jan. 16, 2024. 
 

A version of this article appeared on WebMD.com.

TOPLINE:

Among adolescent pregnancies in the United States, the prevalence of e-cigarette use during the third trimester increased from 0.8% in 2016 to 4.1% in 2021, according to research published online on December 13 in JAMA Network Open. 

METHODOLOGY:

• Researchers analyzed data from the 2016-2021 Pregnancy Risk Assessment Monitoring System.
• They focused on 10,428 adolescents aged 10-19 years who had had a singleton birth and provided information about their use of e-cigarettes or cigarettes.

TAKEAWAY:

• Whereas the researchers found a roughly fivefold increase in the exclusive use of e-cigarettes, the percentage of patients using only cigarettes decreased from 9.2% in 2017 to 3.2% in 2021.
• The percentage of patients who both vaped and smoked fluctuated between 0.6% and 1.6%.
• The rate of small-for-gestational-age (SGA) births for adolescents who did not smoke or vape (12.9%) did not differ significantly from that among adolescents who exclusively used e-cigarettes (16.8%) or those who used both cigarettes and e-cigarettes (17.6%).
• The researchers found use of cigarettes only was associated with a significantly higher rate of SGA births: 24.6%.

IN PRACTICE:

“Exclusive e-cigarette use and dual use of cigarettes and e-cigarettes did not seem to be statistically significantly associated with SGA birth in our analysis, but this finding should be interpreted with caution given the low prevalence of use and the limited sample size,” the study authors wrote.

SOURCE:

Xiaozhong Wen, MD, PhD, with the Jacobs School of Medicine and Biomedical Sciences at the State University of New York at Buffalo, was the corresponding author of the study. 

LIMITATIONS:

Participants may have underreported their use of e-cigarettes and cigarettes because of fears of social stigma. The researchers lacked information about vaping in the first and second trimesters, exposure to secondhand smoke, cannabis use, and diet. 

DISCLOSURES:

The research was supported by the National Institute on Drug Abuse; the Food and Drug Administration Center for Tobacco Products; the National Heart, Lung, and Blood Institute; and the American Heart Association. A study coauthor has received grants from Pfizer and personal fees from Johnson & Johnson, the World Health Organization, and the Campaign for Tobacco-Free Kids.
 

A version of this article appeared on Medscape.com.

TOPLINE:

Among adolescent pregnancies in the United States, the prevalence of e-cigarette use during the third trimester increased from 0.8% in 2016 to 4.1% in 2021, according to research published online on December 13 in JAMA Network Open. 

METHODOLOGY:

• Researchers analyzed data from the 2016-2021 Pregnancy Risk Assessment Monitoring System.
• They focused on 10,428 adolescents aged 10-19 years who had had a singleton birth and provided information about their use of e-cigarettes or cigarettes.

TAKEAWAY:

• Whereas the researchers found a roughly fivefold increase in the exclusive use of e-cigarettes, the percentage of patients using only cigarettes decreased from 9.2% in 2017 to 3.2% in 2021.
• The percentage of patients who both vaped and smoked fluctuated between 0.6% and 1.6%.
• The rate of small-for-gestational-age (SGA) births for adolescents who did not smoke or vape (12.9%) did not differ significantly from that among adolescents who exclusively used e-cigarettes (16.8%) or those who used both cigarettes and e-cigarettes (17.6%).
• The researchers found use of cigarettes only was associated with a significantly higher rate of SGA births: 24.6%.

IN PRACTICE:

“Exclusive e-cigarette use and dual use of cigarettes and e-cigarettes did not seem to be statistically significantly associated with SGA birth in our analysis, but this finding should be interpreted with caution given the low prevalence of use and the limited sample size,” the study authors wrote.

SOURCE:

Xiaozhong Wen, MD, PhD, with the Jacobs School of Medicine and Biomedical Sciences at the State University of New York at Buffalo, was the corresponding author of the study. 

LIMITATIONS:

Participants may have underreported their use of e-cigarettes and cigarettes because of fears of social stigma. The researchers lacked information about vaping in the first and second trimesters, exposure to secondhand smoke, cannabis use, and diet. 

DISCLOSURES:

The research was supported by the National Institute on Drug Abuse; the Food and Drug Administration Center for Tobacco Products; the National Heart, Lung, and Blood Institute; and the American Heart Association. A study coauthor has received grants from Pfizer and personal fees from Johnson & Johnson, the World Health Organization, and the Campaign for Tobacco-Free Kids.
 

A version of this article appeared on Medscape.com.

TOPLINE:

Among adolescent pregnancies in the United States, the prevalence of e-cigarette use during the third trimester increased from 0.8% in 2016 to 4.1% in 2021, according to research published online on December 13 in JAMA Network Open. 

METHODOLOGY:

• Researchers analyzed data from the 2016-2021 Pregnancy Risk Assessment Monitoring System.
• They focused on 10,428 adolescents aged 10-19 years who had had a singleton birth and provided information about their use of e-cigarettes or cigarettes.

TAKEAWAY:

• Whereas the researchers found a roughly fivefold increase in the exclusive use of e-cigarettes, the percentage of patients using only cigarettes decreased from 9.2% in 2017 to 3.2% in 2021.
• The percentage of patients who both vaped and smoked fluctuated between 0.6% and 1.6%.
• The rate of small-for-gestational-age (SGA) births for adolescents who did not smoke or vape (12.9%) did not differ significantly from that among adolescents who exclusively used e-cigarettes (16.8%) or those who used both cigarettes and e-cigarettes (17.6%).
• The researchers found use of cigarettes only was associated with a significantly higher rate of SGA births: 24.6%.

IN PRACTICE:

“Exclusive e-cigarette use and dual use of cigarettes and e-cigarettes did not seem to be statistically significantly associated with SGA birth in our analysis, but this finding should be interpreted with caution given the low prevalence of use and the limited sample size,” the study authors wrote.

SOURCE:

Xiaozhong Wen, MD, PhD, with the Jacobs School of Medicine and Biomedical Sciences at the State University of New York at Buffalo, was the corresponding author of the study. 

LIMITATIONS:

Participants may have underreported their use of e-cigarettes and cigarettes because of fears of social stigma. The researchers lacked information about vaping in the first and second trimesters, exposure to secondhand smoke, cannabis use, and diet. 

DISCLOSURES:

The research was supported by the National Institute on Drug Abuse; the Food and Drug Administration Center for Tobacco Products; the National Heart, Lung, and Blood Institute; and the American Heart Association. A study coauthor has received grants from Pfizer and personal fees from Johnson & Johnson, the World Health Organization, and the Campaign for Tobacco-Free Kids.
 

A version of this article appeared on Medscape.com.

A digital stethoscope that uses artificial intelligence (AI) is better at detecting heart murmurs associated with clinically significant valvular heart disease (VHD) than is a primary care physician (PCP) using a traditional stethoscope, a new study shows.

The results suggest collecting relevant sounds through a stethoscope (auscultation) using AI-powered technology is an important primary care tool to detect VHD, study author Moshe A. Rancier, MD, medical director, Massachusetts General Brigham Community Physicians, Lawrence, Massachusetts, said in an interview.

“Incorporating this AI-assisted device into the primary care exam will help identify patients at risk for VHD earlier and eventually decrease costs in our healthcare system,” he said, because timely detection could avoid emergency room visits and surgeries.

The findings were presented at the annual scientific sessions of the American Heart Association.
 

VHD Common

Clinically significant VHD, indicating structural damage to heart valves, affects 1 in 10 adults older than 65 years. Patients may be asymptomatic or present to their PCP with an unspecific symptom like fatigue or malaise.

If VHD is undiagnosed and left untreated, patients could develop more severe symptoms, even be at risk for death, and their quality of life is significantly affected, said Dr. Rancier.

Cardiac auscultation, the current point-of-care clinical standard, has relatively low sensitivity for detecting VHD, leaving most patients undiagnosed.

The deep learning–based AI tool uses sound data to detect cardiac murmurs associated with clinically significant VHD. The device used in the study (Eko; Eko Health) is approved by the US Food and Drug Administration and is on the market.

The tool identifies background sounds that might affect the evaluation. “If there’s any noise or breath sounds, it tells me this is not a good heart sound, and asks me to record again,” said Dr. Rancier.

A doctor using the AI-assisted stethoscope carries out the auscultation exam with the sound data captured by a smartphone or tablet and sent to the AI server. “I get an answer in a second as to if there’s a murmur or not,” said Dr. Rancier.

Not only that, but the tool can determine if it’s a systolic or diastolic murmur, he added.
 

Real-World Population

The study enrolled a “real-world” population of 368 patients, median age 70 years, 61% female, 70% White, and 18% Hispanic without a prior VHD diagnosis or history of murmur, from three primary care clinics in Queens, New York, and Lawrence and Haverhill, Massachusetts. 

About 79% of the cohort had hypertension, 68% had dyslipidemia, and 38% had diabetes, “which aligns with the population in the US,” said Dr. Rancier.

Each study participant had a regular exam carried out by Dr. Rancier using a traditional stethoscope to detect murmurs and an exam by a technician with a digital stethoscope that collected phonocardiogram (PCG) data for analysis by AI.

In addition, each patient received an echocardiogram 1-2 weeks later to confirm whether clinically significant VHD was present. An expert panel of cardiologists also reviewed the patient’s PCG recordings to confirm the presence of audible murmurs.

Dr. Rancier and the expert panel were blinded to AI and echocardiogram results.

Researchers calculated performance metrics for both PCP auscultation and the AI in detecting audible VHD.

The study showed that AI improved sensitivity to detect audible VHD by over twofold compared with PCP auscultation (94.1% vs 41.2%), with limited impact on specificity (84.5% vs 95.5%).

Dr. Rancier stressed the importance of sensitivity because clinicians tend to under-detect murmurs. “You don’t want to miss those patients because the consequences of undiagnosed VHD are dire.”

The AI tool identified 22 patients with moderate or greater VHD who were previously undiagnosed, whereas PCPs identified eight previously undiagnosed patients with VHD.

Dr. Rancier sees this tool being used beyond primary care, perhaps by emergency room personnel.

The authors plan to follow study participants and assess outcomes at for 6-12 months. They also aim to include more patients to increase the study’s power.
 

Expanding the Technology

They are also interested to see whether the technology can determine which valve is affected; for example, whether the issue is aortic stenosis or mitral regurgitation.

A limitation of the study was its small sample size.

Commenting on the findings, Dan Roden, MD, professor of medicine, pharmacology, and biomedical informatics, senior vice president for personalized medicine at Vanderbilt University Medical Center, Nashville, Tennessee, and chair of the American Heart Association Council on Genomic and Precision Medicine, noted that it demonstrated the AI-based stethoscope “did extraordinarily well” in predicting VHD. 

“I see this as an emerging technology — using an AI-enabled stethoscope and perhaps combining it with other imaging modalities, like an AI-enabled echocardiogram built into your stethoscope,” said Dr. Roden.

“Use of these new tools to detect the presence of valvular disease, as well as the extent of valvular disease and the extent of other kinds of heart disease, will likely help to transform CVD care.” 

The study was funded by Eko Health Inc. Dr. Rancier and Dr. Roden have no relevant conflicts of interest. 
 

A version of this article appeared on Medscape.com.

A digital stethoscope that uses artificial intelligence (AI) is better at detecting heart murmurs associated with clinically significant valvular heart disease (VHD) than is a primary care physician (PCP) using a traditional stethoscope, a new study shows.

The results suggest collecting relevant sounds through a stethoscope (auscultation) using AI-powered technology is an important primary care tool to detect VHD, study author Moshe A. Rancier, MD, medical director, Massachusetts General Brigham Community Physicians, Lawrence, Massachusetts, said in an interview.

“Incorporating this AI-assisted device into the primary care exam will help identify patients at risk for VHD earlier and eventually decrease costs in our healthcare system,” he said, because timely detection could avoid emergency room visits and surgeries.

The findings were presented at the annual scientific sessions of the American Heart Association.
 

VHD Common

Clinically significant VHD, indicating structural damage to heart valves, affects 1 in 10 adults older than 65 years. Patients may be asymptomatic or present to their PCP with an unspecific symptom like fatigue or malaise.

If VHD is undiagnosed and left untreated, patients could develop more severe symptoms, even be at risk for death, and their quality of life is significantly affected, said Dr. Rancier.

Cardiac auscultation, the current point-of-care clinical standard, has relatively low sensitivity for detecting VHD, leaving most patients undiagnosed.

The deep learning–based AI tool uses sound data to detect cardiac murmurs associated with clinically significant VHD. The device used in the study (Eko; Eko Health) is approved by the US Food and Drug Administration and is on the market.

The tool identifies background sounds that might affect the evaluation. “If there’s any noise or breath sounds, it tells me this is not a good heart sound, and asks me to record again,” said Dr. Rancier.

A doctor using the AI-assisted stethoscope carries out the auscultation exam with the sound data captured by a smartphone or tablet and sent to the AI server. “I get an answer in a second as to if there’s a murmur or not,” said Dr. Rancier.

Not only that, but the tool can determine if it’s a systolic or diastolic murmur, he added.
 

Real-World Population

The study enrolled a “real-world” population of 368 patients, median age 70 years, 61% female, 70% White, and 18% Hispanic without a prior VHD diagnosis or history of murmur, from three primary care clinics in Queens, New York, and Lawrence and Haverhill, Massachusetts. 

About 79% of the cohort had hypertension, 68% had dyslipidemia, and 38% had diabetes, “which aligns with the population in the US,” said Dr. Rancier.

Each study participant had a regular exam carried out by Dr. Rancier using a traditional stethoscope to detect murmurs and an exam by a technician with a digital stethoscope that collected phonocardiogram (PCG) data for analysis by AI.

In addition, each patient received an echocardiogram 1-2 weeks later to confirm whether clinically significant VHD was present. An expert panel of cardiologists also reviewed the patient’s PCG recordings to confirm the presence of audible murmurs.

Dr. Rancier and the expert panel were blinded to AI and echocardiogram results.

Researchers calculated performance metrics for both PCP auscultation and the AI in detecting audible VHD.

The study showed that AI improved sensitivity to detect audible VHD by over twofold compared with PCP auscultation (94.1% vs 41.2%), with limited impact on specificity (84.5% vs 95.5%).

Dr. Rancier stressed the importance of sensitivity because clinicians tend to under-detect murmurs. “You don’t want to miss those patients because the consequences of undiagnosed VHD are dire.”

The AI tool identified 22 patients with moderate or greater VHD who were previously undiagnosed, whereas PCPs identified eight previously undiagnosed patients with VHD.

Dr. Rancier sees this tool being used beyond primary care, perhaps by emergency room personnel.

The authors plan to follow study participants and assess outcomes at for 6-12 months. They also aim to include more patients to increase the study’s power.
 

Expanding the Technology

They are also interested to see whether the technology can determine which valve is affected; for example, whether the issue is aortic stenosis or mitral regurgitation.

A limitation of the study was its small sample size.

Commenting on the findings, Dan Roden, MD, professor of medicine, pharmacology, and biomedical informatics, senior vice president for personalized medicine at Vanderbilt University Medical Center, Nashville, Tennessee, and chair of the American Heart Association Council on Genomic and Precision Medicine, noted that it demonstrated the AI-based stethoscope “did extraordinarily well” in predicting VHD. 

“I see this as an emerging technology — using an AI-enabled stethoscope and perhaps combining it with other imaging modalities, like an AI-enabled echocardiogram built into your stethoscope,” said Dr. Roden.

“Use of these new tools to detect the presence of valvular disease, as well as the extent of valvular disease and the extent of other kinds of heart disease, will likely help to transform CVD care.” 

The study was funded by Eko Health Inc. Dr. Rancier and Dr. Roden have no relevant conflicts of interest. 
 

A version of this article appeared on Medscape.com.

A digital stethoscope that uses artificial intelligence (AI) is better at detecting heart murmurs associated with clinically significant valvular heart disease (VHD) than is a primary care physician (PCP) using a traditional stethoscope, a new study shows.

The results suggest collecting relevant sounds through a stethoscope (auscultation) using AI-powered technology is an important primary care tool to detect VHD, study author Moshe A. Rancier, MD, medical director, Massachusetts General Brigham Community Physicians, Lawrence, Massachusetts, said in an interview.

“Incorporating this AI-assisted device into the primary care exam will help identify patients at risk for VHD earlier and eventually decrease costs in our healthcare system,” he said, because timely detection could avoid emergency room visits and surgeries.

The findings were presented at the annual scientific sessions of the American Heart Association.
 

VHD Common

Clinically significant VHD, indicating structural damage to heart valves, affects 1 in 10 adults older than 65 years. Patients may be asymptomatic or present to their PCP with an unspecific symptom like fatigue or malaise.

If VHD is undiagnosed and left untreated, patients could develop more severe symptoms, even be at risk for death, and their quality of life is significantly affected, said Dr. Rancier.

Cardiac auscultation, the current point-of-care clinical standard, has relatively low sensitivity for detecting VHD, leaving most patients undiagnosed.

The deep learning–based AI tool uses sound data to detect cardiac murmurs associated with clinically significant VHD. The device used in the study (Eko; Eko Health) is approved by the US Food and Drug Administration and is on the market.

The tool identifies background sounds that might affect the evaluation. “If there’s any noise or breath sounds, it tells me this is not a good heart sound, and asks me to record again,” said Dr. Rancier.

A doctor using the AI-assisted stethoscope carries out the auscultation exam with the sound data captured by a smartphone or tablet and sent to the AI server. “I get an answer in a second as to if there’s a murmur or not,” said Dr. Rancier.

Not only that, but the tool can determine if it’s a systolic or diastolic murmur, he added.
 

Real-World Population

The study enrolled a “real-world” population of 368 patients, median age 70 years, 61% female, 70% White, and 18% Hispanic without a prior VHD diagnosis or history of murmur, from three primary care clinics in Queens, New York, and Lawrence and Haverhill, Massachusetts. 

About 79% of the cohort had hypertension, 68% had dyslipidemia, and 38% had diabetes, “which aligns with the population in the US,” said Dr. Rancier.

Each study participant had a regular exam carried out by Dr. Rancier using a traditional stethoscope to detect murmurs and an exam by a technician with a digital stethoscope that collected phonocardiogram (PCG) data for analysis by AI.

In addition, each patient received an echocardiogram 1-2 weeks later to confirm whether clinically significant VHD was present. An expert panel of cardiologists also reviewed the patient’s PCG recordings to confirm the presence of audible murmurs.

Dr. Rancier and the expert panel were blinded to AI and echocardiogram results.

Researchers calculated performance metrics for both PCP auscultation and the AI in detecting audible VHD.

The study showed that AI improved sensitivity to detect audible VHD by over twofold compared with PCP auscultation (94.1% vs 41.2%), with limited impact on specificity (84.5% vs 95.5%).

Dr. Rancier stressed the importance of sensitivity because clinicians tend to under-detect murmurs. “You don’t want to miss those patients because the consequences of undiagnosed VHD are dire.”

The AI tool identified 22 patients with moderate or greater VHD who were previously undiagnosed, whereas PCPs identified eight previously undiagnosed patients with VHD.

Dr. Rancier sees this tool being used beyond primary care, perhaps by emergency room personnel.

The authors plan to follow study participants and assess outcomes at for 6-12 months. They also aim to include more patients to increase the study’s power.
 

Expanding the Technology

They are also interested to see whether the technology can determine which valve is affected; for example, whether the issue is aortic stenosis or mitral regurgitation.

A limitation of the study was its small sample size.

Commenting on the findings, Dan Roden, MD, professor of medicine, pharmacology, and biomedical informatics, senior vice president for personalized medicine at Vanderbilt University Medical Center, Nashville, Tennessee, and chair of the American Heart Association Council on Genomic and Precision Medicine, noted that it demonstrated the AI-based stethoscope “did extraordinarily well” in predicting VHD. 

“I see this as an emerging technology — using an AI-enabled stethoscope and perhaps combining it with other imaging modalities, like an AI-enabled echocardiogram built into your stethoscope,” said Dr. Roden.

“Use of these new tools to detect the presence of valvular disease, as well as the extent of valvular disease and the extent of other kinds of heart disease, will likely help to transform CVD care.” 

The study was funded by Eko Health Inc. Dr. Rancier and Dr. Roden have no relevant conflicts of interest. 
 

A version of this article appeared on Medscape.com.

Changes in tissue thickness in the back of the eye can correlate with worsening or improvement of renal problems and could help predict who will have worsening of kidney function, a new analysis report finds. 

The research, published in the journal Nature Communications, is the first to show an association between chronic kidney disease (CKD) and the thickness of the retinal and choroidal layers in the back of the eye as measured by optical coherence tomography (OCT), a noninvasive imaging technology commonly used to evaluate eye diseases such as age-related macular degeneration (AMD), diabetic eye disease, and retinal detachments.

“These are common scans that people get at the opticians and now in many hospitals,” said Neeraj Dhaun, MD, PhD, a professor of nephrology at the University of Edinburgh, Scotland. (Opticians in the United Kingdom are the equivalent of optometrists in North America.) 
 

CKD Severity Equals Thinner Retinas

“We scanned the back of eye of healthy people as well as patients with various types and degrees of kidney disease, and we found that two layers in the back of eye, the retina and the choroid, were thinner in patients with kidney disease compared to people who are healthy, and that the extent of this thinning predicts whether kidney function would decline going forward over a period of 2 or 3 years,” Dr. Dhaun, the corresponding author of the new paper, said.

The publication is a report of four different studies. The first study measured OCT metrics in 112 patients with CKD, 92 patients with a functional kidney transplant, and 86 control volunteers. The researchers found the retina was 5% thinner in patients with CKD than in healthy controls. They also found that patients with CKD had reduced macular volume: 8.44 ± .44 mm³ vs 8.73 ± .36 mm³ (P < .001). The choroid was also found to be thinner at each of three macular locations measured in patients with CKD vs control volunteers. At baseline, CKD and transplant patients had significantly lower estimated glomerular filtration rate (eGFR) at 55 ± 27 and 55 ± 24 mL/min/1.73 m² compared with control volunteers at 97 ± 14 mL/min/1.73 m².

The second study reported on OCT measurements and kidney histologic injury in 50 patients who had a kidney biopsy within 30 days of their OCT. It found that choroidal thinning at all three macular locations was independently associated with more extensive kidney scarring. 

The third study focused on 25 patients with kidney failure who had a kidney transplant. Their eGFR improved from 8 ± 3 to 58 ± 21 mL/min/1.73 m² in the first week after the transplant. The choroid in these patients thickened about 5% at 1 week and by about 10% at 1 month posttransplant. OCT of 22 kidney donors showed thickening of the choroid a week after nephrectomy before a tendency to thinning over the next year.

The fourth study found that for patients with stable CKD, every 1 mm3 decrease in macular volume correlated to an increased odds of a decline in eGFR by more than 10% at 1 year (2.48; 95% CI, 1.26-5.08; P = .01) and by more than 20% at 2 years (3.75; 95% CI, 1.26-5.08; P = .004).
 

Exploring the Kidney-Eye Connection 

The potential explanation for the correlation between retinal and choroidal thickness and kidney function is unclear, Dr. Dhaun said. 

“We don’t know the exact mechanisms, and these are difficult to define from studies in patients, which is why we are doing more work in animal models of kidney disease to see if we can establish the pathways that lead to the changes in the eye,” he said. 

“However,” Dr. Dhaun added, “what we do know is that kidney disease affects the whole body. For example, kidney disease can lead to high blood pressure and heart disease, as well as diseases in the brain, and it is these effects of kidney disease on the body as whole that we are probably picking up in the back of the eye.” 

OCT has the potential to make the monitoring of patients with CKD and kidney transplant more convenient than it is now, Dr. Dhaun said. “These scanners are available in the community, and what would be ideal at some point in the future is to be able to do a patient’s kidney health check in the community potentially incorporating OCT scanning alongside blood-pressure monitoring and other healthcare measures,” he said.

“The findings provide an exciting example of how noninvasive retinal imaging using OCT can provide quantitative biomarkers of systemic disease,” Amir Kashani, MD, PhD, the Boone Pickens Professor of Ophthalmology and Biomedical Engineering at the Wilmer Eye Institute of Johns Hopkins University in Baltimore, told this news organization. “It is striking that their findings demonstrate some potential of reversible changes in choroidal perfusion after kidney transplantation.”

The finding that choroidal thickness changes in CKD are at least partly reversible with kidney transplantation is a revelation, Dr. Kashani said, and may point to a greater role for ophthalmologists in managing systemic disease. 

“Ophthalmologists can and should use their unique experience and understanding of the eye to help monitor and manage systemic conditions in collaboration with our medicine colleagues,” he said. “There are many systemic diseases that can impact the eye and ophthalmologist are uniquely positioned to help interpret those findings.”

Dr. Kashani noted that a particular strength of the report was the comparison of choroidal measurements in patients who had kidney transplantation and those that had a nephrectomy. “The consistent direction of changes in these two groups suggests the study findings are real and meaningful,” he said.

The study was independently supported. Dr. Dhaun and co-authors report no relevant financial relationships. Dr. Kashani disclosed a financial relationship with Carl Zeiss Meditec.

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

Changes in tissue thickness in the back of the eye can correlate with worsening or improvement of renal problems and could help predict who will have worsening of kidney function, a new analysis report finds. 

The research, published in the journal Nature Communications, is the first to show an association between chronic kidney disease (CKD) and the thickness of the retinal and choroidal layers in the back of the eye as measured by optical coherence tomography (OCT), a noninvasive imaging technology commonly used to evaluate eye diseases such as age-related macular degeneration (AMD), diabetic eye disease, and retinal detachments.

“These are common scans that people get at the opticians and now in many hospitals,” said Neeraj Dhaun, MD, PhD, a professor of nephrology at the University of Edinburgh, Scotland. (Opticians in the United Kingdom are the equivalent of optometrists in North America.) 
 

CKD Severity Equals Thinner Retinas

“We scanned the back of eye of healthy people as well as patients with various types and degrees of kidney disease, and we found that two layers in the back of eye, the retina and the choroid, were thinner in patients with kidney disease compared to people who are healthy, and that the extent of this thinning predicts whether kidney function would decline going forward over a period of 2 or 3 years,” Dr. Dhaun, the corresponding author of the new paper, said.

The publication is a report of four different studies. The first study measured OCT metrics in 112 patients with CKD, 92 patients with a functional kidney transplant, and 86 control volunteers. The researchers found the retina was 5% thinner in patients with CKD than in healthy controls. They also found that patients with CKD had reduced macular volume: 8.44 ± .44 mm³ vs 8.73 ± .36 mm³ (P < .001). The choroid was also found to be thinner at each of three macular locations measured in patients with CKD vs control volunteers. At baseline, CKD and transplant patients had significantly lower estimated glomerular filtration rate (eGFR) at 55 ± 27 and 55 ± 24 mL/min/1.73 m² compared with control volunteers at 97 ± 14 mL/min/1.73 m².

The second study reported on OCT measurements and kidney histologic injury in 50 patients who had a kidney biopsy within 30 days of their OCT. It found that choroidal thinning at all three macular locations was independently associated with more extensive kidney scarring. 

The third study focused on 25 patients with kidney failure who had a kidney transplant. Their eGFR improved from 8 ± 3 to 58 ± 21 mL/min/1.73 m² in the first week after the transplant. The choroid in these patients thickened about 5% at 1 week and by about 10% at 1 month posttransplant. OCT of 22 kidney donors showed thickening of the choroid a week after nephrectomy before a tendency to thinning over the next year.

The fourth study found that for patients with stable CKD, every 1 mm3 decrease in macular volume correlated to an increased odds of a decline in eGFR by more than 10% at 1 year (2.48; 95% CI, 1.26-5.08; P = .01) and by more than 20% at 2 years (3.75; 95% CI, 1.26-5.08; P = .004).
 

Exploring the Kidney-Eye Connection 

The potential explanation for the correlation between retinal and choroidal thickness and kidney function is unclear, Dr. Dhaun said. 

“We don’t know the exact mechanisms, and these are difficult to define from studies in patients, which is why we are doing more work in animal models of kidney disease to see if we can establish the pathways that lead to the changes in the eye,” he said. 

“However,” Dr. Dhaun added, “what we do know is that kidney disease affects the whole body. For example, kidney disease can lead to high blood pressure and heart disease, as well as diseases in the brain, and it is these effects of kidney disease on the body as whole that we are probably picking up in the back of the eye.” 

OCT has the potential to make the monitoring of patients with CKD and kidney transplant more convenient than it is now, Dr. Dhaun said. “These scanners are available in the community, and what would be ideal at some point in the future is to be able to do a patient’s kidney health check in the community potentially incorporating OCT scanning alongside blood-pressure monitoring and other healthcare measures,” he said.

“The findings provide an exciting example of how noninvasive retinal imaging using OCT can provide quantitative biomarkers of systemic disease,” Amir Kashani, MD, PhD, the Boone Pickens Professor of Ophthalmology and Biomedical Engineering at the Wilmer Eye Institute of Johns Hopkins University in Baltimore, told this news organization. “It is striking that their findings demonstrate some potential of reversible changes in choroidal perfusion after kidney transplantation.”

The finding that choroidal thickness changes in CKD are at least partly reversible with kidney transplantation is a revelation, Dr. Kashani said, and may point to a greater role for ophthalmologists in managing systemic disease. 

“Ophthalmologists can and should use their unique experience and understanding of the eye to help monitor and manage systemic conditions in collaboration with our medicine colleagues,” he said. “There are many systemic diseases that can impact the eye and ophthalmologist are uniquely positioned to help interpret those findings.”

Dr. Kashani noted that a particular strength of the report was the comparison of choroidal measurements in patients who had kidney transplantation and those that had a nephrectomy. “The consistent direction of changes in these two groups suggests the study findings are real and meaningful,” he said.

The study was independently supported. Dr. Dhaun and co-authors report no relevant financial relationships. Dr. Kashani disclosed a financial relationship with Carl Zeiss Meditec.

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

Changes in tissue thickness in the back of the eye can correlate with worsening or improvement of renal problems and could help predict who will have worsening of kidney function, a new analysis report finds. 

The research, published in the journal Nature Communications, is the first to show an association between chronic kidney disease (CKD) and the thickness of the retinal and choroidal layers in the back of the eye as measured by optical coherence tomography (OCT), a noninvasive imaging technology commonly used to evaluate eye diseases such as age-related macular degeneration (AMD), diabetic eye disease, and retinal detachments.

“These are common scans that people get at the opticians and now in many hospitals,” said Neeraj Dhaun, MD, PhD, a professor of nephrology at the University of Edinburgh, Scotland. (Opticians in the United Kingdom are the equivalent of optometrists in North America.) 
 

CKD Severity Equals Thinner Retinas

“We scanned the back of eye of healthy people as well as patients with various types and degrees of kidney disease, and we found that two layers in the back of eye, the retina and the choroid, were thinner in patients with kidney disease compared to people who are healthy, and that the extent of this thinning predicts whether kidney function would decline going forward over a period of 2 or 3 years,” Dr. Dhaun, the corresponding author of the new paper, said.

The publication is a report of four different studies. The first study measured OCT metrics in 112 patients with CKD, 92 patients with a functional kidney transplant, and 86 control volunteers. The researchers found the retina was 5% thinner in patients with CKD than in healthy controls. They also found that patients with CKD had reduced macular volume: 8.44 ± .44 mm³ vs 8.73 ± .36 mm³ (P < .001). The choroid was also found to be thinner at each of three macular locations measured in patients with CKD vs control volunteers. At baseline, CKD and transplant patients had significantly lower estimated glomerular filtration rate (eGFR) at 55 ± 27 and 55 ± 24 mL/min/1.73 m² compared with control volunteers at 97 ± 14 mL/min/1.73 m².

The second study reported on OCT measurements and kidney histologic injury in 50 patients who had a kidney biopsy within 30 days of their OCT. It found that choroidal thinning at all three macular locations was independently associated with more extensive kidney scarring. 

The third study focused on 25 patients with kidney failure who had a kidney transplant. Their eGFR improved from 8 ± 3 to 58 ± 21 mL/min/1.73 m² in the first week after the transplant. The choroid in these patients thickened about 5% at 1 week and by about 10% at 1 month posttransplant. OCT of 22 kidney donors showed thickening of the choroid a week after nephrectomy before a tendency to thinning over the next year.

The fourth study found that for patients with stable CKD, every 1 mm3 decrease in macular volume correlated to an increased odds of a decline in eGFR by more than 10% at 1 year (2.48; 95% CI, 1.26-5.08; P = .01) and by more than 20% at 2 years (3.75; 95% CI, 1.26-5.08; P = .004).
 

Exploring the Kidney-Eye Connection 

The potential explanation for the correlation between retinal and choroidal thickness and kidney function is unclear, Dr. Dhaun said. 

“We don’t know the exact mechanisms, and these are difficult to define from studies in patients, which is why we are doing more work in animal models of kidney disease to see if we can establish the pathways that lead to the changes in the eye,” he said. 

“However,” Dr. Dhaun added, “what we do know is that kidney disease affects the whole body. For example, kidney disease can lead to high blood pressure and heart disease, as well as diseases in the brain, and it is these effects of kidney disease on the body as whole that we are probably picking up in the back of the eye.” 

OCT has the potential to make the monitoring of patients with CKD and kidney transplant more convenient than it is now, Dr. Dhaun said. “These scanners are available in the community, and what would be ideal at some point in the future is to be able to do a patient’s kidney health check in the community potentially incorporating OCT scanning alongside blood-pressure monitoring and other healthcare measures,” he said.

“The findings provide an exciting example of how noninvasive retinal imaging using OCT can provide quantitative biomarkers of systemic disease,” Amir Kashani, MD, PhD, the Boone Pickens Professor of Ophthalmology and Biomedical Engineering at the Wilmer Eye Institute of Johns Hopkins University in Baltimore, told this news organization. “It is striking that their findings demonstrate some potential of reversible changes in choroidal perfusion after kidney transplantation.”

The finding that choroidal thickness changes in CKD are at least partly reversible with kidney transplantation is a revelation, Dr. Kashani said, and may point to a greater role for ophthalmologists in managing systemic disease. 

“Ophthalmologists can and should use their unique experience and understanding of the eye to help monitor and manage systemic conditions in collaboration with our medicine colleagues,” he said. “There are many systemic diseases that can impact the eye and ophthalmologist are uniquely positioned to help interpret those findings.”

Dr. Kashani noted that a particular strength of the report was the comparison of choroidal measurements in patients who had kidney transplantation and those that had a nephrectomy. “The consistent direction of changes in these two groups suggests the study findings are real and meaningful,” he said.

The study was independently supported. Dr. Dhaun and co-authors report no relevant financial relationships. Dr. Kashani disclosed a financial relationship with Carl Zeiss Meditec.

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

TOPLINE:

Individuals with overweight or obesity and knee or hip osteoarthritis (OA) who used antiobesity medications and achieved slow-to-moderate weight loss had a lower risk for all-cause mortality than did those with weight gain or stable weight in a population-based cohort study emulating a randomized controlled trial. Patients who rapidly lost weight had mortality similar to those with weight gain or stable weight.

METHODOLOGY:

• The researchers used the IQVIA Medical Research Database to identify overweight or obese individuals with knee or hip OA; they conducted a hypothetical trial comparing the effects of slow-to-moderate weight loss (defined as 2%-10% of body weight) and rapid weight loss (defined as 5% or more of body weight) within 1 year of starting antiobesity medications.
• The final analysis included patients with a mean age of 60.9 years who met the criteria for treatment adherence to orlistat (n = 3028), sibutramine (n = 2919), or rimonabant (n = 797).
• The primary outcome was all-cause mortality over a 5-year follow-up period; secondary outcomes included hypertension, type 2 diabetes, and venous thromboembolism.

TAKEAWAY:

• All-cause mortality at 5 years was 5.3% with weight gain or stable weight, 4.0% with slow to moderate weight loss, and 5.4% with rapid weight loss.
• Hazard ratios for all-cause mortality were 0.72 (95% CI, 0.56-0.92) for slow to moderate weight loss and 0.99 (95% CI, 0.67-1.44) for the rapid weight loss group.
• Weight loss was associated with the secondary outcomes of reduced hypertension, type 2 diabetes, and venous thromboembolism in a dose-dependent manner.
• A slightly increased risk for cardiovascular disease occurred in the rapid weight loss group, compared with the weight gain or stable group, but this difference was not significant.

IN PRACTICE:

“Our finding that gradual weight loss by antiobesity medications lowers all-cause mortality, if confirmed by future studies, could guide policy-making and improve the well-being of patients with overweight or obesity and knee or hip OA,” the researchers wrote.

SOURCE:

The lead author on the study was Jie Wei, MD, of Central South University, Changsha, China. The study was published online in Arthritis & Rheumatology.

LIMITATIONS:

Study limitations included the inability to control for factors such as exercise, diet, and disease severity; the inability to assess the risk for cause-specific mortality; and the inability to account for the impact of pain reduction and improved function as a result of weight loss.

DISCLOSURES:

The study was supported by the National Key Research and Development Plan, the National Natural Science Foundation of China, the Project Program of National Clinical Research Center for Geriatric Disorders, the Natural Science Foundation of Hunan Province, the Central South University Innovation-Driven Research Programme, and the Science and Technology Innovation Program of Hunan Province. The researchers had no financial conflicts to disclose.

A version of this article appeared on Medscape.com.

TOPLINE:

Individuals with overweight or obesity and knee or hip osteoarthritis (OA) who used antiobesity medications and achieved slow-to-moderate weight loss had a lower risk for all-cause mortality than did those with weight gain or stable weight in a population-based cohort study emulating a randomized controlled trial. Patients who rapidly lost weight had mortality similar to those with weight gain or stable weight.

METHODOLOGY:

• The researchers used the IQVIA Medical Research Database to identify overweight or obese individuals with knee or hip OA; they conducted a hypothetical trial comparing the effects of slow-to-moderate weight loss (defined as 2%-10% of body weight) and rapid weight loss (defined as 5% or more of body weight) within 1 year of starting antiobesity medications.
• The final analysis included patients with a mean age of 60.9 years who met the criteria for treatment adherence to orlistat (n = 3028), sibutramine (n = 2919), or rimonabant (n = 797).
• The primary outcome was all-cause mortality over a 5-year follow-up period; secondary outcomes included hypertension, type 2 diabetes, and venous thromboembolism.

TAKEAWAY:

• All-cause mortality at 5 years was 5.3% with weight gain or stable weight, 4.0% with slow to moderate weight loss, and 5.4% with rapid weight loss.
• Hazard ratios for all-cause mortality were 0.72 (95% CI, 0.56-0.92) for slow to moderate weight loss and 0.99 (95% CI, 0.67-1.44) for the rapid weight loss group.
• Weight loss was associated with the secondary outcomes of reduced hypertension, type 2 diabetes, and venous thromboembolism in a dose-dependent manner.
• A slightly increased risk for cardiovascular disease occurred in the rapid weight loss group, compared with the weight gain or stable group, but this difference was not significant.

IN PRACTICE:

“Our finding that gradual weight loss by antiobesity medications lowers all-cause mortality, if confirmed by future studies, could guide policy-making and improve the well-being of patients with overweight or obesity and knee or hip OA,” the researchers wrote.

SOURCE:

The lead author on the study was Jie Wei, MD, of Central South University, Changsha, China. The study was published online in Arthritis & Rheumatology.

LIMITATIONS:

Study limitations included the inability to control for factors such as exercise, diet, and disease severity; the inability to assess the risk for cause-specific mortality; and the inability to account for the impact of pain reduction and improved function as a result of weight loss.

DISCLOSURES:

The study was supported by the National Key Research and Development Plan, the National Natural Science Foundation of China, the Project Program of National Clinical Research Center for Geriatric Disorders, the Natural Science Foundation of Hunan Province, the Central South University Innovation-Driven Research Programme, and the Science and Technology Innovation Program of Hunan Province. The researchers had no financial conflicts to disclose.

A version of this article appeared on Medscape.com.

TOPLINE:

Individuals with overweight or obesity and knee or hip osteoarthritis (OA) who used antiobesity medications and achieved slow-to-moderate weight loss had a lower risk for all-cause mortality than did those with weight gain or stable weight in a population-based cohort study emulating a randomized controlled trial. Patients who rapidly lost weight had mortality similar to those with weight gain or stable weight.

METHODOLOGY:

• The researchers used the IQVIA Medical Research Database to identify overweight or obese individuals with knee or hip OA; they conducted a hypothetical trial comparing the effects of slow-to-moderate weight loss (defined as 2%-10% of body weight) and rapid weight loss (defined as 5% or more of body weight) within 1 year of starting antiobesity medications.
• The final analysis included patients with a mean age of 60.9 years who met the criteria for treatment adherence to orlistat (n = 3028), sibutramine (n = 2919), or rimonabant (n = 797).
• The primary outcome was all-cause mortality over a 5-year follow-up period; secondary outcomes included hypertension, type 2 diabetes, and venous thromboembolism.

TAKEAWAY:

• All-cause mortality at 5 years was 5.3% with weight gain or stable weight, 4.0% with slow to moderate weight loss, and 5.4% with rapid weight loss.
• Hazard ratios for all-cause mortality were 0.72 (95% CI, 0.56-0.92) for slow to moderate weight loss and 0.99 (95% CI, 0.67-1.44) for the rapid weight loss group.
• Weight loss was associated with the secondary outcomes of reduced hypertension, type 2 diabetes, and venous thromboembolism in a dose-dependent manner.
• A slightly increased risk for cardiovascular disease occurred in the rapid weight loss group, compared with the weight gain or stable group, but this difference was not significant.

IN PRACTICE:

“Our finding that gradual weight loss by antiobesity medications lowers all-cause mortality, if confirmed by future studies, could guide policy-making and improve the well-being of patients with overweight or obesity and knee or hip OA,” the researchers wrote.

SOURCE:

The lead author on the study was Jie Wei, MD, of Central South University, Changsha, China. The study was published online in Arthritis & Rheumatology.

LIMITATIONS:

Study limitations included the inability to control for factors such as exercise, diet, and disease severity; the inability to assess the risk for cause-specific mortality; and the inability to account for the impact of pain reduction and improved function as a result of weight loss.

DISCLOSURES:

The study was supported by the National Key Research and Development Plan, the National Natural Science Foundation of China, the Project Program of National Clinical Research Center for Geriatric Disorders, the Natural Science Foundation of Hunan Province, the Central South University Innovation-Driven Research Programme, and the Science and Technology Innovation Program of Hunan Province. The researchers had no financial conflicts to disclose.

A version of this article appeared on Medscape.com.

Psoriatic arthritis (PsA) is consistent with the patient's joint pain, dactylitis, enthesitis, skin plaques, and radiographic findings, making it the most likely diagnosis. 

Rheumatoid arthritis (RA) is possible because of the patient's joint symptoms; however, it is not the correct answer because of negative RF and ACPA tests and skin plaques. 

Osteoarthritis might cause joint pain but does not typically present with prolonged morning stiffness, skin plaques, or the "pencil-in-cup" radiographic finding. 

Gout, an inflammatory arthritis, primarily affects the big toe and does not align with the patient's skin and radiographic manifestations. 

PsA is a chronic inflammatory arthritis that often develops in people with psoriasis. It affects roughly 0.05%- 0.25% of the general population and up to 41% of people with psoriasis. PsA is most seen in White patients between 35 and 55 years and affects both men and women equally. PsA is linked to a higher risk for obesity, hypertension, hyperlipidemia, type 2 diabetes, metabolic syndrome, and other conditions, including uveitis and inflammatory bowel disease.

Clinically, PsA presents with a diverse range of manifestations, encompassing peripheral joint inflammation, often with an asymmetric distribution; axial skeletal involvement reminiscent of spondylitis; dactylitis characterized by sausage-like swelling of fingers or toes; and enthesitis. Common symptoms or findings include early morning stiffness for > 30 minutes; joint pain, tenderness, and swelling; back pain aggravated by rest and relieved by exercise; limited joint motion; and deformity. Although most patients have a preceding condition in skin psoriasis, diagnosis of PsA is often delayed. Furthermore, nearly 80% of patients may exhibit nail changes, such as pitting or onycholysis, compared with about 40% of patients with psoriasis without arthritis. The heterogeneity of its clinical features often necessitates a comprehensive differential diagnosis to distinguish PsA from other spondyloarthropathies and rheumatic diseases. The most accepted classification criteria for PsA are the Classification of Psoriatic Arthritis (CASPAR) criteria, which have been used since 2006.

No laboratory tests are specific for PsA; however, a normal ESR and CRP level should not be used to rule out a diagnosis of PsA because these values are increased in only about 40% of patients. RF and ACPA are classically considered absent in PsA, and a negative RF is regarded as a criterion for diagnosing PsA per the CASPAR classification criteria. Radiographic changes show some characteristic patterns in PsA, including erosive damage, gross joint destruction, joint space narrowing, and "pencil-in-cup" deformity.

PsA treatment options have evolved over the years. Whereas in the past, nonsteroidal anti-inflammatory drugs, glucocorticoids, methotrexate, sulfasalazine, and cyclosporine were commonly prescribed, the development of immunologically targeted biological disease-modifying antirheumatic drugs (DMARDs) and targeted synthetic DMARDs since 2000 has revolutionized the treatment of PsA. Tumor necrosis factor inhibitors (ie, etanercept, infliximab, and adalimumab) have been shown to improve all domains (psoriatic and articular disease) of PsA and are considered a milestone in managing the condition. Other emerging therapeutic strategies in recent years have demonstrated efficacy in treating PsA, including monoclonal antibodies targeting interleukin (IL)-12, IL-23, and IL-17, as well as small-molecule phosphodiesterase 4 and Janus kinase inhibitors.

Although most of these options have the potential to be effective in all clinical domains of the disease, their cross-domain efficacy can vary from patient to patient. In some cases, treatment may not be practical or can lose effectiveness over time, and true disease remission is rare. As a result, clinicians must regularly assess each domain and aim to achieve remission or low disease activity across the different active domains while also being aware of potential adverse events.

Alan Irvine, MD, DSc, Consultant Dermatologist, ADI Dermatology LTD, Dublin, Ireland

Alan Irvine, MD, DSc, has disclosed the following relevant financial relationships:
Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: Sanofi; Abbvie; Regeneron; Leo; Pfizer; Janssen.
Serve(d) as a speaker or member of a speakers bureau for: Sanofi; Abbvie; Regeneron; Leo; Pfizer; Janssen.

Received income in an amount equal to or greater than $250 from: Sanofi; Abbvie; Regeneron; Leo; Pfizer; Janssen.

Image Quizzes are fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.
 

Psoriatic arthritis (PsA) is consistent with the patient's joint pain, dactylitis, enthesitis, skin plaques, and radiographic findings, making it the most likely diagnosis. 

Rheumatoid arthritis (RA) is possible because of the patient's joint symptoms; however, it is not the correct answer because of negative RF and ACPA tests and skin plaques. 

Osteoarthritis might cause joint pain but does not typically present with prolonged morning stiffness, skin plaques, or the "pencil-in-cup" radiographic finding. 

Gout, an inflammatory arthritis, primarily affects the big toe and does not align with the patient's skin and radiographic manifestations. 

PsA is a chronic inflammatory arthritis that often develops in people with psoriasis. It affects roughly 0.05%- 0.25% of the general population and up to 41% of people with psoriasis. PsA is most seen in White patients between 35 and 55 years and affects both men and women equally. PsA is linked to a higher risk for obesity, hypertension, hyperlipidemia, type 2 diabetes, metabolic syndrome, and other conditions, including uveitis and inflammatory bowel disease.

Clinically, PsA presents with a diverse range of manifestations, encompassing peripheral joint inflammation, often with an asymmetric distribution; axial skeletal involvement reminiscent of spondylitis; dactylitis characterized by sausage-like swelling of fingers or toes; and enthesitis. Common symptoms or findings include early morning stiffness for > 30 minutes; joint pain, tenderness, and swelling; back pain aggravated by rest and relieved by exercise; limited joint motion; and deformity. Although most patients have a preceding condition in skin psoriasis, diagnosis of PsA is often delayed. Furthermore, nearly 80% of patients may exhibit nail changes, such as pitting or onycholysis, compared with about 40% of patients with psoriasis without arthritis. The heterogeneity of its clinical features often necessitates a comprehensive differential diagnosis to distinguish PsA from other spondyloarthropathies and rheumatic diseases. The most accepted classification criteria for PsA are the Classification of Psoriatic Arthritis (CASPAR) criteria, which have been used since 2006.

No laboratory tests are specific for PsA; however, a normal ESR and CRP level should not be used to rule out a diagnosis of PsA because these values are increased in only about 40% of patients. RF and ACPA are classically considered absent in PsA, and a negative RF is regarded as a criterion for diagnosing PsA per the CASPAR classification criteria. Radiographic changes show some characteristic patterns in PsA, including erosive damage, gross joint destruction, joint space narrowing, and "pencil-in-cup" deformity.

PsA treatment options have evolved over the years. Whereas in the past, nonsteroidal anti-inflammatory drugs, glucocorticoids, methotrexate, sulfasalazine, and cyclosporine were commonly prescribed, the development of immunologically targeted biological disease-modifying antirheumatic drugs (DMARDs) and targeted synthetic DMARDs since 2000 has revolutionized the treatment of PsA. Tumor necrosis factor inhibitors (ie, etanercept, infliximab, and adalimumab) have been shown to improve all domains (psoriatic and articular disease) of PsA and are considered a milestone in managing the condition. Other emerging therapeutic strategies in recent years have demonstrated efficacy in treating PsA, including monoclonal antibodies targeting interleukin (IL)-12, IL-23, and IL-17, as well as small-molecule phosphodiesterase 4 and Janus kinase inhibitors.

Although most of these options have the potential to be effective in all clinical domains of the disease, their cross-domain efficacy can vary from patient to patient. In some cases, treatment may not be practical or can lose effectiveness over time, and true disease remission is rare. As a result, clinicians must regularly assess each domain and aim to achieve remission or low disease activity across the different active domains while also being aware of potential adverse events.

Alan Irvine, MD, DSc, Consultant Dermatologist, ADI Dermatology LTD, Dublin, Ireland

Alan Irvine, MD, DSc, has disclosed the following relevant financial relationships:
Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: Sanofi; Abbvie; Regeneron; Leo; Pfizer; Janssen.
Serve(d) as a speaker or member of a speakers bureau for: Sanofi; Abbvie; Regeneron; Leo; Pfizer; Janssen.

Received income in an amount equal to or greater than $250 from: Sanofi; Abbvie; Regeneron; Leo; Pfizer; Janssen.

Image Quizzes are fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.
 

Psoriatic arthritis (PsA) is consistent with the patient's joint pain, dactylitis, enthesitis, skin plaques, and radiographic findings, making it the most likely diagnosis. 

Rheumatoid arthritis (RA) is possible because of the patient's joint symptoms; however, it is not the correct answer because of negative RF and ACPA tests and skin plaques. 

Osteoarthritis might cause joint pain but does not typically present with prolonged morning stiffness, skin plaques, or the "pencil-in-cup" radiographic finding. 

Gout, an inflammatory arthritis, primarily affects the big toe and does not align with the patient's skin and radiographic manifestations. 

PsA is a chronic inflammatory arthritis that often develops in people with psoriasis. It affects roughly 0.05%- 0.25% of the general population and up to 41% of people with psoriasis. PsA is most seen in White patients between 35 and 55 years and affects both men and women equally. PsA is linked to a higher risk for obesity, hypertension, hyperlipidemia, type 2 diabetes, metabolic syndrome, and other conditions, including uveitis and inflammatory bowel disease.

Clinically, PsA presents with a diverse range of manifestations, encompassing peripheral joint inflammation, often with an asymmetric distribution; axial skeletal involvement reminiscent of spondylitis; dactylitis characterized by sausage-like swelling of fingers or toes; and enthesitis. Common symptoms or findings include early morning stiffness for > 30 minutes; joint pain, tenderness, and swelling; back pain aggravated by rest and relieved by exercise; limited joint motion; and deformity. Although most patients have a preceding condition in skin psoriasis, diagnosis of PsA is often delayed. Furthermore, nearly 80% of patients may exhibit nail changes, such as pitting or onycholysis, compared with about 40% of patients with psoriasis without arthritis. The heterogeneity of its clinical features often necessitates a comprehensive differential diagnosis to distinguish PsA from other spondyloarthropathies and rheumatic diseases. The most accepted classification criteria for PsA are the Classification of Psoriatic Arthritis (CASPAR) criteria, which have been used since 2006.

No laboratory tests are specific for PsA; however, a normal ESR and CRP level should not be used to rule out a diagnosis of PsA because these values are increased in only about 40% of patients. RF and ACPA are classically considered absent in PsA, and a negative RF is regarded as a criterion for diagnosing PsA per the CASPAR classification criteria. Radiographic changes show some characteristic patterns in PsA, including erosive damage, gross joint destruction, joint space narrowing, and "pencil-in-cup" deformity.

PsA treatment options have evolved over the years. Whereas in the past, nonsteroidal anti-inflammatory drugs, glucocorticoids, methotrexate, sulfasalazine, and cyclosporine were commonly prescribed, the development of immunologically targeted biological disease-modifying antirheumatic drugs (DMARDs) and targeted synthetic DMARDs since 2000 has revolutionized the treatment of PsA. Tumor necrosis factor inhibitors (ie, etanercept, infliximab, and adalimumab) have been shown to improve all domains (psoriatic and articular disease) of PsA and are considered a milestone in managing the condition. Other emerging therapeutic strategies in recent years have demonstrated efficacy in treating PsA, including monoclonal antibodies targeting interleukin (IL)-12, IL-23, and IL-17, as well as small-molecule phosphodiesterase 4 and Janus kinase inhibitors.

Although most of these options have the potential to be effective in all clinical domains of the disease, their cross-domain efficacy can vary from patient to patient. In some cases, treatment may not be practical or can lose effectiveness over time, and true disease remission is rare. As a result, clinicians must regularly assess each domain and aim to achieve remission or low disease activity across the different active domains while also being aware of potential adverse events.

Alan Irvine, MD, DSc, Consultant Dermatologist, ADI Dermatology LTD, Dublin, Ireland

Alan Irvine, MD, DSc, has disclosed the following relevant financial relationships:
Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: Sanofi; Abbvie; Regeneron; Leo; Pfizer; Janssen.
Serve(d) as a speaker or member of a speakers bureau for: Sanofi; Abbvie; Regeneron; Leo; Pfizer; Janssen.

Received income in an amount equal to or greater than $250 from: Sanofi; Abbvie; Regeneron; Leo; Pfizer; Janssen.

Image Quizzes are fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.
 

SAN DIEGO — Only half of teens and young adults on teratogenic medication report being asked about sexual activity by their rheumatologist, and 38% did not know that their medication would be harmful to a fetus, according to a new survey.

While pediatric rheumatology providers may think that health screenings and contraceptive counseling are happening elsewhere, “this study suggests that a lot of patients are being missed, including those on teratogens,” noted Brittany M. Huynh, MD, MPH, a pediatric rheumatology fellow at the Indiana University School of Medicine in Indianapolis. She led the study and presented the findings at the American College of Rheumatology annual meeting.

Indiana University

For the study, Dr. Huynh and colleagues recruited patients aged 14-23 years who were assigned female at birth and were followed at pediatric rheumatology clinics affiliated with Indiana University. Participants completed a one-time survey between October 2020 and July 2022 and were asked about their sexual reproductive health experience and knowledge. Notably, all but four surveys were completed prior to the US Supreme Court Dobbs decision overturning Roe v. Wade.

Of responses from 108 participants, the most common diagnoses were juvenile idiopathic arthritis (52%) and systemic lupus erythematosus (16%). About one third (36%) of patients were on teratogenic medication, with the most common being methotrexate. About three fourths (76%) were White, and the average age of respondents was 16.7.

Most participants (82%) said they had been asked about sexual activity by a health care provider, but only 38% said their pediatric rheumatologist discussed this topic with them. Of the 39 patients on teratogenic medication, 54% said they had been asked about sexual activity by their pediatric rheumatologist, and only 51% said they had received teratogenicity counseling.

A larger percentage (85%) of this group reported receiving sexual activity screenings by any provider, but there was little difference in counseling about teratogenic medication.

This suggests that this type of risk counseling “is almost exclusively done by (pediatric rheumatologists), if at all,” Dr. Huynh noted during her presentation.

In total, 56% of all patients said a provider had talked to them about how to prevent pregnancy, and 20% said they had been counseled about how to get and use emergency contraception. Only 6% of patients said their pediatric rheumatologist had discussed emergency contraception during appointments.

Although sexual activity screenings were associated with current teratogen use, pregnancy prevention counseling and emergency contraceptive counseling were not associated with teratogen use or reported sexual activity.

The survey also revealed that there were gaps in knowledge about the health effects of rheumatic medication. Of the patients on teratogens, 38% did not know that their medication could harm a fetus if they became pregnant. Only 9% of patients not on teratogens correctly answered that their medication would not harm a fetus.

Previous studies have also shown that rheumatology patients do not know that their medications can be teratogenic, noted Cuoghi Edens, MD, a rheumatologist at the University of Chicago, who sees both adult and pediatric patients. She was not involved with the study. The larger challenge is how to best educate patients, she said.

While hopefully a patient’s primary care provider is discussing these issues with them, these patients often see their rheumatologist more frequently and more consistently than other providers, Dr. Edens said.

UChicago Medicine

“We are sometimes the continuity of care for the patient versus their primary care, even though it should be a group effort of trying to some of these questions,” she said.

Conducting reproductive health screenings in pediatric rheumatology clinics can be difficult though, Dr. Edens noted, not only because of time constraints but also because parents often attend appointments with their child and likely have been for years. These screenings are most accurate when done one-on-one, so pivoting and removing the parents from the room can be awkward for providers, Dr. Edens said.

She advised that starting these conversations early on can be one way to ease into talking about reproductive health. In her own practice, Dr. Huynh sets aside time during appointments to speak with adolescent patients privately.

“We always discuss teratogenic medication. I always talk to them about the fact that I’m going to be doing pregnancy testing with their other screening labs because of the risks associated,” she said. “I also specifically set time aside for patients on teratogens to talk about emergency contraception and offer a prescription, if they’re interested.”

Dr. Huynh emphasized that providing easy access to emergency contraception is key. The ACR reproductive health guidelines — although geared toward adults — recommend discussing emergency contraception with patients, and Dr. Huynh advocates writing prescriptions for interested patients.

“They can fill it and have it easily accessible, so that there are no additional barriers, particularly for people who have these higher risks,” she said.

While emergency contraceptives are also available over the counter, it can be awkward for young people to ask for them, she said, and they can be expensive if not covered under insurance. Providing a prescription is one way to avoid those issues, Dr. Huynh said.

“Certainly, you have to have some parent buy-in, because if there is going to be a script, it’s probably going to be under insurance,” she said. “But in my experience, parents are happy to have it around as long as you’re talking it through with them as well as the young person.”

Dr. Huynh and Dr. Edens had no disclosures.

A version of this article appeared on Medscape.com.

SAN DIEGO — Only half of teens and young adults on teratogenic medication report being asked about sexual activity by their rheumatologist, and 38% did not know that their medication would be harmful to a fetus, according to a new survey.

While pediatric rheumatology providers may think that health screenings and contraceptive counseling are happening elsewhere, “this study suggests that a lot of patients are being missed, including those on teratogens,” noted Brittany M. Huynh, MD, MPH, a pediatric rheumatology fellow at the Indiana University School of Medicine in Indianapolis. She led the study and presented the findings at the American College of Rheumatology annual meeting.

Indiana University

For the study, Dr. Huynh and colleagues recruited patients aged 14-23 years who were assigned female at birth and were followed at pediatric rheumatology clinics affiliated with Indiana University. Participants completed a one-time survey between October 2020 and July 2022 and were asked about their sexual reproductive health experience and knowledge. Notably, all but four surveys were completed prior to the US Supreme Court Dobbs decision overturning Roe v. Wade.

Of responses from 108 participants, the most common diagnoses were juvenile idiopathic arthritis (52%) and systemic lupus erythematosus (16%). About one third (36%) of patients were on teratogenic medication, with the most common being methotrexate. About three fourths (76%) were White, and the average age of respondents was 16.7.

Most participants (82%) said they had been asked about sexual activity by a health care provider, but only 38% said their pediatric rheumatologist discussed this topic with them. Of the 39 patients on teratogenic medication, 54% said they had been asked about sexual activity by their pediatric rheumatologist, and only 51% said they had received teratogenicity counseling.

A larger percentage (85%) of this group reported receiving sexual activity screenings by any provider, but there was little difference in counseling about teratogenic medication.

This suggests that this type of risk counseling “is almost exclusively done by (pediatric rheumatologists), if at all,” Dr. Huynh noted during her presentation.

In total, 56% of all patients said a provider had talked to them about how to prevent pregnancy, and 20% said they had been counseled about how to get and use emergency contraception. Only 6% of patients said their pediatric rheumatologist had discussed emergency contraception during appointments.

Although sexual activity screenings were associated with current teratogen use, pregnancy prevention counseling and emergency contraceptive counseling were not associated with teratogen use or reported sexual activity.

The survey also revealed that there were gaps in knowledge about the health effects of rheumatic medication. Of the patients on teratogens, 38% did not know that their medication could harm a fetus if they became pregnant. Only 9% of patients not on teratogens correctly answered that their medication would not harm a fetus.

Previous studies have also shown that rheumatology patients do not know that their medications can be teratogenic, noted Cuoghi Edens, MD, a rheumatologist at the University of Chicago, who sees both adult and pediatric patients. She was not involved with the study. The larger challenge is how to best educate patients, she said.

While hopefully a patient’s primary care provider is discussing these issues with them, these patients often see their rheumatologist more frequently and more consistently than other providers, Dr. Edens said.

UChicago Medicine

“We are sometimes the continuity of care for the patient versus their primary care, even though it should be a group effort of trying to some of these questions,” she said.

Conducting reproductive health screenings in pediatric rheumatology clinics can be difficult though, Dr. Edens noted, not only because of time constraints but also because parents often attend appointments with their child and likely have been for years. These screenings are most accurate when done one-on-one, so pivoting and removing the parents from the room can be awkward for providers, Dr. Edens said.

She advised that starting these conversations early on can be one way to ease into talking about reproductive health. In her own practice, Dr. Huynh sets aside time during appointments to speak with adolescent patients privately.

“We always discuss teratogenic medication. I always talk to them about the fact that I’m going to be doing pregnancy testing with their other screening labs because of the risks associated,” she said. “I also specifically set time aside for patients on teratogens to talk about emergency contraception and offer a prescription, if they’re interested.”

Dr. Huynh emphasized that providing easy access to emergency contraception is key. The ACR reproductive health guidelines — although geared toward adults — recommend discussing emergency contraception with patients, and Dr. Huynh advocates writing prescriptions for interested patients.

“They can fill it and have it easily accessible, so that there are no additional barriers, particularly for people who have these higher risks,” she said.

While emergency contraceptives are also available over the counter, it can be awkward for young people to ask for them, she said, and they can be expensive if not covered under insurance. Providing a prescription is one way to avoid those issues, Dr. Huynh said.

“Certainly, you have to have some parent buy-in, because if there is going to be a script, it’s probably going to be under insurance,” she said. “But in my experience, parents are happy to have it around as long as you’re talking it through with them as well as the young person.”

Dr. Huynh and Dr. Edens had no disclosures.

A version of this article appeared on Medscape.com.

SAN DIEGO — Only half of teens and young adults on teratogenic medication report being asked about sexual activity by their rheumatologist, and 38% did not know that their medication would be harmful to a fetus, according to a new survey.

While pediatric rheumatology providers may think that health screenings and contraceptive counseling are happening elsewhere, “this study suggests that a lot of patients are being missed, including those on teratogens,” noted Brittany M. Huynh, MD, MPH, a pediatric rheumatology fellow at the Indiana University School of Medicine in Indianapolis. She led the study and presented the findings at the American College of Rheumatology annual meeting.

Indiana University

For the study, Dr. Huynh and colleagues recruited patients aged 14-23 years who were assigned female at birth and were followed at pediatric rheumatology clinics affiliated with Indiana University. Participants completed a one-time survey between October 2020 and July 2022 and were asked about their sexual reproductive health experience and knowledge. Notably, all but four surveys were completed prior to the US Supreme Court Dobbs decision overturning Roe v. Wade.

Of responses from 108 participants, the most common diagnoses were juvenile idiopathic arthritis (52%) and systemic lupus erythematosus (16%). About one third (36%) of patients were on teratogenic medication, with the most common being methotrexate. About three fourths (76%) were White, and the average age of respondents was 16.7.

Most participants (82%) said they had been asked about sexual activity by a health care provider, but only 38% said their pediatric rheumatologist discussed this topic with them. Of the 39 patients on teratogenic medication, 54% said they had been asked about sexual activity by their pediatric rheumatologist, and only 51% said they had received teratogenicity counseling.

A larger percentage (85%) of this group reported receiving sexual activity screenings by any provider, but there was little difference in counseling about teratogenic medication.

This suggests that this type of risk counseling “is almost exclusively done by (pediatric rheumatologists), if at all,” Dr. Huynh noted during her presentation.

In total, 56% of all patients said a provider had talked to them about how to prevent pregnancy, and 20% said they had been counseled about how to get and use emergency contraception. Only 6% of patients said their pediatric rheumatologist had discussed emergency contraception during appointments.

Although sexual activity screenings were associated with current teratogen use, pregnancy prevention counseling and emergency contraceptive counseling were not associated with teratogen use or reported sexual activity.

The survey also revealed that there were gaps in knowledge about the health effects of rheumatic medication. Of the patients on teratogens, 38% did not know that their medication could harm a fetus if they became pregnant. Only 9% of patients not on teratogens correctly answered that their medication would not harm a fetus.

Previous studies have also shown that rheumatology patients do not know that their medications can be teratogenic, noted Cuoghi Edens, MD, a rheumatologist at the University of Chicago, who sees both adult and pediatric patients. She was not involved with the study. The larger challenge is how to best educate patients, she said.

While hopefully a patient’s primary care provider is discussing these issues with them, these patients often see their rheumatologist more frequently and more consistently than other providers, Dr. Edens said.

UChicago Medicine

“We are sometimes the continuity of care for the patient versus their primary care, even though it should be a group effort of trying to some of these questions,” she said.

Conducting reproductive health screenings in pediatric rheumatology clinics can be difficult though, Dr. Edens noted, not only because of time constraints but also because parents often attend appointments with their child and likely have been for years. These screenings are most accurate when done one-on-one, so pivoting and removing the parents from the room can be awkward for providers, Dr. Edens said.

She advised that starting these conversations early on can be one way to ease into talking about reproductive health. In her own practice, Dr. Huynh sets aside time during appointments to speak with adolescent patients privately.

“We always discuss teratogenic medication. I always talk to them about the fact that I’m going to be doing pregnancy testing with their other screening labs because of the risks associated,” she said. “I also specifically set time aside for patients on teratogens to talk about emergency contraception and offer a prescription, if they’re interested.”

Dr. Huynh emphasized that providing easy access to emergency contraception is key. The ACR reproductive health guidelines — although geared toward adults — recommend discussing emergency contraception with patients, and Dr. Huynh advocates writing prescriptions for interested patients.

“They can fill it and have it easily accessible, so that there are no additional barriers, particularly for people who have these higher risks,” she said.

While emergency contraceptives are also available over the counter, it can be awkward for young people to ask for them, she said, and they can be expensive if not covered under insurance. Providing a prescription is one way to avoid those issues, Dr. Huynh said.

“Certainly, you have to have some parent buy-in, because if there is going to be a script, it’s probably going to be under insurance,” she said. “But in my experience, parents are happy to have it around as long as you’re talking it through with them as well as the young person.”

Dr. Huynh and Dr. Edens had no disclosures.

A version of this article appeared on Medscape.com.

SAN DIEGO — Long-term follow-up from the only randomized controlled trial to compare salvage autologous stem cell transplant with a standard two-drug regimen in patients with relapsed or refractory multiple myeloma found no benefit to salvage transplant. 

Patients receiving a second, salvage-autologous stem cell transplant alongside lenalidomide-dexamethasone maintenance therapy did not demonstrate improved progression-free survival (PFS) or overall survival compared with patients who continued the two-drug regimen without salvage transplant, according to research presented at the American Society of Hematology annual meeting.

The primary phase 3 analysis, published in 2021, showed no survival benefit following salvage transplant at the time of relapse, though it only followed patients for a median of 37 months. 

However, because a significant fraction of patients in the transplant arm — about 29% — did not undergo the planned salvage transplant before dropping out of the study, the researchers performed further analyses that “suggested a survival benefit in patients who actually received the transplant,” first author Marc-Andrea Baertsch, MD, of the German Cancer Research Center and University Hospital Heidelberg, reported at ASH.

Now, the latest analysis, which followed patients for a median of 99 months (8.25 years), confirmed the initial 2021 findings, Dr. Baertsch explained. 

“The writing on the wall is clear: Don’t repeat a transplant at the time of relapse for those who have already gotten a transplant,” said Manni Mohyuddin, MD, of the University of Utah in Salt Lake City, who was not involved in the research. Dr. Mohyuddin added, however, that this finding doesn’t apply to those who haven’t yet gotten a transplant. “Data from other trials suggests a role of transplant in this situation, depending on the unique circumstances.” 

The current trial included 282 adult patients, aged 75 years or younger, with relapsed or refractory multiple myeloma. Between 2010 and 2016, patients in the intention-to-treat analysis (n = 277) were randomized to lenalidomide-dexamethasone reinduction and maintenance, along with salvage high-dose chemotherapy with melphalan and autologous stem cell transplantation (n = 139) or just continuous lenalidomide-dexamethasone until progression (n = 138). 

Patients in both arms received three cycles of lenalidomide-dexamethasone up front: 25 mg of lenalidomide on days 1 through 21, and 40 mg of dexamethasone on days 1, 8, 15, and 22 in 4-week cycles. Those in the salvage transplant arm then received high-dose chemotherapy with 200 mg/m² of melphalan followed by transplant and 10 mg of lenalidomide maintenance therapy daily, while those in the control arm continued with receiving lenalidomide-dexamethasone.

All patients had received one to three prior lines of therapy, had good performance status, and had a time-to-disease-progression of at least 12 months after frontline autologous stem cell transplant.

In the primary 2021 study, patients in the salvage transplant group did not demonstrate a survival benefit (hazard ratio [HR] for PFS, 0.87; HR for overall survival, 0.81). 

In the latest analysis, no survival benefit emerged after following patients for a median of about 8 years. Patients in the salvage transplant arm had a median PFS of 20.5 months vs 19.3 months in the continuous therapy arms (HR, 0.98; 95% CI, 0.76-1.27; P = .9). Median overall survival was 67.1 months in the salvage transplant arm and 62.7 months in the continuous treatment arm (HR, 0.89; 95% CI, 0.66 - 1.20; P = .44).

Time to first progression after frontline transplant was associated with a PFS benefit but did not predict an overall survival benefit, Dr. Baertsch noted. 

When evaluating outcomes from the time of salvage transplant to account for the high number of dropouts, the PFS and overall survival findings held. Patients who received salvage transplant did not experience significantly improved PFS (HR, 0.91) or overall survival (76.3 months in the salvage group vs 65.9 months in the continuous treatment arm; HR, 0.80). 

The lack of PFS and overall survival benefit occurred across all myeloma subgroups, Dr. Baertsch said. 

Overall, the results indicate that “ a repeat transplant at the time of relapse for patients who had already gotten a transplant previously was no better than continuing a two-drug regimen,” Dr. Mohyuddin said.

However, he noted, “a lot has changed for myeloma care” since this trial was initially conducted. “We now have better regimens available that do not involve a transplant. If a repeat transplant couldn’t beat a two-drug regimen, it surely cannot beat a three drug or four drug regimen.” 

Dr. Baertsch reported no disclosures.

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

SAN DIEGO — Long-term follow-up from the only randomized controlled trial to compare salvage autologous stem cell transplant with a standard two-drug regimen in patients with relapsed or refractory multiple myeloma found no benefit to salvage transplant. 

Patients receiving a second, salvage-autologous stem cell transplant alongside lenalidomide-dexamethasone maintenance therapy did not demonstrate improved progression-free survival (PFS) or overall survival compared with patients who continued the two-drug regimen without salvage transplant, according to research presented at the American Society of Hematology annual meeting.

The primary phase 3 analysis, published in 2021, showed no survival benefit following salvage transplant at the time of relapse, though it only followed patients for a median of 37 months. 

However, because a significant fraction of patients in the transplant arm — about 29% — did not undergo the planned salvage transplant before dropping out of the study, the researchers performed further analyses that “suggested a survival benefit in patients who actually received the transplant,” first author Marc-Andrea Baertsch, MD, of the German Cancer Research Center and University Hospital Heidelberg, reported at ASH.

Now, the latest analysis, which followed patients for a median of 99 months (8.25 years), confirmed the initial 2021 findings, Dr. Baertsch explained. 

“The writing on the wall is clear: Don’t repeat a transplant at the time of relapse for those who have already gotten a transplant,” said Manni Mohyuddin, MD, of the University of Utah in Salt Lake City, who was not involved in the research. Dr. Mohyuddin added, however, that this finding doesn’t apply to those who haven’t yet gotten a transplant. “Data from other trials suggests a role of transplant in this situation, depending on the unique circumstances.” 

The current trial included 282 adult patients, aged 75 years or younger, with relapsed or refractory multiple myeloma. Between 2010 and 2016, patients in the intention-to-treat analysis (n = 277) were randomized to lenalidomide-dexamethasone reinduction and maintenance, along with salvage high-dose chemotherapy with melphalan and autologous stem cell transplantation (n = 139) or just continuous lenalidomide-dexamethasone until progression (n = 138). 

Patients in both arms received three cycles of lenalidomide-dexamethasone up front: 25 mg of lenalidomide on days 1 through 21, and 40 mg of dexamethasone on days 1, 8, 15, and 22 in 4-week cycles. Those in the salvage transplant arm then received high-dose chemotherapy with 200 mg/m² of melphalan followed by transplant and 10 mg of lenalidomide maintenance therapy daily, while those in the control arm continued with receiving lenalidomide-dexamethasone.

All patients had received one to three prior lines of therapy, had good performance status, and had a time-to-disease-progression of at least 12 months after frontline autologous stem cell transplant.

In the primary 2021 study, patients in the salvage transplant group did not demonstrate a survival benefit (hazard ratio [HR] for PFS, 0.87; HR for overall survival, 0.81). 

In the latest analysis, no survival benefit emerged after following patients for a median of about 8 years. Patients in the salvage transplant arm had a median PFS of 20.5 months vs 19.3 months in the continuous therapy arms (HR, 0.98; 95% CI, 0.76-1.27; P = .9). Median overall survival was 67.1 months in the salvage transplant arm and 62.7 months in the continuous treatment arm (HR, 0.89; 95% CI, 0.66 - 1.20; P = .44).

Time to first progression after frontline transplant was associated with a PFS benefit but did not predict an overall survival benefit, Dr. Baertsch noted. 

When evaluating outcomes from the time of salvage transplant to account for the high number of dropouts, the PFS and overall survival findings held. Patients who received salvage transplant did not experience significantly improved PFS (HR, 0.91) or overall survival (76.3 months in the salvage group vs 65.9 months in the continuous treatment arm; HR, 0.80). 

The lack of PFS and overall survival benefit occurred across all myeloma subgroups, Dr. Baertsch said. 

Overall, the results indicate that “ a repeat transplant at the time of relapse for patients who had already gotten a transplant previously was no better than continuing a two-drug regimen,” Dr. Mohyuddin said.

However, he noted, “a lot has changed for myeloma care” since this trial was initially conducted. “We now have better regimens available that do not involve a transplant. If a repeat transplant couldn’t beat a two-drug regimen, it surely cannot beat a three drug or four drug regimen.” 

Dr. Baertsch reported no disclosures.

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

SAN DIEGO — Long-term follow-up from the only randomized controlled trial to compare salvage autologous stem cell transplant with a standard two-drug regimen in patients with relapsed or refractory multiple myeloma found no benefit to salvage transplant. 

Patients receiving a second, salvage-autologous stem cell transplant alongside lenalidomide-dexamethasone maintenance therapy did not demonstrate improved progression-free survival (PFS) or overall survival compared with patients who continued the two-drug regimen without salvage transplant, according to research presented at the American Society of Hematology annual meeting.

The primary phase 3 analysis, published in 2021, showed no survival benefit following salvage transplant at the time of relapse, though it only followed patients for a median of 37 months. 

However, because a significant fraction of patients in the transplant arm — about 29% — did not undergo the planned salvage transplant before dropping out of the study, the researchers performed further analyses that “suggested a survival benefit in patients who actually received the transplant,” first author Marc-Andrea Baertsch, MD, of the German Cancer Research Center and University Hospital Heidelberg, reported at ASH.

Now, the latest analysis, which followed patients for a median of 99 months (8.25 years), confirmed the initial 2021 findings, Dr. Baertsch explained. 

“The writing on the wall is clear: Don’t repeat a transplant at the time of relapse for those who have already gotten a transplant,” said Manni Mohyuddin, MD, of the University of Utah in Salt Lake City, who was not involved in the research. Dr. Mohyuddin added, however, that this finding doesn’t apply to those who haven’t yet gotten a transplant. “Data from other trials suggests a role of transplant in this situation, depending on the unique circumstances.” 

The current trial included 282 adult patients, aged 75 years or younger, with relapsed or refractory multiple myeloma. Between 2010 and 2016, patients in the intention-to-treat analysis (n = 277) were randomized to lenalidomide-dexamethasone reinduction and maintenance, along with salvage high-dose chemotherapy with melphalan and autologous stem cell transplantation (n = 139) or just continuous lenalidomide-dexamethasone until progression (n = 138). 

Patients in both arms received three cycles of lenalidomide-dexamethasone up front: 25 mg of lenalidomide on days 1 through 21, and 40 mg of dexamethasone on days 1, 8, 15, and 22 in 4-week cycles. Those in the salvage transplant arm then received high-dose chemotherapy with 200 mg/m² of melphalan followed by transplant and 10 mg of lenalidomide maintenance therapy daily, while those in the control arm continued with receiving lenalidomide-dexamethasone.

All patients had received one to three prior lines of therapy, had good performance status, and had a time-to-disease-progression of at least 12 months after frontline autologous stem cell transplant.

In the primary 2021 study, patients in the salvage transplant group did not demonstrate a survival benefit (hazard ratio [HR] for PFS, 0.87; HR for overall survival, 0.81). 

In the latest analysis, no survival benefit emerged after following patients for a median of about 8 years. Patients in the salvage transplant arm had a median PFS of 20.5 months vs 19.3 months in the continuous therapy arms (HR, 0.98; 95% CI, 0.76-1.27; P = .9). Median overall survival was 67.1 months in the salvage transplant arm and 62.7 months in the continuous treatment arm (HR, 0.89; 95% CI, 0.66 - 1.20; P = .44).

Time to first progression after frontline transplant was associated with a PFS benefit but did not predict an overall survival benefit, Dr. Baertsch noted. 

When evaluating outcomes from the time of salvage transplant to account for the high number of dropouts, the PFS and overall survival findings held. Patients who received salvage transplant did not experience significantly improved PFS (HR, 0.91) or overall survival (76.3 months in the salvage group vs 65.9 months in the continuous treatment arm; HR, 0.80). 

The lack of PFS and overall survival benefit occurred across all myeloma subgroups, Dr. Baertsch said. 

Overall, the results indicate that “ a repeat transplant at the time of relapse for patients who had already gotten a transplant previously was no better than continuing a two-drug regimen,” Dr. Mohyuddin said.

However, he noted, “a lot has changed for myeloma care” since this trial was initially conducted. “We now have better regimens available that do not involve a transplant. If a repeat transplant couldn’t beat a two-drug regimen, it surely cannot beat a three drug or four drug regimen.” 

Dr. Baertsch reported no disclosures.

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