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Fungi inside cancer cells: ‘A new and emerging hallmark’
The investigators characterized the cancer mycobiome within 17,401 tissue, blood, and plasma samples from four international cohorts, revealing new information about fungi distribution, association with immune cells, and potential prognostic value.
Fungi were detected in all cancer types studied and were often intracellular, reported Lian Narunsky-Haziza, PhD, of Weizmann Institute of Science, Rehovot, Israel, and colleagues.
Additionally, multiple fungal-bacterial-immune ecologies were detected across tumors, and intratumoral fungi stratified clinical outcomes, including immunotherapy response, they noted. Also, cell-free fungal DNA diagnosed healthy and cancer patients in early-stage disease.
The findings, published online in the journal Cell, have potential implications for cancer detection, diagnosis, and treatment, the researchers suggested.
The existence of fungi in most human cancers “is both a surprise and to be expected,” study coauthor Rob Knight, PhD, a professor at the University of California, San Diego, stated in a press release. “It is surprising because we don’t know how fungi could get into tumors throughout the body. But it is also expected, because it fits the pattern of healthy microbiomes throughout the body, including the gut, mouth, and skin, where bacteria and fungi interact as part of a complex community.”
Exploration of the associations between cancer and microbes are nothing new, but cancer-associated fungi have rarely been examined, the authors noted.
The findings from this pan-cancer analysis, which suggested “prognostic and diagnostic capacities of the tissue and plasma mycobiomes, even in stage I cancers,” complement current “understanding of the interaction between cancer cells and the bacteria that exist in tumors alongside fungi, bacteria that have been shown to affect cancer growth, metastasis, and response to therapy,” they explained.
Of note, the study revealed multiple correlations between the presence of specific fungi in tumors and conditions related to treatment. For example, patients with breast cancer whose tumors contained Malassezia globosa – a fungus found naturally on the skin – had a much lower survival rate than those whose tumors did not contain the fungus. Furthermore, specific fungi were more prevalent in breast tumors from older vs. younger patients, in lung tumors of smokers vs. nonsmokers, and in melanoma tumors that responded to immunotherapy vs. those that did not respond.
These findings suggest that fungal activity is “a new and emerging hallmark of cancer,” stated study coleader Ravid Straussman, PhD, of the Weizmann molecular cell biology department. “These findings should drive us to better explore the potential effects of tumor fungi and to re-examine almost everything we know about cancer through a ‘microbiome lens.’ ”
Unique relationships observed between fungi and bacteria – for example, tumors that contain Aspergillus fungi tended to have specific bacteria in them, whereas tumors that contain Malassezia fungi tended to have other bacteria in them – may have implications for treatment, as they correlated with both tumor immunity and patient survival, according to the authors.
“This study sheds new light on the complex biological environment within tumors, and future research will reveal how fungi affect cancerous growth,” said coauthor Yitzhak Pilpel, PhD, a principal investigator at the Weizmann molecular genetics department. “The fact that fungi can be found not only in cancer cells but also in immune cells implies that, in the future, we’ll probably find that fungi have some effect not only on the cancer cells but also on immune cells and their activity.”
A further finding related to the presence of fungal and bacterial DNA in human blood further suggests that measuring microbial DNA in the blood could lead to early detection of cancer, the authors noted.
Dr. Straussman’s research is supported by the Swiss Society Institute for Cancer Prevention Research, the Fabricant-Morse Families Research Fund for Humanity, the Dr. Chantal d’Adesky Scheinberg Research Fund, and the Dr. Dvora and Haim Teitelbaum Endowment Fund.
A version of this article first appeared on Medscape.com.
The investigators characterized the cancer mycobiome within 17,401 tissue, blood, and plasma samples from four international cohorts, revealing new information about fungi distribution, association with immune cells, and potential prognostic value.
Fungi were detected in all cancer types studied and were often intracellular, reported Lian Narunsky-Haziza, PhD, of Weizmann Institute of Science, Rehovot, Israel, and colleagues.
Additionally, multiple fungal-bacterial-immune ecologies were detected across tumors, and intratumoral fungi stratified clinical outcomes, including immunotherapy response, they noted. Also, cell-free fungal DNA diagnosed healthy and cancer patients in early-stage disease.
The findings, published online in the journal Cell, have potential implications for cancer detection, diagnosis, and treatment, the researchers suggested.
The existence of fungi in most human cancers “is both a surprise and to be expected,” study coauthor Rob Knight, PhD, a professor at the University of California, San Diego, stated in a press release. “It is surprising because we don’t know how fungi could get into tumors throughout the body. But it is also expected, because it fits the pattern of healthy microbiomes throughout the body, including the gut, mouth, and skin, where bacteria and fungi interact as part of a complex community.”
Exploration of the associations between cancer and microbes are nothing new, but cancer-associated fungi have rarely been examined, the authors noted.
The findings from this pan-cancer analysis, which suggested “prognostic and diagnostic capacities of the tissue and plasma mycobiomes, even in stage I cancers,” complement current “understanding of the interaction between cancer cells and the bacteria that exist in tumors alongside fungi, bacteria that have been shown to affect cancer growth, metastasis, and response to therapy,” they explained.
Of note, the study revealed multiple correlations between the presence of specific fungi in tumors and conditions related to treatment. For example, patients with breast cancer whose tumors contained Malassezia globosa – a fungus found naturally on the skin – had a much lower survival rate than those whose tumors did not contain the fungus. Furthermore, specific fungi were more prevalent in breast tumors from older vs. younger patients, in lung tumors of smokers vs. nonsmokers, and in melanoma tumors that responded to immunotherapy vs. those that did not respond.
These findings suggest that fungal activity is “a new and emerging hallmark of cancer,” stated study coleader Ravid Straussman, PhD, of the Weizmann molecular cell biology department. “These findings should drive us to better explore the potential effects of tumor fungi and to re-examine almost everything we know about cancer through a ‘microbiome lens.’ ”
Unique relationships observed between fungi and bacteria – for example, tumors that contain Aspergillus fungi tended to have specific bacteria in them, whereas tumors that contain Malassezia fungi tended to have other bacteria in them – may have implications for treatment, as they correlated with both tumor immunity and patient survival, according to the authors.
“This study sheds new light on the complex biological environment within tumors, and future research will reveal how fungi affect cancerous growth,” said coauthor Yitzhak Pilpel, PhD, a principal investigator at the Weizmann molecular genetics department. “The fact that fungi can be found not only in cancer cells but also in immune cells implies that, in the future, we’ll probably find that fungi have some effect not only on the cancer cells but also on immune cells and their activity.”
A further finding related to the presence of fungal and bacterial DNA in human blood further suggests that measuring microbial DNA in the blood could lead to early detection of cancer, the authors noted.
Dr. Straussman’s research is supported by the Swiss Society Institute for Cancer Prevention Research, the Fabricant-Morse Families Research Fund for Humanity, the Dr. Chantal d’Adesky Scheinberg Research Fund, and the Dr. Dvora and Haim Teitelbaum Endowment Fund.
A version of this article first appeared on Medscape.com.
The investigators characterized the cancer mycobiome within 17,401 tissue, blood, and plasma samples from four international cohorts, revealing new information about fungi distribution, association with immune cells, and potential prognostic value.
Fungi were detected in all cancer types studied and were often intracellular, reported Lian Narunsky-Haziza, PhD, of Weizmann Institute of Science, Rehovot, Israel, and colleagues.
Additionally, multiple fungal-bacterial-immune ecologies were detected across tumors, and intratumoral fungi stratified clinical outcomes, including immunotherapy response, they noted. Also, cell-free fungal DNA diagnosed healthy and cancer patients in early-stage disease.
The findings, published online in the journal Cell, have potential implications for cancer detection, diagnosis, and treatment, the researchers suggested.
The existence of fungi in most human cancers “is both a surprise and to be expected,” study coauthor Rob Knight, PhD, a professor at the University of California, San Diego, stated in a press release. “It is surprising because we don’t know how fungi could get into tumors throughout the body. But it is also expected, because it fits the pattern of healthy microbiomes throughout the body, including the gut, mouth, and skin, where bacteria and fungi interact as part of a complex community.”
Exploration of the associations between cancer and microbes are nothing new, but cancer-associated fungi have rarely been examined, the authors noted.
The findings from this pan-cancer analysis, which suggested “prognostic and diagnostic capacities of the tissue and plasma mycobiomes, even in stage I cancers,” complement current “understanding of the interaction between cancer cells and the bacteria that exist in tumors alongside fungi, bacteria that have been shown to affect cancer growth, metastasis, and response to therapy,” they explained.
Of note, the study revealed multiple correlations between the presence of specific fungi in tumors and conditions related to treatment. For example, patients with breast cancer whose tumors contained Malassezia globosa – a fungus found naturally on the skin – had a much lower survival rate than those whose tumors did not contain the fungus. Furthermore, specific fungi were more prevalent in breast tumors from older vs. younger patients, in lung tumors of smokers vs. nonsmokers, and in melanoma tumors that responded to immunotherapy vs. those that did not respond.
These findings suggest that fungal activity is “a new and emerging hallmark of cancer,” stated study coleader Ravid Straussman, PhD, of the Weizmann molecular cell biology department. “These findings should drive us to better explore the potential effects of tumor fungi and to re-examine almost everything we know about cancer through a ‘microbiome lens.’ ”
Unique relationships observed between fungi and bacteria – for example, tumors that contain Aspergillus fungi tended to have specific bacteria in them, whereas tumors that contain Malassezia fungi tended to have other bacteria in them – may have implications for treatment, as they correlated with both tumor immunity and patient survival, according to the authors.
“This study sheds new light on the complex biological environment within tumors, and future research will reveal how fungi affect cancerous growth,” said coauthor Yitzhak Pilpel, PhD, a principal investigator at the Weizmann molecular genetics department. “The fact that fungi can be found not only in cancer cells but also in immune cells implies that, in the future, we’ll probably find that fungi have some effect not only on the cancer cells but also on immune cells and their activity.”
A further finding related to the presence of fungal and bacterial DNA in human blood further suggests that measuring microbial DNA in the blood could lead to early detection of cancer, the authors noted.
Dr. Straussman’s research is supported by the Swiss Society Institute for Cancer Prevention Research, the Fabricant-Morse Families Research Fund for Humanity, the Dr. Chantal d’Adesky Scheinberg Research Fund, and the Dr. Dvora and Haim Teitelbaum Endowment Fund.
A version of this article first appeared on Medscape.com.
FROM CELL
Doctors urge screening for autoimmune disorders for patients with celiac disease
Diagnosed at age 4, Dr. Mollo has been on a gluten-free diet for 41 years, which she says has kept her healthy and may also be why she hasn’t developed other autoimmune diseases. It’s also played a part in her thinking about screening patients with CD.
“I think [physicians] should definitely be screening people with celiac disease for autoimmune disorders, especially if they see things like anemia or if a child has dropped on the growth chart and has nutrient deficiencies,” said Dr. Mollo, whose daughter also has the disease. “I would recommend that they see someone who specializes in celiac disease so they can get monitored and have regular follow-up checks for nutrient deficiencies and other autoimmune disorders.”
Dr. Mollo’s views on screening are echoed by many CD specialists and physicians, who cite multiple studies that have found that people with the disease face higher risks for diabetes, thyroid conditions, arthritis, and other autoimmune disorders.
Gastroenterologist Alessio Fasano, MD, with Massachusetts General Hospital, Boston, said there has been a “shift in the paradigm in thinking” about cross-screening for CD and autoimmune disorders. As result, he believes the answer to the question of whether to routinely do so is a no-brainer.
“The bottom line is, if you have CD, it [should be] routine that during your annual follow-ups you check for the possibility of the onset of other autoimmune disease. And people with other autoimmune diseases, like type 1 diabetes, should also be screened for CD because of the comorbidity,” said Dr. Fasano, professor of pediatrics and gastroenterology at Harvard Medical School and professor of nutrition at the Harvard School of Public Health, both in Boston. “This is what we call good clinical practice.”
Screening, despite lack of consensus guidelines
Other CD specialists differ on the need for universal cross-screening but agree that, at least in some cases, people with one autoimmune disorder should be tested for others.
Jolanda Denham, MD, a pediatric gastroenterologist affiliated with Nemours Children’s Hospital in Orlando, routinely recommends that her patients with CD be screened for certain autoimmune disorders – such as type 1 diabetes and autoimmune thyroid and liver diseases – even though medical organizations have not developed clear consensus or standard guidelines on cross-screening.
“There currently is no evidence to support the screening of celiac patients for all autoimmune and rheumatologic disorders,” she said. “It is true that celiac disease is an autoimmune disorder, and as such, there is a definite increased risk of these disorders in patients with celiac disease and vice versa.”
Echoing Dr. Denham, New York–based gastroenterologist Benjamin Lebwohl, MD, president of the Society for the Study of Celiac Disease, urges physicians to look beyond consensus guidelines and to err on the side of caution and make the best decisions for their patients on a case-by-case basis.
“Given the increased risk of certain autoimmune conditions in people with celiac disease, it behooves physicians to have a low threshold to evaluate for these conditions if any suggestive symptoms are present,” said Dr. Lebwohl, director of clinical research at the Celiac Disease Center at Columbia University, New York.
“Whether to screen for these conditions among people who are entirely without symptoms is less certain, and there is no consensus on that. But it is reasonable and common to include some basic tests with annual blood work, such as thyroid function and a liver profile, since both autoimmune thyroid disease and autoimmune liver disease can be silent early on and the patient would potentially benefit from identification and treatment of these conditions,” he said.
The American Diabetes Association and the International Society of Pediatric and Adolescent Diabetes do recommend that people with diabetes be screened for CD years after diagnosis, noted Robert Rapaport, MD, a pediatric endocrinologist, with Kravis Children’s Hospital, New York. But in a study published in 2021, he and colleagues found that this wasn’t occurring, which prompted them to recommend yearly screening.
“There is a consensus that in children with type 1 diabetes, we screen them for other autoimmune disorders, specifically for thyroid disease and celiac disease,” said Dr. Rapaport, who is also Emma Elizabeth Sullivan Professor of Pediatric Endocrinology and Diabetes at Icahn School of Medicine at Mount Sinai, New York. “But there is no consensus going the other way – for patients with celiac disease, what other autoimmune conditions they should be screened for.”
This hasn’t kept some doctors from extending cross-screening efforts to their patients.
“At our center, we screen ... for thyroid disease and autoimmune liver disease as part of routine healthcare maintenance for our celiac disease patients. We discuss symptoms of diabetes and send screening with [hemoglobin] A1c for anyone who has symptoms,” said Lui Edwin, MD, a pediatric gastroenterologist with Children’s Hospital Colorado, Aurora, and director of the Colorado Center for Celiac Disease, who delivered a lecture on CD-autoimmune screening at the International Celiac Disease Symposium in October.
“It is definitely worth screening for celiac disease in [those with] other autoimmune disorders,” Dr. Edwin added.
“The symptoms can be very heterogeneous. Diagnosing and treating celiac disease can make a huge impact with respect to symptoms, quality of life, and preventing disease-related complications,” he said.
Mounting evidence linking CD to autoimmune disorders
Many studies have linked CD to a variety of other autoimmune disorders. The association could be due to common genetic factors or because CD might lead to such conditions. Researchers have found that people diagnosed with CD later in life are more likely to develop other autoimmune disorders.
Some studies have also found that people with certain autoimmune diseases are more likely to also have CD. In addition, some individuals develop what’s known as nonceliac gluten sensitivity, which is not an autoimmune disease but a gluten intolerance not unlike lactose intolerance.
In light of these coexisting conditions in many people with CD and other autoimmune disorders, as well as the fact that the prevalence of CD is on the rise, some specialists argue that the benefits of routine cross-screening outweigh the risks.
Going gluten free has preventive advantages
In a landmark 2012 study, researchers with the Celiac Disease Center at Columbia University stopped short of recommending routine screening for the general public or asymptomatic individuals in high-prevalence groups. But they concluded that more screening of symptomatic individuals – and close relatives – would speed treatment for those with more than one autoimmune disorder.
They also noted that some studies have found that a gluten-free diet might help prevent the development of other autoimmune disorders.
Marisa Gallant Stahl, MD, a gastroenterologist with Children’s Hospital Colorado, agreed that it is important that physicians keep gluten-free diets in mind when determining which patients to cross-screen.
“The literature is mixed, but some studies suggest that treating celiac disease with a gluten-free diet actually augments the treatment and control of other autoimmune disorders [and] adherence to a gluten-free diet does reduce the risk of cancer associated with celiac disease,” she said.
Dr. Denham agreed. “Strict adherence to a gluten-free diet definitely protects against the development of enteropathy-associated T-cell lymphoma but may be protective against non-Hodgkin’s lymphoma and adenocarcinoma of the small intestine as well. All three are associated with long-term nonadherence to a gluten-free diet.”
She also noted that a gluten-free diet may help people with CD manage other autoimmune disorders, which can be complicated by CD.
“Good control of celiac disease will help prevent complications that can worsen symptoms and outcomes of concomitant autoimmune and rheumatologic disorders,” she said.
Other factors to consider
Dr. Fasano added that autoimmune disorders can be complicated by CD in cases in which oral medications or healthful foods are not properly absorbed in the intestines.
“For example, with Hashimoto’s disease, if you have hormone replacement with oral treatments and your intestines are not 100% functional because you have inflammation, then you may have a problem [with] the absorption of medications like levothyroxine,” he said.
“It’s the same story with diabetes. You don’t take insulin by mouth, but glucose [control] strongly depends on several factors, mostly what comes from the diet, and if it’s erratic, that can be a problem. ... So, the treatment of autoimmune diseases can be influenced by celiac disease,” he said.
In addition, Dr. Fasano and others believe that people with CD and other autoimmune disorders should be managed by a team of experts who can personalize the care on the basis of specific needs of the individual patient. These should include specialists, dietitians, mental health counselors, and family social workers.
“It has to be a multidisciplinary approach to maintain the good health of an individual,” Dr. Fasano said. “Celiac disease is the quintessential example in which the primary care physician needs to be the quarterback of the team, the patient is active in his or her health, and [specialists] not only deliver personalized care but also preventive intervention, particularly the prevention of comorbidities.”
Financial disclosures for those quoted in this article were not available at the time of publication.
A version of this article first appeared on Medscape.com.
Diagnosed at age 4, Dr. Mollo has been on a gluten-free diet for 41 years, which she says has kept her healthy and may also be why she hasn’t developed other autoimmune diseases. It’s also played a part in her thinking about screening patients with CD.
“I think [physicians] should definitely be screening people with celiac disease for autoimmune disorders, especially if they see things like anemia or if a child has dropped on the growth chart and has nutrient deficiencies,” said Dr. Mollo, whose daughter also has the disease. “I would recommend that they see someone who specializes in celiac disease so they can get monitored and have regular follow-up checks for nutrient deficiencies and other autoimmune disorders.”
Dr. Mollo’s views on screening are echoed by many CD specialists and physicians, who cite multiple studies that have found that people with the disease face higher risks for diabetes, thyroid conditions, arthritis, and other autoimmune disorders.
Gastroenterologist Alessio Fasano, MD, with Massachusetts General Hospital, Boston, said there has been a “shift in the paradigm in thinking” about cross-screening for CD and autoimmune disorders. As result, he believes the answer to the question of whether to routinely do so is a no-brainer.
“The bottom line is, if you have CD, it [should be] routine that during your annual follow-ups you check for the possibility of the onset of other autoimmune disease. And people with other autoimmune diseases, like type 1 diabetes, should also be screened for CD because of the comorbidity,” said Dr. Fasano, professor of pediatrics and gastroenterology at Harvard Medical School and professor of nutrition at the Harvard School of Public Health, both in Boston. “This is what we call good clinical practice.”
Screening, despite lack of consensus guidelines
Other CD specialists differ on the need for universal cross-screening but agree that, at least in some cases, people with one autoimmune disorder should be tested for others.
Jolanda Denham, MD, a pediatric gastroenterologist affiliated with Nemours Children’s Hospital in Orlando, routinely recommends that her patients with CD be screened for certain autoimmune disorders – such as type 1 diabetes and autoimmune thyroid and liver diseases – even though medical organizations have not developed clear consensus or standard guidelines on cross-screening.
“There currently is no evidence to support the screening of celiac patients for all autoimmune and rheumatologic disorders,” she said. “It is true that celiac disease is an autoimmune disorder, and as such, there is a definite increased risk of these disorders in patients with celiac disease and vice versa.”
Echoing Dr. Denham, New York–based gastroenterologist Benjamin Lebwohl, MD, president of the Society for the Study of Celiac Disease, urges physicians to look beyond consensus guidelines and to err on the side of caution and make the best decisions for their patients on a case-by-case basis.
“Given the increased risk of certain autoimmune conditions in people with celiac disease, it behooves physicians to have a low threshold to evaluate for these conditions if any suggestive symptoms are present,” said Dr. Lebwohl, director of clinical research at the Celiac Disease Center at Columbia University, New York.
“Whether to screen for these conditions among people who are entirely without symptoms is less certain, and there is no consensus on that. But it is reasonable and common to include some basic tests with annual blood work, such as thyroid function and a liver profile, since both autoimmune thyroid disease and autoimmune liver disease can be silent early on and the patient would potentially benefit from identification and treatment of these conditions,” he said.
The American Diabetes Association and the International Society of Pediatric and Adolescent Diabetes do recommend that people with diabetes be screened for CD years after diagnosis, noted Robert Rapaport, MD, a pediatric endocrinologist, with Kravis Children’s Hospital, New York. But in a study published in 2021, he and colleagues found that this wasn’t occurring, which prompted them to recommend yearly screening.
“There is a consensus that in children with type 1 diabetes, we screen them for other autoimmune disorders, specifically for thyroid disease and celiac disease,” said Dr. Rapaport, who is also Emma Elizabeth Sullivan Professor of Pediatric Endocrinology and Diabetes at Icahn School of Medicine at Mount Sinai, New York. “But there is no consensus going the other way – for patients with celiac disease, what other autoimmune conditions they should be screened for.”
This hasn’t kept some doctors from extending cross-screening efforts to their patients.
“At our center, we screen ... for thyroid disease and autoimmune liver disease as part of routine healthcare maintenance for our celiac disease patients. We discuss symptoms of diabetes and send screening with [hemoglobin] A1c for anyone who has symptoms,” said Lui Edwin, MD, a pediatric gastroenterologist with Children’s Hospital Colorado, Aurora, and director of the Colorado Center for Celiac Disease, who delivered a lecture on CD-autoimmune screening at the International Celiac Disease Symposium in October.
“It is definitely worth screening for celiac disease in [those with] other autoimmune disorders,” Dr. Edwin added.
“The symptoms can be very heterogeneous. Diagnosing and treating celiac disease can make a huge impact with respect to symptoms, quality of life, and preventing disease-related complications,” he said.
Mounting evidence linking CD to autoimmune disorders
Many studies have linked CD to a variety of other autoimmune disorders. The association could be due to common genetic factors or because CD might lead to such conditions. Researchers have found that people diagnosed with CD later in life are more likely to develop other autoimmune disorders.
Some studies have also found that people with certain autoimmune diseases are more likely to also have CD. In addition, some individuals develop what’s known as nonceliac gluten sensitivity, which is not an autoimmune disease but a gluten intolerance not unlike lactose intolerance.
In light of these coexisting conditions in many people with CD and other autoimmune disorders, as well as the fact that the prevalence of CD is on the rise, some specialists argue that the benefits of routine cross-screening outweigh the risks.
Going gluten free has preventive advantages
In a landmark 2012 study, researchers with the Celiac Disease Center at Columbia University stopped short of recommending routine screening for the general public or asymptomatic individuals in high-prevalence groups. But they concluded that more screening of symptomatic individuals – and close relatives – would speed treatment for those with more than one autoimmune disorder.
They also noted that some studies have found that a gluten-free diet might help prevent the development of other autoimmune disorders.
Marisa Gallant Stahl, MD, a gastroenterologist with Children’s Hospital Colorado, agreed that it is important that physicians keep gluten-free diets in mind when determining which patients to cross-screen.
“The literature is mixed, but some studies suggest that treating celiac disease with a gluten-free diet actually augments the treatment and control of other autoimmune disorders [and] adherence to a gluten-free diet does reduce the risk of cancer associated with celiac disease,” she said.
Dr. Denham agreed. “Strict adherence to a gluten-free diet definitely protects against the development of enteropathy-associated T-cell lymphoma but may be protective against non-Hodgkin’s lymphoma and adenocarcinoma of the small intestine as well. All three are associated with long-term nonadherence to a gluten-free diet.”
She also noted that a gluten-free diet may help people with CD manage other autoimmune disorders, which can be complicated by CD.
“Good control of celiac disease will help prevent complications that can worsen symptoms and outcomes of concomitant autoimmune and rheumatologic disorders,” she said.
Other factors to consider
Dr. Fasano added that autoimmune disorders can be complicated by CD in cases in which oral medications or healthful foods are not properly absorbed in the intestines.
“For example, with Hashimoto’s disease, if you have hormone replacement with oral treatments and your intestines are not 100% functional because you have inflammation, then you may have a problem [with] the absorption of medications like levothyroxine,” he said.
“It’s the same story with diabetes. You don’t take insulin by mouth, but glucose [control] strongly depends on several factors, mostly what comes from the diet, and if it’s erratic, that can be a problem. ... So, the treatment of autoimmune diseases can be influenced by celiac disease,” he said.
In addition, Dr. Fasano and others believe that people with CD and other autoimmune disorders should be managed by a team of experts who can personalize the care on the basis of specific needs of the individual patient. These should include specialists, dietitians, mental health counselors, and family social workers.
“It has to be a multidisciplinary approach to maintain the good health of an individual,” Dr. Fasano said. “Celiac disease is the quintessential example in which the primary care physician needs to be the quarterback of the team, the patient is active in his or her health, and [specialists] not only deliver personalized care but also preventive intervention, particularly the prevention of comorbidities.”
Financial disclosures for those quoted in this article were not available at the time of publication.
A version of this article first appeared on Medscape.com.
Diagnosed at age 4, Dr. Mollo has been on a gluten-free diet for 41 years, which she says has kept her healthy and may also be why she hasn’t developed other autoimmune diseases. It’s also played a part in her thinking about screening patients with CD.
“I think [physicians] should definitely be screening people with celiac disease for autoimmune disorders, especially if they see things like anemia or if a child has dropped on the growth chart and has nutrient deficiencies,” said Dr. Mollo, whose daughter also has the disease. “I would recommend that they see someone who specializes in celiac disease so they can get monitored and have regular follow-up checks for nutrient deficiencies and other autoimmune disorders.”
Dr. Mollo’s views on screening are echoed by many CD specialists and physicians, who cite multiple studies that have found that people with the disease face higher risks for diabetes, thyroid conditions, arthritis, and other autoimmune disorders.
Gastroenterologist Alessio Fasano, MD, with Massachusetts General Hospital, Boston, said there has been a “shift in the paradigm in thinking” about cross-screening for CD and autoimmune disorders. As result, he believes the answer to the question of whether to routinely do so is a no-brainer.
“The bottom line is, if you have CD, it [should be] routine that during your annual follow-ups you check for the possibility of the onset of other autoimmune disease. And people with other autoimmune diseases, like type 1 diabetes, should also be screened for CD because of the comorbidity,” said Dr. Fasano, professor of pediatrics and gastroenterology at Harvard Medical School and professor of nutrition at the Harvard School of Public Health, both in Boston. “This is what we call good clinical practice.”
Screening, despite lack of consensus guidelines
Other CD specialists differ on the need for universal cross-screening but agree that, at least in some cases, people with one autoimmune disorder should be tested for others.
Jolanda Denham, MD, a pediatric gastroenterologist affiliated with Nemours Children’s Hospital in Orlando, routinely recommends that her patients with CD be screened for certain autoimmune disorders – such as type 1 diabetes and autoimmune thyroid and liver diseases – even though medical organizations have not developed clear consensus or standard guidelines on cross-screening.
“There currently is no evidence to support the screening of celiac patients for all autoimmune and rheumatologic disorders,” she said. “It is true that celiac disease is an autoimmune disorder, and as such, there is a definite increased risk of these disorders in patients with celiac disease and vice versa.”
Echoing Dr. Denham, New York–based gastroenterologist Benjamin Lebwohl, MD, president of the Society for the Study of Celiac Disease, urges physicians to look beyond consensus guidelines and to err on the side of caution and make the best decisions for their patients on a case-by-case basis.
“Given the increased risk of certain autoimmune conditions in people with celiac disease, it behooves physicians to have a low threshold to evaluate for these conditions if any suggestive symptoms are present,” said Dr. Lebwohl, director of clinical research at the Celiac Disease Center at Columbia University, New York.
“Whether to screen for these conditions among people who are entirely without symptoms is less certain, and there is no consensus on that. But it is reasonable and common to include some basic tests with annual blood work, such as thyroid function and a liver profile, since both autoimmune thyroid disease and autoimmune liver disease can be silent early on and the patient would potentially benefit from identification and treatment of these conditions,” he said.
The American Diabetes Association and the International Society of Pediatric and Adolescent Diabetes do recommend that people with diabetes be screened for CD years after diagnosis, noted Robert Rapaport, MD, a pediatric endocrinologist, with Kravis Children’s Hospital, New York. But in a study published in 2021, he and colleagues found that this wasn’t occurring, which prompted them to recommend yearly screening.
“There is a consensus that in children with type 1 diabetes, we screen them for other autoimmune disorders, specifically for thyroid disease and celiac disease,” said Dr. Rapaport, who is also Emma Elizabeth Sullivan Professor of Pediatric Endocrinology and Diabetes at Icahn School of Medicine at Mount Sinai, New York. “But there is no consensus going the other way – for patients with celiac disease, what other autoimmune conditions they should be screened for.”
This hasn’t kept some doctors from extending cross-screening efforts to their patients.
“At our center, we screen ... for thyroid disease and autoimmune liver disease as part of routine healthcare maintenance for our celiac disease patients. We discuss symptoms of diabetes and send screening with [hemoglobin] A1c for anyone who has symptoms,” said Lui Edwin, MD, a pediatric gastroenterologist with Children’s Hospital Colorado, Aurora, and director of the Colorado Center for Celiac Disease, who delivered a lecture on CD-autoimmune screening at the International Celiac Disease Symposium in October.
“It is definitely worth screening for celiac disease in [those with] other autoimmune disorders,” Dr. Edwin added.
“The symptoms can be very heterogeneous. Diagnosing and treating celiac disease can make a huge impact with respect to symptoms, quality of life, and preventing disease-related complications,” he said.
Mounting evidence linking CD to autoimmune disorders
Many studies have linked CD to a variety of other autoimmune disorders. The association could be due to common genetic factors or because CD might lead to such conditions. Researchers have found that people diagnosed with CD later in life are more likely to develop other autoimmune disorders.
Some studies have also found that people with certain autoimmune diseases are more likely to also have CD. In addition, some individuals develop what’s known as nonceliac gluten sensitivity, which is not an autoimmune disease but a gluten intolerance not unlike lactose intolerance.
In light of these coexisting conditions in many people with CD and other autoimmune disorders, as well as the fact that the prevalence of CD is on the rise, some specialists argue that the benefits of routine cross-screening outweigh the risks.
Going gluten free has preventive advantages
In a landmark 2012 study, researchers with the Celiac Disease Center at Columbia University stopped short of recommending routine screening for the general public or asymptomatic individuals in high-prevalence groups. But they concluded that more screening of symptomatic individuals – and close relatives – would speed treatment for those with more than one autoimmune disorder.
They also noted that some studies have found that a gluten-free diet might help prevent the development of other autoimmune disorders.
Marisa Gallant Stahl, MD, a gastroenterologist with Children’s Hospital Colorado, agreed that it is important that physicians keep gluten-free diets in mind when determining which patients to cross-screen.
“The literature is mixed, but some studies suggest that treating celiac disease with a gluten-free diet actually augments the treatment and control of other autoimmune disorders [and] adherence to a gluten-free diet does reduce the risk of cancer associated with celiac disease,” she said.
Dr. Denham agreed. “Strict adherence to a gluten-free diet definitely protects against the development of enteropathy-associated T-cell lymphoma but may be protective against non-Hodgkin’s lymphoma and adenocarcinoma of the small intestine as well. All three are associated with long-term nonadherence to a gluten-free diet.”
She also noted that a gluten-free diet may help people with CD manage other autoimmune disorders, which can be complicated by CD.
“Good control of celiac disease will help prevent complications that can worsen symptoms and outcomes of concomitant autoimmune and rheumatologic disorders,” she said.
Other factors to consider
Dr. Fasano added that autoimmune disorders can be complicated by CD in cases in which oral medications or healthful foods are not properly absorbed in the intestines.
“For example, with Hashimoto’s disease, if you have hormone replacement with oral treatments and your intestines are not 100% functional because you have inflammation, then you may have a problem [with] the absorption of medications like levothyroxine,” he said.
“It’s the same story with diabetes. You don’t take insulin by mouth, but glucose [control] strongly depends on several factors, mostly what comes from the diet, and if it’s erratic, that can be a problem. ... So, the treatment of autoimmune diseases can be influenced by celiac disease,” he said.
In addition, Dr. Fasano and others believe that people with CD and other autoimmune disorders should be managed by a team of experts who can personalize the care on the basis of specific needs of the individual patient. These should include specialists, dietitians, mental health counselors, and family social workers.
“It has to be a multidisciplinary approach to maintain the good health of an individual,” Dr. Fasano said. “Celiac disease is the quintessential example in which the primary care physician needs to be the quarterback of the team, the patient is active in his or her health, and [specialists] not only deliver personalized care but also preventive intervention, particularly the prevention of comorbidities.”
Financial disclosures for those quoted in this article were not available at the time of publication.
A version of this article first appeared on Medscape.com.
Hiccups in patients with cancer often overlooked, undertreated
But even if recognized, hiccups may not be treated effectively, according to a national survey of cancer care clinicians.
When poorly controlled, persistent hiccups can affect a patient’s quality of life, with 40% of survey respondents considering chronic hiccups “much more” or “somewhat more” severe than nausea and vomiting.
Overall, the findings indicate that patients with cancer who develop persistent hiccups are “truly suffering,” the authors wrote.
The survey results were published online recently in the American Journal of Hospice and Palliative Medicine.
Hiccups may simply be a nuisance for most, but these spasms can become problematic for patients with cancer, leading to sleep deprivation, fatigue, aspiration pneumonia, compromised food intake, weight loss, pain, and even death.
Hiccups can develop when the nerve that controls the diaphragm becomes irritated, which can be triggered by certain chemotherapy drugs.
Yet few studies have focused on hiccups in patients with cancer and none, until now, has sought the perspectives of cancer care clinicians.
Aminah Jatoi, MD, medical oncologist with the Mayo Clinic in Rochester, Minn., and two Mayo colleagues developed a survey, alongside MeterHealth, which this news organization distributed to clinicians with an interest in cancer care.
The survey gauged clinicians’ awareness or lack of awareness about clinically significant hiccups as well as treatments for hiccups and whether they consider hiccups an unmet palliative need.
A total of 684 clinicians completed two eligibility screening questions, which required them to have cared for more than 10 patients with cancer in the past 6 months with clinically significant hiccups (defined as hiccups that lasted more than 48 hours or occurred from cancer or cancer care).
Among 113 eligible health care professionals, 90 completed the survey: 42 physicians, 29 nurses, 15 nurse practitioners, and 4 physician assistants.
The survey revealed three key issues.
The first is that hiccups appear to be an underrecognized issue.
Among health care professionals who answered the eligibility screening questions, fewer than 20% reported caring for more than 10 patients with cancer in the past 6 months who had persistent hiccups. Most of these clinicians reported caring for more than 1,000 patients per year.
Given that 15%-40% of patients with cancer report hiccups, this finding suggests that hiccups are not widely recognized by health care professionals.
Second: The survey data showed that hiccups often increase patients’ anxiety, fatigue, and sleep problems and can decrease productivity at work or school.
In fact, when comparing hiccups to nausea and vomiting – sometimes described as one of the most severe side effects of cancer care – 40% of respondents rated hiccups as “much more” or “somewhat more” severe than nausea and vomiting for their patients and 38% rated the severity of the two issues as “about the same.”
Finally, even when hiccups are recognized and treated, about 20% of respondents said that current therapies are not very effective, and more treatment options are needed.
Among the survey respondents, the most frequently prescribed medications for chronic hiccups were the antipsychotic chlorpromazine, the muscle relaxant baclofen (Lioresal), the antiemetic metoclopramide (Metozolv ODT, Reglan), and the anticonvulsants gabapentin (Neurontin) and carbamazepine (Tegretol).
Survey respondents who provided comments about current treatments for hiccups highlighted a range of challenges. One respondent said, “When current therapies do not work, it can be very demoralizing to our patients.” Another said, “I feel like it is a gamble whether treatment for hiccups will work or not.”
Still another felt that while current treatments work “quite well to halt hiccups,” they come with side effects which can be “quite severe.”
These results “clearly point to the unmet needs of hiccups in patients with cancer and should prompt more research aimed at generating more palliative options,” the authors said.
This research had no commercial funding. MeterHealth reviewed the manuscript and provided input on the accuracy of methods and results. Dr. Jatoi reports serving on an advisory board for MeterHealth (honoraria to institution).
A version of this article first appeared on Medscape.com.
But even if recognized, hiccups may not be treated effectively, according to a national survey of cancer care clinicians.
When poorly controlled, persistent hiccups can affect a patient’s quality of life, with 40% of survey respondents considering chronic hiccups “much more” or “somewhat more” severe than nausea and vomiting.
Overall, the findings indicate that patients with cancer who develop persistent hiccups are “truly suffering,” the authors wrote.
The survey results were published online recently in the American Journal of Hospice and Palliative Medicine.
Hiccups may simply be a nuisance for most, but these spasms can become problematic for patients with cancer, leading to sleep deprivation, fatigue, aspiration pneumonia, compromised food intake, weight loss, pain, and even death.
Hiccups can develop when the nerve that controls the diaphragm becomes irritated, which can be triggered by certain chemotherapy drugs.
Yet few studies have focused on hiccups in patients with cancer and none, until now, has sought the perspectives of cancer care clinicians.
Aminah Jatoi, MD, medical oncologist with the Mayo Clinic in Rochester, Minn., and two Mayo colleagues developed a survey, alongside MeterHealth, which this news organization distributed to clinicians with an interest in cancer care.
The survey gauged clinicians’ awareness or lack of awareness about clinically significant hiccups as well as treatments for hiccups and whether they consider hiccups an unmet palliative need.
A total of 684 clinicians completed two eligibility screening questions, which required them to have cared for more than 10 patients with cancer in the past 6 months with clinically significant hiccups (defined as hiccups that lasted more than 48 hours or occurred from cancer or cancer care).
Among 113 eligible health care professionals, 90 completed the survey: 42 physicians, 29 nurses, 15 nurse practitioners, and 4 physician assistants.
The survey revealed three key issues.
The first is that hiccups appear to be an underrecognized issue.
Among health care professionals who answered the eligibility screening questions, fewer than 20% reported caring for more than 10 patients with cancer in the past 6 months who had persistent hiccups. Most of these clinicians reported caring for more than 1,000 patients per year.
Given that 15%-40% of patients with cancer report hiccups, this finding suggests that hiccups are not widely recognized by health care professionals.
Second: The survey data showed that hiccups often increase patients’ anxiety, fatigue, and sleep problems and can decrease productivity at work or school.
In fact, when comparing hiccups to nausea and vomiting – sometimes described as one of the most severe side effects of cancer care – 40% of respondents rated hiccups as “much more” or “somewhat more” severe than nausea and vomiting for their patients and 38% rated the severity of the two issues as “about the same.”
Finally, even when hiccups are recognized and treated, about 20% of respondents said that current therapies are not very effective, and more treatment options are needed.
Among the survey respondents, the most frequently prescribed medications for chronic hiccups were the antipsychotic chlorpromazine, the muscle relaxant baclofen (Lioresal), the antiemetic metoclopramide (Metozolv ODT, Reglan), and the anticonvulsants gabapentin (Neurontin) and carbamazepine (Tegretol).
Survey respondents who provided comments about current treatments for hiccups highlighted a range of challenges. One respondent said, “When current therapies do not work, it can be very demoralizing to our patients.” Another said, “I feel like it is a gamble whether treatment for hiccups will work or not.”
Still another felt that while current treatments work “quite well to halt hiccups,” they come with side effects which can be “quite severe.”
These results “clearly point to the unmet needs of hiccups in patients with cancer and should prompt more research aimed at generating more palliative options,” the authors said.
This research had no commercial funding. MeterHealth reviewed the manuscript and provided input on the accuracy of methods and results. Dr. Jatoi reports serving on an advisory board for MeterHealth (honoraria to institution).
A version of this article first appeared on Medscape.com.
But even if recognized, hiccups may not be treated effectively, according to a national survey of cancer care clinicians.
When poorly controlled, persistent hiccups can affect a patient’s quality of life, with 40% of survey respondents considering chronic hiccups “much more” or “somewhat more” severe than nausea and vomiting.
Overall, the findings indicate that patients with cancer who develop persistent hiccups are “truly suffering,” the authors wrote.
The survey results were published online recently in the American Journal of Hospice and Palliative Medicine.
Hiccups may simply be a nuisance for most, but these spasms can become problematic for patients with cancer, leading to sleep deprivation, fatigue, aspiration pneumonia, compromised food intake, weight loss, pain, and even death.
Hiccups can develop when the nerve that controls the diaphragm becomes irritated, which can be triggered by certain chemotherapy drugs.
Yet few studies have focused on hiccups in patients with cancer and none, until now, has sought the perspectives of cancer care clinicians.
Aminah Jatoi, MD, medical oncologist with the Mayo Clinic in Rochester, Minn., and two Mayo colleagues developed a survey, alongside MeterHealth, which this news organization distributed to clinicians with an interest in cancer care.
The survey gauged clinicians’ awareness or lack of awareness about clinically significant hiccups as well as treatments for hiccups and whether they consider hiccups an unmet palliative need.
A total of 684 clinicians completed two eligibility screening questions, which required them to have cared for more than 10 patients with cancer in the past 6 months with clinically significant hiccups (defined as hiccups that lasted more than 48 hours or occurred from cancer or cancer care).
Among 113 eligible health care professionals, 90 completed the survey: 42 physicians, 29 nurses, 15 nurse practitioners, and 4 physician assistants.
The survey revealed three key issues.
The first is that hiccups appear to be an underrecognized issue.
Among health care professionals who answered the eligibility screening questions, fewer than 20% reported caring for more than 10 patients with cancer in the past 6 months who had persistent hiccups. Most of these clinicians reported caring for more than 1,000 patients per year.
Given that 15%-40% of patients with cancer report hiccups, this finding suggests that hiccups are not widely recognized by health care professionals.
Second: The survey data showed that hiccups often increase patients’ anxiety, fatigue, and sleep problems and can decrease productivity at work or school.
In fact, when comparing hiccups to nausea and vomiting – sometimes described as one of the most severe side effects of cancer care – 40% of respondents rated hiccups as “much more” or “somewhat more” severe than nausea and vomiting for their patients and 38% rated the severity of the two issues as “about the same.”
Finally, even when hiccups are recognized and treated, about 20% of respondents said that current therapies are not very effective, and more treatment options are needed.
Among the survey respondents, the most frequently prescribed medications for chronic hiccups were the antipsychotic chlorpromazine, the muscle relaxant baclofen (Lioresal), the antiemetic metoclopramide (Metozolv ODT, Reglan), and the anticonvulsants gabapentin (Neurontin) and carbamazepine (Tegretol).
Survey respondents who provided comments about current treatments for hiccups highlighted a range of challenges. One respondent said, “When current therapies do not work, it can be very demoralizing to our patients.” Another said, “I feel like it is a gamble whether treatment for hiccups will work or not.”
Still another felt that while current treatments work “quite well to halt hiccups,” they come with side effects which can be “quite severe.”
These results “clearly point to the unmet needs of hiccups in patients with cancer and should prompt more research aimed at generating more palliative options,” the authors said.
This research had no commercial funding. MeterHealth reviewed the manuscript and provided input on the accuracy of methods and results. Dr. Jatoi reports serving on an advisory board for MeterHealth (honoraria to institution).
A version of this article first appeared on Medscape.com.
FROM THE AMERICAN JOURNAL OF HOSPICE AND PALLIATIVE MEDICINE
Patient harm, not malpractice, top of mind for emergency medicine physicians
according to a study published in JAMA Network Open.
The cross-sectional study was conducted by researchers from Soroka University Medical Center, Israel; the University of Massachusetts, Worcester; Beth Israel Deaconess Medical Center; Harvard Medical School, Boston; and the University of Massachusetts, Amherst.
Online survey responses were collected from 1,222 emergency department attending physicians and advanced practice clinicians (APCs) in acute care hospitals throughout Massachusetts from January to September 2020.
Participants were asked to rank their level of agreement – from “strongly disagree” to “strongly agree” – with two statements: “In my day-to-day practice, I am fearful of making a mistake which results in [1] harm to the patient” (fear of harm) and [2] “being sued” (fear of suit).
The average age of the participants was about 44 years; 54.2% were men, 45.1% were women, and 0.7% were of other gender. Approximately 70% of responses were from MDs or DOs, and the remainder were from nurse practitioners and physician assistants. Participants had between 5 and 19 years of experience (median, 10 years).
The study found that the mean score was greater with regard to fear of harm than to fear of suit, regardless of clinician type, experience, or sex and whether the survey was completed before or after the start of the COVID-19 pandemic. There was no significant difference in mean scores regarding fear of suit before the pandemic and after it.
“Our data show a significantly greater fear of harming a patient than a fear of a malpractice suit,” Linda Isbell, PhD, professor of psychology at the University of Massachusetts, Amherst, who is one of the study’s authors, told this news organization. “There is a genuine concern and fear of harming patients and a desire to provide the best care for the patient’s well-being.”
In general, fear-of-harm and fear-of-suit scores decreased as providers gained experience. Those with less than 5 years of experience reported the highest levels of both.
“Although our data do not specifically provide reasons why age may impact [fear] levels, it is possible that with more practice experience ... providers have a better sense of the likelihood of patient harm and malpractice and how to manage such outcomes should they happen,” says Dr. Isbell. She noted that a longitudinal study is necessary to confirm this hypothesis.
One exception was female APCs, whose fear-of-harm scores remained relatively steady across all experience levels. Among male APCs, fear of causing patient harm decreased among those with 5-14 years of experience but increased slightly at 14-44 years of experience.
While previous research typically focused on fear of malpractice as a significant driver of defensive medicine, such as testing excessively, this study examined providers’ fear of harming patients because of a medical error.
The findings suggest “that fear of harm should be considered with, and may be more consequential than, fear of suit in medical decision-making,” the authors note.
“[F]ear can motivate people to engage in more careful and thorough information processing, which can drive behaviors in systematic ways,” says Dr. Isbell. “It is possible that one’s fear of harming a patient is triggering a high level of vigilance, reflected in the practice of defensive medicine across different types of patients – some of whom may be better off with less testing and referrals.”
Rade B. Vukmir, MD, JD, FACEP, an emergency medicine physician and spokesman for the American College of Emergency Physicians, says defensive medicine is common in the specialty and that it occurs 20%-40% of the time.
“Early in practice, the proverbial worst sin is missing a diagnosis, so that’s where the overtesting mentality comes from,” he says. In addition, “there are cities where you can’t drive a mile without seeing a half dozen legal advertisements. That imposes a cost burden on the system, [adding] roughly 20% to the cost of overall care.”
Emergency medicine providers attempt to minimize testing, but between their role as “America’s safety net” and the difficult circumstances they often face when treating patients, it takes a while to strike a balance, Dr. Vukmir acknowledges.
“There’s a training correlation, which showed up [in this study]; as people got further advanced in training, they felt more comfortable and felt the need to do it less,” says Dr. Vukmir.
The study was funded by a grant from the Agency for Healthcare Research and Quality. Dr. Isbell reports no conflicts of interest. Dr. Vukmir has disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
according to a study published in JAMA Network Open.
The cross-sectional study was conducted by researchers from Soroka University Medical Center, Israel; the University of Massachusetts, Worcester; Beth Israel Deaconess Medical Center; Harvard Medical School, Boston; and the University of Massachusetts, Amherst.
Online survey responses were collected from 1,222 emergency department attending physicians and advanced practice clinicians (APCs) in acute care hospitals throughout Massachusetts from January to September 2020.
Participants were asked to rank their level of agreement – from “strongly disagree” to “strongly agree” – with two statements: “In my day-to-day practice, I am fearful of making a mistake which results in [1] harm to the patient” (fear of harm) and [2] “being sued” (fear of suit).
The average age of the participants was about 44 years; 54.2% were men, 45.1% were women, and 0.7% were of other gender. Approximately 70% of responses were from MDs or DOs, and the remainder were from nurse practitioners and physician assistants. Participants had between 5 and 19 years of experience (median, 10 years).
The study found that the mean score was greater with regard to fear of harm than to fear of suit, regardless of clinician type, experience, or sex and whether the survey was completed before or after the start of the COVID-19 pandemic. There was no significant difference in mean scores regarding fear of suit before the pandemic and after it.
“Our data show a significantly greater fear of harming a patient than a fear of a malpractice suit,” Linda Isbell, PhD, professor of psychology at the University of Massachusetts, Amherst, who is one of the study’s authors, told this news organization. “There is a genuine concern and fear of harming patients and a desire to provide the best care for the patient’s well-being.”
In general, fear-of-harm and fear-of-suit scores decreased as providers gained experience. Those with less than 5 years of experience reported the highest levels of both.
“Although our data do not specifically provide reasons why age may impact [fear] levels, it is possible that with more practice experience ... providers have a better sense of the likelihood of patient harm and malpractice and how to manage such outcomes should they happen,” says Dr. Isbell. She noted that a longitudinal study is necessary to confirm this hypothesis.
One exception was female APCs, whose fear-of-harm scores remained relatively steady across all experience levels. Among male APCs, fear of causing patient harm decreased among those with 5-14 years of experience but increased slightly at 14-44 years of experience.
While previous research typically focused on fear of malpractice as a significant driver of defensive medicine, such as testing excessively, this study examined providers’ fear of harming patients because of a medical error.
The findings suggest “that fear of harm should be considered with, and may be more consequential than, fear of suit in medical decision-making,” the authors note.
“[F]ear can motivate people to engage in more careful and thorough information processing, which can drive behaviors in systematic ways,” says Dr. Isbell. “It is possible that one’s fear of harming a patient is triggering a high level of vigilance, reflected in the practice of defensive medicine across different types of patients – some of whom may be better off with less testing and referrals.”
Rade B. Vukmir, MD, JD, FACEP, an emergency medicine physician and spokesman for the American College of Emergency Physicians, says defensive medicine is common in the specialty and that it occurs 20%-40% of the time.
“Early in practice, the proverbial worst sin is missing a diagnosis, so that’s where the overtesting mentality comes from,” he says. In addition, “there are cities where you can’t drive a mile without seeing a half dozen legal advertisements. That imposes a cost burden on the system, [adding] roughly 20% to the cost of overall care.”
Emergency medicine providers attempt to minimize testing, but between their role as “America’s safety net” and the difficult circumstances they often face when treating patients, it takes a while to strike a balance, Dr. Vukmir acknowledges.
“There’s a training correlation, which showed up [in this study]; as people got further advanced in training, they felt more comfortable and felt the need to do it less,” says Dr. Vukmir.
The study was funded by a grant from the Agency for Healthcare Research and Quality. Dr. Isbell reports no conflicts of interest. Dr. Vukmir has disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
according to a study published in JAMA Network Open.
The cross-sectional study was conducted by researchers from Soroka University Medical Center, Israel; the University of Massachusetts, Worcester; Beth Israel Deaconess Medical Center; Harvard Medical School, Boston; and the University of Massachusetts, Amherst.
Online survey responses were collected from 1,222 emergency department attending physicians and advanced practice clinicians (APCs) in acute care hospitals throughout Massachusetts from January to September 2020.
Participants were asked to rank their level of agreement – from “strongly disagree” to “strongly agree” – with two statements: “In my day-to-day practice, I am fearful of making a mistake which results in [1] harm to the patient” (fear of harm) and [2] “being sued” (fear of suit).
The average age of the participants was about 44 years; 54.2% were men, 45.1% were women, and 0.7% were of other gender. Approximately 70% of responses were from MDs or DOs, and the remainder were from nurse practitioners and physician assistants. Participants had between 5 and 19 years of experience (median, 10 years).
The study found that the mean score was greater with regard to fear of harm than to fear of suit, regardless of clinician type, experience, or sex and whether the survey was completed before or after the start of the COVID-19 pandemic. There was no significant difference in mean scores regarding fear of suit before the pandemic and after it.
“Our data show a significantly greater fear of harming a patient than a fear of a malpractice suit,” Linda Isbell, PhD, professor of psychology at the University of Massachusetts, Amherst, who is one of the study’s authors, told this news organization. “There is a genuine concern and fear of harming patients and a desire to provide the best care for the patient’s well-being.”
In general, fear-of-harm and fear-of-suit scores decreased as providers gained experience. Those with less than 5 years of experience reported the highest levels of both.
“Although our data do not specifically provide reasons why age may impact [fear] levels, it is possible that with more practice experience ... providers have a better sense of the likelihood of patient harm and malpractice and how to manage such outcomes should they happen,” says Dr. Isbell. She noted that a longitudinal study is necessary to confirm this hypothesis.
One exception was female APCs, whose fear-of-harm scores remained relatively steady across all experience levels. Among male APCs, fear of causing patient harm decreased among those with 5-14 years of experience but increased slightly at 14-44 years of experience.
While previous research typically focused on fear of malpractice as a significant driver of defensive medicine, such as testing excessively, this study examined providers’ fear of harming patients because of a medical error.
The findings suggest “that fear of harm should be considered with, and may be more consequential than, fear of suit in medical decision-making,” the authors note.
“[F]ear can motivate people to engage in more careful and thorough information processing, which can drive behaviors in systematic ways,” says Dr. Isbell. “It is possible that one’s fear of harming a patient is triggering a high level of vigilance, reflected in the practice of defensive medicine across different types of patients – some of whom may be better off with less testing and referrals.”
Rade B. Vukmir, MD, JD, FACEP, an emergency medicine physician and spokesman for the American College of Emergency Physicians, says defensive medicine is common in the specialty and that it occurs 20%-40% of the time.
“Early in practice, the proverbial worst sin is missing a diagnosis, so that’s where the overtesting mentality comes from,” he says. In addition, “there are cities where you can’t drive a mile without seeing a half dozen legal advertisements. That imposes a cost burden on the system, [adding] roughly 20% to the cost of overall care.”
Emergency medicine providers attempt to minimize testing, but between their role as “America’s safety net” and the difficult circumstances they often face when treating patients, it takes a while to strike a balance, Dr. Vukmir acknowledges.
“There’s a training correlation, which showed up [in this study]; as people got further advanced in training, they felt more comfortable and felt the need to do it less,” says Dr. Vukmir.
The study was funded by a grant from the Agency for Healthcare Research and Quality. Dr. Isbell reports no conflicts of interest. Dr. Vukmir has disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM JAMA NETWORK OPEN
Is there a doctor on the plane? Tips for providing in-flight assistance
In most cases, passengers on an airline flight are representative of the general population, which means that anyone could have an emergency at any time.
as determined on the basis of in-flight medical emergencies that resulted in calls to a physician-directed medical communications center, said Amy Faith Ho, MD, MPH of Integrative Emergency Services, Dallas–Fort Worth, in a presentation at the annual meeting of the American College of Emergency Physicians.
The study authors reviewed records of 11,920 in-flight medical emergencies between Jan. 1, 2008, and Oct. 31, 2010. The data showed that physician passengers provided medical assistance in nearly half of in-flight emergencies (48.1%) and that flights were diverted because of the emergency in 7.3% of cases.
The majority of the in-flight emergencies involved syncope or presyncope (37.4% of cases), followed by respiratory symptoms (12.1%) and nausea or vomiting (9.5%), according to the study.
When a physician is faced with an in-flight emergency, the medical team includes the physician himself, medical ground control, and the flight attendants, said Dr. Ho. Requirements may vary among airlines, but all flight attendants will be trained in cardiopulmonary resuscitation (CPR) or basic life support, as well as use of automated external defibrillators (AEDs).
Physician call centers (medical ground control) can provide additional assistance remotely, she said.
The in-flight medical bag
Tools in a physician’s in-flight toolbox start with the first-aid kit. Airplanes also have an emergency medical kit (EMK), an oxygen tank, and an AED.
The minimum EMK contents are mandated by the Federal Aviation Administration, said Dr. Ho. The standard equipment includes a stethoscope, a sphygmomanometer, and three sizes of oropharyngeal airways. Other items include self-inflating manual resuscitation devices and CPR masks in thee sizes, alcohol sponges, gloves, adhesive tape, scissors, a tourniquet, as well as saline solution, needles, syringes, and an intravenous administration set consisting of tubing and two Y connectors.
An EMK also should contain the following medications: nonnarcotic analgesic tablets, antihistamine tablets, an injectable antihistamine, atropine, aspirin tablets, a bronchodilator, and epinephrine (both 1:1000; 1 injectable cc and 1:10,000; two injectable cc). Nitroglycerin tablets and 5 cc of 20 mg/mL injectable cardiac lidocaine are part of the mandated kit as well, according to Dr. Ho.
Some airlines carry additional supplies on all their flights, said Dr. Ho. Notably, American Airlines and British Airways carry EpiPens for adults and children, as well as opioid reversal medication (naloxone) and glucose for managing low blood sugar. American Airlines and Delta stock antiemetics, and Delta also carries naloxone. British Airways is unique in stocking additional cardiac medications, both oral and injectable.
How to handle an in-flight emergency
Physicians should always carry a copy of their medical license when traveling for documentation by the airline if they assist in a medical emergency during a flight, Dr. Ho emphasized. “Staff” personnel should be used. These include the flight attendants, medical ground control, and other passengers who might have useful skills, such as nursing, the ability to perform CPR, or therapy/counseling to calm a frightened patient. If needed, “crowdsource additional supplies from passengers,” such as a glucometer or pulse oximeter.
Legal lessons
Physicians are not obligated to assist during an in-flight medical emergency, said Dr. Ho. Legal jurisdiction can vary. In the United States, a bystander who assists in an emergency is generally protected by Good Samaritan laws; for international airlines, the laws may vary; those where the airline is based usually apply.
The Aviation Medical Assistance Act, passed in 1998, protects individuals from being sued for negligence while providing medical assistance, “unless the individual, while rendering such assistance, is guilty of gross negligence of willful misconduct,” Dr. Ho noted. The Aviation Medical Assistance Act also protects the airline itself “if the carrier in good faith believes that the passenger is a medically qualified individual.”
Dr. Ho disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
In most cases, passengers on an airline flight are representative of the general population, which means that anyone could have an emergency at any time.
as determined on the basis of in-flight medical emergencies that resulted in calls to a physician-directed medical communications center, said Amy Faith Ho, MD, MPH of Integrative Emergency Services, Dallas–Fort Worth, in a presentation at the annual meeting of the American College of Emergency Physicians.
The study authors reviewed records of 11,920 in-flight medical emergencies between Jan. 1, 2008, and Oct. 31, 2010. The data showed that physician passengers provided medical assistance in nearly half of in-flight emergencies (48.1%) and that flights were diverted because of the emergency in 7.3% of cases.
The majority of the in-flight emergencies involved syncope or presyncope (37.4% of cases), followed by respiratory symptoms (12.1%) and nausea or vomiting (9.5%), according to the study.
When a physician is faced with an in-flight emergency, the medical team includes the physician himself, medical ground control, and the flight attendants, said Dr. Ho. Requirements may vary among airlines, but all flight attendants will be trained in cardiopulmonary resuscitation (CPR) or basic life support, as well as use of automated external defibrillators (AEDs).
Physician call centers (medical ground control) can provide additional assistance remotely, she said.
The in-flight medical bag
Tools in a physician’s in-flight toolbox start with the first-aid kit. Airplanes also have an emergency medical kit (EMK), an oxygen tank, and an AED.
The minimum EMK contents are mandated by the Federal Aviation Administration, said Dr. Ho. The standard equipment includes a stethoscope, a sphygmomanometer, and three sizes of oropharyngeal airways. Other items include self-inflating manual resuscitation devices and CPR masks in thee sizes, alcohol sponges, gloves, adhesive tape, scissors, a tourniquet, as well as saline solution, needles, syringes, and an intravenous administration set consisting of tubing and two Y connectors.
An EMK also should contain the following medications: nonnarcotic analgesic tablets, antihistamine tablets, an injectable antihistamine, atropine, aspirin tablets, a bronchodilator, and epinephrine (both 1:1000; 1 injectable cc and 1:10,000; two injectable cc). Nitroglycerin tablets and 5 cc of 20 mg/mL injectable cardiac lidocaine are part of the mandated kit as well, according to Dr. Ho.
Some airlines carry additional supplies on all their flights, said Dr. Ho. Notably, American Airlines and British Airways carry EpiPens for adults and children, as well as opioid reversal medication (naloxone) and glucose for managing low blood sugar. American Airlines and Delta stock antiemetics, and Delta also carries naloxone. British Airways is unique in stocking additional cardiac medications, both oral and injectable.
How to handle an in-flight emergency
Physicians should always carry a copy of their medical license when traveling for documentation by the airline if they assist in a medical emergency during a flight, Dr. Ho emphasized. “Staff” personnel should be used. These include the flight attendants, medical ground control, and other passengers who might have useful skills, such as nursing, the ability to perform CPR, or therapy/counseling to calm a frightened patient. If needed, “crowdsource additional supplies from passengers,” such as a glucometer or pulse oximeter.
Legal lessons
Physicians are not obligated to assist during an in-flight medical emergency, said Dr. Ho. Legal jurisdiction can vary. In the United States, a bystander who assists in an emergency is generally protected by Good Samaritan laws; for international airlines, the laws may vary; those where the airline is based usually apply.
The Aviation Medical Assistance Act, passed in 1998, protects individuals from being sued for negligence while providing medical assistance, “unless the individual, while rendering such assistance, is guilty of gross negligence of willful misconduct,” Dr. Ho noted. The Aviation Medical Assistance Act also protects the airline itself “if the carrier in good faith believes that the passenger is a medically qualified individual.”
Dr. Ho disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
In most cases, passengers on an airline flight are representative of the general population, which means that anyone could have an emergency at any time.
as determined on the basis of in-flight medical emergencies that resulted in calls to a physician-directed medical communications center, said Amy Faith Ho, MD, MPH of Integrative Emergency Services, Dallas–Fort Worth, in a presentation at the annual meeting of the American College of Emergency Physicians.
The study authors reviewed records of 11,920 in-flight medical emergencies between Jan. 1, 2008, and Oct. 31, 2010. The data showed that physician passengers provided medical assistance in nearly half of in-flight emergencies (48.1%) and that flights were diverted because of the emergency in 7.3% of cases.
The majority of the in-flight emergencies involved syncope or presyncope (37.4% of cases), followed by respiratory symptoms (12.1%) and nausea or vomiting (9.5%), according to the study.
When a physician is faced with an in-flight emergency, the medical team includes the physician himself, medical ground control, and the flight attendants, said Dr. Ho. Requirements may vary among airlines, but all flight attendants will be trained in cardiopulmonary resuscitation (CPR) or basic life support, as well as use of automated external defibrillators (AEDs).
Physician call centers (medical ground control) can provide additional assistance remotely, she said.
The in-flight medical bag
Tools in a physician’s in-flight toolbox start with the first-aid kit. Airplanes also have an emergency medical kit (EMK), an oxygen tank, and an AED.
The minimum EMK contents are mandated by the Federal Aviation Administration, said Dr. Ho. The standard equipment includes a stethoscope, a sphygmomanometer, and three sizes of oropharyngeal airways. Other items include self-inflating manual resuscitation devices and CPR masks in thee sizes, alcohol sponges, gloves, adhesive tape, scissors, a tourniquet, as well as saline solution, needles, syringes, and an intravenous administration set consisting of tubing and two Y connectors.
An EMK also should contain the following medications: nonnarcotic analgesic tablets, antihistamine tablets, an injectable antihistamine, atropine, aspirin tablets, a bronchodilator, and epinephrine (both 1:1000; 1 injectable cc and 1:10,000; two injectable cc). Nitroglycerin tablets and 5 cc of 20 mg/mL injectable cardiac lidocaine are part of the mandated kit as well, according to Dr. Ho.
Some airlines carry additional supplies on all their flights, said Dr. Ho. Notably, American Airlines and British Airways carry EpiPens for adults and children, as well as opioid reversal medication (naloxone) and glucose for managing low blood sugar. American Airlines and Delta stock antiemetics, and Delta also carries naloxone. British Airways is unique in stocking additional cardiac medications, both oral and injectable.
How to handle an in-flight emergency
Physicians should always carry a copy of their medical license when traveling for documentation by the airline if they assist in a medical emergency during a flight, Dr. Ho emphasized. “Staff” personnel should be used. These include the flight attendants, medical ground control, and other passengers who might have useful skills, such as nursing, the ability to perform CPR, or therapy/counseling to calm a frightened patient. If needed, “crowdsource additional supplies from passengers,” such as a glucometer or pulse oximeter.
Legal lessons
Physicians are not obligated to assist during an in-flight medical emergency, said Dr. Ho. Legal jurisdiction can vary. In the United States, a bystander who assists in an emergency is generally protected by Good Samaritan laws; for international airlines, the laws may vary; those where the airline is based usually apply.
The Aviation Medical Assistance Act, passed in 1998, protects individuals from being sued for negligence while providing medical assistance, “unless the individual, while rendering such assistance, is guilty of gross negligence of willful misconduct,” Dr. Ho noted. The Aviation Medical Assistance Act also protects the airline itself “if the carrier in good faith believes that the passenger is a medically qualified individual.”
Dr. Ho disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM ACEP 2022
RSV causes 1 in 50 deaths in children under age 5: European study
But RSV – formally known as respiratory syncytial virus – is also a problem in high-income nations. In those countries, 1 in 56 otherwise healthy babies are hospitalized with RSV during their first year of life, said the study, which was published in the Lancet Respiratory Medicine.
Researchers looked at the health records of 9,154 infants born between July 1, 2017, and July 31, 2020, who were treated at health centers across Europe. Previous studies have concentrated on babies with preexisting conditions, but this one looked at otherwise healthy children, researchers said.
“This is the lowest-risk baby who is being hospitalized for this, so really, numbers are really much higher than I think some people would have guessed,” said study coauthor Louis Bont, MD, a professor of pediatric infectious diseases at Wilhelmina Children’s Hospital at University Medical Center Utrecht in the Netherlands, according to CNN. He is also chairman of the ReSViNET foundation, which aims to reduce RSV infection globally.
The study said more than 97% of deaths from RSV occur in low-income and middle-income countries. The study concluded that “maternal vaccination and passive [immunization] could have a profound impact on the RSV burden.”
In developed nations, children who get RSV usually survive because they have access to ventilators and other health care equipment. Still, just being treated for RSV can have long-range negative effects on a child’s health, Kristina Deeter, MD, chair of pediatrics at the University of Nevada, Reno, told CNN.
“Whether that is just traumatic psychosocial, emotional issues after hospitalization or even having more vulnerable lungs – you can develop asthma later on, for instance, if you’ve had a really severe infection at a young age – it can damage your lungs permanently,” she said of the study. “It’s still an important virus in our world and something that we really focus on.”
The Lancet study was published days after the CDC warned public health officials that respiratory viruses, including RSV, are surging among children across the country.
A version of this article first appeared on WebMD.com.
But RSV – formally known as respiratory syncytial virus – is also a problem in high-income nations. In those countries, 1 in 56 otherwise healthy babies are hospitalized with RSV during their first year of life, said the study, which was published in the Lancet Respiratory Medicine.
Researchers looked at the health records of 9,154 infants born between July 1, 2017, and July 31, 2020, who were treated at health centers across Europe. Previous studies have concentrated on babies with preexisting conditions, but this one looked at otherwise healthy children, researchers said.
“This is the lowest-risk baby who is being hospitalized for this, so really, numbers are really much higher than I think some people would have guessed,” said study coauthor Louis Bont, MD, a professor of pediatric infectious diseases at Wilhelmina Children’s Hospital at University Medical Center Utrecht in the Netherlands, according to CNN. He is also chairman of the ReSViNET foundation, which aims to reduce RSV infection globally.
The study said more than 97% of deaths from RSV occur in low-income and middle-income countries. The study concluded that “maternal vaccination and passive [immunization] could have a profound impact on the RSV burden.”
In developed nations, children who get RSV usually survive because they have access to ventilators and other health care equipment. Still, just being treated for RSV can have long-range negative effects on a child’s health, Kristina Deeter, MD, chair of pediatrics at the University of Nevada, Reno, told CNN.
“Whether that is just traumatic psychosocial, emotional issues after hospitalization or even having more vulnerable lungs – you can develop asthma later on, for instance, if you’ve had a really severe infection at a young age – it can damage your lungs permanently,” she said of the study. “It’s still an important virus in our world and something that we really focus on.”
The Lancet study was published days after the CDC warned public health officials that respiratory viruses, including RSV, are surging among children across the country.
A version of this article first appeared on WebMD.com.
But RSV – formally known as respiratory syncytial virus – is also a problem in high-income nations. In those countries, 1 in 56 otherwise healthy babies are hospitalized with RSV during their first year of life, said the study, which was published in the Lancet Respiratory Medicine.
Researchers looked at the health records of 9,154 infants born between July 1, 2017, and July 31, 2020, who were treated at health centers across Europe. Previous studies have concentrated on babies with preexisting conditions, but this one looked at otherwise healthy children, researchers said.
“This is the lowest-risk baby who is being hospitalized for this, so really, numbers are really much higher than I think some people would have guessed,” said study coauthor Louis Bont, MD, a professor of pediatric infectious diseases at Wilhelmina Children’s Hospital at University Medical Center Utrecht in the Netherlands, according to CNN. He is also chairman of the ReSViNET foundation, which aims to reduce RSV infection globally.
The study said more than 97% of deaths from RSV occur in low-income and middle-income countries. The study concluded that “maternal vaccination and passive [immunization] could have a profound impact on the RSV burden.”
In developed nations, children who get RSV usually survive because they have access to ventilators and other health care equipment. Still, just being treated for RSV can have long-range negative effects on a child’s health, Kristina Deeter, MD, chair of pediatrics at the University of Nevada, Reno, told CNN.
“Whether that is just traumatic psychosocial, emotional issues after hospitalization or even having more vulnerable lungs – you can develop asthma later on, for instance, if you’ve had a really severe infection at a young age – it can damage your lungs permanently,” she said of the study. “It’s still an important virus in our world and something that we really focus on.”
The Lancet study was published days after the CDC warned public health officials that respiratory viruses, including RSV, are surging among children across the country.
A version of this article first appeared on WebMD.com.
FROM LANCET RESPIRATORY MEDICINE
Children and COVID: Weekly cases continue to hold fairly steady
The incidence of new COVID-19 cases in children seems to have stabilized as the national count remained under 30,000 for the fifth consecutive week, but hospitalization data may indicate some possible turbulence.
Just over 28,000 pediatric cases were reported during the week of Nov. 4-10, a drop of 5.4% from the previous week, the American Academy of Pediatrics and the Children’s Hospital Association said in their weekly COVID-19 report involving data from state and territorial health departments, several of which are no longer updating their websites.
The stability in weekly cases, however, comes in contrast to a very recent and considerable increase in new hospital admissions of children aged 0-17 years with confirmed COVID-19. That rate, which was 0.18 hospitalizations per 100,000 population on Nov. 7 and 0.19 per 100,000 on Nov. 8 and 9, jumped all the way to 0.34 on Nov. 10 and 0.48 on Nov. 11, according to data from the Centers for Disease Control and Prevention. That is the highest rate since the closing days of the Omicron surge in February.
The rate for Nov. 12, the most recent one available, was down slightly to 0.47 admissions per 100,000. There doesn’t seem to be any evidence in the CDC’s data of a similar sudden increase in new hospitalizations among any other age group, and no age group, including children, shows any sign of a recent increase in emergency department visits with diagnosed COVID. (The CDC has not yet responded to our inquiry about this development.)
The two most recent 7-day averages for new admissions in children aged 0-17 show a small increase, but they cover the periods of Oct. 15 to Oct. 31, when there were 126 admissions per day, and Nov. 1 to Nov. 7, when the average went up to 133 per day, the CDC said on its COVID Data Tracker.
The CDC does not publish a weekly count of new COVID cases, but its latest data on the rate of incident cases seem to agree with the AAP/CHA figures: A gradual decline in all age groups, including children, since the beginning of September.
Vaccinations, on the other hand, bucked their recent trend and increased in the last week. About 43,000 children under age 5 years received their initial dose of COVID vaccine during Nov. 3-9, compared with 30,000 and 33,000 the 2 previous weeks, while 5- to 11-year-olds hit their highest weekly mark (31,000) since late August and 12- to 17-year-olds had their biggest week (27,000) since mid-August, the AAP reported based on CDC data.
The incidence of new COVID-19 cases in children seems to have stabilized as the national count remained under 30,000 for the fifth consecutive week, but hospitalization data may indicate some possible turbulence.
Just over 28,000 pediatric cases were reported during the week of Nov. 4-10, a drop of 5.4% from the previous week, the American Academy of Pediatrics and the Children’s Hospital Association said in their weekly COVID-19 report involving data from state and territorial health departments, several of which are no longer updating their websites.
The stability in weekly cases, however, comes in contrast to a very recent and considerable increase in new hospital admissions of children aged 0-17 years with confirmed COVID-19. That rate, which was 0.18 hospitalizations per 100,000 population on Nov. 7 and 0.19 per 100,000 on Nov. 8 and 9, jumped all the way to 0.34 on Nov. 10 and 0.48 on Nov. 11, according to data from the Centers for Disease Control and Prevention. That is the highest rate since the closing days of the Omicron surge in February.
The rate for Nov. 12, the most recent one available, was down slightly to 0.47 admissions per 100,000. There doesn’t seem to be any evidence in the CDC’s data of a similar sudden increase in new hospitalizations among any other age group, and no age group, including children, shows any sign of a recent increase in emergency department visits with diagnosed COVID. (The CDC has not yet responded to our inquiry about this development.)
The two most recent 7-day averages for new admissions in children aged 0-17 show a small increase, but they cover the periods of Oct. 15 to Oct. 31, when there were 126 admissions per day, and Nov. 1 to Nov. 7, when the average went up to 133 per day, the CDC said on its COVID Data Tracker.
The CDC does not publish a weekly count of new COVID cases, but its latest data on the rate of incident cases seem to agree with the AAP/CHA figures: A gradual decline in all age groups, including children, since the beginning of September.
Vaccinations, on the other hand, bucked their recent trend and increased in the last week. About 43,000 children under age 5 years received their initial dose of COVID vaccine during Nov. 3-9, compared with 30,000 and 33,000 the 2 previous weeks, while 5- to 11-year-olds hit their highest weekly mark (31,000) since late August and 12- to 17-year-olds had their biggest week (27,000) since mid-August, the AAP reported based on CDC data.
The incidence of new COVID-19 cases in children seems to have stabilized as the national count remained under 30,000 for the fifth consecutive week, but hospitalization data may indicate some possible turbulence.
Just over 28,000 pediatric cases were reported during the week of Nov. 4-10, a drop of 5.4% from the previous week, the American Academy of Pediatrics and the Children’s Hospital Association said in their weekly COVID-19 report involving data from state and territorial health departments, several of which are no longer updating their websites.
The stability in weekly cases, however, comes in contrast to a very recent and considerable increase in new hospital admissions of children aged 0-17 years with confirmed COVID-19. That rate, which was 0.18 hospitalizations per 100,000 population on Nov. 7 and 0.19 per 100,000 on Nov. 8 and 9, jumped all the way to 0.34 on Nov. 10 and 0.48 on Nov. 11, according to data from the Centers for Disease Control and Prevention. That is the highest rate since the closing days of the Omicron surge in February.
The rate for Nov. 12, the most recent one available, was down slightly to 0.47 admissions per 100,000. There doesn’t seem to be any evidence in the CDC’s data of a similar sudden increase in new hospitalizations among any other age group, and no age group, including children, shows any sign of a recent increase in emergency department visits with diagnosed COVID. (The CDC has not yet responded to our inquiry about this development.)
The two most recent 7-day averages for new admissions in children aged 0-17 show a small increase, but they cover the periods of Oct. 15 to Oct. 31, when there were 126 admissions per day, and Nov. 1 to Nov. 7, when the average went up to 133 per day, the CDC said on its COVID Data Tracker.
The CDC does not publish a weekly count of new COVID cases, but its latest data on the rate of incident cases seem to agree with the AAP/CHA figures: A gradual decline in all age groups, including children, since the beginning of September.
Vaccinations, on the other hand, bucked their recent trend and increased in the last week. About 43,000 children under age 5 years received their initial dose of COVID vaccine during Nov. 3-9, compared with 30,000 and 33,000 the 2 previous weeks, while 5- to 11-year-olds hit their highest weekly mark (31,000) since late August and 12- to 17-year-olds had their biggest week (27,000) since mid-August, the AAP reported based on CDC data.
Meditation for children
Meditation has become a popular practice in the United States over the last decade. It is not limited to adults, but can be learned and practiced by children and teenagers also. Variants are being used in many schools as parts of a social and emotional learning curriculum, and different kinds of mindfulness practices are common parts of psychological treatments. In this month’s column, we will review the evidence that supports the efficacy of a meditation practice to treat the mental health problems that are common in children and adolescents, and review how it might be a useful adjunct to the screening, education, and treatments that you offer your young patients.
There are many different types of meditation practices, but the unifying feature is known as mindfulness. Most broadly, mindfulness refers to a state of nonjudgmental awareness of one’s thoughts, feelings, or sensations. A mindfulness meditation practice involves physical stillness and focused attention, typically on the physical sensations of one’s breath. When thoughts, feelings, or physical sensations intrude on the stillness, one learns to cultivate a nonjudgmental awareness of those experiences without disrupting the state of quiet concentration. It could be said that meditation is easy to learn and difficult to master, and that is why it should be practiced regularly. Part of its growing popularity has undoubtedly been served by the ease with which people can access a variety of guided meditations (through apps, YouTube, and beyond) that make it relatively easy to access a variety of methods to learn how to practice mindfulness meditation.
The benefits of meditation in adults are well-established, including lower blood pressure, lower rates of heart disease, lower markers of inflammation, better sleep, and self-described levels of well-being. Meditation appears to be especially effective at mitigating the cardiovascular, metabolic, autoimmune, and inflammatory consequences of high-stress or unhealthy lifestyles in adults. Children and adolescents typically do not suffer from these diseases, but there is growing evidence that mindfulness practices can improve self-reported stress management skills, well-being, and sleep in young people; skills that can protect their physical and mental health. In addition, there is some evidence that mindfulness can be effective as a treatment for the common psychiatric illnesses of youth.
Anxiety
There is robust evidence for the efficacy of mindfulness-based interventions (including a regular mindfulness meditation practice) in the treatment of anxiety disorders in youth. Multiple studies and meta-analyses have demonstrated significant and sustained improvement in anxiety symptoms in these young patients. This makes sense when one considers that most psychotherapy treatments for anxiety include the cultivation of self-awareness and the ability to recognize the feelings of anxiety. This is critical as youth with anxiety disorders often mistake these feelings for facts. The treatment then shifts toward practice tolerating these feelings to help children develop an appreciation that they can face and manage anxiety and that it does not need to be avoided. Part of tolerating these feelings includes building skills to facilitate calm and physical relaxation in the face of these anxious feelings.
This is the core of exposure-based psychotherapies. Mindfulness practices echo the cultivation of self-awareness with focus and physical calm. Studies have shown that mindfulness-based interventions have significant and lasting effects on the symptoms of anxiety disorders in youth, including those youth with comorbid ADHD and learning disabilities. It is important to be aware that, for youth who have experienced trauma, mindfulness meditation can trigger a flood of re-experiencing phenomena, and it is important that those youth also are receiving treatment for PTSD.
Depression
There is evidence that some of the symptoms that occur as part of depression in adolescents improve with mindfulness-based interventions. In particular, symptoms of anger, irritability, disruptive behaviors, suicidality, and even impulsive self-injury improve with mindfulness-based interventions. Dialectical behavioral therapy (DBT) and acceptance and commitment therapy (ACT) have the nonjudgmental self-awareness of mindfulness built in as a component of the therapy. But mindfulness practices without explicit cognitive and behavioral components of psychotherapy for depression are not effective as stand-alone treatment of major depressive disorder in youth.
Multiple meta-analyses have demonstrated that stimulant treatment is more effective than behavioral or environmental interventions in the treatment of ADHD in children and adolescents, and combined treatments have not shown substantial additional improvement over medications alone in randomized controlled studies. But there is a lot of interest in finding effective treatments beyond medications that will help children with ADHD build important cognitive and behavioral skills that may lag developmentally.
Now there is an emerging body of evidence indicating that mindfulness skills in children with ADHD are quite effective for improving their sustained attention, social skills, behavioral control, and even hyperactivity. Additionally, methods to teach mindfulness skills to children who struggle with stillness and focused attention have been developed for these studies (“mindful martial arts”). Again, this intervention has not yet shown the same level of efficacy as medication treatments for ADHD symptoms, but it has demonstrated promise in early trials. Interestingly, it has also shown promise as a component of parenting interventions for youth with ADHD.
You do not need to wait for decisive evidence from randomized controlled trials to recommend mindfulness training for your patients with anxiety, ADHD, or even depression. Indeed, this practice alone may be adequate as a treatment for mild to moderate anxiety disorders. But you can also recommend it as an empowering and effective adjunctive treatment for almost every psychiatric illness and subclinical syndrome, and one that is affordable and easy for families to access. It would be valuable for you to recommend that your patients and their parents both try a mindfulness practice alongside your recommendations about healthy sleep, exercise, and nutrition. There are free apps such as Smiling Mind, Sound Mind, and Thrive Global that families can try together. Some children may need to move physically to be able to practice mindfulness, so yoga or walking meditations can be a better practice for them. When parents can try mindfulness practice alongside their children, it will facilitate their child’s efforts to develop these skills, and the improved sleep, focus, and stress management skills in parents can make a significant difference in the health and well-being of the whole family.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].
Meditation has become a popular practice in the United States over the last decade. It is not limited to adults, but can be learned and practiced by children and teenagers also. Variants are being used in many schools as parts of a social and emotional learning curriculum, and different kinds of mindfulness practices are common parts of psychological treatments. In this month’s column, we will review the evidence that supports the efficacy of a meditation practice to treat the mental health problems that are common in children and adolescents, and review how it might be a useful adjunct to the screening, education, and treatments that you offer your young patients.
There are many different types of meditation practices, but the unifying feature is known as mindfulness. Most broadly, mindfulness refers to a state of nonjudgmental awareness of one’s thoughts, feelings, or sensations. A mindfulness meditation practice involves physical stillness and focused attention, typically on the physical sensations of one’s breath. When thoughts, feelings, or physical sensations intrude on the stillness, one learns to cultivate a nonjudgmental awareness of those experiences without disrupting the state of quiet concentration. It could be said that meditation is easy to learn and difficult to master, and that is why it should be practiced regularly. Part of its growing popularity has undoubtedly been served by the ease with which people can access a variety of guided meditations (through apps, YouTube, and beyond) that make it relatively easy to access a variety of methods to learn how to practice mindfulness meditation.
The benefits of meditation in adults are well-established, including lower blood pressure, lower rates of heart disease, lower markers of inflammation, better sleep, and self-described levels of well-being. Meditation appears to be especially effective at mitigating the cardiovascular, metabolic, autoimmune, and inflammatory consequences of high-stress or unhealthy lifestyles in adults. Children and adolescents typically do not suffer from these diseases, but there is growing evidence that mindfulness practices can improve self-reported stress management skills, well-being, and sleep in young people; skills that can protect their physical and mental health. In addition, there is some evidence that mindfulness can be effective as a treatment for the common psychiatric illnesses of youth.
Anxiety
There is robust evidence for the efficacy of mindfulness-based interventions (including a regular mindfulness meditation practice) in the treatment of anxiety disorders in youth. Multiple studies and meta-analyses have demonstrated significant and sustained improvement in anxiety symptoms in these young patients. This makes sense when one considers that most psychotherapy treatments for anxiety include the cultivation of self-awareness and the ability to recognize the feelings of anxiety. This is critical as youth with anxiety disorders often mistake these feelings for facts. The treatment then shifts toward practice tolerating these feelings to help children develop an appreciation that they can face and manage anxiety and that it does not need to be avoided. Part of tolerating these feelings includes building skills to facilitate calm and physical relaxation in the face of these anxious feelings.
This is the core of exposure-based psychotherapies. Mindfulness practices echo the cultivation of self-awareness with focus and physical calm. Studies have shown that mindfulness-based interventions have significant and lasting effects on the symptoms of anxiety disorders in youth, including those youth with comorbid ADHD and learning disabilities. It is important to be aware that, for youth who have experienced trauma, mindfulness meditation can trigger a flood of re-experiencing phenomena, and it is important that those youth also are receiving treatment for PTSD.
Depression
There is evidence that some of the symptoms that occur as part of depression in adolescents improve with mindfulness-based interventions. In particular, symptoms of anger, irritability, disruptive behaviors, suicidality, and even impulsive self-injury improve with mindfulness-based interventions. Dialectical behavioral therapy (DBT) and acceptance and commitment therapy (ACT) have the nonjudgmental self-awareness of mindfulness built in as a component of the therapy. But mindfulness practices without explicit cognitive and behavioral components of psychotherapy for depression are not effective as stand-alone treatment of major depressive disorder in youth.
Multiple meta-analyses have demonstrated that stimulant treatment is more effective than behavioral or environmental interventions in the treatment of ADHD in children and adolescents, and combined treatments have not shown substantial additional improvement over medications alone in randomized controlled studies. But there is a lot of interest in finding effective treatments beyond medications that will help children with ADHD build important cognitive and behavioral skills that may lag developmentally.
Now there is an emerging body of evidence indicating that mindfulness skills in children with ADHD are quite effective for improving their sustained attention, social skills, behavioral control, and even hyperactivity. Additionally, methods to teach mindfulness skills to children who struggle with stillness and focused attention have been developed for these studies (“mindful martial arts”). Again, this intervention has not yet shown the same level of efficacy as medication treatments for ADHD symptoms, but it has demonstrated promise in early trials. Interestingly, it has also shown promise as a component of parenting interventions for youth with ADHD.
You do not need to wait for decisive evidence from randomized controlled trials to recommend mindfulness training for your patients with anxiety, ADHD, or even depression. Indeed, this practice alone may be adequate as a treatment for mild to moderate anxiety disorders. But you can also recommend it as an empowering and effective adjunctive treatment for almost every psychiatric illness and subclinical syndrome, and one that is affordable and easy for families to access. It would be valuable for you to recommend that your patients and their parents both try a mindfulness practice alongside your recommendations about healthy sleep, exercise, and nutrition. There are free apps such as Smiling Mind, Sound Mind, and Thrive Global that families can try together. Some children may need to move physically to be able to practice mindfulness, so yoga or walking meditations can be a better practice for them. When parents can try mindfulness practice alongside their children, it will facilitate their child’s efforts to develop these skills, and the improved sleep, focus, and stress management skills in parents can make a significant difference in the health and well-being of the whole family.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].
Meditation has become a popular practice in the United States over the last decade. It is not limited to adults, but can be learned and practiced by children and teenagers also. Variants are being used in many schools as parts of a social and emotional learning curriculum, and different kinds of mindfulness practices are common parts of psychological treatments. In this month’s column, we will review the evidence that supports the efficacy of a meditation practice to treat the mental health problems that are common in children and adolescents, and review how it might be a useful adjunct to the screening, education, and treatments that you offer your young patients.
There are many different types of meditation practices, but the unifying feature is known as mindfulness. Most broadly, mindfulness refers to a state of nonjudgmental awareness of one’s thoughts, feelings, or sensations. A mindfulness meditation practice involves physical stillness and focused attention, typically on the physical sensations of one’s breath. When thoughts, feelings, or physical sensations intrude on the stillness, one learns to cultivate a nonjudgmental awareness of those experiences without disrupting the state of quiet concentration. It could be said that meditation is easy to learn and difficult to master, and that is why it should be practiced regularly. Part of its growing popularity has undoubtedly been served by the ease with which people can access a variety of guided meditations (through apps, YouTube, and beyond) that make it relatively easy to access a variety of methods to learn how to practice mindfulness meditation.
The benefits of meditation in adults are well-established, including lower blood pressure, lower rates of heart disease, lower markers of inflammation, better sleep, and self-described levels of well-being. Meditation appears to be especially effective at mitigating the cardiovascular, metabolic, autoimmune, and inflammatory consequences of high-stress or unhealthy lifestyles in adults. Children and adolescents typically do not suffer from these diseases, but there is growing evidence that mindfulness practices can improve self-reported stress management skills, well-being, and sleep in young people; skills that can protect their physical and mental health. In addition, there is some evidence that mindfulness can be effective as a treatment for the common psychiatric illnesses of youth.
Anxiety
There is robust evidence for the efficacy of mindfulness-based interventions (including a regular mindfulness meditation practice) in the treatment of anxiety disorders in youth. Multiple studies and meta-analyses have demonstrated significant and sustained improvement in anxiety symptoms in these young patients. This makes sense when one considers that most psychotherapy treatments for anxiety include the cultivation of self-awareness and the ability to recognize the feelings of anxiety. This is critical as youth with anxiety disorders often mistake these feelings for facts. The treatment then shifts toward practice tolerating these feelings to help children develop an appreciation that they can face and manage anxiety and that it does not need to be avoided. Part of tolerating these feelings includes building skills to facilitate calm and physical relaxation in the face of these anxious feelings.
This is the core of exposure-based psychotherapies. Mindfulness practices echo the cultivation of self-awareness with focus and physical calm. Studies have shown that mindfulness-based interventions have significant and lasting effects on the symptoms of anxiety disorders in youth, including those youth with comorbid ADHD and learning disabilities. It is important to be aware that, for youth who have experienced trauma, mindfulness meditation can trigger a flood of re-experiencing phenomena, and it is important that those youth also are receiving treatment for PTSD.
Depression
There is evidence that some of the symptoms that occur as part of depression in adolescents improve with mindfulness-based interventions. In particular, symptoms of anger, irritability, disruptive behaviors, suicidality, and even impulsive self-injury improve with mindfulness-based interventions. Dialectical behavioral therapy (DBT) and acceptance and commitment therapy (ACT) have the nonjudgmental self-awareness of mindfulness built in as a component of the therapy. But mindfulness practices without explicit cognitive and behavioral components of psychotherapy for depression are not effective as stand-alone treatment of major depressive disorder in youth.
Multiple meta-analyses have demonstrated that stimulant treatment is more effective than behavioral or environmental interventions in the treatment of ADHD in children and adolescents, and combined treatments have not shown substantial additional improvement over medications alone in randomized controlled studies. But there is a lot of interest in finding effective treatments beyond medications that will help children with ADHD build important cognitive and behavioral skills that may lag developmentally.
Now there is an emerging body of evidence indicating that mindfulness skills in children with ADHD are quite effective for improving their sustained attention, social skills, behavioral control, and even hyperactivity. Additionally, methods to teach mindfulness skills to children who struggle with stillness and focused attention have been developed for these studies (“mindful martial arts”). Again, this intervention has not yet shown the same level of efficacy as medication treatments for ADHD symptoms, but it has demonstrated promise in early trials. Interestingly, it has also shown promise as a component of parenting interventions for youth with ADHD.
You do not need to wait for decisive evidence from randomized controlled trials to recommend mindfulness training for your patients with anxiety, ADHD, or even depression. Indeed, this practice alone may be adequate as a treatment for mild to moderate anxiety disorders. But you can also recommend it as an empowering and effective adjunctive treatment for almost every psychiatric illness and subclinical syndrome, and one that is affordable and easy for families to access. It would be valuable for you to recommend that your patients and their parents both try a mindfulness practice alongside your recommendations about healthy sleep, exercise, and nutrition. There are free apps such as Smiling Mind, Sound Mind, and Thrive Global that families can try together. Some children may need to move physically to be able to practice mindfulness, so yoga or walking meditations can be a better practice for them. When parents can try mindfulness practice alongside their children, it will facilitate their child’s efforts to develop these skills, and the improved sleep, focus, and stress management skills in parents can make a significant difference in the health and well-being of the whole family.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].
Combination therapy may boost remission in JIA
Benefit endures at 3 years
PHILADELPHIA – Aggressive therapy using conventional synthetic disease-modifying antirheumatic drugs (DMARDs) in combination with biologic agents early, soon after a child is diagnosed with polyarticular juvenile idiopathic arthritis (pJIA), enabled more patients to achieve clinical remission and longer times in inactive disease than more conventional therapeutic approaches, 3-year results of prospective, observational study demonstrated.
The results of The Childhood Arthritis and Rheumatology Research Alliance STOP-JIA study, which Yukiko Kimura, MD, presented at the annual meeting of the American College of Rheumatology, showed early combination therapy had benefits, compared with other treatment strategies that were more evident at 3 years than at 1 year of study.
“The STOP-JIA study showed that, after 3 years, patients who started a biologic early on in combination with methotrexate spent more time in inactive disease and achieved clinical remission more often when compared to those started on traditional step-up therapy,” Dr. Kimura, chief of pediatric rheumatology at Hackensack (N.J.) Meridian Health and professor of pediatrics at the Hackensack Meridian School of Medicine, said at a press conference. “This study shows that the treatment of poly-JIA patients receive initially very early on in their disease matters even 3 years after that treatment was started.”
The study compared three CARRA consensus treatment plans (CTP) for untreated pediatric pJIA patients: step-up (SU) – starting conventional synthetic DMARD therapy and adding a biologic if needed after 3 or more months; early-combination (EC) therapy – starting synthetic and biologic DMARDs together; and biologic first (BF) therapy – starting biologic DMARD monotherapy.
Dr. Kimura explained the rationale for the study. “Since biologic treatments were introduced more than 20 years ago, the prognosis for JIA significantly improved. These very effective medicines often work wonders, quickly reducing pain and inflammation in joint disease activity,” she said in the press conference. “What is not known, however, is when is the best time to start these very effective treatments.”
The most common approach is to start with a synthetic DMARD, typically methotrexate, and wait before starting a biologic, Dr. Kimura said.
“But even though methotrexate can work very well by itself, it does not work for every patient, and we don’t know whether waiting months for it to work and then starting a biologic might potentially lessen their effectiveness,” Dr. Kimura added. “We don’t know if there’s a window of opportunity that’s lost while waiting to see whether methotrexate will work.”
The study originally enrolled 400 patients, 297 of whom completed the 3-year visit – 190 in SU, 76 in EC and 31 in BF. At 12 months, the study found no statistically significant difference in clinically inactive disease (CID) between the groups, Dr. Kimura said.
Even at the 3-year visit, the percentage of patients in CID off glucocorticoids and clinical Juvenile Arthritis Disease Activity Score based on 10 joints inactive disease (cJADAS 10 ID) did not differ among the three groups, Dr. Kimura said in presenting the results. “But,” she added, “greater proportions of early-combination CTP group were able to achieve clinical remissions and spend more time with inactive disease in both CID and cJADAS 10.”
A closer look at the outcomes showed some separation between early-combination therapy and the other two treatment plans. The incidence of clinical remission (at any time point over 36 months) was 67.1% in the EC group vs. 49.1% and 47.3%, respectively, in the BF and SU groups, Dr. Kimura said. “The difference between the early-combination and step-up groups was highly significant [P = .007],” she added.
EC also had an edge in the percentage of time patients spent in CID (over 36 months): 39.2% versus 32% and 27.4%, respectively, in the BF and SU groups (P = .006 for EV vs. SU), as well as cJADAS 10 ID (50.6% in EC group vs. 42.8% and 37.5%, respectively in the BF and SU groups; P = .005 for EC vs. SU).
Dr. Kimura said that the STOP JIA trial will continue with longer-term analysis and ongoing monitoring of study patients through the CARRA registry. “These longer-term analyses and readouts will be important because even though the results at 12 months didn’t seem as definitive, it seems the longer we go, the more impact we see of the treatments that were started early on in this disease.”
The findings from this study are “significantly important,” Nina T. Washington, MD, MPH, a pediatric rheumatologist at the University of New Mexico Hospital, Albuquerque, and the Mary Bridge Children’s Hospital in Tacoma, Wash., said in an interview. “At least for the past decade we’ve really been advocating towards earlier and aggressive therapy, and that’s what this study shows: the sooner you can treat this disease, the sooner you can attack those joints that are inflamed, the better outcome you give the patient.”
The study also confirms that pediatric rheumatologists are not overtreating patients with pJIA, she added.
“In a sense we’re actually treating and preventing and if you have a child that has arthritis, it’s okay to treat that child,” Dr. Washington said. “For me that’s the most reassuring thing: that I’m not necessarily going overboard. If I have a child with polyarticular JIA and they have multiple inflamed joints and I have the evidence as they’re sitting in front of me, and I treat them. I’m going to give them the best outcome.”
The Patient Centered Outcomes Research Institute provided study funding. Dr. Kimura is chair of the CARRA JIA disease research committee and cochair of the CARRA Registry and Research Oversight Committee. She disclosed a financial relationship with Genentech. Dr. Washington has no relevant relationships to disclose.
Benefit endures at 3 years
Benefit endures at 3 years
PHILADELPHIA – Aggressive therapy using conventional synthetic disease-modifying antirheumatic drugs (DMARDs) in combination with biologic agents early, soon after a child is diagnosed with polyarticular juvenile idiopathic arthritis (pJIA), enabled more patients to achieve clinical remission and longer times in inactive disease than more conventional therapeutic approaches, 3-year results of prospective, observational study demonstrated.
The results of The Childhood Arthritis and Rheumatology Research Alliance STOP-JIA study, which Yukiko Kimura, MD, presented at the annual meeting of the American College of Rheumatology, showed early combination therapy had benefits, compared with other treatment strategies that were more evident at 3 years than at 1 year of study.
“The STOP-JIA study showed that, after 3 years, patients who started a biologic early on in combination with methotrexate spent more time in inactive disease and achieved clinical remission more often when compared to those started on traditional step-up therapy,” Dr. Kimura, chief of pediatric rheumatology at Hackensack (N.J.) Meridian Health and professor of pediatrics at the Hackensack Meridian School of Medicine, said at a press conference. “This study shows that the treatment of poly-JIA patients receive initially very early on in their disease matters even 3 years after that treatment was started.”
The study compared three CARRA consensus treatment plans (CTP) for untreated pediatric pJIA patients: step-up (SU) – starting conventional synthetic DMARD therapy and adding a biologic if needed after 3 or more months; early-combination (EC) therapy – starting synthetic and biologic DMARDs together; and biologic first (BF) therapy – starting biologic DMARD monotherapy.
Dr. Kimura explained the rationale for the study. “Since biologic treatments were introduced more than 20 years ago, the prognosis for JIA significantly improved. These very effective medicines often work wonders, quickly reducing pain and inflammation in joint disease activity,” she said in the press conference. “What is not known, however, is when is the best time to start these very effective treatments.”
The most common approach is to start with a synthetic DMARD, typically methotrexate, and wait before starting a biologic, Dr. Kimura said.
“But even though methotrexate can work very well by itself, it does not work for every patient, and we don’t know whether waiting months for it to work and then starting a biologic might potentially lessen their effectiveness,” Dr. Kimura added. “We don’t know if there’s a window of opportunity that’s lost while waiting to see whether methotrexate will work.”
The study originally enrolled 400 patients, 297 of whom completed the 3-year visit – 190 in SU, 76 in EC and 31 in BF. At 12 months, the study found no statistically significant difference in clinically inactive disease (CID) between the groups, Dr. Kimura said.
Even at the 3-year visit, the percentage of patients in CID off glucocorticoids and clinical Juvenile Arthritis Disease Activity Score based on 10 joints inactive disease (cJADAS 10 ID) did not differ among the three groups, Dr. Kimura said in presenting the results. “But,” she added, “greater proportions of early-combination CTP group were able to achieve clinical remissions and spend more time with inactive disease in both CID and cJADAS 10.”
A closer look at the outcomes showed some separation between early-combination therapy and the other two treatment plans. The incidence of clinical remission (at any time point over 36 months) was 67.1% in the EC group vs. 49.1% and 47.3%, respectively, in the BF and SU groups, Dr. Kimura said. “The difference between the early-combination and step-up groups was highly significant [P = .007],” she added.
EC also had an edge in the percentage of time patients spent in CID (over 36 months): 39.2% versus 32% and 27.4%, respectively, in the BF and SU groups (P = .006 for EV vs. SU), as well as cJADAS 10 ID (50.6% in EC group vs. 42.8% and 37.5%, respectively in the BF and SU groups; P = .005 for EC vs. SU).
Dr. Kimura said that the STOP JIA trial will continue with longer-term analysis and ongoing monitoring of study patients through the CARRA registry. “These longer-term analyses and readouts will be important because even though the results at 12 months didn’t seem as definitive, it seems the longer we go, the more impact we see of the treatments that were started early on in this disease.”
The findings from this study are “significantly important,” Nina T. Washington, MD, MPH, a pediatric rheumatologist at the University of New Mexico Hospital, Albuquerque, and the Mary Bridge Children’s Hospital in Tacoma, Wash., said in an interview. “At least for the past decade we’ve really been advocating towards earlier and aggressive therapy, and that’s what this study shows: the sooner you can treat this disease, the sooner you can attack those joints that are inflamed, the better outcome you give the patient.”
The study also confirms that pediatric rheumatologists are not overtreating patients with pJIA, she added.
“In a sense we’re actually treating and preventing and if you have a child that has arthritis, it’s okay to treat that child,” Dr. Washington said. “For me that’s the most reassuring thing: that I’m not necessarily going overboard. If I have a child with polyarticular JIA and they have multiple inflamed joints and I have the evidence as they’re sitting in front of me, and I treat them. I’m going to give them the best outcome.”
The Patient Centered Outcomes Research Institute provided study funding. Dr. Kimura is chair of the CARRA JIA disease research committee and cochair of the CARRA Registry and Research Oversight Committee. She disclosed a financial relationship with Genentech. Dr. Washington has no relevant relationships to disclose.
PHILADELPHIA – Aggressive therapy using conventional synthetic disease-modifying antirheumatic drugs (DMARDs) in combination with biologic agents early, soon after a child is diagnosed with polyarticular juvenile idiopathic arthritis (pJIA), enabled more patients to achieve clinical remission and longer times in inactive disease than more conventional therapeutic approaches, 3-year results of prospective, observational study demonstrated.
The results of The Childhood Arthritis and Rheumatology Research Alliance STOP-JIA study, which Yukiko Kimura, MD, presented at the annual meeting of the American College of Rheumatology, showed early combination therapy had benefits, compared with other treatment strategies that were more evident at 3 years than at 1 year of study.
“The STOP-JIA study showed that, after 3 years, patients who started a biologic early on in combination with methotrexate spent more time in inactive disease and achieved clinical remission more often when compared to those started on traditional step-up therapy,” Dr. Kimura, chief of pediatric rheumatology at Hackensack (N.J.) Meridian Health and professor of pediatrics at the Hackensack Meridian School of Medicine, said at a press conference. “This study shows that the treatment of poly-JIA patients receive initially very early on in their disease matters even 3 years after that treatment was started.”
The study compared three CARRA consensus treatment plans (CTP) for untreated pediatric pJIA patients: step-up (SU) – starting conventional synthetic DMARD therapy and adding a biologic if needed after 3 or more months; early-combination (EC) therapy – starting synthetic and biologic DMARDs together; and biologic first (BF) therapy – starting biologic DMARD monotherapy.
Dr. Kimura explained the rationale for the study. “Since biologic treatments were introduced more than 20 years ago, the prognosis for JIA significantly improved. These very effective medicines often work wonders, quickly reducing pain and inflammation in joint disease activity,” she said in the press conference. “What is not known, however, is when is the best time to start these very effective treatments.”
The most common approach is to start with a synthetic DMARD, typically methotrexate, and wait before starting a biologic, Dr. Kimura said.
“But even though methotrexate can work very well by itself, it does not work for every patient, and we don’t know whether waiting months for it to work and then starting a biologic might potentially lessen their effectiveness,” Dr. Kimura added. “We don’t know if there’s a window of opportunity that’s lost while waiting to see whether methotrexate will work.”
The study originally enrolled 400 patients, 297 of whom completed the 3-year visit – 190 in SU, 76 in EC and 31 in BF. At 12 months, the study found no statistically significant difference in clinically inactive disease (CID) between the groups, Dr. Kimura said.
Even at the 3-year visit, the percentage of patients in CID off glucocorticoids and clinical Juvenile Arthritis Disease Activity Score based on 10 joints inactive disease (cJADAS 10 ID) did not differ among the three groups, Dr. Kimura said in presenting the results. “But,” she added, “greater proportions of early-combination CTP group were able to achieve clinical remissions and spend more time with inactive disease in both CID and cJADAS 10.”
A closer look at the outcomes showed some separation between early-combination therapy and the other two treatment plans. The incidence of clinical remission (at any time point over 36 months) was 67.1% in the EC group vs. 49.1% and 47.3%, respectively, in the BF and SU groups, Dr. Kimura said. “The difference between the early-combination and step-up groups was highly significant [P = .007],” she added.
EC also had an edge in the percentage of time patients spent in CID (over 36 months): 39.2% versus 32% and 27.4%, respectively, in the BF and SU groups (P = .006 for EV vs. SU), as well as cJADAS 10 ID (50.6% in EC group vs. 42.8% and 37.5%, respectively in the BF and SU groups; P = .005 for EC vs. SU).
Dr. Kimura said that the STOP JIA trial will continue with longer-term analysis and ongoing monitoring of study patients through the CARRA registry. “These longer-term analyses and readouts will be important because even though the results at 12 months didn’t seem as definitive, it seems the longer we go, the more impact we see of the treatments that were started early on in this disease.”
The findings from this study are “significantly important,” Nina T. Washington, MD, MPH, a pediatric rheumatologist at the University of New Mexico Hospital, Albuquerque, and the Mary Bridge Children’s Hospital in Tacoma, Wash., said in an interview. “At least for the past decade we’ve really been advocating towards earlier and aggressive therapy, and that’s what this study shows: the sooner you can treat this disease, the sooner you can attack those joints that are inflamed, the better outcome you give the patient.”
The study also confirms that pediatric rheumatologists are not overtreating patients with pJIA, she added.
“In a sense we’re actually treating and preventing and if you have a child that has arthritis, it’s okay to treat that child,” Dr. Washington said. “For me that’s the most reassuring thing: that I’m not necessarily going overboard. If I have a child with polyarticular JIA and they have multiple inflamed joints and I have the evidence as they’re sitting in front of me, and I treat them. I’m going to give them the best outcome.”
The Patient Centered Outcomes Research Institute provided study funding. Dr. Kimura is chair of the CARRA JIA disease research committee and cochair of the CARRA Registry and Research Oversight Committee. She disclosed a financial relationship with Genentech. Dr. Washington has no relevant relationships to disclose.
AT ACR 2022
Love them or hate them, masks in schools work
This transcript has been edited for clarity.
Welcome to Impact Factor, your weekly dose of commentary on a new medical study. I’m Dr. F. Perry Wilson of the Yale School of Medicine.
On March 26, 2022, Hawaii became the last state in the United States to lift its indoor mask mandate. By the time the current school year started, there were essentially no public school mask mandates either.
Whether you viewed the mask as an emblem of stalwart defiance against a rampaging virus, or a scarlet letter emblematic of the overreaches of public policy, you probably aren’t seeing them much anymore.
And yet, the debate about masks still rages. Who was right, who was wrong? Who trusted science, and what does the science even say? If we brought our country into marriage counseling, would we be told it is time to move on? To look forward, not backward? To plan for our bright future together?
Perhaps. But this question isn’t really moot just because masks have largely disappeared in the United States. Variants may emerge that lead to more infection waves – and other pandemics may occur in the future. And so I think it is important to discuss a study that, with quite rigorous analysis, attempts to answer the following question: Did masking in schools lower students’ and teachers’ risk of COVID?
We are talking about this study, appearing in the New England Journal of Medicine. The short version goes like this.
Researchers had access to two important sources of data. One – an accounting of all the teachers and students (more than 300,000 of them) in 79 public, noncharter school districts in Eastern Massachusetts who tested positive for COVID every week. Two – the date that each of those school districts lifted their mask mandates or (in the case of two districts) didn’t.
Right away, I’m sure you’re thinking of potential issues. Districts that kept masks even when the statewide ban was lifted are likely quite a bit different from districts that dropped masks right away. You’re right, of course – hold on to that thought; we’ll get there.
But first – the big question – would districts that kept their masks on longer do better when it comes to the rate of COVID infection?
When everyone was masking, COVID case rates were pretty similar. Statewide mandates are lifted in late February – and most school districts remove their mandates within a few weeks – the black line are the two districts (Boston and Chelsea) where mask mandates remained in place.
Prior to the mask mandate lifting, you see very similar COVID rates in districts that would eventually remove the mandate and those that would not, with a bit of noise around the initial Omicron wave which saw just a huge amount of people get infected.
And then, after the mandate was lifted, separation. Districts that held on to masks longer had lower rates of COVID infection.
In all, over the 15-weeks of the study, there were roughly 12,000 extra cases of COVID in the mask-free school districts, which corresponds to about 35% of the total COVID burden during that time. And, yes, kids do well with COVID – on average. But 12,000 extra cases is enough to translate into a significant number of important clinical outcomes – think hospitalizations and post-COVID syndromes. And of course, maybe most importantly, missed school days. Positive kids were not allowed in class no matter what district they were in.
Okay – I promised we’d address confounders. This was not a cluster-randomized trial, where some school districts had their mandates removed based on the vicissitudes of a virtual coin flip, as much as many of us would have been interested to see that. The decision to remove masks was up to the various school boards – and they had a lot of pressure on them from many different directions. But all we need to worry about is whether any of those things that pressure a school board to keep masks on would ALSO lead to fewer COVID cases. That’s how confounders work, and how you can get false results in a study like this.
And yes – districts that kept the masks on longer were different than those who took them right off. But check out how they were different.
The districts that kept masks on longer had more low-income students. More Black and Latino students. More students per classroom. These are all risk factors that increase the risk of COVID infection. In other words, the confounding here goes in the opposite direction of the results. If anything, these factors should make you more certain that masking works.
The authors also adjusted for other factors – the community transmission of COVID-19, vaccination rates, school district sizes, and so on. No major change in the results.
One concern I addressed to Dr. Ellie Murray, the biostatistician on the study – could districts that removed masks simply have been testing more to compensate, leading to increased capturing of cases?
If anything, the schools that kept masks on were testing more than the schools that took them off – again that would tend to imply that the results are even stronger than what was reported.
Is this a perfect study? Of course not – it’s one study, it’s from one state. And the relatively large effects from keeping masks on for one or 2 weeks require us to really embrace the concept of exponential growth of infections, but, if COVID has taught us anything, it is that small changes in initial conditions can have pretty big effects.
My daughter, who goes to a public school here in Connecticut, unmasked, was home with COVID this past week. She’s fine. But you know what? She missed a week of school. I worked from home to be with her – though I didn’t test positive. And that is a real cost to both of us that I think we need to consider when we consider the value of masks. Yes, they’re annoying – but if they keep kids in school, might they be worth it? Perhaps not for now, as cases aren’t surging. But in the future, be it a particularly concerning variant, or a whole new pandemic, we should not discount the simple, cheap, and apparently beneficial act of wearing masks to decrease transmission.
Dr. Perry Wilson is an associate professor of medicine and director of the Clinical and Translational Research Accelerator at Yale University, New Haven, Conn. He disclosed no relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
This transcript has been edited for clarity.
Welcome to Impact Factor, your weekly dose of commentary on a new medical study. I’m Dr. F. Perry Wilson of the Yale School of Medicine.
On March 26, 2022, Hawaii became the last state in the United States to lift its indoor mask mandate. By the time the current school year started, there were essentially no public school mask mandates either.
Whether you viewed the mask as an emblem of stalwart defiance against a rampaging virus, or a scarlet letter emblematic of the overreaches of public policy, you probably aren’t seeing them much anymore.
And yet, the debate about masks still rages. Who was right, who was wrong? Who trusted science, and what does the science even say? If we brought our country into marriage counseling, would we be told it is time to move on? To look forward, not backward? To plan for our bright future together?
Perhaps. But this question isn’t really moot just because masks have largely disappeared in the United States. Variants may emerge that lead to more infection waves – and other pandemics may occur in the future. And so I think it is important to discuss a study that, with quite rigorous analysis, attempts to answer the following question: Did masking in schools lower students’ and teachers’ risk of COVID?
We are talking about this study, appearing in the New England Journal of Medicine. The short version goes like this.
Researchers had access to two important sources of data. One – an accounting of all the teachers and students (more than 300,000 of them) in 79 public, noncharter school districts in Eastern Massachusetts who tested positive for COVID every week. Two – the date that each of those school districts lifted their mask mandates or (in the case of two districts) didn’t.
Right away, I’m sure you’re thinking of potential issues. Districts that kept masks even when the statewide ban was lifted are likely quite a bit different from districts that dropped masks right away. You’re right, of course – hold on to that thought; we’ll get there.
But first – the big question – would districts that kept their masks on longer do better when it comes to the rate of COVID infection?
When everyone was masking, COVID case rates were pretty similar. Statewide mandates are lifted in late February – and most school districts remove their mandates within a few weeks – the black line are the two districts (Boston and Chelsea) where mask mandates remained in place.
Prior to the mask mandate lifting, you see very similar COVID rates in districts that would eventually remove the mandate and those that would not, with a bit of noise around the initial Omicron wave which saw just a huge amount of people get infected.
And then, after the mandate was lifted, separation. Districts that held on to masks longer had lower rates of COVID infection.
In all, over the 15-weeks of the study, there were roughly 12,000 extra cases of COVID in the mask-free school districts, which corresponds to about 35% of the total COVID burden during that time. And, yes, kids do well with COVID – on average. But 12,000 extra cases is enough to translate into a significant number of important clinical outcomes – think hospitalizations and post-COVID syndromes. And of course, maybe most importantly, missed school days. Positive kids were not allowed in class no matter what district they were in.
Okay – I promised we’d address confounders. This was not a cluster-randomized trial, where some school districts had their mandates removed based on the vicissitudes of a virtual coin flip, as much as many of us would have been interested to see that. The decision to remove masks was up to the various school boards – and they had a lot of pressure on them from many different directions. But all we need to worry about is whether any of those things that pressure a school board to keep masks on would ALSO lead to fewer COVID cases. That’s how confounders work, and how you can get false results in a study like this.
And yes – districts that kept the masks on longer were different than those who took them right off. But check out how they were different.
The districts that kept masks on longer had more low-income students. More Black and Latino students. More students per classroom. These are all risk factors that increase the risk of COVID infection. In other words, the confounding here goes in the opposite direction of the results. If anything, these factors should make you more certain that masking works.
The authors also adjusted for other factors – the community transmission of COVID-19, vaccination rates, school district sizes, and so on. No major change in the results.
One concern I addressed to Dr. Ellie Murray, the biostatistician on the study – could districts that removed masks simply have been testing more to compensate, leading to increased capturing of cases?
If anything, the schools that kept masks on were testing more than the schools that took them off – again that would tend to imply that the results are even stronger than what was reported.
Is this a perfect study? Of course not – it’s one study, it’s from one state. And the relatively large effects from keeping masks on for one or 2 weeks require us to really embrace the concept of exponential growth of infections, but, if COVID has taught us anything, it is that small changes in initial conditions can have pretty big effects.
My daughter, who goes to a public school here in Connecticut, unmasked, was home with COVID this past week. She’s fine. But you know what? She missed a week of school. I worked from home to be with her – though I didn’t test positive. And that is a real cost to both of us that I think we need to consider when we consider the value of masks. Yes, they’re annoying – but if they keep kids in school, might they be worth it? Perhaps not for now, as cases aren’t surging. But in the future, be it a particularly concerning variant, or a whole new pandemic, we should not discount the simple, cheap, and apparently beneficial act of wearing masks to decrease transmission.
Dr. Perry Wilson is an associate professor of medicine and director of the Clinical and Translational Research Accelerator at Yale University, New Haven, Conn. He disclosed no relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
This transcript has been edited for clarity.
Welcome to Impact Factor, your weekly dose of commentary on a new medical study. I’m Dr. F. Perry Wilson of the Yale School of Medicine.
On March 26, 2022, Hawaii became the last state in the United States to lift its indoor mask mandate. By the time the current school year started, there were essentially no public school mask mandates either.
Whether you viewed the mask as an emblem of stalwart defiance against a rampaging virus, or a scarlet letter emblematic of the overreaches of public policy, you probably aren’t seeing them much anymore.
And yet, the debate about masks still rages. Who was right, who was wrong? Who trusted science, and what does the science even say? If we brought our country into marriage counseling, would we be told it is time to move on? To look forward, not backward? To plan for our bright future together?
Perhaps. But this question isn’t really moot just because masks have largely disappeared in the United States. Variants may emerge that lead to more infection waves – and other pandemics may occur in the future. And so I think it is important to discuss a study that, with quite rigorous analysis, attempts to answer the following question: Did masking in schools lower students’ and teachers’ risk of COVID?
We are talking about this study, appearing in the New England Journal of Medicine. The short version goes like this.
Researchers had access to two important sources of data. One – an accounting of all the teachers and students (more than 300,000 of them) in 79 public, noncharter school districts in Eastern Massachusetts who tested positive for COVID every week. Two – the date that each of those school districts lifted their mask mandates or (in the case of two districts) didn’t.
Right away, I’m sure you’re thinking of potential issues. Districts that kept masks even when the statewide ban was lifted are likely quite a bit different from districts that dropped masks right away. You’re right, of course – hold on to that thought; we’ll get there.
But first – the big question – would districts that kept their masks on longer do better when it comes to the rate of COVID infection?
When everyone was masking, COVID case rates were pretty similar. Statewide mandates are lifted in late February – and most school districts remove their mandates within a few weeks – the black line are the two districts (Boston and Chelsea) where mask mandates remained in place.
Prior to the mask mandate lifting, you see very similar COVID rates in districts that would eventually remove the mandate and those that would not, with a bit of noise around the initial Omicron wave which saw just a huge amount of people get infected.
And then, after the mandate was lifted, separation. Districts that held on to masks longer had lower rates of COVID infection.
In all, over the 15-weeks of the study, there were roughly 12,000 extra cases of COVID in the mask-free school districts, which corresponds to about 35% of the total COVID burden during that time. And, yes, kids do well with COVID – on average. But 12,000 extra cases is enough to translate into a significant number of important clinical outcomes – think hospitalizations and post-COVID syndromes. And of course, maybe most importantly, missed school days. Positive kids were not allowed in class no matter what district they were in.
Okay – I promised we’d address confounders. This was not a cluster-randomized trial, where some school districts had their mandates removed based on the vicissitudes of a virtual coin flip, as much as many of us would have been interested to see that. The decision to remove masks was up to the various school boards – and they had a lot of pressure on them from many different directions. But all we need to worry about is whether any of those things that pressure a school board to keep masks on would ALSO lead to fewer COVID cases. That’s how confounders work, and how you can get false results in a study like this.
And yes – districts that kept the masks on longer were different than those who took them right off. But check out how they were different.
The districts that kept masks on longer had more low-income students. More Black and Latino students. More students per classroom. These are all risk factors that increase the risk of COVID infection. In other words, the confounding here goes in the opposite direction of the results. If anything, these factors should make you more certain that masking works.
The authors also adjusted for other factors – the community transmission of COVID-19, vaccination rates, school district sizes, and so on. No major change in the results.
One concern I addressed to Dr. Ellie Murray, the biostatistician on the study – could districts that removed masks simply have been testing more to compensate, leading to increased capturing of cases?
If anything, the schools that kept masks on were testing more than the schools that took them off – again that would tend to imply that the results are even stronger than what was reported.
Is this a perfect study? Of course not – it’s one study, it’s from one state. And the relatively large effects from keeping masks on for one or 2 weeks require us to really embrace the concept of exponential growth of infections, but, if COVID has taught us anything, it is that small changes in initial conditions can have pretty big effects.
My daughter, who goes to a public school here in Connecticut, unmasked, was home with COVID this past week. She’s fine. But you know what? She missed a week of school. I worked from home to be with her – though I didn’t test positive. And that is a real cost to both of us that I think we need to consider when we consider the value of masks. Yes, they’re annoying – but if they keep kids in school, might they be worth it? Perhaps not for now, as cases aren’t surging. But in the future, be it a particularly concerning variant, or a whole new pandemic, we should not discount the simple, cheap, and apparently beneficial act of wearing masks to decrease transmission.
Dr. Perry Wilson is an associate professor of medicine and director of the Clinical and Translational Research Accelerator at Yale University, New Haven, Conn. He disclosed no relevant conflicts of interest.
A version of this article first appeared on Medscape.com.