Heidi Splete

Several adverse infant outcomes were significantly more likely for infants whose mothers had diagnoses of sleep apnea or insomnia, based on data from approximately 5,000 infants.

Sleep disturbance is common during pregnancy, and “sleep disorders during pregnancy can have significant consequences for both the pregnant person and their infant,” write Jennifer N. Felder, PhD, of the University of California, San Francisco, and colleagues.

However, data on the impact of maternal insomnia on specific infant outcomes are limited, they said.

In a study published recently in the journal Sleep Health, the researchers reviewed data from 3,371 pregnant women diagnosed with sleep apnea and 3,213 with insomnia. Of these, 2,357 and 2,212 were matched with controls in a propensity-score analysis. The referent controls were matched for maternal characteristics, obstetric factors, and infant factors among individuals without a sleep disorder. All were singleton pregnancies.

Adverse infant outcomes included the following:

• One- and 5-minute Apgar scores less than 7.
• Respiratory distress syndrome.
• Neonatal intensive care unit admission.
• Hypoglycemia.
• Infant death.
• Hospital stay of longer than 2 days for vaginal delivery or longer than 4 days for cesarean delivery.
• Emergency department visit before 3 months of age.
• Emergency department visit in the first year of life.
• Composite measure of adverse infant outcomes.

Compared with matched controls, the infants born to mothers with sleep apnea had a significantly increased risk for any adverse outcome (50.1% vs. 53.5%) and of the specific outcomes of low 1-minute Apgar scores (6.3% vs. 9.6%), neonatal ICU stays (6.3% vs. 8.4%), and an emergency department visit in the first year of life (33.6% vs. 36.9%).

For infants born to mothers with insomnia, the only significant difference in outcomes compared with controls was an increased likelihood of an emergency department visit (37.2% vs. 32.3%).

“Research on possible mechanisms of the relation between maternal prenatal sleep apnea and poorer birth and infant outcomes associations is small but growing, implicating systemic inflammation and late or prolonged fetal heart rate decelerations,” the researchers write in their discussion.

Research on insomnia during pregnancy and adverse infant outcomes is limited, and the largest studies have been complicated by the effects of insomnia medication; therefore, “our finding that infants born to mothers with an insomnia diagnosis were at increased risk of only emergency room visit, but no other analyzed infant outcomes, is important and novel,” they note.

The findings were limited by several factors, including the reliance on medical records, which may lack details on how routinely health care professionals assessed sleep disorders, the researchers noted. “Consequently, the findings presented here may reflect more severe cases of insomnia and sleep apnea, and may not represent the population of individuals with diagnosed sleep apnea or insomnia during pregnancy generally,” the authors say. Other limitations included a lack of information on treatment of sleep disorders and on the timing of diagnosis (before pregnancy or during pregnancy).

However, the results were strengthened by the large, population-based sample and use of codes to highlight research questions, the researchers said.

In light of the health consequences of sleep disorders in pregnancy, the data suggest that sleep apnea and insomnia in pregnant women may serve as targets for risk assessment of adverse infant outcomes, and more research is needed to determine whether addressing sleep issues reduces these outcomes, they concluded.

The study was supported by the University of California, San Francisco, Preterm Birth Initiative and by grants to lead author Dr. Felder from the National Center for Complementary and Integrative Health and to a coauthor from the National Heart, Lung, and Blood Institute. The researchers reported no relevant financial relationships.

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

Several adverse infant outcomes were significantly more likely for infants whose mothers had diagnoses of sleep apnea or insomnia, based on data from approximately 5,000 infants.

Sleep disturbance is common during pregnancy, and “sleep disorders during pregnancy can have significant consequences for both the pregnant person and their infant,” write Jennifer N. Felder, PhD, of the University of California, San Francisco, and colleagues.

However, data on the impact of maternal insomnia on specific infant outcomes are limited, they said.

In a study published recently in the journal Sleep Health, the researchers reviewed data from 3,371 pregnant women diagnosed with sleep apnea and 3,213 with insomnia. Of these, 2,357 and 2,212 were matched with controls in a propensity-score analysis. The referent controls were matched for maternal characteristics, obstetric factors, and infant factors among individuals without a sleep disorder. All were singleton pregnancies.

Adverse infant outcomes included the following:

• One- and 5-minute Apgar scores less than 7.
• Respiratory distress syndrome.
• Neonatal intensive care unit admission.
• Hypoglycemia.
• Infant death.
• Hospital stay of longer than 2 days for vaginal delivery or longer than 4 days for cesarean delivery.
• Emergency department visit before 3 months of age.
• Emergency department visit in the first year of life.
• Composite measure of adverse infant outcomes.

Compared with matched controls, the infants born to mothers with sleep apnea had a significantly increased risk for any adverse outcome (50.1% vs. 53.5%) and of the specific outcomes of low 1-minute Apgar scores (6.3% vs. 9.6%), neonatal ICU stays (6.3% vs. 8.4%), and an emergency department visit in the first year of life (33.6% vs. 36.9%).

For infants born to mothers with insomnia, the only significant difference in outcomes compared with controls was an increased likelihood of an emergency department visit (37.2% vs. 32.3%).

“Research on possible mechanisms of the relation between maternal prenatal sleep apnea and poorer birth and infant outcomes associations is small but growing, implicating systemic inflammation and late or prolonged fetal heart rate decelerations,” the researchers write in their discussion.

Research on insomnia during pregnancy and adverse infant outcomes is limited, and the largest studies have been complicated by the effects of insomnia medication; therefore, “our finding that infants born to mothers with an insomnia diagnosis were at increased risk of only emergency room visit, but no other analyzed infant outcomes, is important and novel,” they note.

The findings were limited by several factors, including the reliance on medical records, which may lack details on how routinely health care professionals assessed sleep disorders, the researchers noted. “Consequently, the findings presented here may reflect more severe cases of insomnia and sleep apnea, and may not represent the population of individuals with diagnosed sleep apnea or insomnia during pregnancy generally,” the authors say. Other limitations included a lack of information on treatment of sleep disorders and on the timing of diagnosis (before pregnancy or during pregnancy).

However, the results were strengthened by the large, population-based sample and use of codes to highlight research questions, the researchers said.

In light of the health consequences of sleep disorders in pregnancy, the data suggest that sleep apnea and insomnia in pregnant women may serve as targets for risk assessment of adverse infant outcomes, and more research is needed to determine whether addressing sleep issues reduces these outcomes, they concluded.

The study was supported by the University of California, San Francisco, Preterm Birth Initiative and by grants to lead author Dr. Felder from the National Center for Complementary and Integrative Health and to a coauthor from the National Heart, Lung, and Blood Institute. The researchers reported no relevant financial relationships.

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

Several adverse infant outcomes were significantly more likely for infants whose mothers had diagnoses of sleep apnea or insomnia, based on data from approximately 5,000 infants.

Sleep disturbance is common during pregnancy, and “sleep disorders during pregnancy can have significant consequences for both the pregnant person and their infant,” write Jennifer N. Felder, PhD, of the University of California, San Francisco, and colleagues.

However, data on the impact of maternal insomnia on specific infant outcomes are limited, they said.

In a study published recently in the journal Sleep Health, the researchers reviewed data from 3,371 pregnant women diagnosed with sleep apnea and 3,213 with insomnia. Of these, 2,357 and 2,212 were matched with controls in a propensity-score analysis. The referent controls were matched for maternal characteristics, obstetric factors, and infant factors among individuals without a sleep disorder. All were singleton pregnancies.

Adverse infant outcomes included the following:

• One- and 5-minute Apgar scores less than 7.
• Respiratory distress syndrome.
• Neonatal intensive care unit admission.
• Hypoglycemia.
• Infant death.
• Hospital stay of longer than 2 days for vaginal delivery or longer than 4 days for cesarean delivery.
• Emergency department visit before 3 months of age.
• Emergency department visit in the first year of life.
• Composite measure of adverse infant outcomes.

Compared with matched controls, the infants born to mothers with sleep apnea had a significantly increased risk for any adverse outcome (50.1% vs. 53.5%) and of the specific outcomes of low 1-minute Apgar scores (6.3% vs. 9.6%), neonatal ICU stays (6.3% vs. 8.4%), and an emergency department visit in the first year of life (33.6% vs. 36.9%).

For infants born to mothers with insomnia, the only significant difference in outcomes compared with controls was an increased likelihood of an emergency department visit (37.2% vs. 32.3%).

“Research on possible mechanisms of the relation between maternal prenatal sleep apnea and poorer birth and infant outcomes associations is small but growing, implicating systemic inflammation and late or prolonged fetal heart rate decelerations,” the researchers write in their discussion.

Research on insomnia during pregnancy and adverse infant outcomes is limited, and the largest studies have been complicated by the effects of insomnia medication; therefore, “our finding that infants born to mothers with an insomnia diagnosis were at increased risk of only emergency room visit, but no other analyzed infant outcomes, is important and novel,” they note.

The findings were limited by several factors, including the reliance on medical records, which may lack details on how routinely health care professionals assessed sleep disorders, the researchers noted. “Consequently, the findings presented here may reflect more severe cases of insomnia and sleep apnea, and may not represent the population of individuals with diagnosed sleep apnea or insomnia during pregnancy generally,” the authors say. Other limitations included a lack of information on treatment of sleep disorders and on the timing of diagnosis (before pregnancy or during pregnancy).

However, the results were strengthened by the large, population-based sample and use of codes to highlight research questions, the researchers said.

In light of the health consequences of sleep disorders in pregnancy, the data suggest that sleep apnea and insomnia in pregnant women may serve as targets for risk assessment of adverse infant outcomes, and more research is needed to determine whether addressing sleep issues reduces these outcomes, they concluded.

The study was supported by the University of California, San Francisco, Preterm Birth Initiative and by grants to lead author Dr. Felder from the National Center for Complementary and Integrative Health and to a coauthor from the National Heart, Lung, and Blood Institute. The researchers reported no relevant financial relationships.

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

A biosimilar drug to the tumor necrosis factor inhibitor adalimumab, marketed as Idacio (adalimumab-aacf), has been approved by the Food and Drug Administration for use in the United States, according to a press release from manufacturer Fresenius Kabi.

Idacio is a citrate-free, low-concentration formulation of adalimumab and is now approved for use for all but three of the indications that currently apply to the reference adalimumab product (Humira): rheumatoid arthritis, polyarticular juvenile idiopathic arthritis, psoriatic arthritis in adults, ankylosing spondylitis, Crohn’s disease in adults and children aged 6 years or older, ulcerative colitis in adults, and plaque psoriasis in adults. It does not apply to Humira’s indications for hidradenitis suppurativa, uveitis, or ulcerative colitis in pediatric patients aged 5 years and older.

Wikimedia Commons/FitzColinGerald/Creative Commons License

Idacio is the eighth adalimumab biosimilar to be approved in the United States. Its approval was based on evidence of a similar profile of pharmacokinetics, safety, efficacy, and immunogenicity to Humira.

Idacio was first launched in 2019 and has been marketed in more than 37 countries worldwide, according to Fresenius Kabi. The U.S. launch is scheduled for July, and Idacio will be available as a self-administered prefilled syringe or prefilled pen.

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

A biosimilar drug to the tumor necrosis factor inhibitor adalimumab, marketed as Idacio (adalimumab-aacf), has been approved by the Food and Drug Administration for use in the United States, according to a press release from manufacturer Fresenius Kabi.

Idacio is a citrate-free, low-concentration formulation of adalimumab and is now approved for use for all but three of the indications that currently apply to the reference adalimumab product (Humira): rheumatoid arthritis, polyarticular juvenile idiopathic arthritis, psoriatic arthritis in adults, ankylosing spondylitis, Crohn’s disease in adults and children aged 6 years or older, ulcerative colitis in adults, and plaque psoriasis in adults. It does not apply to Humira’s indications for hidradenitis suppurativa, uveitis, or ulcerative colitis in pediatric patients aged 5 years and older.

Wikimedia Commons/FitzColinGerald/Creative Commons License

Idacio is the eighth adalimumab biosimilar to be approved in the United States. Its approval was based on evidence of a similar profile of pharmacokinetics, safety, efficacy, and immunogenicity to Humira.

Idacio was first launched in 2019 and has been marketed in more than 37 countries worldwide, according to Fresenius Kabi. The U.S. launch is scheduled for July, and Idacio will be available as a self-administered prefilled syringe or prefilled pen.

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

A biosimilar drug to the tumor necrosis factor inhibitor adalimumab, marketed as Idacio (adalimumab-aacf), has been approved by the Food and Drug Administration for use in the United States, according to a press release from manufacturer Fresenius Kabi.

Idacio is a citrate-free, low-concentration formulation of adalimumab and is now approved for use for all but three of the indications that currently apply to the reference adalimumab product (Humira): rheumatoid arthritis, polyarticular juvenile idiopathic arthritis, psoriatic arthritis in adults, ankylosing spondylitis, Crohn’s disease in adults and children aged 6 years or older, ulcerative colitis in adults, and plaque psoriasis in adults. It does not apply to Humira’s indications for hidradenitis suppurativa, uveitis, or ulcerative colitis in pediatric patients aged 5 years and older.

Wikimedia Commons/FitzColinGerald/Creative Commons License

Idacio is the eighth adalimumab biosimilar to be approved in the United States. Its approval was based on evidence of a similar profile of pharmacokinetics, safety, efficacy, and immunogenicity to Humira.

Idacio was first launched in 2019 and has been marketed in more than 37 countries worldwide, according to Fresenius Kabi. The U.S. launch is scheduled for July, and Idacio will be available as a self-administered prefilled syringe or prefilled pen.

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

LAS VEGAS – Improving diversity in dermatology starts with education, Susan C. Taylor, MD, said in a presentation at Medscape Live’s annual Las Vegas Dermatology Seminar, where she led a panel discussion on opportunities to improve diversity in the specialty.

The growing ethnic minority population in the United States “underscores the need for medical education to ensure dermatologists are prepared to provide quality care for patients of diverse racial and ethnic backgrounds,” said Dr. Taylor, the Bernett L. Johnson Jr., MD, Professor, and vice chair for diversity, equity, and inclusion in the department of dermatology at the University of Pennsylvania.

Improving education includes diversifying resource material, she said. A recent study in the Journal of the American Academy of Dermatology showed the representation of skin tones on Google searches for skin conditions was mostly light skin (91.7%), although non-Hispanic Whites account for less than two-thirds (approximately 60%) of the U.S. population, she said. Many people with darker skin tones “are not finding people who look like themselves” when they search skin conditions online, she noted.

The lack of diversity in images occurs not only on Google, “but in our textbooks, which are the foundational resources for our students,” said Nada M. Elbuluk, MD, founder and director of the Skin of Color and Pigmentary Disorders Program at the University of Southern California, Los Angeles. She also established the Dermatology Diversity and Inclusion Program at USC.

Although more than 13% of Americans are Black, only 3% of dermatologists in the United States are Black, Dr. Callender noted. Similarly, 4.2% of dermatologists in the United States are Hispanic or Latino, but these groups make up more than 18% of the general U.S. population, according to a recent study, she said.

Cheryl M. Burgess, MD, founder and medical director of the Center for Dermatology and Dermatologic Surgery in Washington, presented a roadmap of strategies for improving diversity in dermatology, starting with increasing STEM education at the high school and college levels among all populations and increasing the pipeline of underrepresented students to medical schools.

Then, faculty should work to increase interest in dermatology among underrepresented medical students and increase the numbers of underrepresented medical students in dermatology residency programs, said Dr. Burgess, assistant clinical professor of dermatology at Georgetown University and George Washington University, Washington.

“The more diversity we have in our specialty, the more we learn from each other,” and increased diversity can promote new research questions, said Andrew F. Alexis, MD, vice chair for diversity and inclusion in the department of dermatology and professor of clinical dermatology at Weill Cornell Medicine, New York.

Increasing the diversity of populations in clinical trials is another important strategy to improve diversity in dermatology, he emphasized.

Mentoring is an excellent way to help underrepresented students develop and pursue a career in dermatology, the panelists agreed. Time is precious for everyone, so don’t hesitate to use Zoom and other technology to help connect with mentees, Dr. Burgess advised.

Dr. Taylor added that mentoring doesn’t have to be a huge time commitment, it can be as simple as volunteering once a year at a school career forum. “It is so gratifying to have these young people looking up to you,” she said.

The panelists disclosed relationships with multiple companies, but none were relevant to this panel discussion. MedscapeLive and this news organization are owned by the same parent company.

LAS VEGAS – Improving diversity in dermatology starts with education, Susan C. Taylor, MD, said in a presentation at Medscape Live’s annual Las Vegas Dermatology Seminar, where she led a panel discussion on opportunities to improve diversity in the specialty.

The growing ethnic minority population in the United States “underscores the need for medical education to ensure dermatologists are prepared to provide quality care for patients of diverse racial and ethnic backgrounds,” said Dr. Taylor, the Bernett L. Johnson Jr., MD, Professor, and vice chair for diversity, equity, and inclusion in the department of dermatology at the University of Pennsylvania.

Improving education includes diversifying resource material, she said. A recent study in the Journal of the American Academy of Dermatology showed the representation of skin tones on Google searches for skin conditions was mostly light skin (91.7%), although non-Hispanic Whites account for less than two-thirds (approximately 60%) of the U.S. population, she said. Many people with darker skin tones “are not finding people who look like themselves” when they search skin conditions online, she noted.

The lack of diversity in images occurs not only on Google, “but in our textbooks, which are the foundational resources for our students,” said Nada M. Elbuluk, MD, founder and director of the Skin of Color and Pigmentary Disorders Program at the University of Southern California, Los Angeles. She also established the Dermatology Diversity and Inclusion Program at USC.

Although more than 13% of Americans are Black, only 3% of dermatologists in the United States are Black, Dr. Callender noted. Similarly, 4.2% of dermatologists in the United States are Hispanic or Latino, but these groups make up more than 18% of the general U.S. population, according to a recent study, she said.

Cheryl M. Burgess, MD, founder and medical director of the Center for Dermatology and Dermatologic Surgery in Washington, presented a roadmap of strategies for improving diversity in dermatology, starting with increasing STEM education at the high school and college levels among all populations and increasing the pipeline of underrepresented students to medical schools.

Then, faculty should work to increase interest in dermatology among underrepresented medical students and increase the numbers of underrepresented medical students in dermatology residency programs, said Dr. Burgess, assistant clinical professor of dermatology at Georgetown University and George Washington University, Washington.

“The more diversity we have in our specialty, the more we learn from each other,” and increased diversity can promote new research questions, said Andrew F. Alexis, MD, vice chair for diversity and inclusion in the department of dermatology and professor of clinical dermatology at Weill Cornell Medicine, New York.

Increasing the diversity of populations in clinical trials is another important strategy to improve diversity in dermatology, he emphasized.

Mentoring is an excellent way to help underrepresented students develop and pursue a career in dermatology, the panelists agreed. Time is precious for everyone, so don’t hesitate to use Zoom and other technology to help connect with mentees, Dr. Burgess advised.

Dr. Taylor added that mentoring doesn’t have to be a huge time commitment, it can be as simple as volunteering once a year at a school career forum. “It is so gratifying to have these young people looking up to you,” she said.

The panelists disclosed relationships with multiple companies, but none were relevant to this panel discussion. MedscapeLive and this news organization are owned by the same parent company.

LAS VEGAS – Improving diversity in dermatology starts with education, Susan C. Taylor, MD, said in a presentation at Medscape Live’s annual Las Vegas Dermatology Seminar, where she led a panel discussion on opportunities to improve diversity in the specialty.

The growing ethnic minority population in the United States “underscores the need for medical education to ensure dermatologists are prepared to provide quality care for patients of diverse racial and ethnic backgrounds,” said Dr. Taylor, the Bernett L. Johnson Jr., MD, Professor, and vice chair for diversity, equity, and inclusion in the department of dermatology at the University of Pennsylvania.

Improving education includes diversifying resource material, she said. A recent study in the Journal of the American Academy of Dermatology showed the representation of skin tones on Google searches for skin conditions was mostly light skin (91.7%), although non-Hispanic Whites account for less than two-thirds (approximately 60%) of the U.S. population, she said. Many people with darker skin tones “are not finding people who look like themselves” when they search skin conditions online, she noted.

The lack of diversity in images occurs not only on Google, “but in our textbooks, which are the foundational resources for our students,” said Nada M. Elbuluk, MD, founder and director of the Skin of Color and Pigmentary Disorders Program at the University of Southern California, Los Angeles. She also established the Dermatology Diversity and Inclusion Program at USC.

Although more than 13% of Americans are Black, only 3% of dermatologists in the United States are Black, Dr. Callender noted. Similarly, 4.2% of dermatologists in the United States are Hispanic or Latino, but these groups make up more than 18% of the general U.S. population, according to a recent study, she said.

Cheryl M. Burgess, MD, founder and medical director of the Center for Dermatology and Dermatologic Surgery in Washington, presented a roadmap of strategies for improving diversity in dermatology, starting with increasing STEM education at the high school and college levels among all populations and increasing the pipeline of underrepresented students to medical schools.

Then, faculty should work to increase interest in dermatology among underrepresented medical students and increase the numbers of underrepresented medical students in dermatology residency programs, said Dr. Burgess, assistant clinical professor of dermatology at Georgetown University and George Washington University, Washington.

“The more diversity we have in our specialty, the more we learn from each other,” and increased diversity can promote new research questions, said Andrew F. Alexis, MD, vice chair for diversity and inclusion in the department of dermatology and professor of clinical dermatology at Weill Cornell Medicine, New York.

Increasing the diversity of populations in clinical trials is another important strategy to improve diversity in dermatology, he emphasized.

Mentoring is an excellent way to help underrepresented students develop and pursue a career in dermatology, the panelists agreed. Time is precious for everyone, so don’t hesitate to use Zoom and other technology to help connect with mentees, Dr. Burgess advised.

Dr. Taylor added that mentoring doesn’t have to be a huge time commitment, it can be as simple as volunteering once a year at a school career forum. “It is so gratifying to have these young people looking up to you,” she said.

The panelists disclosed relationships with multiple companies, but none were relevant to this panel discussion. MedscapeLive and this news organization are owned by the same parent company.

Metabolic syndrome is associated with a significantly increased risk for gout in young men, but the risk can be mitigated by improvement in individual components of the syndrome, based on data from a pair of population-based studies totaling more than 4 million individuals.

Gout remains the most common type of inflammatory arthritis in men, and the rate has been rising among younger adults, Yeonghee Eun, MD, PhD, of Sungkyunkwan University, Seoul, South Korea, and colleagues wrote. An increasing body of evidence suggests a link between gout and metabolic syndrome (MetS), but large studies have been lacking, especially in younger adults.

In a study published in Frontiers in Medicine, the researchers reviewed data from 3,569,104 men aged 20-39 years who underwent a health checkup between 2009 and 2012 in South Korea, based on the Korean National Health Insurance Service. The primary outcome of incident gout was identified using claims data. The mean age of the participants was 31.5 years.

Over a mean follow-up of 7.4 years, the incidence of gout was 3.36 per 1,000 person-years. The risk of developing gout was more than twice as high among individuals who met MetS criteria than in those who did not (adjusted hazard ratio, 2.44).

MetS was defined as the presence of at least two of the following components: hypertriglyceridemia, abdominal obesity, reduced HDL cholesterol, elevated blood pressure, and elevated fasting glucose.

Overall, individuals with all five MetS components had a fivefold increase in gout risk, compared with people who did not have MetS (aHR, 5.24). In an analysis of each component of MetS, hypertriglyceridemia and abdominal obesity showed the strongest association with gout (aHRs of 2.08 and 2.33, respectively).

The impact of MetS on risk of incident gout was greater in younger participants, which suggests that the management of MetS in young people should be emphasized, the researchers said.

In a further analysis of body mass index subgroups, MetS had the greatest impact on gout risk for individuals who were underweight (aHR, 3.82). “In particular, in the underweight group, the risk of gout increased 10-fold when abdominal obesity was present,” the researchers said.

The study was limited by several factors including potential selection bias and potential overestimation of gout incidence because of the use of diagnostic codes, the researchers noted. Other limitations included lack of control for nutritional or dietary risk factors and the inability to include cases that occurred after the study period.

However, findings were strengthened by the large number of participants with MetS who were underweight or normal weight, the researchers wrote. More research on the mechanism of action is needed, but the data suggest that MetS is a key risk factor in the development of gout in young men.

In a second study, published in Arthritis & Rheumatology, Dr. Eun and colleagues examined associations between MetS changes and incident gout in young men. Although previous studies have shown that changes in MetS status can alter the risk of cardiovascular events, atrial fibrillation, end-stage renal disease, and all-cause mortality, the impact of these changes on gout has not been well studied, they said. The researchers used the same study cohort, the National Health Insurance Service database in South Korea. They reviewed data from 1,293,166 individuals aged 20-39 years. Of these, 18,473 were diagnosed with gout for an incidence rate 3.36/1,000 person-years. The researchers compared gout incidence for men who met criteria for MetS at three health checkups and those without MetS.

Overall, patients with MetS at all three checkups had a nearly fourfold higher risk of gout than those who never had MetS, with an adjusted hazard ratio of 3.82, the researchers wrote. The development of MetS over the study period more than doubled the risk of gout, but recovery from MetS reduced incident gout risk by approximately 50% (aHR, 0.52).

In findings similar to the Frontiers in Medicine study, the greatest associations with gout were noted for changes in elevated triglycerides and changes in abdominal obesity; aHRs for development and recovery for elevated triglycerides were 1.74 and 0.56, respectively, and for abdominal obesity, 1.94 and 0.69, respectively.

More research is needed to explore the mechanism by which both abdominal obesity and elevated triglycerides drive the development of gout, the researchers wrote in their discussion.

Also similar to the Frontiers study, the associations among changes in MetS and incident gout were greater for the youngest participants (in their 20s) and in the underweight or normal weight BMI groups.

Limitations of the second study included possible selection bias because of the study population of workplace employees who participated in regular health checks and the lack of data on women or on men aged 40 years and older, the researchers noted. Other limitations included possible misclassification of MetS because of varying health checkup results and drug claims, and lack of data on serum urate, which prevented assessment of hyperuricemia as a cause of gout.

However, the results were strengthened by the large sample size and suggest that MetS is a modifiable risk factor for gout, the researchers concluded.

Neither of the studies received outside funding. The researchers had no financial conflicts to disclose.

Metabolic syndrome is associated with a significantly increased risk for gout in young men, but the risk can be mitigated by improvement in individual components of the syndrome, based on data from a pair of population-based studies totaling more than 4 million individuals.

Gout remains the most common type of inflammatory arthritis in men, and the rate has been rising among younger adults, Yeonghee Eun, MD, PhD, of Sungkyunkwan University, Seoul, South Korea, and colleagues wrote. An increasing body of evidence suggests a link between gout and metabolic syndrome (MetS), but large studies have been lacking, especially in younger adults.

In a study published in Frontiers in Medicine, the researchers reviewed data from 3,569,104 men aged 20-39 years who underwent a health checkup between 2009 and 2012 in South Korea, based on the Korean National Health Insurance Service. The primary outcome of incident gout was identified using claims data. The mean age of the participants was 31.5 years.

Over a mean follow-up of 7.4 years, the incidence of gout was 3.36 per 1,000 person-years. The risk of developing gout was more than twice as high among individuals who met MetS criteria than in those who did not (adjusted hazard ratio, 2.44).

MetS was defined as the presence of at least two of the following components: hypertriglyceridemia, abdominal obesity, reduced HDL cholesterol, elevated blood pressure, and elevated fasting glucose.

Overall, individuals with all five MetS components had a fivefold increase in gout risk, compared with people who did not have MetS (aHR, 5.24). In an analysis of each component of MetS, hypertriglyceridemia and abdominal obesity showed the strongest association with gout (aHRs of 2.08 and 2.33, respectively).

The impact of MetS on risk of incident gout was greater in younger participants, which suggests that the management of MetS in young people should be emphasized, the researchers said.

In a further analysis of body mass index subgroups, MetS had the greatest impact on gout risk for individuals who were underweight (aHR, 3.82). “In particular, in the underweight group, the risk of gout increased 10-fold when abdominal obesity was present,” the researchers said.

The study was limited by several factors including potential selection bias and potential overestimation of gout incidence because of the use of diagnostic codes, the researchers noted. Other limitations included lack of control for nutritional or dietary risk factors and the inability to include cases that occurred after the study period.

However, findings were strengthened by the large number of participants with MetS who were underweight or normal weight, the researchers wrote. More research on the mechanism of action is needed, but the data suggest that MetS is a key risk factor in the development of gout in young men.

In a second study, published in Arthritis & Rheumatology, Dr. Eun and colleagues examined associations between MetS changes and incident gout in young men. Although previous studies have shown that changes in MetS status can alter the risk of cardiovascular events, atrial fibrillation, end-stage renal disease, and all-cause mortality, the impact of these changes on gout has not been well studied, they said. The researchers used the same study cohort, the National Health Insurance Service database in South Korea. They reviewed data from 1,293,166 individuals aged 20-39 years. Of these, 18,473 were diagnosed with gout for an incidence rate 3.36/1,000 person-years. The researchers compared gout incidence for men who met criteria for MetS at three health checkups and those without MetS.

Overall, patients with MetS at all three checkups had a nearly fourfold higher risk of gout than those who never had MetS, with an adjusted hazard ratio of 3.82, the researchers wrote. The development of MetS over the study period more than doubled the risk of gout, but recovery from MetS reduced incident gout risk by approximately 50% (aHR, 0.52).

In findings similar to the Frontiers in Medicine study, the greatest associations with gout were noted for changes in elevated triglycerides and changes in abdominal obesity; aHRs for development and recovery for elevated triglycerides were 1.74 and 0.56, respectively, and for abdominal obesity, 1.94 and 0.69, respectively.

More research is needed to explore the mechanism by which both abdominal obesity and elevated triglycerides drive the development of gout, the researchers wrote in their discussion.

Also similar to the Frontiers study, the associations among changes in MetS and incident gout were greater for the youngest participants (in their 20s) and in the underweight or normal weight BMI groups.

Limitations of the second study included possible selection bias because of the study population of workplace employees who participated in regular health checks and the lack of data on women or on men aged 40 years and older, the researchers noted. Other limitations included possible misclassification of MetS because of varying health checkup results and drug claims, and lack of data on serum urate, which prevented assessment of hyperuricemia as a cause of gout.

However, the results were strengthened by the large sample size and suggest that MetS is a modifiable risk factor for gout, the researchers concluded.

Neither of the studies received outside funding. The researchers had no financial conflicts to disclose.

Metabolic syndrome is associated with a significantly increased risk for gout in young men, but the risk can be mitigated by improvement in individual components of the syndrome, based on data from a pair of population-based studies totaling more than 4 million individuals.

Gout remains the most common type of inflammatory arthritis in men, and the rate has been rising among younger adults, Yeonghee Eun, MD, PhD, of Sungkyunkwan University, Seoul, South Korea, and colleagues wrote. An increasing body of evidence suggests a link between gout and metabolic syndrome (MetS), but large studies have been lacking, especially in younger adults.

In a study published in Frontiers in Medicine, the researchers reviewed data from 3,569,104 men aged 20-39 years who underwent a health checkup between 2009 and 2012 in South Korea, based on the Korean National Health Insurance Service. The primary outcome of incident gout was identified using claims data. The mean age of the participants was 31.5 years.

Over a mean follow-up of 7.4 years, the incidence of gout was 3.36 per 1,000 person-years. The risk of developing gout was more than twice as high among individuals who met MetS criteria than in those who did not (adjusted hazard ratio, 2.44).

MetS was defined as the presence of at least two of the following components: hypertriglyceridemia, abdominal obesity, reduced HDL cholesterol, elevated blood pressure, and elevated fasting glucose.

Overall, individuals with all five MetS components had a fivefold increase in gout risk, compared with people who did not have MetS (aHR, 5.24). In an analysis of each component of MetS, hypertriglyceridemia and abdominal obesity showed the strongest association with gout (aHRs of 2.08 and 2.33, respectively).

The impact of MetS on risk of incident gout was greater in younger participants, which suggests that the management of MetS in young people should be emphasized, the researchers said.

In a further analysis of body mass index subgroups, MetS had the greatest impact on gout risk for individuals who were underweight (aHR, 3.82). “In particular, in the underweight group, the risk of gout increased 10-fold when abdominal obesity was present,” the researchers said.

The study was limited by several factors including potential selection bias and potential overestimation of gout incidence because of the use of diagnostic codes, the researchers noted. Other limitations included lack of control for nutritional or dietary risk factors and the inability to include cases that occurred after the study period.

However, findings were strengthened by the large number of participants with MetS who were underweight or normal weight, the researchers wrote. More research on the mechanism of action is needed, but the data suggest that MetS is a key risk factor in the development of gout in young men.

In a second study, published in Arthritis & Rheumatology, Dr. Eun and colleagues examined associations between MetS changes and incident gout in young men. Although previous studies have shown that changes in MetS status can alter the risk of cardiovascular events, atrial fibrillation, end-stage renal disease, and all-cause mortality, the impact of these changes on gout has not been well studied, they said. The researchers used the same study cohort, the National Health Insurance Service database in South Korea. They reviewed data from 1,293,166 individuals aged 20-39 years. Of these, 18,473 were diagnosed with gout for an incidence rate 3.36/1,000 person-years. The researchers compared gout incidence for men who met criteria for MetS at three health checkups and those without MetS.

Overall, patients with MetS at all three checkups had a nearly fourfold higher risk of gout than those who never had MetS, with an adjusted hazard ratio of 3.82, the researchers wrote. The development of MetS over the study period more than doubled the risk of gout, but recovery from MetS reduced incident gout risk by approximately 50% (aHR, 0.52).

In findings similar to the Frontiers in Medicine study, the greatest associations with gout were noted for changes in elevated triglycerides and changes in abdominal obesity; aHRs for development and recovery for elevated triglycerides were 1.74 and 0.56, respectively, and for abdominal obesity, 1.94 and 0.69, respectively.

More research is needed to explore the mechanism by which both abdominal obesity and elevated triglycerides drive the development of gout, the researchers wrote in their discussion.

Also similar to the Frontiers study, the associations among changes in MetS and incident gout were greater for the youngest participants (in their 20s) and in the underweight or normal weight BMI groups.

Limitations of the second study included possible selection bias because of the study population of workplace employees who participated in regular health checks and the lack of data on women or on men aged 40 years and older, the researchers noted. Other limitations included possible misclassification of MetS because of varying health checkup results and drug claims, and lack of data on serum urate, which prevented assessment of hyperuricemia as a cause of gout.

However, the results were strengthened by the large sample size and suggest that MetS is a modifiable risk factor for gout, the researchers concluded.

Neither of the studies received outside funding. The researchers had no financial conflicts to disclose.

A healthier lifestyle mitigated the impact of genetic factors on the risk of thyroid cancer, in a study based on data from more than 260,000 individuals.

Thyroid cancer has increased globally in recent years and ranks 9th among 36 cancers worldwide, at a considerable cost to health care systems, wrote Xiuming Feng of Guangxi Medical University, Nanning, Guangxi, China, and colleagues.

SciePro/Science Source

Both genetic and lifestyle factors are related to thyroid cancer; previous research suggests a heritability of about 50%, but data on the impact of modifiable lifestyle factors on thyroid cancer are limited, the researchers said.

In a prospective cohort study published in JAMA Network Open, the researchers used data from the UK Biobank and recruited adults aged 40-69 years during March 2006–October 2010. The final study population included 264,956 individuals of European descent. The median age of the participants was 57 years, and 52% were women.

Data on lifestyle behaviors were collected using interviews and questionnaires. The researchers constructed a total lifestyle score based on five variables: diet, physical activity, weight, smoking, and alcohol consumption. Each variable was assigned a score of 0 or 1, with 1 being favorable lifestyle behavior. Lifestyle was divided into three categories: unfavorable (scores 0-1), intermediate (score 2), and favorable (scores 3-5).

Each individual’s polygenic risk score (PRS) was categorized as low, intermediate, or high based on a meta–genome-wide association study of three cohorts.

The main outcome was the development of thyroid cancer.

The researchers identified 423 incident thyroid cancer cases over a median follow-up of 11.1 years.

Overall, higher PRSs were significantly associated with thyroid cancer (hazard ratio, 2.25; 95% confidence interval [CI], 1.91-2.64; P < .00001) as was an unfavorable lifestyle score (HR, 1.93; 95% CI, 1.50-2.49; P < .001 for trend).

An unfavorable lifestyle was significantly associated with thyroid cancer in the highest PRS group, and individuals with high PRS and unfavorable lifestyle had a nearly fivefold increased risk of thyroid cancer (HR, 4.89; 95% CI, 3.03-7.91; P < .001). By extension, “Adherence to a healthier lifestyle could decrease the incidence of thyroid cancer in individuals with a higher PRS,” the researchers wrote in their discussion.

The findings were limited by several factors, including the availability of only baseline lifestyle data, and lack of data on iodine intake, radiation exposure, experience, and family history, the researchers noted. Other limitations include the potential lack of generalizability to populations other than the individuals of European descent in the current study, they said.

However, the study is the first known to address the association among lifestyle, genetic factors, and risk of thyroid cancer, and was strengthened by the large study population, and the results suggest that lifestyle interventions may help reduce the risk of thyroid cancer in those with a genetic predisposition, they concluded.

Healthy living can make a difference

The incidence of thyroid cancer has increased annually, and exploring the possible risk factors could prevent the occurrence of thyroid cancer, corresponding author Xiaobo Yang, PhD, said in an interview.

Previous studies have reported that thyroid cancer is related to genetics and lifestyle, said Dr. Yang. “However, whether healthy lifestyle was associated with thyroid cancer risk and could attenuate the impact of genetic variants on thyroid cancer remains equivocal; therefore, it is crucial to determine the associations between genetic and lifestyle with thyroid cancer,” he said.

“To our surprise, we found that adherence to healthier lifestyle also could reduce the risk of thyroid cancer in those with high genetic predispositions,” said Dr. Yang. “The findings highlight the potential role of lifestyle interventions on thyroid cancer, especially in those with high genetic risk, because the heritability of thyroid cancer was very high, approximately 50%,” he said. “More attention should be paid to the role of healthier lifestyle in the prevention of cancer,” he added.

“Adherence to a healthier lifestyle could decrease the risk of thyroid cancer, which is the important message for clinicians,” said Dr. Yang. “It is not too soon to comment on implications for clinical practice, because many studies have maintained the consistent comment that healthier lifestyle could prevent the occurrence of cancer,” he said.

The relationship between sex-specific lifestyle factors such as smoking and alcohol use and thyroid cancer remains uncertain, and more research is needed to validate these associations, Dr. Yang said. More research also is needed to confirm the complex mechanism between lifestyle and genetics in thyroid cancer, he added.

The study was supported by the National Key R&D Program of China and the National Natural Science Foundation of China. The researchers had no financial conflicts to disclose.

A healthier lifestyle mitigated the impact of genetic factors on the risk of thyroid cancer, in a study based on data from more than 260,000 individuals.

Thyroid cancer has increased globally in recent years and ranks 9th among 36 cancers worldwide, at a considerable cost to health care systems, wrote Xiuming Feng of Guangxi Medical University, Nanning, Guangxi, China, and colleagues.

SciePro/Science Source

Both genetic and lifestyle factors are related to thyroid cancer; previous research suggests a heritability of about 50%, but data on the impact of modifiable lifestyle factors on thyroid cancer are limited, the researchers said.

In a prospective cohort study published in JAMA Network Open, the researchers used data from the UK Biobank and recruited adults aged 40-69 years during March 2006–October 2010. The final study population included 264,956 individuals of European descent. The median age of the participants was 57 years, and 52% were women.

Data on lifestyle behaviors were collected using interviews and questionnaires. The researchers constructed a total lifestyle score based on five variables: diet, physical activity, weight, smoking, and alcohol consumption. Each variable was assigned a score of 0 or 1, with 1 being favorable lifestyle behavior. Lifestyle was divided into three categories: unfavorable (scores 0-1), intermediate (score 2), and favorable (scores 3-5).

Each individual’s polygenic risk score (PRS) was categorized as low, intermediate, or high based on a meta–genome-wide association study of three cohorts.

The main outcome was the development of thyroid cancer.

The researchers identified 423 incident thyroid cancer cases over a median follow-up of 11.1 years.

Overall, higher PRSs were significantly associated with thyroid cancer (hazard ratio, 2.25; 95% confidence interval [CI], 1.91-2.64; P < .00001) as was an unfavorable lifestyle score (HR, 1.93; 95% CI, 1.50-2.49; P < .001 for trend).

An unfavorable lifestyle was significantly associated with thyroid cancer in the highest PRS group, and individuals with high PRS and unfavorable lifestyle had a nearly fivefold increased risk of thyroid cancer (HR, 4.89; 95% CI, 3.03-7.91; P < .001). By extension, “Adherence to a healthier lifestyle could decrease the incidence of thyroid cancer in individuals with a higher PRS,” the researchers wrote in their discussion.

The findings were limited by several factors, including the availability of only baseline lifestyle data, and lack of data on iodine intake, radiation exposure, experience, and family history, the researchers noted. Other limitations include the potential lack of generalizability to populations other than the individuals of European descent in the current study, they said.

However, the study is the first known to address the association among lifestyle, genetic factors, and risk of thyroid cancer, and was strengthened by the large study population, and the results suggest that lifestyle interventions may help reduce the risk of thyroid cancer in those with a genetic predisposition, they concluded.

Healthy living can make a difference

The incidence of thyroid cancer has increased annually, and exploring the possible risk factors could prevent the occurrence of thyroid cancer, corresponding author Xiaobo Yang, PhD, said in an interview.

Previous studies have reported that thyroid cancer is related to genetics and lifestyle, said Dr. Yang. “However, whether healthy lifestyle was associated with thyroid cancer risk and could attenuate the impact of genetic variants on thyroid cancer remains equivocal; therefore, it is crucial to determine the associations between genetic and lifestyle with thyroid cancer,” he said.

“To our surprise, we found that adherence to healthier lifestyle also could reduce the risk of thyroid cancer in those with high genetic predispositions,” said Dr. Yang. “The findings highlight the potential role of lifestyle interventions on thyroid cancer, especially in those with high genetic risk, because the heritability of thyroid cancer was very high, approximately 50%,” he said. “More attention should be paid to the role of healthier lifestyle in the prevention of cancer,” he added.

“Adherence to a healthier lifestyle could decrease the risk of thyroid cancer, which is the important message for clinicians,” said Dr. Yang. “It is not too soon to comment on implications for clinical practice, because many studies have maintained the consistent comment that healthier lifestyle could prevent the occurrence of cancer,” he said.

The relationship between sex-specific lifestyle factors such as smoking and alcohol use and thyroid cancer remains uncertain, and more research is needed to validate these associations, Dr. Yang said. More research also is needed to confirm the complex mechanism between lifestyle and genetics in thyroid cancer, he added.

The study was supported by the National Key R&D Program of China and the National Natural Science Foundation of China. The researchers had no financial conflicts to disclose.

A healthier lifestyle mitigated the impact of genetic factors on the risk of thyroid cancer, in a study based on data from more than 260,000 individuals.

Thyroid cancer has increased globally in recent years and ranks 9th among 36 cancers worldwide, at a considerable cost to health care systems, wrote Xiuming Feng of Guangxi Medical University, Nanning, Guangxi, China, and colleagues.

SciePro/Science Source

Both genetic and lifestyle factors are related to thyroid cancer; previous research suggests a heritability of about 50%, but data on the impact of modifiable lifestyle factors on thyroid cancer are limited, the researchers said.

In a prospective cohort study published in JAMA Network Open, the researchers used data from the UK Biobank and recruited adults aged 40-69 years during March 2006–October 2010. The final study population included 264,956 individuals of European descent. The median age of the participants was 57 years, and 52% were women.

Data on lifestyle behaviors were collected using interviews and questionnaires. The researchers constructed a total lifestyle score based on five variables: diet, physical activity, weight, smoking, and alcohol consumption. Each variable was assigned a score of 0 or 1, with 1 being favorable lifestyle behavior. Lifestyle was divided into three categories: unfavorable (scores 0-1), intermediate (score 2), and favorable (scores 3-5).

Each individual’s polygenic risk score (PRS) was categorized as low, intermediate, or high based on a meta–genome-wide association study of three cohorts.

The main outcome was the development of thyroid cancer.

The researchers identified 423 incident thyroid cancer cases over a median follow-up of 11.1 years.

Overall, higher PRSs were significantly associated with thyroid cancer (hazard ratio, 2.25; 95% confidence interval [CI], 1.91-2.64; P < .00001) as was an unfavorable lifestyle score (HR, 1.93; 95% CI, 1.50-2.49; P < .001 for trend).

An unfavorable lifestyle was significantly associated with thyroid cancer in the highest PRS group, and individuals with high PRS and unfavorable lifestyle had a nearly fivefold increased risk of thyroid cancer (HR, 4.89; 95% CI, 3.03-7.91; P < .001). By extension, “Adherence to a healthier lifestyle could decrease the incidence of thyroid cancer in individuals with a higher PRS,” the researchers wrote in their discussion.

The findings were limited by several factors, including the availability of only baseline lifestyle data, and lack of data on iodine intake, radiation exposure, experience, and family history, the researchers noted. Other limitations include the potential lack of generalizability to populations other than the individuals of European descent in the current study, they said.

However, the study is the first known to address the association among lifestyle, genetic factors, and risk of thyroid cancer, and was strengthened by the large study population, and the results suggest that lifestyle interventions may help reduce the risk of thyroid cancer in those with a genetic predisposition, they concluded.

Healthy living can make a difference

The incidence of thyroid cancer has increased annually, and exploring the possible risk factors could prevent the occurrence of thyroid cancer, corresponding author Xiaobo Yang, PhD, said in an interview.

Previous studies have reported that thyroid cancer is related to genetics and lifestyle, said Dr. Yang. “However, whether healthy lifestyle was associated with thyroid cancer risk and could attenuate the impact of genetic variants on thyroid cancer remains equivocal; therefore, it is crucial to determine the associations between genetic and lifestyle with thyroid cancer,” he said.

“To our surprise, we found that adherence to healthier lifestyle also could reduce the risk of thyroid cancer in those with high genetic predispositions,” said Dr. Yang. “The findings highlight the potential role of lifestyle interventions on thyroid cancer, especially in those with high genetic risk, because the heritability of thyroid cancer was very high, approximately 50%,” he said. “More attention should be paid to the role of healthier lifestyle in the prevention of cancer,” he added.

“Adherence to a healthier lifestyle could decrease the risk of thyroid cancer, which is the important message for clinicians,” said Dr. Yang. “It is not too soon to comment on implications for clinical practice, because many studies have maintained the consistent comment that healthier lifestyle could prevent the occurrence of cancer,” he said.

The relationship between sex-specific lifestyle factors such as smoking and alcohol use and thyroid cancer remains uncertain, and more research is needed to validate these associations, Dr. Yang said. More research also is needed to confirm the complex mechanism between lifestyle and genetics in thyroid cancer, he added.

The study was supported by the National Key R&D Program of China and the National Natural Science Foundation of China. The researchers had no financial conflicts to disclose.

Patients with ulcerative colitis who were treated with upadacitinib showed significant improvement in symptoms compared to placebo within days of starting treatment, according to results of a new study.

Immunosuppressants and biologics used to treat moderate to severe disease can vary in their response times from weeks to months, and some ambulatory patients fail to respond to these treatments, wrote Edward V. Loftus Jr., MD, of the Mayo Clinic, Rochester, Minn., and colleagues.

“The lack of effective, quick-acting therapies may lead patients to experience prolonged relapses, reduced quality of life, and a significant burden of illness,” the researchers said.

Upadacitinib, an oral, once-daily reversible JAK inhibitor, is approved by the Food and Drug Administration for patients with moderate to severe ulcerative colitis (UC) who have not responded to at least one tumor necrosis factor (TNF) blocker, but the time frame for response to upadacitinib has not been well studied, they said.

In a study published online in Clinical Gastroenterology and Hepatology, the researchers reviewed data from two phase 3 randomized, placebo-controlled induction trials, U-ACHIEVE Induction (NCT02819635) and U-ACCOMPLISH (NCT03653026), that assessed the safety and efficacy of a 45-mg daily dose of upadacitinib for managing symptoms of moderate to severe UC over an 8-week period.

The intent-to-treat analysis included 660 patients who had been randomized to received upadacitinib and 328 in the placebo group. Demographics were similar between the groups. Symptom improvement was based on changes in inflammatory markers high-sensitivity C-reactive protein (hs-CRP) and fecal calprotectin (FCP) measured at week 2. Quality of life was assessed at 2 and 8 weeks.

Between 1 and 3 days after starting treatment, significantly greater percentages of patients in the treatment arm achieved a reduction of at least 50% from baseline in hs-CRP (75.7% vs. 21.9%) and FCP (48.2% vs. 20.2%).

The significant differences in symptom improvement persisted for 14 days from the first dose.

Patients in the upadacitinib group also showed increased rates of clinical remission/response (26.9%/59.4%) based on Partial Mayo scores at week 2 compared with placebo patients (4.3%/22.3%). Treated patients showed significant improvements in quality of life at weeks 2 and 8.

In addition, patient-reported UC symptoms of stool frequency, rectal bleeding, abdominal pain, and bowel urgency improved significantly compared with placebo by day 3, the researchers noted. “In this study, upadacitinib led to absence of rectal bleeding by day 1 and absence of abdominal pain and bowel urgency by day 3 in a significant proportion of patients vs. placebo (all P < .05),” they said.

The findings were limited by the post hoc design, but reflect results of other studies, including those of the JAK inhibitor tofacitinib, the researchers noted. The results of the current study demonstrate the ability of upadacitinib to alleviate key UC symptoms as early as 1 day after the first dose, they concluded.
 

Need for rapid onset treatment

A majority of biologics used to treat IBD take weeks to months to exert an effect, “so it is crucial that a drug with more rapid onset of action become available,” Atsushi Sakuraba, MD, director of clinical trial/IBD research at the University of Chicago, said in an interview.

Dr. Sakuraba, who was not involved in the study, said he was surprised by the findings.

“It is amazing that upadacitinib started to show response in 1-3 days and showed superior rates of remission/response versus placebo by week 2,” he said.

“Clinicians treating IBD patients should take the time to response into consideration, because it leads to rapid improvement in quality of life and reduced need for steroids,” Dr. Sakuraba said. The current study findings need to be confirmed in real life studies, he cautioned.
 

Expanding clinical options

Jeffrey Berinstein, MD, of the University of Michigan, Ann Arbor, who was not involved with the study, said in an interview that he was not surprised by upadacitinib’s quick action, which supports what he has seen in clinical practice. “We now have post hoc data from the phase 3, multicenter induction trials ... to provide us with hard evidence to support our observations,” he noted.

The current study is important because many patients with UC can be very symptomatic, with rectal bleeding, diarrhea, urgency, and abdominal pain, he said in an interview.

“It is often critical to have a fast-acting medication to avoid worsening symptoms, hospitalization, and severe complications. This study shows that upadacitinib, a new oral small molecule that selectively inhibits JAK-1, works within 1 day to improve symptoms and within 2 weeks to improve CRP and fecal calprotectin,” he said.

The takeaway message to clinicians is that upadacitinib is effective, relatively safe, and fast-acting option for patients with UC who have previously failed an anti-TNF agent, he said.

Challenges remain, however.

“Despite this exciting new therapeutic, there is still significant research needed to break our current therapeutic efficacy ceiling and get more IBD patients into a stable and durable remission,” Dr. Berinstein said. “Additional research is needed to develop personalized treatment strategies to address the unique needs of individual patients and to guide optimal medical management.”

Dr. Berinstein and his team are exploring the use of upadacitinib on the sickest IBD patients, “those admitted to the hospital with acute severe ulcerative colitis,” he said. Emerging data from multiple academic centers suggest that “upadacitinib induction may be a viable treatment strategy for these very high-risk patients. Of course, large prospective trials will be needed to confirm this,” he added.

The study was funded by AbbVie, which markets upadacitinib (Rinvoq). Lead author Dr. Loftus and several study authors disclosed financial relationships with AbbVie and other companies. Dr. Sakuraba and Dr. Berinstein reported having no relevant financial conflicts.

Patients with ulcerative colitis who were treated with upadacitinib showed significant improvement in symptoms compared to placebo within days of starting treatment, according to results of a new study.

Immunosuppressants and biologics used to treat moderate to severe disease can vary in their response times from weeks to months, and some ambulatory patients fail to respond to these treatments, wrote Edward V. Loftus Jr., MD, of the Mayo Clinic, Rochester, Minn., and colleagues.

“The lack of effective, quick-acting therapies may lead patients to experience prolonged relapses, reduced quality of life, and a significant burden of illness,” the researchers said.

Upadacitinib, an oral, once-daily reversible JAK inhibitor, is approved by the Food and Drug Administration for patients with moderate to severe ulcerative colitis (UC) who have not responded to at least one tumor necrosis factor (TNF) blocker, but the time frame for response to upadacitinib has not been well studied, they said.

In a study published online in Clinical Gastroenterology and Hepatology, the researchers reviewed data from two phase 3 randomized, placebo-controlled induction trials, U-ACHIEVE Induction (NCT02819635) and U-ACCOMPLISH (NCT03653026), that assessed the safety and efficacy of a 45-mg daily dose of upadacitinib for managing symptoms of moderate to severe UC over an 8-week period.

The intent-to-treat analysis included 660 patients who had been randomized to received upadacitinib and 328 in the placebo group. Demographics were similar between the groups. Symptom improvement was based on changes in inflammatory markers high-sensitivity C-reactive protein (hs-CRP) and fecal calprotectin (FCP) measured at week 2. Quality of life was assessed at 2 and 8 weeks.

Between 1 and 3 days after starting treatment, significantly greater percentages of patients in the treatment arm achieved a reduction of at least 50% from baseline in hs-CRP (75.7% vs. 21.9%) and FCP (48.2% vs. 20.2%).

The significant differences in symptom improvement persisted for 14 days from the first dose.

Patients in the upadacitinib group also showed increased rates of clinical remission/response (26.9%/59.4%) based on Partial Mayo scores at week 2 compared with placebo patients (4.3%/22.3%). Treated patients showed significant improvements in quality of life at weeks 2 and 8.

In addition, patient-reported UC symptoms of stool frequency, rectal bleeding, abdominal pain, and bowel urgency improved significantly compared with placebo by day 3, the researchers noted. “In this study, upadacitinib led to absence of rectal bleeding by day 1 and absence of abdominal pain and bowel urgency by day 3 in a significant proportion of patients vs. placebo (all P < .05),” they said.

The findings were limited by the post hoc design, but reflect results of other studies, including those of the JAK inhibitor tofacitinib, the researchers noted. The results of the current study demonstrate the ability of upadacitinib to alleviate key UC symptoms as early as 1 day after the first dose, they concluded.
 

Need for rapid onset treatment

A majority of biologics used to treat IBD take weeks to months to exert an effect, “so it is crucial that a drug with more rapid onset of action become available,” Atsushi Sakuraba, MD, director of clinical trial/IBD research at the University of Chicago, said in an interview.

Dr. Sakuraba, who was not involved in the study, said he was surprised by the findings.

“It is amazing that upadacitinib started to show response in 1-3 days and showed superior rates of remission/response versus placebo by week 2,” he said.

“Clinicians treating IBD patients should take the time to response into consideration, because it leads to rapid improvement in quality of life and reduced need for steroids,” Dr. Sakuraba said. The current study findings need to be confirmed in real life studies, he cautioned.
 

Expanding clinical options

Jeffrey Berinstein, MD, of the University of Michigan, Ann Arbor, who was not involved with the study, said in an interview that he was not surprised by upadacitinib’s quick action, which supports what he has seen in clinical practice. “We now have post hoc data from the phase 3, multicenter induction trials ... to provide us with hard evidence to support our observations,” he noted.

The current study is important because many patients with UC can be very symptomatic, with rectal bleeding, diarrhea, urgency, and abdominal pain, he said in an interview.

“It is often critical to have a fast-acting medication to avoid worsening symptoms, hospitalization, and severe complications. This study shows that upadacitinib, a new oral small molecule that selectively inhibits JAK-1, works within 1 day to improve symptoms and within 2 weeks to improve CRP and fecal calprotectin,” he said.

The takeaway message to clinicians is that upadacitinib is effective, relatively safe, and fast-acting option for patients with UC who have previously failed an anti-TNF agent, he said.

Challenges remain, however.

“Despite this exciting new therapeutic, there is still significant research needed to break our current therapeutic efficacy ceiling and get more IBD patients into a stable and durable remission,” Dr. Berinstein said. “Additional research is needed to develop personalized treatment strategies to address the unique needs of individual patients and to guide optimal medical management.”

Dr. Berinstein and his team are exploring the use of upadacitinib on the sickest IBD patients, “those admitted to the hospital with acute severe ulcerative colitis,” he said. Emerging data from multiple academic centers suggest that “upadacitinib induction may be a viable treatment strategy for these very high-risk patients. Of course, large prospective trials will be needed to confirm this,” he added.

The study was funded by AbbVie, which markets upadacitinib (Rinvoq). Lead author Dr. Loftus and several study authors disclosed financial relationships with AbbVie and other companies. Dr. Sakuraba and Dr. Berinstein reported having no relevant financial conflicts.

Patients with ulcerative colitis who were treated with upadacitinib showed significant improvement in symptoms compared to placebo within days of starting treatment, according to results of a new study.

Immunosuppressants and biologics used to treat moderate to severe disease can vary in their response times from weeks to months, and some ambulatory patients fail to respond to these treatments, wrote Edward V. Loftus Jr., MD, of the Mayo Clinic, Rochester, Minn., and colleagues.

“The lack of effective, quick-acting therapies may lead patients to experience prolonged relapses, reduced quality of life, and a significant burden of illness,” the researchers said.

Upadacitinib, an oral, once-daily reversible JAK inhibitor, is approved by the Food and Drug Administration for patients with moderate to severe ulcerative colitis (UC) who have not responded to at least one tumor necrosis factor (TNF) blocker, but the time frame for response to upadacitinib has not been well studied, they said.

In a study published online in Clinical Gastroenterology and Hepatology, the researchers reviewed data from two phase 3 randomized, placebo-controlled induction trials, U-ACHIEVE Induction (NCT02819635) and U-ACCOMPLISH (NCT03653026), that assessed the safety and efficacy of a 45-mg daily dose of upadacitinib for managing symptoms of moderate to severe UC over an 8-week period.

The intent-to-treat analysis included 660 patients who had been randomized to received upadacitinib and 328 in the placebo group. Demographics were similar between the groups. Symptom improvement was based on changes in inflammatory markers high-sensitivity C-reactive protein (hs-CRP) and fecal calprotectin (FCP) measured at week 2. Quality of life was assessed at 2 and 8 weeks.

Between 1 and 3 days after starting treatment, significantly greater percentages of patients in the treatment arm achieved a reduction of at least 50% from baseline in hs-CRP (75.7% vs. 21.9%) and FCP (48.2% vs. 20.2%).

The significant differences in symptom improvement persisted for 14 days from the first dose.

Patients in the upadacitinib group also showed increased rates of clinical remission/response (26.9%/59.4%) based on Partial Mayo scores at week 2 compared with placebo patients (4.3%/22.3%). Treated patients showed significant improvements in quality of life at weeks 2 and 8.

In addition, patient-reported UC symptoms of stool frequency, rectal bleeding, abdominal pain, and bowel urgency improved significantly compared with placebo by day 3, the researchers noted. “In this study, upadacitinib led to absence of rectal bleeding by day 1 and absence of abdominal pain and bowel urgency by day 3 in a significant proportion of patients vs. placebo (all P < .05),” they said.

The findings were limited by the post hoc design, but reflect results of other studies, including those of the JAK inhibitor tofacitinib, the researchers noted. The results of the current study demonstrate the ability of upadacitinib to alleviate key UC symptoms as early as 1 day after the first dose, they concluded.
 

Need for rapid onset treatment

A majority of biologics used to treat IBD take weeks to months to exert an effect, “so it is crucial that a drug with more rapid onset of action become available,” Atsushi Sakuraba, MD, director of clinical trial/IBD research at the University of Chicago, said in an interview.

Dr. Sakuraba, who was not involved in the study, said he was surprised by the findings.

“It is amazing that upadacitinib started to show response in 1-3 days and showed superior rates of remission/response versus placebo by week 2,” he said.

“Clinicians treating IBD patients should take the time to response into consideration, because it leads to rapid improvement in quality of life and reduced need for steroids,” Dr. Sakuraba said. The current study findings need to be confirmed in real life studies, he cautioned.
 

Expanding clinical options

Jeffrey Berinstein, MD, of the University of Michigan, Ann Arbor, who was not involved with the study, said in an interview that he was not surprised by upadacitinib’s quick action, which supports what he has seen in clinical practice. “We now have post hoc data from the phase 3, multicenter induction trials ... to provide us with hard evidence to support our observations,” he noted.

The current study is important because many patients with UC can be very symptomatic, with rectal bleeding, diarrhea, urgency, and abdominal pain, he said in an interview.

“It is often critical to have a fast-acting medication to avoid worsening symptoms, hospitalization, and severe complications. This study shows that upadacitinib, a new oral small molecule that selectively inhibits JAK-1, works within 1 day to improve symptoms and within 2 weeks to improve CRP and fecal calprotectin,” he said.

The takeaway message to clinicians is that upadacitinib is effective, relatively safe, and fast-acting option for patients with UC who have previously failed an anti-TNF agent, he said.

Challenges remain, however.

“Despite this exciting new therapeutic, there is still significant research needed to break our current therapeutic efficacy ceiling and get more IBD patients into a stable and durable remission,” Dr. Berinstein said. “Additional research is needed to develop personalized treatment strategies to address the unique needs of individual patients and to guide optimal medical management.”

Dr. Berinstein and his team are exploring the use of upadacitinib on the sickest IBD patients, “those admitted to the hospital with acute severe ulcerative colitis,” he said. Emerging data from multiple academic centers suggest that “upadacitinib induction may be a viable treatment strategy for these very high-risk patients. Of course, large prospective trials will be needed to confirm this,” he added.

The study was funded by AbbVie, which markets upadacitinib (Rinvoq). Lead author Dr. Loftus and several study authors disclosed financial relationships with AbbVie and other companies. Dr. Sakuraba and Dr. Berinstein reported having no relevant financial conflicts.

The rate of postpartum hemorrhage for hospital deliveries in the United States increased significantly over a 20-year period, according to data from more than 76 million delivery hospitalizations from the National Inpatient Sample.

Postpartum hemorrhage remains the leading cause of maternal morbidity and mortality worldwide, and many clinical and patient-level risk factors appear to be on the rise, wrote Chiara M. Corbetta-Rastelli, MD, of the University of California, San Francisco, and colleagues.

Although practice changes have been introduced to reduce postpartum hemorrhage, recent trends in postpartum hemorrhage risk and outcomes in the context of such changes as hemorrhage safety bundles have not been examined, they said.

In a study published in Obstetrics & Gynecology, the researchers reviewed data from hospitalizations for females aged 15-54 years for deliveries between 2000 and 2019 using the National Inpatient Sample. They used a regression analysis to estimate average annual percentage changes (AAPC). Their objectives were to characterize trends and also to assess the association between risk factors and the occurrence of postpartum hemorrhage and related interventions. Demographics, clinical factors, and hospital characteristics were mainly similar between the group of patients with postpartum hemorrhage and those with no postpartum hemorrhage.

Approximately 3% (2.3 million) of 76.7 million hospitalizations for delivery were complicated by postpartum hemorrhage during the study period, and the annual rate increased from 2.7% to 4.3%.

Overall, 21.4% of individuals with delivery hospitalizations complicated by postpartum hemorrhage had one postpartum risk factor, and 1.4% had two or more risk factors. The number of individuals with at least one risk factor for postpartum hemorrhage increased significantly, from 18.6% to 26.9%, during the study period, with an annual percentage change of 1.9%.

Compared with deliveries in individuals without risk factors, individuals with one risk factor had slightly higher odds of postpartum hemorrhage (odds ratio, 1.14), but those with two or more risk factors were more than twice as likely to experience postpartum hemorrhage as those with no risk factors (OR, 2.31).

The researchers also examined the association of specific risk factors and interventions related to hemorrhage, notably blood transfusion and peripartum hysterectomy. Blood transfusions in individuals with postpartum hemorrhage increased from 5.4% to 16.7% between 2000 and 2011, (AAPC, 10.2%) then decreased from 16.7% to 12.6% from 2011 to 2019 (AAPC, –3.9%).

Peripartum hysterectomy in the study population increased from 1.4% to 2.4% from 2000 to 2009 (AAPC 5.0%), remained steady from 2009 to 2016, and then decreased from 2.1% to 0.9% from 2016 to 2019 (AAPC –27%).

Other risk factors associated with postpartum hemorrhage itself and with blood transfusion and hysterectomy in the setting of postpartum hemorrhage included prior cesarean delivery with placenta previa or accreta, placenta previa without prior cesarean delivery, and antepartum hemorrhage or placental abruption, the researchers noted.

“In addition to placental abnormalities, risk factors such as preeclampsia with severe features, polyhydramnios, and uterine leiomyomas demonstrated the highest rates of increase in our data,” they wrote in their discussion. These trends may lead to continuing increases in postpartum hemorrhage risk, which was not fully explained by the increase in risk factors seen in the current study, the researchers said.

The study findings were limited by several factors, including the use of billing codes that could lead to misclassification of diagnoses, as well as possible differences in the definition and coding for postpartum hemorrhage among hospitals, the researchers noted. Other limitations were the exclusion of cases of readmission for postpartum hemorrhage and lack of clinical details involving use of medications or nonoperative interventions, they said.

Notably, the study finding of stable to decreasing peripartum hysterectomy rates in hospitalized patients with postpartum hemorrhage conflicts with another recent study showing an increase in peripartum hysterectomy from 2009 to 2020, but this difference may reflect changes in billing, indications for hysterectomy, or study modeling, they said.

The current study was strengthened by the use of a large database to analyze population trends, a contemporary study period, and the inclusion of meaningful outcomes such as peripartum hysterectomy, the researchers wrote.

The shift in blood transfusion and peripartum hysterectomy may reflect the implementation of protocols to promote early intervention and identification of postpartum hemorrhage, they concluded.
 

Interventions can have an effect

“Hemorrhage remains a leading cause of maternal mortality in the United States and blood transfusion is the most common severe maternal morbidity,” Catherine M. Albright, MD, MS, associate professor of maternal-fetal medicine at the University of Washington, Seattle, said in an interview. “It is important to understand the current state, especially given that many hospitals have implemented policies and procedures to better identify and treat postpartum hemorrhage,” she said.

Dr. Albright said, “I was pleased to see that they did not just look at a diagnosis of postpartum hemorrhage but rather also looked at complications arising from postpartum hemorrhage, such as blood transfusion or hysterectomy.”

Postpartum hemorrhage is often a clinical diagnosis that uses estimated blood loss, a notoriously inaccurate measure, said Dr. Albright. “Additionally, the definitions of postpartum hemorrhage, as well as the ICD codes, changed during the time period of the study,” she noted. “These factors all could lead to both underreporting and overreporting of the true incidence of postpartum hemorrhage. Blood transfusion and hysterectomy are more objective outcomes and demonstrate true morbidity,” she said.

“Most of the risk factors that are listed in the article are not modifiable during that pregnancy,” said Dr. Albright. For example, a history of a prior cesarean or having a twin pregnancy is not something that can be changed, she said. “Many of the other risk factors or associated clinical factors, such as obesity, chronic hypertension, and pregestational diabetes, are modifiable, but before pregnancy. Universal and easy access to primary medical care prior to and between pregnancies may help to mitigate some of these factors,” she noted.

Looking ahead, “It would be helpful to ensure that these types of data are available at the state and hospital level; this will allow for local evaluation of programs that are in place to reduce postpartum hemorrhage risk and improve identification and treatment,” Dr. Albright said.

The study received no outside funding. Dr. Corbetta-Rastelli and Dr. Albright had no financial conflicts to disclose.

The rate of postpartum hemorrhage for hospital deliveries in the United States increased significantly over a 20-year period, according to data from more than 76 million delivery hospitalizations from the National Inpatient Sample.

Postpartum hemorrhage remains the leading cause of maternal morbidity and mortality worldwide, and many clinical and patient-level risk factors appear to be on the rise, wrote Chiara M. Corbetta-Rastelli, MD, of the University of California, San Francisco, and colleagues.

Although practice changes have been introduced to reduce postpartum hemorrhage, recent trends in postpartum hemorrhage risk and outcomes in the context of such changes as hemorrhage safety bundles have not been examined, they said.

In a study published in Obstetrics & Gynecology, the researchers reviewed data from hospitalizations for females aged 15-54 years for deliveries between 2000 and 2019 using the National Inpatient Sample. They used a regression analysis to estimate average annual percentage changes (AAPC). Their objectives were to characterize trends and also to assess the association between risk factors and the occurrence of postpartum hemorrhage and related interventions. Demographics, clinical factors, and hospital characteristics were mainly similar between the group of patients with postpartum hemorrhage and those with no postpartum hemorrhage.

Approximately 3% (2.3 million) of 76.7 million hospitalizations for delivery were complicated by postpartum hemorrhage during the study period, and the annual rate increased from 2.7% to 4.3%.

Overall, 21.4% of individuals with delivery hospitalizations complicated by postpartum hemorrhage had one postpartum risk factor, and 1.4% had two or more risk factors. The number of individuals with at least one risk factor for postpartum hemorrhage increased significantly, from 18.6% to 26.9%, during the study period, with an annual percentage change of 1.9%.

Compared with deliveries in individuals without risk factors, individuals with one risk factor had slightly higher odds of postpartum hemorrhage (odds ratio, 1.14), but those with two or more risk factors were more than twice as likely to experience postpartum hemorrhage as those with no risk factors (OR, 2.31).

The researchers also examined the association of specific risk factors and interventions related to hemorrhage, notably blood transfusion and peripartum hysterectomy. Blood transfusions in individuals with postpartum hemorrhage increased from 5.4% to 16.7% between 2000 and 2011, (AAPC, 10.2%) then decreased from 16.7% to 12.6% from 2011 to 2019 (AAPC, –3.9%).

Peripartum hysterectomy in the study population increased from 1.4% to 2.4% from 2000 to 2009 (AAPC 5.0%), remained steady from 2009 to 2016, and then decreased from 2.1% to 0.9% from 2016 to 2019 (AAPC –27%).

Other risk factors associated with postpartum hemorrhage itself and with blood transfusion and hysterectomy in the setting of postpartum hemorrhage included prior cesarean delivery with placenta previa or accreta, placenta previa without prior cesarean delivery, and antepartum hemorrhage or placental abruption, the researchers noted.

“In addition to placental abnormalities, risk factors such as preeclampsia with severe features, polyhydramnios, and uterine leiomyomas demonstrated the highest rates of increase in our data,” they wrote in their discussion. These trends may lead to continuing increases in postpartum hemorrhage risk, which was not fully explained by the increase in risk factors seen in the current study, the researchers said.

The study findings were limited by several factors, including the use of billing codes that could lead to misclassification of diagnoses, as well as possible differences in the definition and coding for postpartum hemorrhage among hospitals, the researchers noted. Other limitations were the exclusion of cases of readmission for postpartum hemorrhage and lack of clinical details involving use of medications or nonoperative interventions, they said.

Notably, the study finding of stable to decreasing peripartum hysterectomy rates in hospitalized patients with postpartum hemorrhage conflicts with another recent study showing an increase in peripartum hysterectomy from 2009 to 2020, but this difference may reflect changes in billing, indications for hysterectomy, or study modeling, they said.

The current study was strengthened by the use of a large database to analyze population trends, a contemporary study period, and the inclusion of meaningful outcomes such as peripartum hysterectomy, the researchers wrote.

The shift in blood transfusion and peripartum hysterectomy may reflect the implementation of protocols to promote early intervention and identification of postpartum hemorrhage, they concluded.
 

Interventions can have an effect

“Hemorrhage remains a leading cause of maternal mortality in the United States and blood transfusion is the most common severe maternal morbidity,” Catherine M. Albright, MD, MS, associate professor of maternal-fetal medicine at the University of Washington, Seattle, said in an interview. “It is important to understand the current state, especially given that many hospitals have implemented policies and procedures to better identify and treat postpartum hemorrhage,” she said.

Dr. Albright said, “I was pleased to see that they did not just look at a diagnosis of postpartum hemorrhage but rather also looked at complications arising from postpartum hemorrhage, such as blood transfusion or hysterectomy.”

Postpartum hemorrhage is often a clinical diagnosis that uses estimated blood loss, a notoriously inaccurate measure, said Dr. Albright. “Additionally, the definitions of postpartum hemorrhage, as well as the ICD codes, changed during the time period of the study,” she noted. “These factors all could lead to both underreporting and overreporting of the true incidence of postpartum hemorrhage. Blood transfusion and hysterectomy are more objective outcomes and demonstrate true morbidity,” she said.

“Most of the risk factors that are listed in the article are not modifiable during that pregnancy,” said Dr. Albright. For example, a history of a prior cesarean or having a twin pregnancy is not something that can be changed, she said. “Many of the other risk factors or associated clinical factors, such as obesity, chronic hypertension, and pregestational diabetes, are modifiable, but before pregnancy. Universal and easy access to primary medical care prior to and between pregnancies may help to mitigate some of these factors,” she noted.

Looking ahead, “It would be helpful to ensure that these types of data are available at the state and hospital level; this will allow for local evaluation of programs that are in place to reduce postpartum hemorrhage risk and improve identification and treatment,” Dr. Albright said.

The study received no outside funding. Dr. Corbetta-Rastelli and Dr. Albright had no financial conflicts to disclose.

The rate of postpartum hemorrhage for hospital deliveries in the United States increased significantly over a 20-year period, according to data from more than 76 million delivery hospitalizations from the National Inpatient Sample.

Postpartum hemorrhage remains the leading cause of maternal morbidity and mortality worldwide, and many clinical and patient-level risk factors appear to be on the rise, wrote Chiara M. Corbetta-Rastelli, MD, of the University of California, San Francisco, and colleagues.

Although practice changes have been introduced to reduce postpartum hemorrhage, recent trends in postpartum hemorrhage risk and outcomes in the context of such changes as hemorrhage safety bundles have not been examined, they said.

In a study published in Obstetrics & Gynecology, the researchers reviewed data from hospitalizations for females aged 15-54 years for deliveries between 2000 and 2019 using the National Inpatient Sample. They used a regression analysis to estimate average annual percentage changes (AAPC). Their objectives were to characterize trends and also to assess the association between risk factors and the occurrence of postpartum hemorrhage and related interventions. Demographics, clinical factors, and hospital characteristics were mainly similar between the group of patients with postpartum hemorrhage and those with no postpartum hemorrhage.

Approximately 3% (2.3 million) of 76.7 million hospitalizations for delivery were complicated by postpartum hemorrhage during the study period, and the annual rate increased from 2.7% to 4.3%.

Overall, 21.4% of individuals with delivery hospitalizations complicated by postpartum hemorrhage had one postpartum risk factor, and 1.4% had two or more risk factors. The number of individuals with at least one risk factor for postpartum hemorrhage increased significantly, from 18.6% to 26.9%, during the study period, with an annual percentage change of 1.9%.

Compared with deliveries in individuals without risk factors, individuals with one risk factor had slightly higher odds of postpartum hemorrhage (odds ratio, 1.14), but those with two or more risk factors were more than twice as likely to experience postpartum hemorrhage as those with no risk factors (OR, 2.31).

The researchers also examined the association of specific risk factors and interventions related to hemorrhage, notably blood transfusion and peripartum hysterectomy. Blood transfusions in individuals with postpartum hemorrhage increased from 5.4% to 16.7% between 2000 and 2011, (AAPC, 10.2%) then decreased from 16.7% to 12.6% from 2011 to 2019 (AAPC, –3.9%).

Peripartum hysterectomy in the study population increased from 1.4% to 2.4% from 2000 to 2009 (AAPC 5.0%), remained steady from 2009 to 2016, and then decreased from 2.1% to 0.9% from 2016 to 2019 (AAPC –27%).

Other risk factors associated with postpartum hemorrhage itself and with blood transfusion and hysterectomy in the setting of postpartum hemorrhage included prior cesarean delivery with placenta previa or accreta, placenta previa without prior cesarean delivery, and antepartum hemorrhage or placental abruption, the researchers noted.

“In addition to placental abnormalities, risk factors such as preeclampsia with severe features, polyhydramnios, and uterine leiomyomas demonstrated the highest rates of increase in our data,” they wrote in their discussion. These trends may lead to continuing increases in postpartum hemorrhage risk, which was not fully explained by the increase in risk factors seen in the current study, the researchers said.

The study findings were limited by several factors, including the use of billing codes that could lead to misclassification of diagnoses, as well as possible differences in the definition and coding for postpartum hemorrhage among hospitals, the researchers noted. Other limitations were the exclusion of cases of readmission for postpartum hemorrhage and lack of clinical details involving use of medications or nonoperative interventions, they said.

Notably, the study finding of stable to decreasing peripartum hysterectomy rates in hospitalized patients with postpartum hemorrhage conflicts with another recent study showing an increase in peripartum hysterectomy from 2009 to 2020, but this difference may reflect changes in billing, indications for hysterectomy, or study modeling, they said.

The current study was strengthened by the use of a large database to analyze population trends, a contemporary study period, and the inclusion of meaningful outcomes such as peripartum hysterectomy, the researchers wrote.

The shift in blood transfusion and peripartum hysterectomy may reflect the implementation of protocols to promote early intervention and identification of postpartum hemorrhage, they concluded.
 

Interventions can have an effect

“Hemorrhage remains a leading cause of maternal mortality in the United States and blood transfusion is the most common severe maternal morbidity,” Catherine M. Albright, MD, MS, associate professor of maternal-fetal medicine at the University of Washington, Seattle, said in an interview. “It is important to understand the current state, especially given that many hospitals have implemented policies and procedures to better identify and treat postpartum hemorrhage,” she said.

Dr. Albright said, “I was pleased to see that they did not just look at a diagnosis of postpartum hemorrhage but rather also looked at complications arising from postpartum hemorrhage, such as blood transfusion or hysterectomy.”

Postpartum hemorrhage is often a clinical diagnosis that uses estimated blood loss, a notoriously inaccurate measure, said Dr. Albright. “Additionally, the definitions of postpartum hemorrhage, as well as the ICD codes, changed during the time period of the study,” she noted. “These factors all could lead to both underreporting and overreporting of the true incidence of postpartum hemorrhage. Blood transfusion and hysterectomy are more objective outcomes and demonstrate true morbidity,” she said.

“Most of the risk factors that are listed in the article are not modifiable during that pregnancy,” said Dr. Albright. For example, a history of a prior cesarean or having a twin pregnancy is not something that can be changed, she said. “Many of the other risk factors or associated clinical factors, such as obesity, chronic hypertension, and pregestational diabetes, are modifiable, but before pregnancy. Universal and easy access to primary medical care prior to and between pregnancies may help to mitigate some of these factors,” she noted.

Looking ahead, “It would be helpful to ensure that these types of data are available at the state and hospital level; this will allow for local evaluation of programs that are in place to reduce postpartum hemorrhage risk and improve identification and treatment,” Dr. Albright said.

The study received no outside funding. Dr. Corbetta-Rastelli and Dr. Albright had no financial conflicts to disclose.

Researchers have identified pathogenic gene variations in 12% of cases of sudden unexplained death in children.

The new study, which involved 116 cases of sudden infant death syndrome or sudden unexplained deaths in children (SUDC), suggests that available methods of chromosome testing could be used to help screen for the conditions, which together account for roughly 1,800 fatalities a year in the United States.

“Even though the Back to Sleep campaign has been incredibly effective and safe sleep practices have been promoted for years, sudden unexplained death in pediatrics remains a leading cause of death for infants and children,” said Catherine Brownstein, MPH, PhD, of Boston Children’s Hospital, lead author of the new study.

The findings suggest that chromosomal microarray analysis (CMA), the method that the researchers used in the study, “should be considered in the genetic evaluation of SUDC,” Dr. Brownstein said. The approach is the first-line method of identifying conditions such as autism spectrum disorder, developmental disabilities, multiple congenital anomalies, and epilepsy, she noted.

In the study, published in Advanced Genetics, Dr. Brownstein and her colleagues used CMA to test genes from 116 deceased infants and toddlers up to age 28 months whose deaths were classified as SIDS or SUDC (the latter term applies to children older than 1 year).

The average age at the time of death was 5.7 months; 59% of the patients were boys. In 14 of the children (12%), the CMA test identified genetic variations in the form of deletions or duplications that were pathogenic (five cases) or uncertain but “favoring pathogenicity” (nine cases). Such deletions or duplications are known as copy number variants (CNVs).

CNVs are present in most people and are not necessarily associated with disease, according to the researchers. However, certain CNVs have been linked to ASD, attention-deficit/hyperactivity disorder, schizophrenia, Crohn’s disease, epilepsy, and various congenital abnormalities.

Dr. Brownstein’s group also compared pathogenicity in the SUDC group with that of a cohort of children with ASD and with healthy control persons. They found no significant difference in pathogenicity between SUDC and autism with regard to duplications. However, children in the SUDC group were significantly more likely to have higher pathogenicity scores for deletions, compared with control persons. Some of the CMVs did not appear connected to SIDS or SUDC; two cases in boys were undiagnosed cases of Klinefelter syndrome.

The study findings were limited by several factors, including the small sample size and the inability to conduct CMA analyses on parents or obtain family history, the researchers note. Other limitations were that phenotypic data were available only from autopsy material and medical records and that the study focused on younger children, the researchers add. They did not speculate about the causes of deaths in the other cases they examined.

In the current study, the other 88% of cases could involve nongenetic factors or genetic factors that aren’t measured by next-generation sequencing or chromosomal microarray, Dr. Brownstein said. “Undiagnosed disease programs looking for genetic causes for diseases in living patients identify a cause in about 1 in 4 cases,” she said. “While 12% is a modest percentage, the CNVs identified provide additional information. In the future, the goal would be to capture the full range of potential genetic changes.”

Previous research by Dr. Brownstein’s group at Robert’s Program, a clinical service for SUDC families at Boston Children’s Hospital, found genetic variants that might cause sudden death in children.

“We began this study with the simple question of whether, as a population, these children carry more copy number variation, which they do,” she said. “However, none of the CMA findings we identified are currently associated with SUDC, so much more investigation is necessary to find out if they are coincidental, risk factors, or causative.”

Looking ahead, she said, “Ideally, we would want every family affected by sudden unexplained death in pediatrics to have genetic testing, including a chromosomal microarray. Once we have more families enrolled and tested, we will be able to understand the risk factors for SIDS and SUDC much better.”

Benjamin Solomon, MD, clinical director at the National Human Genome Research Institute, Bethesda, Md., said the new research “may bring answers for individual situations as well as enable research to understand the overall biological underpinnings and causes of disease.”

The findings “help reinforce the heterogeneous nature of SUDC and related conditions,” Dr. Solomon said. “The results also highlight some of the challenges regarding how to interpret the possible clinical effects of genetic changes. That is, every person has genetic changes, and interpreting how certain genetic changes may or may not contribute to a disease or health care outcome can be challenging.”

Research is needed to understand not only the overall causes of SUDC but also how the different causes interact, Dr. Solomon said. “Eventually, better understanding of the causes could lead to knowledge that would enable interventions that could help prevent or reduce these devastating outcomes.”

The study was supported by the Robert’s Program on Sudden Unexplained Death in Pediatrics, the Jude Zayac Foundation, multiple grants from the Eunice Kennedy Shriver National Institutes of Health/National Institute of Child Health and Human Development, the Boston Children’s Hospital Intellectual and Developmental Disabilities Research Center Molecular Genetics Core Facility (supported by the NIH/NICHD), and by the NIH National Institute of Mental Health. The researchers and Dr. Solomon have disclosed no relevant financial relationships.

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

Researchers have identified pathogenic gene variations in 12% of cases of sudden unexplained death in children.

The new study, which involved 116 cases of sudden infant death syndrome or sudden unexplained deaths in children (SUDC), suggests that available methods of chromosome testing could be used to help screen for the conditions, which together account for roughly 1,800 fatalities a year in the United States.

“Even though the Back to Sleep campaign has been incredibly effective and safe sleep practices have been promoted for years, sudden unexplained death in pediatrics remains a leading cause of death for infants and children,” said Catherine Brownstein, MPH, PhD, of Boston Children’s Hospital, lead author of the new study.

The findings suggest that chromosomal microarray analysis (CMA), the method that the researchers used in the study, “should be considered in the genetic evaluation of SUDC,” Dr. Brownstein said. The approach is the first-line method of identifying conditions such as autism spectrum disorder, developmental disabilities, multiple congenital anomalies, and epilepsy, she noted.

In the study, published in Advanced Genetics, Dr. Brownstein and her colleagues used CMA to test genes from 116 deceased infants and toddlers up to age 28 months whose deaths were classified as SIDS or SUDC (the latter term applies to children older than 1 year).

The average age at the time of death was 5.7 months; 59% of the patients were boys. In 14 of the children (12%), the CMA test identified genetic variations in the form of deletions or duplications that were pathogenic (five cases) or uncertain but “favoring pathogenicity” (nine cases). Such deletions or duplications are known as copy number variants (CNVs).

CNVs are present in most people and are not necessarily associated with disease, according to the researchers. However, certain CNVs have been linked to ASD, attention-deficit/hyperactivity disorder, schizophrenia, Crohn’s disease, epilepsy, and various congenital abnormalities.

Dr. Brownstein’s group also compared pathogenicity in the SUDC group with that of a cohort of children with ASD and with healthy control persons. They found no significant difference in pathogenicity between SUDC and autism with regard to duplications. However, children in the SUDC group were significantly more likely to have higher pathogenicity scores for deletions, compared with control persons. Some of the CMVs did not appear connected to SIDS or SUDC; two cases in boys were undiagnosed cases of Klinefelter syndrome.

The study findings were limited by several factors, including the small sample size and the inability to conduct CMA analyses on parents or obtain family history, the researchers note. Other limitations were that phenotypic data were available only from autopsy material and medical records and that the study focused on younger children, the researchers add. They did not speculate about the causes of deaths in the other cases they examined.

In the current study, the other 88% of cases could involve nongenetic factors or genetic factors that aren’t measured by next-generation sequencing or chromosomal microarray, Dr. Brownstein said. “Undiagnosed disease programs looking for genetic causes for diseases in living patients identify a cause in about 1 in 4 cases,” she said. “While 12% is a modest percentage, the CNVs identified provide additional information. In the future, the goal would be to capture the full range of potential genetic changes.”

Previous research by Dr. Brownstein’s group at Robert’s Program, a clinical service for SUDC families at Boston Children’s Hospital, found genetic variants that might cause sudden death in children.

“We began this study with the simple question of whether, as a population, these children carry more copy number variation, which they do,” she said. “However, none of the CMA findings we identified are currently associated with SUDC, so much more investigation is necessary to find out if they are coincidental, risk factors, or causative.”

Looking ahead, she said, “Ideally, we would want every family affected by sudden unexplained death in pediatrics to have genetic testing, including a chromosomal microarray. Once we have more families enrolled and tested, we will be able to understand the risk factors for SIDS and SUDC much better.”

Benjamin Solomon, MD, clinical director at the National Human Genome Research Institute, Bethesda, Md., said the new research “may bring answers for individual situations as well as enable research to understand the overall biological underpinnings and causes of disease.”

The findings “help reinforce the heterogeneous nature of SUDC and related conditions,” Dr. Solomon said. “The results also highlight some of the challenges regarding how to interpret the possible clinical effects of genetic changes. That is, every person has genetic changes, and interpreting how certain genetic changes may or may not contribute to a disease or health care outcome can be challenging.”

Research is needed to understand not only the overall causes of SUDC but also how the different causes interact, Dr. Solomon said. “Eventually, better understanding of the causes could lead to knowledge that would enable interventions that could help prevent or reduce these devastating outcomes.”

The study was supported by the Robert’s Program on Sudden Unexplained Death in Pediatrics, the Jude Zayac Foundation, multiple grants from the Eunice Kennedy Shriver National Institutes of Health/National Institute of Child Health and Human Development, the Boston Children’s Hospital Intellectual and Developmental Disabilities Research Center Molecular Genetics Core Facility (supported by the NIH/NICHD), and by the NIH National Institute of Mental Health. The researchers and Dr. Solomon have disclosed no relevant financial relationships.

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

Researchers have identified pathogenic gene variations in 12% of cases of sudden unexplained death in children.

The new study, which involved 116 cases of sudden infant death syndrome or sudden unexplained deaths in children (SUDC), suggests that available methods of chromosome testing could be used to help screen for the conditions, which together account for roughly 1,800 fatalities a year in the United States.

“Even though the Back to Sleep campaign has been incredibly effective and safe sleep practices have been promoted for years, sudden unexplained death in pediatrics remains a leading cause of death for infants and children,” said Catherine Brownstein, MPH, PhD, of Boston Children’s Hospital, lead author of the new study.

The findings suggest that chromosomal microarray analysis (CMA), the method that the researchers used in the study, “should be considered in the genetic evaluation of SUDC,” Dr. Brownstein said. The approach is the first-line method of identifying conditions such as autism spectrum disorder, developmental disabilities, multiple congenital anomalies, and epilepsy, she noted.

In the study, published in Advanced Genetics, Dr. Brownstein and her colleagues used CMA to test genes from 116 deceased infants and toddlers up to age 28 months whose deaths were classified as SIDS or SUDC (the latter term applies to children older than 1 year).

The average age at the time of death was 5.7 months; 59% of the patients were boys. In 14 of the children (12%), the CMA test identified genetic variations in the form of deletions or duplications that were pathogenic (five cases) or uncertain but “favoring pathogenicity” (nine cases). Such deletions or duplications are known as copy number variants (CNVs).

CNVs are present in most people and are not necessarily associated with disease, according to the researchers. However, certain CNVs have been linked to ASD, attention-deficit/hyperactivity disorder, schizophrenia, Crohn’s disease, epilepsy, and various congenital abnormalities.

Dr. Brownstein’s group also compared pathogenicity in the SUDC group with that of a cohort of children with ASD and with healthy control persons. They found no significant difference in pathogenicity between SUDC and autism with regard to duplications. However, children in the SUDC group were significantly more likely to have higher pathogenicity scores for deletions, compared with control persons. Some of the CMVs did not appear connected to SIDS or SUDC; two cases in boys were undiagnosed cases of Klinefelter syndrome.

The study findings were limited by several factors, including the small sample size and the inability to conduct CMA analyses on parents or obtain family history, the researchers note. Other limitations were that phenotypic data were available only from autopsy material and medical records and that the study focused on younger children, the researchers add. They did not speculate about the causes of deaths in the other cases they examined.

In the current study, the other 88% of cases could involve nongenetic factors or genetic factors that aren’t measured by next-generation sequencing or chromosomal microarray, Dr. Brownstein said. “Undiagnosed disease programs looking for genetic causes for diseases in living patients identify a cause in about 1 in 4 cases,” she said. “While 12% is a modest percentage, the CNVs identified provide additional information. In the future, the goal would be to capture the full range of potential genetic changes.”

Previous research by Dr. Brownstein’s group at Robert’s Program, a clinical service for SUDC families at Boston Children’s Hospital, found genetic variants that might cause sudden death in children.

“We began this study with the simple question of whether, as a population, these children carry more copy number variation, which they do,” she said. “However, none of the CMA findings we identified are currently associated with SUDC, so much more investigation is necessary to find out if they are coincidental, risk factors, or causative.”

Looking ahead, she said, “Ideally, we would want every family affected by sudden unexplained death in pediatrics to have genetic testing, including a chromosomal microarray. Once we have more families enrolled and tested, we will be able to understand the risk factors for SIDS and SUDC much better.”

Benjamin Solomon, MD, clinical director at the National Human Genome Research Institute, Bethesda, Md., said the new research “may bring answers for individual situations as well as enable research to understand the overall biological underpinnings and causes of disease.”

The findings “help reinforce the heterogeneous nature of SUDC and related conditions,” Dr. Solomon said. “The results also highlight some of the challenges regarding how to interpret the possible clinical effects of genetic changes. That is, every person has genetic changes, and interpreting how certain genetic changes may or may not contribute to a disease or health care outcome can be challenging.”

Research is needed to understand not only the overall causes of SUDC but also how the different causes interact, Dr. Solomon said. “Eventually, better understanding of the causes could lead to knowledge that would enable interventions that could help prevent or reduce these devastating outcomes.”

The study was supported by the Robert’s Program on Sudden Unexplained Death in Pediatrics, the Jude Zayac Foundation, multiple grants from the Eunice Kennedy Shriver National Institutes of Health/National Institute of Child Health and Human Development, the Boston Children’s Hospital Intellectual and Developmental Disabilities Research Center Molecular Genetics Core Facility (supported by the NIH/NICHD), and by the NIH National Institute of Mental Health. The researchers and Dr. Solomon have disclosed no relevant financial relationships.

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

The exploration started in 2004 with a 62-year-old man who presented to an emergency department with acute shortness of breath, tachycardia with chest discomfort, and light-headedness, Amado Alejandro Baez, MD, said in a presentation at the 2022 scientific assembly of the American College of Emergency Physicians.

The patient arrived on day 20 after a radical cystoprostatectomy. He had driven 4 hours from another city for a urology follow-up visit. On arrival, he developed respiratory distress symptoms and presented to the emergency department, said Dr. Baez, professor of emergency medicine and epidemiology at the Medical College of Georgia/Augusta University and triple-board certified in EMS, emergency medicine, and critical care.

The patient developed a massive pulmonary embolism with acute cor pulmonale (right-sided heart failure). An electrocardiogram showed an S1Q3T3, demonstrating the distinctive nature of right ventricular failure, said Dr. Baez.

Research has demonstrated the differences in physiology between the right and left ventricles, he said.

Dr. Baez highlighted some of the features of right ventricle (RV) failure and how to manage it. Notably, the RV is thinner and less resilient. “RV failure patients may fall off the Starling curve,” in contrast to patients with isolated left ventricle (LV) failure.

RV pressure overload is associated with a range of conditions, such as pericardial disease, pulmonary embolism, acute respiratory distress syndrome, and pulmonary arterial hypertension. When combined with RV overload, patients may develop intracardiac shunting or coronary heart disease, Dr. Baez said. Decreased contractility associated with RV failure can result from sepsis, right ventricular myocardial infarction, myocarditis, and arrhythmia.

Dr. Baez cited the 2018 scientific statement from the American Heart Association on the evaluation and management of right-sided heart failure. The authors of the statement noted that the complicated geometry of the right heart makes functional assessment a challenge. They wrote that various hemodynamic and biochemical markers can help guide clinical assessment and therapeutic decision-making.

Increased RV afterload drives multiple factors that can ultimately lead to cardiogenic shock and death, said Dr. Baez. These factors include decreased RV oxygen delivery, decreased RV coronary perfusion, decreased systemic blood pressure, and low carbon monoxide levels. RV afterload also leads to decreased RV contractility, an increase in RV oxygen demand, and tension in the RV wall, and it may contribute to tricuspid valve insufficiency, neurohormonal activation, and RV ischemia.

Treatment strategies involve improving symptoms and stopping disease progression, said Baez. In its scientific statement, the AHA recommends steps for assessing RV and LV function so as to identify RV failure as soon as possible, he said. After excluding pericardial disease, the AHA advises diagnosis and treatment of etiology-specific causes, such as right ventricular MI, pulmonary embolism, and sepsis. For arrhythmias, it recommends maintaining sinus rhythm when possible and considering a pacemaker to maintain atrioventricular synchrony and to avoid excessive bradycardia.

In its statement, the AHA also recommends optimizing preload with right arterial pressure/central venous pressure of 8-12 mm Hg, said Dr. Baez. Preload optimization combined with afterload reduction and improved contractility are hallmarks of care for patients with RV failure.

Avoiding systemic hypotension can prevent sequelae, such as myocardial ischemia and further hypotension, he said.

Optimization of fluid status is another key to managing RV failure, said Dr. Baez. Right heart coronary perfusion pressure can be protected by maintaining mean arterial pressure, and consideration should be given to reducing the RV afterload. Other strategies include inotropic medications and rhythm stabilization.

In general, for RV failure patients, “correct hypoxia, hypercarbia, and acidosis and avoid intubation when possible,” he said. Extracorporeal membrane oxygenation (ECMO) may be an option, depending on how many mechanical ventilator settings need to be adjusted.

In a study by Dr. Baez and colleagues published in Critical Care Medicine, the authors presented a Bayesian probability model for plasma lactate and severity of illness in cases of acute pulmonary embolism. “This Bayesian model demonstrated that the combination of shock index and lactate yield superior diagnostic gains than those compare to the sPESI and lactate,” Dr. Baez said.

The care model needs to be specific to the etiology, he added. Volume management in congested pulmonary hypertension involves a “squeeze and diurese” strategy.

According to the Internet Book of Critical Care, for patients with mean arterial pressure (MAP) of 60 mm Hg, central venous pressure (CVP) of 25 mm Hg, renal perfusion pressure of 25 mm Hg, and no urine output, a vasopressor should be added to treatment, Dr. Baez said. In cases in which the MAP 75 mm Hg, the CVP is 25 mm Hg, the renal perfusion pressure is 50 mm Hg, and the patient has good urine output, vasopressors should be continued and fluid should be removed through use of a diuretic. For patients with a MAP of 75 mm Hg, a CVP of 12 mm Hg, and renal perfusion pressure of 63 mm Hg who have good urine output, the diuretic and the vasopressor should be discontinued.

Dr. Baez also reviewed several clinical studies of the utility of acute mechanical circulatory support systems for RV failure.

In two small studies involving a heart pump and a right ventricular assistive device, the 30-day survival rate was approximately 72%-73%. A study of 179 patients involving ECMO showed an in-hospital mortality rate of 38.6%, he said.

Overall, “prompt diagnosis, hemodynamic support, and initiation of specific treatment” are the foundations of managing RV failure, he concluded.

Dr. Baez disclosed no relevant financial relationships.

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

The exploration started in 2004 with a 62-year-old man who presented to an emergency department with acute shortness of breath, tachycardia with chest discomfort, and light-headedness, Amado Alejandro Baez, MD, said in a presentation at the 2022 scientific assembly of the American College of Emergency Physicians.

The patient arrived on day 20 after a radical cystoprostatectomy. He had driven 4 hours from another city for a urology follow-up visit. On arrival, he developed respiratory distress symptoms and presented to the emergency department, said Dr. Baez, professor of emergency medicine and epidemiology at the Medical College of Georgia/Augusta University and triple-board certified in EMS, emergency medicine, and critical care.

The patient developed a massive pulmonary embolism with acute cor pulmonale (right-sided heart failure). An electrocardiogram showed an S1Q3T3, demonstrating the distinctive nature of right ventricular failure, said Dr. Baez.

Research has demonstrated the differences in physiology between the right and left ventricles, he said.

Dr. Baez highlighted some of the features of right ventricle (RV) failure and how to manage it. Notably, the RV is thinner and less resilient. “RV failure patients may fall off the Starling curve,” in contrast to patients with isolated left ventricle (LV) failure.

RV pressure overload is associated with a range of conditions, such as pericardial disease, pulmonary embolism, acute respiratory distress syndrome, and pulmonary arterial hypertension. When combined with RV overload, patients may develop intracardiac shunting or coronary heart disease, Dr. Baez said. Decreased contractility associated with RV failure can result from sepsis, right ventricular myocardial infarction, myocarditis, and arrhythmia.

Dr. Baez cited the 2018 scientific statement from the American Heart Association on the evaluation and management of right-sided heart failure. The authors of the statement noted that the complicated geometry of the right heart makes functional assessment a challenge. They wrote that various hemodynamic and biochemical markers can help guide clinical assessment and therapeutic decision-making.

Increased RV afterload drives multiple factors that can ultimately lead to cardiogenic shock and death, said Dr. Baez. These factors include decreased RV oxygen delivery, decreased RV coronary perfusion, decreased systemic blood pressure, and low carbon monoxide levels. RV afterload also leads to decreased RV contractility, an increase in RV oxygen demand, and tension in the RV wall, and it may contribute to tricuspid valve insufficiency, neurohormonal activation, and RV ischemia.

Treatment strategies involve improving symptoms and stopping disease progression, said Baez. In its scientific statement, the AHA recommends steps for assessing RV and LV function so as to identify RV failure as soon as possible, he said. After excluding pericardial disease, the AHA advises diagnosis and treatment of etiology-specific causes, such as right ventricular MI, pulmonary embolism, and sepsis. For arrhythmias, it recommends maintaining sinus rhythm when possible and considering a pacemaker to maintain atrioventricular synchrony and to avoid excessive bradycardia.

In its statement, the AHA also recommends optimizing preload with right arterial pressure/central venous pressure of 8-12 mm Hg, said Dr. Baez. Preload optimization combined with afterload reduction and improved contractility are hallmarks of care for patients with RV failure.

Avoiding systemic hypotension can prevent sequelae, such as myocardial ischemia and further hypotension, he said.

Optimization of fluid status is another key to managing RV failure, said Dr. Baez. Right heart coronary perfusion pressure can be protected by maintaining mean arterial pressure, and consideration should be given to reducing the RV afterload. Other strategies include inotropic medications and rhythm stabilization.

In general, for RV failure patients, “correct hypoxia, hypercarbia, and acidosis and avoid intubation when possible,” he said. Extracorporeal membrane oxygenation (ECMO) may be an option, depending on how many mechanical ventilator settings need to be adjusted.

In a study by Dr. Baez and colleagues published in Critical Care Medicine, the authors presented a Bayesian probability model for plasma lactate and severity of illness in cases of acute pulmonary embolism. “This Bayesian model demonstrated that the combination of shock index and lactate yield superior diagnostic gains than those compare to the sPESI and lactate,” Dr. Baez said.

The care model needs to be specific to the etiology, he added. Volume management in congested pulmonary hypertension involves a “squeeze and diurese” strategy.

According to the Internet Book of Critical Care, for patients with mean arterial pressure (MAP) of 60 mm Hg, central venous pressure (CVP) of 25 mm Hg, renal perfusion pressure of 25 mm Hg, and no urine output, a vasopressor should be added to treatment, Dr. Baez said. In cases in which the MAP 75 mm Hg, the CVP is 25 mm Hg, the renal perfusion pressure is 50 mm Hg, and the patient has good urine output, vasopressors should be continued and fluid should be removed through use of a diuretic. For patients with a MAP of 75 mm Hg, a CVP of 12 mm Hg, and renal perfusion pressure of 63 mm Hg who have good urine output, the diuretic and the vasopressor should be discontinued.

Dr. Baez also reviewed several clinical studies of the utility of acute mechanical circulatory support systems for RV failure.

In two small studies involving a heart pump and a right ventricular assistive device, the 30-day survival rate was approximately 72%-73%. A study of 179 patients involving ECMO showed an in-hospital mortality rate of 38.6%, he said.

Overall, “prompt diagnosis, hemodynamic support, and initiation of specific treatment” are the foundations of managing RV failure, he concluded.

Dr. Baez disclosed no relevant financial relationships.

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

The exploration started in 2004 with a 62-year-old man who presented to an emergency department with acute shortness of breath, tachycardia with chest discomfort, and light-headedness, Amado Alejandro Baez, MD, said in a presentation at the 2022 scientific assembly of the American College of Emergency Physicians.

The patient arrived on day 20 after a radical cystoprostatectomy. He had driven 4 hours from another city for a urology follow-up visit. On arrival, he developed respiratory distress symptoms and presented to the emergency department, said Dr. Baez, professor of emergency medicine and epidemiology at the Medical College of Georgia/Augusta University and triple-board certified in EMS, emergency medicine, and critical care.

The patient developed a massive pulmonary embolism with acute cor pulmonale (right-sided heart failure). An electrocardiogram showed an S1Q3T3, demonstrating the distinctive nature of right ventricular failure, said Dr. Baez.

Research has demonstrated the differences in physiology between the right and left ventricles, he said.

Dr. Baez highlighted some of the features of right ventricle (RV) failure and how to manage it. Notably, the RV is thinner and less resilient. “RV failure patients may fall off the Starling curve,” in contrast to patients with isolated left ventricle (LV) failure.

RV pressure overload is associated with a range of conditions, such as pericardial disease, pulmonary embolism, acute respiratory distress syndrome, and pulmonary arterial hypertension. When combined with RV overload, patients may develop intracardiac shunting or coronary heart disease, Dr. Baez said. Decreased contractility associated with RV failure can result from sepsis, right ventricular myocardial infarction, myocarditis, and arrhythmia.

Dr. Baez cited the 2018 scientific statement from the American Heart Association on the evaluation and management of right-sided heart failure. The authors of the statement noted that the complicated geometry of the right heart makes functional assessment a challenge. They wrote that various hemodynamic and biochemical markers can help guide clinical assessment and therapeutic decision-making.

Increased RV afterload drives multiple factors that can ultimately lead to cardiogenic shock and death, said Dr. Baez. These factors include decreased RV oxygen delivery, decreased RV coronary perfusion, decreased systemic blood pressure, and low carbon monoxide levels. RV afterload also leads to decreased RV contractility, an increase in RV oxygen demand, and tension in the RV wall, and it may contribute to tricuspid valve insufficiency, neurohormonal activation, and RV ischemia.

Treatment strategies involve improving symptoms and stopping disease progression, said Baez. In its scientific statement, the AHA recommends steps for assessing RV and LV function so as to identify RV failure as soon as possible, he said. After excluding pericardial disease, the AHA advises diagnosis and treatment of etiology-specific causes, such as right ventricular MI, pulmonary embolism, and sepsis. For arrhythmias, it recommends maintaining sinus rhythm when possible and considering a pacemaker to maintain atrioventricular synchrony and to avoid excessive bradycardia.

In its statement, the AHA also recommends optimizing preload with right arterial pressure/central venous pressure of 8-12 mm Hg, said Dr. Baez. Preload optimization combined with afterload reduction and improved contractility are hallmarks of care for patients with RV failure.

Avoiding systemic hypotension can prevent sequelae, such as myocardial ischemia and further hypotension, he said.

Optimization of fluid status is another key to managing RV failure, said Dr. Baez. Right heart coronary perfusion pressure can be protected by maintaining mean arterial pressure, and consideration should be given to reducing the RV afterload. Other strategies include inotropic medications and rhythm stabilization.

In general, for RV failure patients, “correct hypoxia, hypercarbia, and acidosis and avoid intubation when possible,” he said. Extracorporeal membrane oxygenation (ECMO) may be an option, depending on how many mechanical ventilator settings need to be adjusted.

In a study by Dr. Baez and colleagues published in Critical Care Medicine, the authors presented a Bayesian probability model for plasma lactate and severity of illness in cases of acute pulmonary embolism. “This Bayesian model demonstrated that the combination of shock index and lactate yield superior diagnostic gains than those compare to the sPESI and lactate,” Dr. Baez said.

The care model needs to be specific to the etiology, he added. Volume management in congested pulmonary hypertension involves a “squeeze and diurese” strategy.

According to the Internet Book of Critical Care, for patients with mean arterial pressure (MAP) of 60 mm Hg, central venous pressure (CVP) of 25 mm Hg, renal perfusion pressure of 25 mm Hg, and no urine output, a vasopressor should be added to treatment, Dr. Baez said. In cases in which the MAP 75 mm Hg, the CVP is 25 mm Hg, the renal perfusion pressure is 50 mm Hg, and the patient has good urine output, vasopressors should be continued and fluid should be removed through use of a diuretic. For patients with a MAP of 75 mm Hg, a CVP of 12 mm Hg, and renal perfusion pressure of 63 mm Hg who have good urine output, the diuretic and the vasopressor should be discontinued.

Dr. Baez also reviewed several clinical studies of the utility of acute mechanical circulatory support systems for RV failure.

In two small studies involving a heart pump and a right ventricular assistive device, the 30-day survival rate was approximately 72%-73%. A study of 179 patients involving ECMO showed an in-hospital mortality rate of 38.6%, he said.

Overall, “prompt diagnosis, hemodynamic support, and initiation of specific treatment” are the foundations of managing RV failure, he concluded.

Dr. Baez disclosed no relevant financial relationships.

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

LAS VEGAS – Effective management of alopecia areata starts with confirmation of the correct diagnosis and assessment of disease severity, Brett King, MD, said in a presentation at MedscapeLive’s annual Las Vegas Dermatology Seminar.

“Some patients don’t have alopecia, but they have been managed for it,” he said. “Whenever there is an ounce of doubt, take a biopsy,” he advised.

Syldavia/iStock/Getty Images Plus

Assessing disease severity in patients with alopecia areata (AA) is especially important as new therapies become available, said Dr. King, associate professor of dermatology at Yale University, New Haven, Conn. The Severity of Alopecia Tool (SALT) Score has been available since 2004, and remains a useful tool to estimate percent hair loss. The SALT Score divides the scalp into four sections: 18% each for the right and left sides, 40% for the top of the head, and 24% for the back of the head, said Dr. King. However, the SALT Score can be enhanced or modified based on a holistic approach to disease severity that categorizes alopecia as mild (scalp hair loss of 20% or less), moderate (scalp hair loss of 21 to 49%), or severe (scalp hair loss of 50% or more).

For example, if a patient’s hair loss based on SALT Score is mild or moderate, increase the severity by 1 level (from mild to moderate, or moderate to severe) if any of the following conditions apply: Noticeable eyebrow or eyelash involvement, inadequate treatment response after 6 months, diffuse positive hair pull test consistent with rapid progression of AA, or a negative impact on psychosocial functioning because of AA, he said.
 

Treatment advances

Understanding of the pathogenesis of AA has been slow to evolve, Dr. King noted. “We haven’t been able to shake this concept that people are causing the disease by being depressed,” as noted in the literature from the 1950s.

In 2014, breakthrough research changed the game by identifying the roles of interferon gamma and interleukin 15, Dr. King said. Since then, more research has been conducted on Janus kinase (JAK) inhibitors for AA. Dr. King was a coinvestigator on a 2014 case report in which a patient with psoriasis and alopecia universalis experienced regrowth of most of his body hair after 8 months of daily oral tofacitinib, a JAK inhibitor.

However, despite the dramatic results in some patients, “tofacitinib doesn’t always work,” said Dr. King. In his experience, patients for whom tofacitinib didn’t work were those with complete or nearly complete scalp hair loss for more than 10 years.

Approval of baricitinib

Dr. King’s recent work supported the approval in June 2022 of oral baricitinib, a JAK inhibitor, for AA. He reviewed data from his late-breaker abstract presented at the annual meeting of the American Academy of Dermatology in March 2022, where he reported that almost 40% of adults with AA treated with 4 mg of baricitinib daily had significant hair regrowth over 52 weeks.

Two other oral JAK inhibitors in the pipeline for AA are deuruxolitinib and ritlecitinib, which significantly increased the proportion of patients achieving SALT scores of 20 or less, compared with patients on placebo in early clinical trials. Data on both were presented at the annual meeting of the European Academy of Dermatology and Venereology.

So far, topical JAK inhibitors have not shown success in hair regrowth for AA patients, said Dr. King. Phase 2 studies of both ruxolitinib 1.5% cream and delgocitinib ointment were ineffective for AA.
 

Emerging role for oral minoxidil

Oral minoxidil has had a recent resurgence as an adjunct therapy to the new JAK inhibitors. A study published in 1987 found that, with oral minoxidil monotherapy, a cosmetic response was seen in 18% of patients with AA, Dr. King said.

In a study published in the Journal of the American Academy of Dermatology, Dr. King and colleagues noted that dose escalation is sometimes needed for effective treatment of AA with tofacitinib. They examined the effect of adding oral minoxidil to tofacitinib in patients with severe AA as a way to increase efficacy without increasing tofacitinib dosage. They reviewed data from 12 patients ages 18-51 years who were prescribed 5 mg of tofacitinib twice daily, plus 2.5 mg oral minoxidil daily for women and 2.5 mg of minoxidil twice daily for men; women received a lower dose to minimize the side effect of hypertrichosis.

After 6 months, 67% (eight patients) achieved at least 75% hair regrowth; of those eight patients, seven (58% of the total) had hair regrowth on a twice-daily dose of 5 mg tofacitinib with no need for dose escalation, Dr. King said.

More research is needed, but oral minoxidil may be a useful adjunct treatment for some patients with AA, he added.

During a question and answer session, Dr. King was asked to elaborate on the mechanism of minoxidil in combination with JAK inhibitors. “The truth is that I just don’t know” why the combination works for some patients. However, the majority of patients who succeed with this combination regrow hair by 4 months. “There is something special about that combination.”

Dr. King disclosed serving as a consultant or adviser for AbbVie, AltruBio, Almirall, AnaptysBio, Arena Pharmaceuticals, Bioniz, Bristol Myers Squibb, Concert Pharmaceuticals, Horizon, Incyte, Leo Pharma, Eli Lilly, Otsuka, Pfizer, Regeneron, Sanofi Genzyme, Twi Biotechnology, Viela Bio, and Visterra; serving as a speaker or as a member of the speakers bureau for Incyte, Pfizer, Regeneron, Sanofi Genzyme; and receiving research funding from Concert Pharmaceuticals, Eli Lilly, and Pfizer.

MedscapeLive and this news organization are owned by the same parent company.

LAS VEGAS – Effective management of alopecia areata starts with confirmation of the correct diagnosis and assessment of disease severity, Brett King, MD, said in a presentation at MedscapeLive’s annual Las Vegas Dermatology Seminar.

“Some patients don’t have alopecia, but they have been managed for it,” he said. “Whenever there is an ounce of doubt, take a biopsy,” he advised.

Syldavia/iStock/Getty Images Plus

Assessing disease severity in patients with alopecia areata (AA) is especially important as new therapies become available, said Dr. King, associate professor of dermatology at Yale University, New Haven, Conn. The Severity of Alopecia Tool (SALT) Score has been available since 2004, and remains a useful tool to estimate percent hair loss. The SALT Score divides the scalp into four sections: 18% each for the right and left sides, 40% for the top of the head, and 24% for the back of the head, said Dr. King. However, the SALT Score can be enhanced or modified based on a holistic approach to disease severity that categorizes alopecia as mild (scalp hair loss of 20% or less), moderate (scalp hair loss of 21 to 49%), or severe (scalp hair loss of 50% or more).

For example, if a patient’s hair loss based on SALT Score is mild or moderate, increase the severity by 1 level (from mild to moderate, or moderate to severe) if any of the following conditions apply: Noticeable eyebrow or eyelash involvement, inadequate treatment response after 6 months, diffuse positive hair pull test consistent with rapid progression of AA, or a negative impact on psychosocial functioning because of AA, he said.
 

Treatment advances

Understanding of the pathogenesis of AA has been slow to evolve, Dr. King noted. “We haven’t been able to shake this concept that people are causing the disease by being depressed,” as noted in the literature from the 1950s.

In 2014, breakthrough research changed the game by identifying the roles of interferon gamma and interleukin 15, Dr. King said. Since then, more research has been conducted on Janus kinase (JAK) inhibitors for AA. Dr. King was a coinvestigator on a 2014 case report in which a patient with psoriasis and alopecia universalis experienced regrowth of most of his body hair after 8 months of daily oral tofacitinib, a JAK inhibitor.

However, despite the dramatic results in some patients, “tofacitinib doesn’t always work,” said Dr. King. In his experience, patients for whom tofacitinib didn’t work were those with complete or nearly complete scalp hair loss for more than 10 years.

Approval of baricitinib

Dr. King’s recent work supported the approval in June 2022 of oral baricitinib, a JAK inhibitor, for AA. He reviewed data from his late-breaker abstract presented at the annual meeting of the American Academy of Dermatology in March 2022, where he reported that almost 40% of adults with AA treated with 4 mg of baricitinib daily had significant hair regrowth over 52 weeks.

Two other oral JAK inhibitors in the pipeline for AA are deuruxolitinib and ritlecitinib, which significantly increased the proportion of patients achieving SALT scores of 20 or less, compared with patients on placebo in early clinical trials. Data on both were presented at the annual meeting of the European Academy of Dermatology and Venereology.

So far, topical JAK inhibitors have not shown success in hair regrowth for AA patients, said Dr. King. Phase 2 studies of both ruxolitinib 1.5% cream and delgocitinib ointment were ineffective for AA.
 

Emerging role for oral minoxidil

Oral minoxidil has had a recent resurgence as an adjunct therapy to the new JAK inhibitors. A study published in 1987 found that, with oral minoxidil monotherapy, a cosmetic response was seen in 18% of patients with AA, Dr. King said.

In a study published in the Journal of the American Academy of Dermatology, Dr. King and colleagues noted that dose escalation is sometimes needed for effective treatment of AA with tofacitinib. They examined the effect of adding oral minoxidil to tofacitinib in patients with severe AA as a way to increase efficacy without increasing tofacitinib dosage. They reviewed data from 12 patients ages 18-51 years who were prescribed 5 mg of tofacitinib twice daily, plus 2.5 mg oral minoxidil daily for women and 2.5 mg of minoxidil twice daily for men; women received a lower dose to minimize the side effect of hypertrichosis.

After 6 months, 67% (eight patients) achieved at least 75% hair regrowth; of those eight patients, seven (58% of the total) had hair regrowth on a twice-daily dose of 5 mg tofacitinib with no need for dose escalation, Dr. King said.

More research is needed, but oral minoxidil may be a useful adjunct treatment for some patients with AA, he added.

During a question and answer session, Dr. King was asked to elaborate on the mechanism of minoxidil in combination with JAK inhibitors. “The truth is that I just don’t know” why the combination works for some patients. However, the majority of patients who succeed with this combination regrow hair by 4 months. “There is something special about that combination.”

Dr. King disclosed serving as a consultant or adviser for AbbVie, AltruBio, Almirall, AnaptysBio, Arena Pharmaceuticals, Bioniz, Bristol Myers Squibb, Concert Pharmaceuticals, Horizon, Incyte, Leo Pharma, Eli Lilly, Otsuka, Pfizer, Regeneron, Sanofi Genzyme, Twi Biotechnology, Viela Bio, and Visterra; serving as a speaker or as a member of the speakers bureau for Incyte, Pfizer, Regeneron, Sanofi Genzyme; and receiving research funding from Concert Pharmaceuticals, Eli Lilly, and Pfizer.

MedscapeLive and this news organization are owned by the same parent company.

LAS VEGAS – Effective management of alopecia areata starts with confirmation of the correct diagnosis and assessment of disease severity, Brett King, MD, said in a presentation at MedscapeLive’s annual Las Vegas Dermatology Seminar.

“Some patients don’t have alopecia, but they have been managed for it,” he said. “Whenever there is an ounce of doubt, take a biopsy,” he advised.

Syldavia/iStock/Getty Images Plus

Assessing disease severity in patients with alopecia areata (AA) is especially important as new therapies become available, said Dr. King, associate professor of dermatology at Yale University, New Haven, Conn. The Severity of Alopecia Tool (SALT) Score has been available since 2004, and remains a useful tool to estimate percent hair loss. The SALT Score divides the scalp into four sections: 18% each for the right and left sides, 40% for the top of the head, and 24% for the back of the head, said Dr. King. However, the SALT Score can be enhanced or modified based on a holistic approach to disease severity that categorizes alopecia as mild (scalp hair loss of 20% or less), moderate (scalp hair loss of 21 to 49%), or severe (scalp hair loss of 50% or more).

For example, if a patient’s hair loss based on SALT Score is mild or moderate, increase the severity by 1 level (from mild to moderate, or moderate to severe) if any of the following conditions apply: Noticeable eyebrow or eyelash involvement, inadequate treatment response after 6 months, diffuse positive hair pull test consistent with rapid progression of AA, or a negative impact on psychosocial functioning because of AA, he said.
 

Treatment advances

Understanding of the pathogenesis of AA has been slow to evolve, Dr. King noted. “We haven’t been able to shake this concept that people are causing the disease by being depressed,” as noted in the literature from the 1950s.

In 2014, breakthrough research changed the game by identifying the roles of interferon gamma and interleukin 15, Dr. King said. Since then, more research has been conducted on Janus kinase (JAK) inhibitors for AA. Dr. King was a coinvestigator on a 2014 case report in which a patient with psoriasis and alopecia universalis experienced regrowth of most of his body hair after 8 months of daily oral tofacitinib, a JAK inhibitor.

However, despite the dramatic results in some patients, “tofacitinib doesn’t always work,” said Dr. King. In his experience, patients for whom tofacitinib didn’t work were those with complete or nearly complete scalp hair loss for more than 10 years.

Approval of baricitinib

Dr. King’s recent work supported the approval in June 2022 of oral baricitinib, a JAK inhibitor, for AA. He reviewed data from his late-breaker abstract presented at the annual meeting of the American Academy of Dermatology in March 2022, where he reported that almost 40% of adults with AA treated with 4 mg of baricitinib daily had significant hair regrowth over 52 weeks.

Two other oral JAK inhibitors in the pipeline for AA are deuruxolitinib and ritlecitinib, which significantly increased the proportion of patients achieving SALT scores of 20 or less, compared with patients on placebo in early clinical trials. Data on both were presented at the annual meeting of the European Academy of Dermatology and Venereology.

So far, topical JAK inhibitors have not shown success in hair regrowth for AA patients, said Dr. King. Phase 2 studies of both ruxolitinib 1.5% cream and delgocitinib ointment were ineffective for AA.
 

Emerging role for oral minoxidil

Oral minoxidil has had a recent resurgence as an adjunct therapy to the new JAK inhibitors. A study published in 1987 found that, with oral minoxidil monotherapy, a cosmetic response was seen in 18% of patients with AA, Dr. King said.

In a study published in the Journal of the American Academy of Dermatology, Dr. King and colleagues noted that dose escalation is sometimes needed for effective treatment of AA with tofacitinib. They examined the effect of adding oral minoxidil to tofacitinib in patients with severe AA as a way to increase efficacy without increasing tofacitinib dosage. They reviewed data from 12 patients ages 18-51 years who were prescribed 5 mg of tofacitinib twice daily, plus 2.5 mg oral minoxidil daily for women and 2.5 mg of minoxidil twice daily for men; women received a lower dose to minimize the side effect of hypertrichosis.

After 6 months, 67% (eight patients) achieved at least 75% hair regrowth; of those eight patients, seven (58% of the total) had hair regrowth on a twice-daily dose of 5 mg tofacitinib with no need for dose escalation, Dr. King said.

More research is needed, but oral minoxidil may be a useful adjunct treatment for some patients with AA, he added.

During a question and answer session, Dr. King was asked to elaborate on the mechanism of minoxidil in combination with JAK inhibitors. “The truth is that I just don’t know” why the combination works for some patients. However, the majority of patients who succeed with this combination regrow hair by 4 months. “There is something special about that combination.”

Dr. King disclosed serving as a consultant or adviser for AbbVie, AltruBio, Almirall, AnaptysBio, Arena Pharmaceuticals, Bioniz, Bristol Myers Squibb, Concert Pharmaceuticals, Horizon, Incyte, Leo Pharma, Eli Lilly, Otsuka, Pfizer, Regeneron, Sanofi Genzyme, Twi Biotechnology, Viela Bio, and Visterra; serving as a speaker or as a member of the speakers bureau for Incyte, Pfizer, Regeneron, Sanofi Genzyme; and receiving research funding from Concert Pharmaceuticals, Eli Lilly, and Pfizer.

MedscapeLive and this news organization are owned by the same parent company.