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Endocrine-disrupting plastics pose growing health threat
Many types of plastics pose an unrecognized threat to human health by leaching endocrine-disrupting chemicals, and a new report from the Endocrine Society and the International Pollutants Elimination Network presents their dangers and risks.
Written in a consumer-friendly form designed to guide public interest groups and policy makers, the report also can be used by clinicians to inform discussions with patients about the potential dangers of plastics and how they can reduce their exposure to endocrine-disrupting chemicals.
The report, Plastics, EDCs, & Health, defines endocrine-disrupting chemicals (EDCs) as “an exogenous chemical, or mixture of chemicals, that interferes with any aspect of hormone action.” Hormones in the body must be released at specific times, and therefore interference with their normal activity can have profound effects on health in areas including growth and reproductive development, according to the report.
The available data show “more and more information about the different chemicals and the different effects they are having,” said lead author, Jodi Flaws, PhD, of the University of Illinois at Urbana-Champaign, in a virtual press conference accompanying the release of the report.
Although numerous EDCs have been identified, a recent study suggested that many potentially dangerous chemical additives remain unknown because they are identified as confidential or simply not well described, the report authors said. In addition, creation of more plastic products will likely lead to increased exposure to EDCs and make health problems worse, said report coauthor Pauliina Damdimopoulou, PhD, of the Karolinska Institutet in Stockholm.
Lesser-known EDCs populate consumer products
Most consumers are aware of bisphenol A and phthalates as known EDCs, said Dr. Flaws, but the report identifies other lesser-known EDCs including per- and polyfluoroalkyl substances (PFAS), dioxins, flame retardants, and UV stabilizers.
For example, PFAS have been used for decades in a range of consumer products including stain resistant clothes, fast food wrappers, carpet and furniture treatments, cookware, and firefighting foams, according to the report. Consequently, PFAS have become common in many water sources including surface water, drinking water, and ground water because of how they are disposed. “Consumption of fish and other aquatic creatures caught in waterways contaminated with PFAS also poses heightened risks due to bioaccumulation of persistent chemicals in these animals,” the report authors noted. Human exposures to PFAS have been documented in urine, serum, plasma, placenta, umbilical cord, breast milk, and fetal tissues, they added.
Brominated flame retardants are another lesser-known EDC highlighted in the report. These chemical additives are used in plastics such as electronics cases to reduce the spread of fire, as well as in furniture foam and other building materials, the authors wrote. UV stabilizers, which also have been linked to health problems, often are used in manufacturing cars and other machinery.
Microplastics create large risk
Microplastics, defined as plastic particles less than 5 mm in diameter, are another source of exposure to EDCs that is not well publicized, according to the report. Plastic waste disposal often leads to the release of microplastics, which can infiltrate soil and water. Plastic waste is often dumped or burned; outdoor burning of plastic causes emission of dioxins into the air and ground.
“Not only do microplastics contain endogenous chemical additives, which are not bound to the microplastic and can leach out of the microplastic and expose the population, they can also bind and accumulate toxic chemicals from the surrounding environment such as sea water and sediment,” the report authors said.
Recycling is not an easy answer, either. Often more chemicals are created and released during the process of using plastics to make other plastics, according to the report.
Overall, more awareness of the potential for increased exposure to EDCs and support of strategies to seek out alternatives to hazardous chemicals is needed at the global level, the authors wrote. For example, the European Union has proposed a chemicals strategy that includes improved classification of EDCs and banning identified EDCs in consumer products.
New data support ongoing dangers
“It was important to produce the report at this time because several new studies came out on the effects of EDCs from plastics on human health,” Dr. Flaws said in an interview. “Further, there was not previously a single source that brought together all the information in a manner that was targeted towards the public, policy makers, and others,” she said.
Dr. Flaws said that what has surprised her most in the recent research is the fact that plastics contain such a range of chemicals and EDCs.
“A good take-home message [from the report] is that plastics can contain endocrine-disrupting chemicals that can interfere with normal hormones and lead to adverse health outcomes,” she said. “I suggest limiting the use of plastics as much as possible. I know this is very hard to do, so if someone needs to use plastic, they should not heat food or drink in plastic containers,” she emphasized. Individuals also can limit reuse of plastics over and over,” she said. “Heating and repeated use/washing often causes plastics to leach EDCs into food and drink that we then get into our bodies.”
Additional research is needed to understand the mechanisms by which EDCs from plastics cause damage, Dr. Flaws emphasized. “Given that it is not possible to eliminate plastics at this time, if we understood mechanisms of action, we could develop ways to prevent toxicity or treat EDC-induced adverse health outcomes,” she said. “We also need research designed to develop plastics or ‘green materials’ that do not contain endocrine disruptors and do not cause health problems or damage the environment,” she noted.
The report was produced as a joint effort of the Endocrine Society and International Pollutants Elimination Network. The report authors had no financial conflicts to disclose.
Many types of plastics pose an unrecognized threat to human health by leaching endocrine-disrupting chemicals, and a new report from the Endocrine Society and the International Pollutants Elimination Network presents their dangers and risks.
Written in a consumer-friendly form designed to guide public interest groups and policy makers, the report also can be used by clinicians to inform discussions with patients about the potential dangers of plastics and how they can reduce their exposure to endocrine-disrupting chemicals.
The report, Plastics, EDCs, & Health, defines endocrine-disrupting chemicals (EDCs) as “an exogenous chemical, or mixture of chemicals, that interferes with any aspect of hormone action.” Hormones in the body must be released at specific times, and therefore interference with their normal activity can have profound effects on health in areas including growth and reproductive development, according to the report.
The available data show “more and more information about the different chemicals and the different effects they are having,” said lead author, Jodi Flaws, PhD, of the University of Illinois at Urbana-Champaign, in a virtual press conference accompanying the release of the report.
Although numerous EDCs have been identified, a recent study suggested that many potentially dangerous chemical additives remain unknown because they are identified as confidential or simply not well described, the report authors said. In addition, creation of more plastic products will likely lead to increased exposure to EDCs and make health problems worse, said report coauthor Pauliina Damdimopoulou, PhD, of the Karolinska Institutet in Stockholm.
Lesser-known EDCs populate consumer products
Most consumers are aware of bisphenol A and phthalates as known EDCs, said Dr. Flaws, but the report identifies other lesser-known EDCs including per- and polyfluoroalkyl substances (PFAS), dioxins, flame retardants, and UV stabilizers.
For example, PFAS have been used for decades in a range of consumer products including stain resistant clothes, fast food wrappers, carpet and furniture treatments, cookware, and firefighting foams, according to the report. Consequently, PFAS have become common in many water sources including surface water, drinking water, and ground water because of how they are disposed. “Consumption of fish and other aquatic creatures caught in waterways contaminated with PFAS also poses heightened risks due to bioaccumulation of persistent chemicals in these animals,” the report authors noted. Human exposures to PFAS have been documented in urine, serum, plasma, placenta, umbilical cord, breast milk, and fetal tissues, they added.
Brominated flame retardants are another lesser-known EDC highlighted in the report. These chemical additives are used in plastics such as electronics cases to reduce the spread of fire, as well as in furniture foam and other building materials, the authors wrote. UV stabilizers, which also have been linked to health problems, often are used in manufacturing cars and other machinery.
Microplastics create large risk
Microplastics, defined as plastic particles less than 5 mm in diameter, are another source of exposure to EDCs that is not well publicized, according to the report. Plastic waste disposal often leads to the release of microplastics, which can infiltrate soil and water. Plastic waste is often dumped or burned; outdoor burning of plastic causes emission of dioxins into the air and ground.
“Not only do microplastics contain endogenous chemical additives, which are not bound to the microplastic and can leach out of the microplastic and expose the population, they can also bind and accumulate toxic chemicals from the surrounding environment such as sea water and sediment,” the report authors said.
Recycling is not an easy answer, either. Often more chemicals are created and released during the process of using plastics to make other plastics, according to the report.
Overall, more awareness of the potential for increased exposure to EDCs and support of strategies to seek out alternatives to hazardous chemicals is needed at the global level, the authors wrote. For example, the European Union has proposed a chemicals strategy that includes improved classification of EDCs and banning identified EDCs in consumer products.
New data support ongoing dangers
“It was important to produce the report at this time because several new studies came out on the effects of EDCs from plastics on human health,” Dr. Flaws said in an interview. “Further, there was not previously a single source that brought together all the information in a manner that was targeted towards the public, policy makers, and others,” she said.
Dr. Flaws said that what has surprised her most in the recent research is the fact that plastics contain such a range of chemicals and EDCs.
“A good take-home message [from the report] is that plastics can contain endocrine-disrupting chemicals that can interfere with normal hormones and lead to adverse health outcomes,” she said. “I suggest limiting the use of plastics as much as possible. I know this is very hard to do, so if someone needs to use plastic, they should not heat food or drink in plastic containers,” she emphasized. Individuals also can limit reuse of plastics over and over,” she said. “Heating and repeated use/washing often causes plastics to leach EDCs into food and drink that we then get into our bodies.”
Additional research is needed to understand the mechanisms by which EDCs from plastics cause damage, Dr. Flaws emphasized. “Given that it is not possible to eliminate plastics at this time, if we understood mechanisms of action, we could develop ways to prevent toxicity or treat EDC-induced adverse health outcomes,” she said. “We also need research designed to develop plastics or ‘green materials’ that do not contain endocrine disruptors and do not cause health problems or damage the environment,” she noted.
The report was produced as a joint effort of the Endocrine Society and International Pollutants Elimination Network. The report authors had no financial conflicts to disclose.
Many types of plastics pose an unrecognized threat to human health by leaching endocrine-disrupting chemicals, and a new report from the Endocrine Society and the International Pollutants Elimination Network presents their dangers and risks.
Written in a consumer-friendly form designed to guide public interest groups and policy makers, the report also can be used by clinicians to inform discussions with patients about the potential dangers of plastics and how they can reduce their exposure to endocrine-disrupting chemicals.
The report, Plastics, EDCs, & Health, defines endocrine-disrupting chemicals (EDCs) as “an exogenous chemical, or mixture of chemicals, that interferes with any aspect of hormone action.” Hormones in the body must be released at specific times, and therefore interference with their normal activity can have profound effects on health in areas including growth and reproductive development, according to the report.
The available data show “more and more information about the different chemicals and the different effects they are having,” said lead author, Jodi Flaws, PhD, of the University of Illinois at Urbana-Champaign, in a virtual press conference accompanying the release of the report.
Although numerous EDCs have been identified, a recent study suggested that many potentially dangerous chemical additives remain unknown because they are identified as confidential or simply not well described, the report authors said. In addition, creation of more plastic products will likely lead to increased exposure to EDCs and make health problems worse, said report coauthor Pauliina Damdimopoulou, PhD, of the Karolinska Institutet in Stockholm.
Lesser-known EDCs populate consumer products
Most consumers are aware of bisphenol A and phthalates as known EDCs, said Dr. Flaws, but the report identifies other lesser-known EDCs including per- and polyfluoroalkyl substances (PFAS), dioxins, flame retardants, and UV stabilizers.
For example, PFAS have been used for decades in a range of consumer products including stain resistant clothes, fast food wrappers, carpet and furniture treatments, cookware, and firefighting foams, according to the report. Consequently, PFAS have become common in many water sources including surface water, drinking water, and ground water because of how they are disposed. “Consumption of fish and other aquatic creatures caught in waterways contaminated with PFAS also poses heightened risks due to bioaccumulation of persistent chemicals in these animals,” the report authors noted. Human exposures to PFAS have been documented in urine, serum, plasma, placenta, umbilical cord, breast milk, and fetal tissues, they added.
Brominated flame retardants are another lesser-known EDC highlighted in the report. These chemical additives are used in plastics such as electronics cases to reduce the spread of fire, as well as in furniture foam and other building materials, the authors wrote. UV stabilizers, which also have been linked to health problems, often are used in manufacturing cars and other machinery.
Microplastics create large risk
Microplastics, defined as plastic particles less than 5 mm in diameter, are another source of exposure to EDCs that is not well publicized, according to the report. Plastic waste disposal often leads to the release of microplastics, which can infiltrate soil and water. Plastic waste is often dumped or burned; outdoor burning of plastic causes emission of dioxins into the air and ground.
“Not only do microplastics contain endogenous chemical additives, which are not bound to the microplastic and can leach out of the microplastic and expose the population, they can also bind and accumulate toxic chemicals from the surrounding environment such as sea water and sediment,” the report authors said.
Recycling is not an easy answer, either. Often more chemicals are created and released during the process of using plastics to make other plastics, according to the report.
Overall, more awareness of the potential for increased exposure to EDCs and support of strategies to seek out alternatives to hazardous chemicals is needed at the global level, the authors wrote. For example, the European Union has proposed a chemicals strategy that includes improved classification of EDCs and banning identified EDCs in consumer products.
New data support ongoing dangers
“It was important to produce the report at this time because several new studies came out on the effects of EDCs from plastics on human health,” Dr. Flaws said in an interview. “Further, there was not previously a single source that brought together all the information in a manner that was targeted towards the public, policy makers, and others,” she said.
Dr. Flaws said that what has surprised her most in the recent research is the fact that plastics contain such a range of chemicals and EDCs.
“A good take-home message [from the report] is that plastics can contain endocrine-disrupting chemicals that can interfere with normal hormones and lead to adverse health outcomes,” she said. “I suggest limiting the use of plastics as much as possible. I know this is very hard to do, so if someone needs to use plastic, they should not heat food or drink in plastic containers,” she emphasized. Individuals also can limit reuse of plastics over and over,” she said. “Heating and repeated use/washing often causes plastics to leach EDCs into food and drink that we then get into our bodies.”
Additional research is needed to understand the mechanisms by which EDCs from plastics cause damage, Dr. Flaws emphasized. “Given that it is not possible to eliminate plastics at this time, if we understood mechanisms of action, we could develop ways to prevent toxicity or treat EDC-induced adverse health outcomes,” she said. “We also need research designed to develop plastics or ‘green materials’ that do not contain endocrine disruptors and do not cause health problems or damage the environment,” she noted.
The report was produced as a joint effort of the Endocrine Society and International Pollutants Elimination Network. The report authors had no financial conflicts to disclose.
Study results support screening rosacea patients for cardiometabolic disease
according to the results of a meta-analysis of more than 50,000 patients.
To date, “mounting comorbidities of rosacea have been identified, suggesting that rosacea is not simply a skin disease but has links to multiple systemic illnesses,” wrote Qi Chen, MD, of Central South University, Changsha, China, and colleagues. The association with rosacea and cardiometabolic disease has been controversial, they added.
In a study published in the Journal of the American Academy of Dermatology, they identified 13 studies including 50,442 rosacea patients and 1,525,864 controls. Approximately 71% of the rosacea patients were women.
Overall, patients with rosacea showed a statistically significant association for hypertension (risk ratio, 1.20; 95% confidence interval, 1.08-1.34; P = .001) and dyslipidemia (RR, 1.32; 95% CI, 1.10-1.58; P = .002). Specifically, rosacea patients averaged higher standard mean differences of systolic and diastolic blood pressure, total cholesterol, HDL cholesterol and LDL cholesterol, and triglycerides, compared with controls.
Rosacea was not significantly associated with an increased risk for ischemic heart disease, stroke, or diabetes, although the rosacea patients showed significantly increased risk of higher fasting blood glucose, compared with controls.
Findings don’t show causality
The study findings were limited by several factors, including the observational nature of some of the studies and the inability to perform subgroup analyses based on subtype and disease severity, the researchers noted. In addition, most of the rosacea patients were outpatients. “Further investigations are warranted to identify the relationship between rosacea and [cardiometabolic disease] in general populations to further validate the significance of our findings.”
However, the results support the value of screening for cardiometabolic disease in rosacea patients to facilitate diagnosis and treatment of disease at an early stage, they concluded.
“Rosacea has been linked statistically to many comorbidities including depression, anxiety, hypertension, and diabetes mellitus,” Julie Harper, MD, of the Dermatology and Skin Care Center of Birmingham (Alabama), said in an interview.
“This study looked more specifically at cardiometabolic disease and found a statistically significant correlation between rosacea and hypertension, higher total cholesterol, higher triglycerides and higher fasting blood glucose,” she said. However, “while there is an association present in this meta-analysis, we cannot assume a cause-and-effect relationship.”
Although the analysis does not prove causality, the key message for clinicians is that cardiometabolic disease is quite common in rosacea patients, and risk factors should be identified and treated early, said Dr. Harper. “Our patients with and without rosacea will benefit from age-appropriate screening, physical examination, and laboratory evaluation with a primary care physician. For rosacea patients in particular, we can advise them that early research suggests that individuals with rosacea might have an increased risk of hypertension and/or high cholesterol and triglycerides. It never hurts to make an appointment with primary care and to be checked.”
“We need more confirmatory studies that minimize the influence of confounding,” Dr. Harper added. Rosacea also has also been linked to obesity, which is another risk factor for cardiometabolic disease.
The study was supported by multiple grants from the National Natural Science Foundation of China. The researchers had no financial conflicts to disclose. Dr. Harper had no relevant financial conflicts to disclose.
SOURCE: Chen Q et al. J Am Acad Dermatol. 2020 Nov;83(5):1331-40.
according to the results of a meta-analysis of more than 50,000 patients.
To date, “mounting comorbidities of rosacea have been identified, suggesting that rosacea is not simply a skin disease but has links to multiple systemic illnesses,” wrote Qi Chen, MD, of Central South University, Changsha, China, and colleagues. The association with rosacea and cardiometabolic disease has been controversial, they added.
In a study published in the Journal of the American Academy of Dermatology, they identified 13 studies including 50,442 rosacea patients and 1,525,864 controls. Approximately 71% of the rosacea patients were women.
Overall, patients with rosacea showed a statistically significant association for hypertension (risk ratio, 1.20; 95% confidence interval, 1.08-1.34; P = .001) and dyslipidemia (RR, 1.32; 95% CI, 1.10-1.58; P = .002). Specifically, rosacea patients averaged higher standard mean differences of systolic and diastolic blood pressure, total cholesterol, HDL cholesterol and LDL cholesterol, and triglycerides, compared with controls.
Rosacea was not significantly associated with an increased risk for ischemic heart disease, stroke, or diabetes, although the rosacea patients showed significantly increased risk of higher fasting blood glucose, compared with controls.
Findings don’t show causality
The study findings were limited by several factors, including the observational nature of some of the studies and the inability to perform subgroup analyses based on subtype and disease severity, the researchers noted. In addition, most of the rosacea patients were outpatients. “Further investigations are warranted to identify the relationship between rosacea and [cardiometabolic disease] in general populations to further validate the significance of our findings.”
However, the results support the value of screening for cardiometabolic disease in rosacea patients to facilitate diagnosis and treatment of disease at an early stage, they concluded.
“Rosacea has been linked statistically to many comorbidities including depression, anxiety, hypertension, and diabetes mellitus,” Julie Harper, MD, of the Dermatology and Skin Care Center of Birmingham (Alabama), said in an interview.
“This study looked more specifically at cardiometabolic disease and found a statistically significant correlation between rosacea and hypertension, higher total cholesterol, higher triglycerides and higher fasting blood glucose,” she said. However, “while there is an association present in this meta-analysis, we cannot assume a cause-and-effect relationship.”
Although the analysis does not prove causality, the key message for clinicians is that cardiometabolic disease is quite common in rosacea patients, and risk factors should be identified and treated early, said Dr. Harper. “Our patients with and without rosacea will benefit from age-appropriate screening, physical examination, and laboratory evaluation with a primary care physician. For rosacea patients in particular, we can advise them that early research suggests that individuals with rosacea might have an increased risk of hypertension and/or high cholesterol and triglycerides. It never hurts to make an appointment with primary care and to be checked.”
“We need more confirmatory studies that minimize the influence of confounding,” Dr. Harper added. Rosacea also has also been linked to obesity, which is another risk factor for cardiometabolic disease.
The study was supported by multiple grants from the National Natural Science Foundation of China. The researchers had no financial conflicts to disclose. Dr. Harper had no relevant financial conflicts to disclose.
SOURCE: Chen Q et al. J Am Acad Dermatol. 2020 Nov;83(5):1331-40.
according to the results of a meta-analysis of more than 50,000 patients.
To date, “mounting comorbidities of rosacea have been identified, suggesting that rosacea is not simply a skin disease but has links to multiple systemic illnesses,” wrote Qi Chen, MD, of Central South University, Changsha, China, and colleagues. The association with rosacea and cardiometabolic disease has been controversial, they added.
In a study published in the Journal of the American Academy of Dermatology, they identified 13 studies including 50,442 rosacea patients and 1,525,864 controls. Approximately 71% of the rosacea patients were women.
Overall, patients with rosacea showed a statistically significant association for hypertension (risk ratio, 1.20; 95% confidence interval, 1.08-1.34; P = .001) and dyslipidemia (RR, 1.32; 95% CI, 1.10-1.58; P = .002). Specifically, rosacea patients averaged higher standard mean differences of systolic and diastolic blood pressure, total cholesterol, HDL cholesterol and LDL cholesterol, and triglycerides, compared with controls.
Rosacea was not significantly associated with an increased risk for ischemic heart disease, stroke, or diabetes, although the rosacea patients showed significantly increased risk of higher fasting blood glucose, compared with controls.
Findings don’t show causality
The study findings were limited by several factors, including the observational nature of some of the studies and the inability to perform subgroup analyses based on subtype and disease severity, the researchers noted. In addition, most of the rosacea patients were outpatients. “Further investigations are warranted to identify the relationship between rosacea and [cardiometabolic disease] in general populations to further validate the significance of our findings.”
However, the results support the value of screening for cardiometabolic disease in rosacea patients to facilitate diagnosis and treatment of disease at an early stage, they concluded.
“Rosacea has been linked statistically to many comorbidities including depression, anxiety, hypertension, and diabetes mellitus,” Julie Harper, MD, of the Dermatology and Skin Care Center of Birmingham (Alabama), said in an interview.
“This study looked more specifically at cardiometabolic disease and found a statistically significant correlation between rosacea and hypertension, higher total cholesterol, higher triglycerides and higher fasting blood glucose,” she said. However, “while there is an association present in this meta-analysis, we cannot assume a cause-and-effect relationship.”
Although the analysis does not prove causality, the key message for clinicians is that cardiometabolic disease is quite common in rosacea patients, and risk factors should be identified and treated early, said Dr. Harper. “Our patients with and without rosacea will benefit from age-appropriate screening, physical examination, and laboratory evaluation with a primary care physician. For rosacea patients in particular, we can advise them that early research suggests that individuals with rosacea might have an increased risk of hypertension and/or high cholesterol and triglycerides. It never hurts to make an appointment with primary care and to be checked.”
“We need more confirmatory studies that minimize the influence of confounding,” Dr. Harper added. Rosacea also has also been linked to obesity, which is another risk factor for cardiometabolic disease.
The study was supported by multiple grants from the National Natural Science Foundation of China. The researchers had no financial conflicts to disclose. Dr. Harper had no relevant financial conflicts to disclose.
SOURCE: Chen Q et al. J Am Acad Dermatol. 2020 Nov;83(5):1331-40.
FROM THE JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY
Advent of biologics extended life expectancy but also expenses for RA patients
The widespread use of biologics extended life expectancy but also increased medical costs for adults with RA, based on insurance claims data from nearly 30,000 cases.
“With the advancement of treatment in recent decades, the mortality seems to decrease, while medical expenditures increase,” but previous studies estimating the life-years lost because of RA have shown large variations in results, wrote Ying-Ming Chiu, MD, PhD, of China Medical University, Taichung, Taiwan, and colleagues.
“Estimating long-term or lifetime costs could provide an overall figure of the future impact on the health care system after disease occurrence, and would be useful for cost-effectiveness analysis,” they added.
In a study published in Arthritis & Rheumatology, the researchers identified 29,352 new cases of RA in Taiwan between 2003 and 2016, after the introduction of biologics in Taiwan in 2003. They estimate survival using an algorithm with matched controls and used the survival rates to calculate monthly and lifetime health care expenses.
Overall, the average estimated life expectancy after a diagnosis of RA was 26.3 years, and the average lifetime cost was $72,953 (USD). The average life expectancy was 23.4 years for women and 21.6 years for men. The average lifetime cost was higher for women than for men ($73,112 vs. $63,557), but the annual costs were similar for women and men ($3,123 vs. $2,942). However, “the older the age of diagnosis of RA, the higher the average annual cost for treating RA,” regardless of gender, the researchers noted.
Despite the reduced mortality during the study period, the researchers also identified some loss of life expectancy among RA patients, compared with the general population. The average loss of life expectancy was nearly 5 years during the 14-year study period. The loss of life expectancy ranged from 2 to 13 years (average 9.7 years) for women with RA and from 2 to 8 years (average 4.1 years) for men with RA, compared with those without RA after controlling for age, gender, and year of diagnosis.
The study findings were limited by several factors including the lack of data on quality of life and functional disability, possible underestimation of life expectancy because of delayed RA diagnosis, and limited accuracy on follow-up of younger patients, the researchers noted.
However, the results support evidence from previous studies of an overall increase in life expectancy after the introduction of biologics, with increased expenses that should be monitored for cost-effectiveness, they concluded. More research is needed to determine the effect of biologics on functional disability, quality of life, and cost-effectiveness in a way that also incorporates productivity loss and the need for social services such as long-term care in order to inform decision-making for RA treatment.
The study was supported by the Ministry of Science and Technology, Taiwan, and China Medical University Hospital. The researchers had no financial conflicts to disclose.
SOURCE: Chiu Y-M et al. Arthritis Rheumatol. 2020 Dec 8. doi: 10.1002/ART.41597.
The widespread use of biologics extended life expectancy but also increased medical costs for adults with RA, based on insurance claims data from nearly 30,000 cases.
“With the advancement of treatment in recent decades, the mortality seems to decrease, while medical expenditures increase,” but previous studies estimating the life-years lost because of RA have shown large variations in results, wrote Ying-Ming Chiu, MD, PhD, of China Medical University, Taichung, Taiwan, and colleagues.
“Estimating long-term or lifetime costs could provide an overall figure of the future impact on the health care system after disease occurrence, and would be useful for cost-effectiveness analysis,” they added.
In a study published in Arthritis & Rheumatology, the researchers identified 29,352 new cases of RA in Taiwan between 2003 and 2016, after the introduction of biologics in Taiwan in 2003. They estimate survival using an algorithm with matched controls and used the survival rates to calculate monthly and lifetime health care expenses.
Overall, the average estimated life expectancy after a diagnosis of RA was 26.3 years, and the average lifetime cost was $72,953 (USD). The average life expectancy was 23.4 years for women and 21.6 years for men. The average lifetime cost was higher for women than for men ($73,112 vs. $63,557), but the annual costs were similar for women and men ($3,123 vs. $2,942). However, “the older the age of diagnosis of RA, the higher the average annual cost for treating RA,” regardless of gender, the researchers noted.
Despite the reduced mortality during the study period, the researchers also identified some loss of life expectancy among RA patients, compared with the general population. The average loss of life expectancy was nearly 5 years during the 14-year study period. The loss of life expectancy ranged from 2 to 13 years (average 9.7 years) for women with RA and from 2 to 8 years (average 4.1 years) for men with RA, compared with those without RA after controlling for age, gender, and year of diagnosis.
The study findings were limited by several factors including the lack of data on quality of life and functional disability, possible underestimation of life expectancy because of delayed RA diagnosis, and limited accuracy on follow-up of younger patients, the researchers noted.
However, the results support evidence from previous studies of an overall increase in life expectancy after the introduction of biologics, with increased expenses that should be monitored for cost-effectiveness, they concluded. More research is needed to determine the effect of biologics on functional disability, quality of life, and cost-effectiveness in a way that also incorporates productivity loss and the need for social services such as long-term care in order to inform decision-making for RA treatment.
The study was supported by the Ministry of Science and Technology, Taiwan, and China Medical University Hospital. The researchers had no financial conflicts to disclose.
SOURCE: Chiu Y-M et al. Arthritis Rheumatol. 2020 Dec 8. doi: 10.1002/ART.41597.
The widespread use of biologics extended life expectancy but also increased medical costs for adults with RA, based on insurance claims data from nearly 30,000 cases.
“With the advancement of treatment in recent decades, the mortality seems to decrease, while medical expenditures increase,” but previous studies estimating the life-years lost because of RA have shown large variations in results, wrote Ying-Ming Chiu, MD, PhD, of China Medical University, Taichung, Taiwan, and colleagues.
“Estimating long-term or lifetime costs could provide an overall figure of the future impact on the health care system after disease occurrence, and would be useful for cost-effectiveness analysis,” they added.
In a study published in Arthritis & Rheumatology, the researchers identified 29,352 new cases of RA in Taiwan between 2003 and 2016, after the introduction of biologics in Taiwan in 2003. They estimate survival using an algorithm with matched controls and used the survival rates to calculate monthly and lifetime health care expenses.
Overall, the average estimated life expectancy after a diagnosis of RA was 26.3 years, and the average lifetime cost was $72,953 (USD). The average life expectancy was 23.4 years for women and 21.6 years for men. The average lifetime cost was higher for women than for men ($73,112 vs. $63,557), but the annual costs were similar for women and men ($3,123 vs. $2,942). However, “the older the age of diagnosis of RA, the higher the average annual cost for treating RA,” regardless of gender, the researchers noted.
Despite the reduced mortality during the study period, the researchers also identified some loss of life expectancy among RA patients, compared with the general population. The average loss of life expectancy was nearly 5 years during the 14-year study period. The loss of life expectancy ranged from 2 to 13 years (average 9.7 years) for women with RA and from 2 to 8 years (average 4.1 years) for men with RA, compared with those without RA after controlling for age, gender, and year of diagnosis.
The study findings were limited by several factors including the lack of data on quality of life and functional disability, possible underestimation of life expectancy because of delayed RA diagnosis, and limited accuracy on follow-up of younger patients, the researchers noted.
However, the results support evidence from previous studies of an overall increase in life expectancy after the introduction of biologics, with increased expenses that should be monitored for cost-effectiveness, they concluded. More research is needed to determine the effect of biologics on functional disability, quality of life, and cost-effectiveness in a way that also incorporates productivity loss and the need for social services such as long-term care in order to inform decision-making for RA treatment.
The study was supported by the Ministry of Science and Technology, Taiwan, and China Medical University Hospital. The researchers had no financial conflicts to disclose.
SOURCE: Chiu Y-M et al. Arthritis Rheumatol. 2020 Dec 8. doi: 10.1002/ART.41597.
FROM ARTHRITIS & RHEUMATOLOGY
Rap music mention of mental health topics more than doubles
Mental health distress is rising but often is undertreated among children and young adults in the United States, wrote Alex Kresovich, MA, of the University of North Carolina, Chapel Hill, and colleagues.
“Mental health risk especially is increasing among young Black/ African American male individuals (YBAAM), who are often disproportionately exposed to environmental, economic, and family stressors linked with depression and anxiety,” they said. Adolescents and young adults, especially YBAAM, make up a large part of the audience for rap music.
In recent years, more rap artists have disclosed mental health issues, and they have included mental health topics such as depression and suicidal thoughts into their music, the researchers said.
In a study published in JAMA Pediatrics, the researchers identified 125 songs from the period between 1998 and 2018, then assessed them for references to mental health. The song selections included the top 25 rap songs in 1998, 2003, 2008, 2013, and 2018, based on the Billboard music charts.
The majority of the songs (123) featured lead artists from North America, and 97 of them were Black/African American males. The average age of the artists was 28 years. “Prominent artists captured in the sample included 50 Cent, Drake, Eminem, Kanye West, Jay-Z, and Lil’Wayne, among others,” they said. The researchers divided mental health issues into four categories: anxiety or anxious thinking; depression or depressive thinking; metaphors (such as struggling with mental stability); and suicide or suicidal ideation.
Mental health references rise
Across the study period, 35 songs (28%) mentioned anxiety, 28 (22%) mentioned depression, 8 (6%) mentioned suicide, and 26 (21%) mentioned a mental health metaphor. The proportion of songs with a mental health reference increased in a significant linear trend across the study period for suicide (0%-12%), depression (16%-32%), and mental health metaphors (8%-44%).
All references to suicide or suicidal ideation were found in songs that were popular between 2013 and 2018, the researchers noted.
“This increase is important, given that rap artists serve as role models to their audience, which extends beyond YBAAM to include U.S. young people across strata, constituting a large group with increased risk of mental health issues and underuse of mental health services,” Mr. Kresovich and associates said.
In addition, the researchers found that stressors related to environmental conditions and love were significantly more likely to co-occur with mental health references (adjusted odds ratios 8.1 and 4.8, respectively).
The study findings were limited by several factors including the selection of songs only from the Billboard hot rap songs year-end charts, which “does not fully represent the population of rap music between 1998 and 2018,” the researchers said. In addition, they could not address causation or motivations for the increased mental health references over the study period. “We are also unable to ascertain how U.S. youth interact with this music or are positively or negatively affected by its messages.”
“For example, positively framed references to mental health awareness, treatment, or support may lead to reduced stigma and increased willingness to seek treatment,” Mr. Kresovich and associates wrote. “However, negatively framed references to mental health struggles might lead to negative outcomes, including copycat behavior in which listeners model harmful behavior, such as suicide attempts, if those behaviors are described in lyrics (i.e., the Werther effect),” they added.
Despite these limitations, the results support the need for more research on the impact of rap music as a way to reduce stigma and potentially reduce mental health risk in adolescents and young adults, Mr. Kresovich and associates concluded.
Music may help raise tough topics
The study is important because children and adolescents have more control than ever over the media they consume, Sarah Vinson, MD, founder of the Lorio Psych Group in Atlanta, said in an interview.
“With more and more children with access to their own devices, they spend a great amount of time consuming content, including music,” Dr. Vinson said. “The norms reflected in the lyrics they hear have an impact on their emerging view of themselves, others, and the world.”
The increased recognition of mental health issues by rap musicians as a topic “certainly has the potential to have a positive impact; however, the way that it is discussed can influence [the] nature of that impact,” she explained.
“It is important for people who are dealing with the normal range of human emotions to know that they are not alone. It is even more important for people dealing with suicidality or mental illness to know that,” Dr. Vinson said.
“Validation and sense of connection are human needs, and stigma related to mental illness can be isolating,” she emphasized. “Rappers have a platform and are often people that children and adolescents look up to, for better or for worse.” Through their music, “the rappers are signaling that these topics are worthy of our attention and okay to talk about.”
Unfortunately, many barriers persist for adolescents in need of mental health treatment, said Dr. Vinson. “The children’s mental health workforce, quantitatively, is not enough to meet the current needs,” she said. “Mental health is not reimbursed at the same rate as other kinds of health care, which contributes to healthy systems not prioritizing these services. Additionally, the racial, ethnic, and socioeconomic background of those who are mental health providers is not reflective of the larger population, and mental health training insufficiently incorporates the cultural and structural humility needed to help professionals navigate those differences,” she explained.
“Children at increased risk are those who face many of those environmental barriers that the rappers reference in those lyrics. They are likely to have even poorer access because they are disproportionately impacted by residential segregation, transportation challenges, financial barriers, and structural racism in mental health care,” Dr. Vinson added. A take-home message for clinicians is to find out what their patients are listening to. “One way to understand what is on the hearts and minds of children is to ask them what’s in their playlist,” she said.
Additional research is needed to examine “moderating factors for the impact, good or bad, of increased mental health content in hip hop for young listeners’ mental health awareness, symptoms and/or interest in seeking treatment,” Dr. Vinson concluded.
The study received no outside funding. The researchers had no financial conflicts to disclose.
Dr. Vinson served as chair for a workshop on mental health and hip-hop at the American Psychiatric Association annual meeting. She had no financial conflicts to disclose.
SOURCE: Kresovich A et al. JAMA Pediatr. 2020 Dec 7. doi: 10.1001/jamapediatrics.2020.5155.
This article was updated on December 21, 2020.
Mental health distress is rising but often is undertreated among children and young adults in the United States, wrote Alex Kresovich, MA, of the University of North Carolina, Chapel Hill, and colleagues.
“Mental health risk especially is increasing among young Black/ African American male individuals (YBAAM), who are often disproportionately exposed to environmental, economic, and family stressors linked with depression and anxiety,” they said. Adolescents and young adults, especially YBAAM, make up a large part of the audience for rap music.
In recent years, more rap artists have disclosed mental health issues, and they have included mental health topics such as depression and suicidal thoughts into their music, the researchers said.
In a study published in JAMA Pediatrics, the researchers identified 125 songs from the period between 1998 and 2018, then assessed them for references to mental health. The song selections included the top 25 rap songs in 1998, 2003, 2008, 2013, and 2018, based on the Billboard music charts.
The majority of the songs (123) featured lead artists from North America, and 97 of them were Black/African American males. The average age of the artists was 28 years. “Prominent artists captured in the sample included 50 Cent, Drake, Eminem, Kanye West, Jay-Z, and Lil’Wayne, among others,” they said. The researchers divided mental health issues into four categories: anxiety or anxious thinking; depression or depressive thinking; metaphors (such as struggling with mental stability); and suicide or suicidal ideation.
Mental health references rise
Across the study period, 35 songs (28%) mentioned anxiety, 28 (22%) mentioned depression, 8 (6%) mentioned suicide, and 26 (21%) mentioned a mental health metaphor. The proportion of songs with a mental health reference increased in a significant linear trend across the study period for suicide (0%-12%), depression (16%-32%), and mental health metaphors (8%-44%).
All references to suicide or suicidal ideation were found in songs that were popular between 2013 and 2018, the researchers noted.
“This increase is important, given that rap artists serve as role models to their audience, which extends beyond YBAAM to include U.S. young people across strata, constituting a large group with increased risk of mental health issues and underuse of mental health services,” Mr. Kresovich and associates said.
In addition, the researchers found that stressors related to environmental conditions and love were significantly more likely to co-occur with mental health references (adjusted odds ratios 8.1 and 4.8, respectively).
The study findings were limited by several factors including the selection of songs only from the Billboard hot rap songs year-end charts, which “does not fully represent the population of rap music between 1998 and 2018,” the researchers said. In addition, they could not address causation or motivations for the increased mental health references over the study period. “We are also unable to ascertain how U.S. youth interact with this music or are positively or negatively affected by its messages.”
“For example, positively framed references to mental health awareness, treatment, or support may lead to reduced stigma and increased willingness to seek treatment,” Mr. Kresovich and associates wrote. “However, negatively framed references to mental health struggles might lead to negative outcomes, including copycat behavior in which listeners model harmful behavior, such as suicide attempts, if those behaviors are described in lyrics (i.e., the Werther effect),” they added.
Despite these limitations, the results support the need for more research on the impact of rap music as a way to reduce stigma and potentially reduce mental health risk in adolescents and young adults, Mr. Kresovich and associates concluded.
Music may help raise tough topics
The study is important because children and adolescents have more control than ever over the media they consume, Sarah Vinson, MD, founder of the Lorio Psych Group in Atlanta, said in an interview.
“With more and more children with access to their own devices, they spend a great amount of time consuming content, including music,” Dr. Vinson said. “The norms reflected in the lyrics they hear have an impact on their emerging view of themselves, others, and the world.”
The increased recognition of mental health issues by rap musicians as a topic “certainly has the potential to have a positive impact; however, the way that it is discussed can influence [the] nature of that impact,” she explained.
“It is important for people who are dealing with the normal range of human emotions to know that they are not alone. It is even more important for people dealing with suicidality or mental illness to know that,” Dr. Vinson said.
“Validation and sense of connection are human needs, and stigma related to mental illness can be isolating,” she emphasized. “Rappers have a platform and are often people that children and adolescents look up to, for better or for worse.” Through their music, “the rappers are signaling that these topics are worthy of our attention and okay to talk about.”
Unfortunately, many barriers persist for adolescents in need of mental health treatment, said Dr. Vinson. “The children’s mental health workforce, quantitatively, is not enough to meet the current needs,” she said. “Mental health is not reimbursed at the same rate as other kinds of health care, which contributes to healthy systems not prioritizing these services. Additionally, the racial, ethnic, and socioeconomic background of those who are mental health providers is not reflective of the larger population, and mental health training insufficiently incorporates the cultural and structural humility needed to help professionals navigate those differences,” she explained.
“Children at increased risk are those who face many of those environmental barriers that the rappers reference in those lyrics. They are likely to have even poorer access because they are disproportionately impacted by residential segregation, transportation challenges, financial barriers, and structural racism in mental health care,” Dr. Vinson added. A take-home message for clinicians is to find out what their patients are listening to. “One way to understand what is on the hearts and minds of children is to ask them what’s in their playlist,” she said.
Additional research is needed to examine “moderating factors for the impact, good or bad, of increased mental health content in hip hop for young listeners’ mental health awareness, symptoms and/or interest in seeking treatment,” Dr. Vinson concluded.
The study received no outside funding. The researchers had no financial conflicts to disclose.
Dr. Vinson served as chair for a workshop on mental health and hip-hop at the American Psychiatric Association annual meeting. She had no financial conflicts to disclose.
SOURCE: Kresovich A et al. JAMA Pediatr. 2020 Dec 7. doi: 10.1001/jamapediatrics.2020.5155.
This article was updated on December 21, 2020.
Mental health distress is rising but often is undertreated among children and young adults in the United States, wrote Alex Kresovich, MA, of the University of North Carolina, Chapel Hill, and colleagues.
“Mental health risk especially is increasing among young Black/ African American male individuals (YBAAM), who are often disproportionately exposed to environmental, economic, and family stressors linked with depression and anxiety,” they said. Adolescents and young adults, especially YBAAM, make up a large part of the audience for rap music.
In recent years, more rap artists have disclosed mental health issues, and they have included mental health topics such as depression and suicidal thoughts into their music, the researchers said.
In a study published in JAMA Pediatrics, the researchers identified 125 songs from the period between 1998 and 2018, then assessed them for references to mental health. The song selections included the top 25 rap songs in 1998, 2003, 2008, 2013, and 2018, based on the Billboard music charts.
The majority of the songs (123) featured lead artists from North America, and 97 of them were Black/African American males. The average age of the artists was 28 years. “Prominent artists captured in the sample included 50 Cent, Drake, Eminem, Kanye West, Jay-Z, and Lil’Wayne, among others,” they said. The researchers divided mental health issues into four categories: anxiety or anxious thinking; depression or depressive thinking; metaphors (such as struggling with mental stability); and suicide or suicidal ideation.
Mental health references rise
Across the study period, 35 songs (28%) mentioned anxiety, 28 (22%) mentioned depression, 8 (6%) mentioned suicide, and 26 (21%) mentioned a mental health metaphor. The proportion of songs with a mental health reference increased in a significant linear trend across the study period for suicide (0%-12%), depression (16%-32%), and mental health metaphors (8%-44%).
All references to suicide or suicidal ideation were found in songs that were popular between 2013 and 2018, the researchers noted.
“This increase is important, given that rap artists serve as role models to their audience, which extends beyond YBAAM to include U.S. young people across strata, constituting a large group with increased risk of mental health issues and underuse of mental health services,” Mr. Kresovich and associates said.
In addition, the researchers found that stressors related to environmental conditions and love were significantly more likely to co-occur with mental health references (adjusted odds ratios 8.1 and 4.8, respectively).
The study findings were limited by several factors including the selection of songs only from the Billboard hot rap songs year-end charts, which “does not fully represent the population of rap music between 1998 and 2018,” the researchers said. In addition, they could not address causation or motivations for the increased mental health references over the study period. “We are also unable to ascertain how U.S. youth interact with this music or are positively or negatively affected by its messages.”
“For example, positively framed references to mental health awareness, treatment, or support may lead to reduced stigma and increased willingness to seek treatment,” Mr. Kresovich and associates wrote. “However, negatively framed references to mental health struggles might lead to negative outcomes, including copycat behavior in which listeners model harmful behavior, such as suicide attempts, if those behaviors are described in lyrics (i.e., the Werther effect),” they added.
Despite these limitations, the results support the need for more research on the impact of rap music as a way to reduce stigma and potentially reduce mental health risk in adolescents and young adults, Mr. Kresovich and associates concluded.
Music may help raise tough topics
The study is important because children and adolescents have more control than ever over the media they consume, Sarah Vinson, MD, founder of the Lorio Psych Group in Atlanta, said in an interview.
“With more and more children with access to their own devices, they spend a great amount of time consuming content, including music,” Dr. Vinson said. “The norms reflected in the lyrics they hear have an impact on their emerging view of themselves, others, and the world.”
The increased recognition of mental health issues by rap musicians as a topic “certainly has the potential to have a positive impact; however, the way that it is discussed can influence [the] nature of that impact,” she explained.
“It is important for people who are dealing with the normal range of human emotions to know that they are not alone. It is even more important for people dealing with suicidality or mental illness to know that,” Dr. Vinson said.
“Validation and sense of connection are human needs, and stigma related to mental illness can be isolating,” she emphasized. “Rappers have a platform and are often people that children and adolescents look up to, for better or for worse.” Through their music, “the rappers are signaling that these topics are worthy of our attention and okay to talk about.”
Unfortunately, many barriers persist for adolescents in need of mental health treatment, said Dr. Vinson. “The children’s mental health workforce, quantitatively, is not enough to meet the current needs,” she said. “Mental health is not reimbursed at the same rate as other kinds of health care, which contributes to healthy systems not prioritizing these services. Additionally, the racial, ethnic, and socioeconomic background of those who are mental health providers is not reflective of the larger population, and mental health training insufficiently incorporates the cultural and structural humility needed to help professionals navigate those differences,” she explained.
“Children at increased risk are those who face many of those environmental barriers that the rappers reference in those lyrics. They are likely to have even poorer access because they are disproportionately impacted by residential segregation, transportation challenges, financial barriers, and structural racism in mental health care,” Dr. Vinson added. A take-home message for clinicians is to find out what their patients are listening to. “One way to understand what is on the hearts and minds of children is to ask them what’s in their playlist,” she said.
Additional research is needed to examine “moderating factors for the impact, good or bad, of increased mental health content in hip hop for young listeners’ mental health awareness, symptoms and/or interest in seeking treatment,” Dr. Vinson concluded.
The study received no outside funding. The researchers had no financial conflicts to disclose.
Dr. Vinson served as chair for a workshop on mental health and hip-hop at the American Psychiatric Association annual meeting. She had no financial conflicts to disclose.
SOURCE: Kresovich A et al. JAMA Pediatr. 2020 Dec 7. doi: 10.1001/jamapediatrics.2020.5155.
This article was updated on December 21, 2020.
FROM JAMA PEDIATRICS
Mortality higher in older adults hospitalized for IBD
Adults older than 65 years with inflammatory bowel diseases (IBD) had significantly higher rates of inpatient mortality, compared with those younger than 65 years, independent of factors including disease severity, based on data from more than 200,000 hospital admissions.
Older adults use a disproportionate share of health care resources, but data on outcomes among hospitalized older adults with gastrointestinal illness are limited, Jeffrey Schwartz, MD, of Beth Israel Deaconess Medical Center and Harvard Medical School, both in Boston, and colleagues wrote in the Journal of Clinical Gastroenterology.
“In particular, there remains a significant concern that elderly patients are more susceptible to the development of opportunistic infections and malignancy in the setting of biological therapy, which has evolved into the standard of care for IBD over the past 10 years,” they wrote.
In their study, the researchers identified 162,800 hospital admissions for Crohn’s disease and 96,450 admissions for ulcerative colitis. Of these, 20% and 30%, respectively, were older than 65 years, which the researchers designated as the geriatric group.
In a multivariate analysis, age older than 65 years was significantly associated with increased mortality in both Crohn’s disease (odds ratio, 3.47; 95% confidence interval, 2.72-4.44; P < .001) and ulcerative colitis (OR, 2.75; 95% CI, 2.16-3.49; P < .001). The association was independent of factors included comorbidities, admission type, hospital type, inpatient surgery, and IBD subtype.
The most frequent cause of death in both groups across all ages and disease subtypes was infections (approximately 80% for all groups). The total hospital length of stay was significantly longer for geriatric patients, compared with younger patients with Crohn’s disease, in multivariate analysis (average increase, 0.19 days; P = .009). The total charges also were significantly higher among geriatric Crohn’s disease patients, compared with younger patients (average increase, $2,467; P = .012). No significant differences in hospital stay or total charges appeared between geriatric and younger patients with ulcerative colitis.
The study findings were limited by several factors such as the inclusion of older patients with IBD who were hospitalized for other reasons and by the potential for increased mortality because of comorbidities among elderly patients, the researchers noted. However, the findings support the limited data from similar previous studies and showed greater inpatient mortality for older adults with IBD, compared with hospital inpatients overall.
“Given the high prevalence of IBD patients that require inpatient admission, as well as the rapidly aging nature of the U.S. population, further studies are needed targeting geriatric patients with UC [ulcerative colitis] and CD [Crohn’s disease] to improve their overall management and quality of care to determine if this mortality risk can be reduced,” they concluded.
Tune in to risks in older adults
The study is important because the percentage of the population older than 65 years has been increasing; “at the same time, we are seeing more elderly patients being newly diagnosed with Crohn’s disease and ulcerative colitis,” said Russell D. Cohen, MD, of the University of Chicago, in an interview. “These patients are more vulnerable to complications of the diseases, such as infections, as well as complications from the medications used to treat these diseases.” However, older adults are often excluded from clinical trials and even from many observational studies in IBD, he noted.
“We have known from past studies that infections such as sepsis are a leading cause of death in our IBD patients,” said Dr. Cohen. “It is also understandable that those patients who have had complicated courses and those with other comorbidities have a higher mortality rate. However, what was surprising in the current study is that, even when the authors controlled for these factors, the geriatric patients still had two and three-quarters to three and a half times the mortality than those who were younger.”
The take-home message for clinicians is that “the geriatric patient with IBD is at a much higher rate for inpatient mortality, most commonly from infectious complications, than younger patients,” Dr. Cohen emphasized. “Quicker attention to what may seem minor but could become a potentially life-threatening infection is imperative. Caution with the use of multiple immune suppressing medications in older patients is paramount, as is timely surgical intervention in IBD patients in whom medications simply are not working.”
Focus research on infection prevention, cost burden
“More research should be directed at finding out whether these deadly infections could be prevented, perhaps by preventative ‘prophylactic’ antibiotics in the elderly patients, especially those on multiple immunosuppressive agents,” said Dr. Cohen. “In addition, research into the undue cost burden that these patients place on our health care system and counter that with better access to the newer, safer biological therapies [most of which Medicare does not cover] rather than corticosteroids.”
The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Cohen disclosed relationships with multiple companies including AbbVie, Bristol-Myers Squibb/Celgene, Eli Lilly, Gilead Sciences, Janssen, Pfizer, Takeda, and UCB Pharma.
SOURCE: Schwartz J et al. J Clin Gastroenterol. 2020 Nov 23. doi: 10.1097/MCG.0000000000001458.
Help your patients better understand their IBD treatment options by sharing AGA’s patient education, “Living with IBD,” in the AGA GI Patient Center at www.gastro.org/IBD.
Adults older than 65 years with inflammatory bowel diseases (IBD) had significantly higher rates of inpatient mortality, compared with those younger than 65 years, independent of factors including disease severity, based on data from more than 200,000 hospital admissions.
Older adults use a disproportionate share of health care resources, but data on outcomes among hospitalized older adults with gastrointestinal illness are limited, Jeffrey Schwartz, MD, of Beth Israel Deaconess Medical Center and Harvard Medical School, both in Boston, and colleagues wrote in the Journal of Clinical Gastroenterology.
“In particular, there remains a significant concern that elderly patients are more susceptible to the development of opportunistic infections and malignancy in the setting of biological therapy, which has evolved into the standard of care for IBD over the past 10 years,” they wrote.
In their study, the researchers identified 162,800 hospital admissions for Crohn’s disease and 96,450 admissions for ulcerative colitis. Of these, 20% and 30%, respectively, were older than 65 years, which the researchers designated as the geriatric group.
In a multivariate analysis, age older than 65 years was significantly associated with increased mortality in both Crohn’s disease (odds ratio, 3.47; 95% confidence interval, 2.72-4.44; P < .001) and ulcerative colitis (OR, 2.75; 95% CI, 2.16-3.49; P < .001). The association was independent of factors included comorbidities, admission type, hospital type, inpatient surgery, and IBD subtype.
The most frequent cause of death in both groups across all ages and disease subtypes was infections (approximately 80% for all groups). The total hospital length of stay was significantly longer for geriatric patients, compared with younger patients with Crohn’s disease, in multivariate analysis (average increase, 0.19 days; P = .009). The total charges also were significantly higher among geriatric Crohn’s disease patients, compared with younger patients (average increase, $2,467; P = .012). No significant differences in hospital stay or total charges appeared between geriatric and younger patients with ulcerative colitis.
The study findings were limited by several factors such as the inclusion of older patients with IBD who were hospitalized for other reasons and by the potential for increased mortality because of comorbidities among elderly patients, the researchers noted. However, the findings support the limited data from similar previous studies and showed greater inpatient mortality for older adults with IBD, compared with hospital inpatients overall.
“Given the high prevalence of IBD patients that require inpatient admission, as well as the rapidly aging nature of the U.S. population, further studies are needed targeting geriatric patients with UC [ulcerative colitis] and CD [Crohn’s disease] to improve their overall management and quality of care to determine if this mortality risk can be reduced,” they concluded.
Tune in to risks in older adults
The study is important because the percentage of the population older than 65 years has been increasing; “at the same time, we are seeing more elderly patients being newly diagnosed with Crohn’s disease and ulcerative colitis,” said Russell D. Cohen, MD, of the University of Chicago, in an interview. “These patients are more vulnerable to complications of the diseases, such as infections, as well as complications from the medications used to treat these diseases.” However, older adults are often excluded from clinical trials and even from many observational studies in IBD, he noted.
“We have known from past studies that infections such as sepsis are a leading cause of death in our IBD patients,” said Dr. Cohen. “It is also understandable that those patients who have had complicated courses and those with other comorbidities have a higher mortality rate. However, what was surprising in the current study is that, even when the authors controlled for these factors, the geriatric patients still had two and three-quarters to three and a half times the mortality than those who were younger.”
The take-home message for clinicians is that “the geriatric patient with IBD is at a much higher rate for inpatient mortality, most commonly from infectious complications, than younger patients,” Dr. Cohen emphasized. “Quicker attention to what may seem minor but could become a potentially life-threatening infection is imperative. Caution with the use of multiple immune suppressing medications in older patients is paramount, as is timely surgical intervention in IBD patients in whom medications simply are not working.”
Focus research on infection prevention, cost burden
“More research should be directed at finding out whether these deadly infections could be prevented, perhaps by preventative ‘prophylactic’ antibiotics in the elderly patients, especially those on multiple immunosuppressive agents,” said Dr. Cohen. “In addition, research into the undue cost burden that these patients place on our health care system and counter that with better access to the newer, safer biological therapies [most of which Medicare does not cover] rather than corticosteroids.”
The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Cohen disclosed relationships with multiple companies including AbbVie, Bristol-Myers Squibb/Celgene, Eli Lilly, Gilead Sciences, Janssen, Pfizer, Takeda, and UCB Pharma.
SOURCE: Schwartz J et al. J Clin Gastroenterol. 2020 Nov 23. doi: 10.1097/MCG.0000000000001458.
Help your patients better understand their IBD treatment options by sharing AGA’s patient education, “Living with IBD,” in the AGA GI Patient Center at www.gastro.org/IBD.
Adults older than 65 years with inflammatory bowel diseases (IBD) had significantly higher rates of inpatient mortality, compared with those younger than 65 years, independent of factors including disease severity, based on data from more than 200,000 hospital admissions.
Older adults use a disproportionate share of health care resources, but data on outcomes among hospitalized older adults with gastrointestinal illness are limited, Jeffrey Schwartz, MD, of Beth Israel Deaconess Medical Center and Harvard Medical School, both in Boston, and colleagues wrote in the Journal of Clinical Gastroenterology.
“In particular, there remains a significant concern that elderly patients are more susceptible to the development of opportunistic infections and malignancy in the setting of biological therapy, which has evolved into the standard of care for IBD over the past 10 years,” they wrote.
In their study, the researchers identified 162,800 hospital admissions for Crohn’s disease and 96,450 admissions for ulcerative colitis. Of these, 20% and 30%, respectively, were older than 65 years, which the researchers designated as the geriatric group.
In a multivariate analysis, age older than 65 years was significantly associated with increased mortality in both Crohn’s disease (odds ratio, 3.47; 95% confidence interval, 2.72-4.44; P < .001) and ulcerative colitis (OR, 2.75; 95% CI, 2.16-3.49; P < .001). The association was independent of factors included comorbidities, admission type, hospital type, inpatient surgery, and IBD subtype.
The most frequent cause of death in both groups across all ages and disease subtypes was infections (approximately 80% for all groups). The total hospital length of stay was significantly longer for geriatric patients, compared with younger patients with Crohn’s disease, in multivariate analysis (average increase, 0.19 days; P = .009). The total charges also were significantly higher among geriatric Crohn’s disease patients, compared with younger patients (average increase, $2,467; P = .012). No significant differences in hospital stay or total charges appeared between geriatric and younger patients with ulcerative colitis.
The study findings were limited by several factors such as the inclusion of older patients with IBD who were hospitalized for other reasons and by the potential for increased mortality because of comorbidities among elderly patients, the researchers noted. However, the findings support the limited data from similar previous studies and showed greater inpatient mortality for older adults with IBD, compared with hospital inpatients overall.
“Given the high prevalence of IBD patients that require inpatient admission, as well as the rapidly aging nature of the U.S. population, further studies are needed targeting geriatric patients with UC [ulcerative colitis] and CD [Crohn’s disease] to improve their overall management and quality of care to determine if this mortality risk can be reduced,” they concluded.
Tune in to risks in older adults
The study is important because the percentage of the population older than 65 years has been increasing; “at the same time, we are seeing more elderly patients being newly diagnosed with Crohn’s disease and ulcerative colitis,” said Russell D. Cohen, MD, of the University of Chicago, in an interview. “These patients are more vulnerable to complications of the diseases, such as infections, as well as complications from the medications used to treat these diseases.” However, older adults are often excluded from clinical trials and even from many observational studies in IBD, he noted.
“We have known from past studies that infections such as sepsis are a leading cause of death in our IBD patients,” said Dr. Cohen. “It is also understandable that those patients who have had complicated courses and those with other comorbidities have a higher mortality rate. However, what was surprising in the current study is that, even when the authors controlled for these factors, the geriatric patients still had two and three-quarters to three and a half times the mortality than those who were younger.”
The take-home message for clinicians is that “the geriatric patient with IBD is at a much higher rate for inpatient mortality, most commonly from infectious complications, than younger patients,” Dr. Cohen emphasized. “Quicker attention to what may seem minor but could become a potentially life-threatening infection is imperative. Caution with the use of multiple immune suppressing medications in older patients is paramount, as is timely surgical intervention in IBD patients in whom medications simply are not working.”
Focus research on infection prevention, cost burden
“More research should be directed at finding out whether these deadly infections could be prevented, perhaps by preventative ‘prophylactic’ antibiotics in the elderly patients, especially those on multiple immunosuppressive agents,” said Dr. Cohen. “In addition, research into the undue cost burden that these patients place on our health care system and counter that with better access to the newer, safer biological therapies [most of which Medicare does not cover] rather than corticosteroids.”
The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Cohen disclosed relationships with multiple companies including AbbVie, Bristol-Myers Squibb/Celgene, Eli Lilly, Gilead Sciences, Janssen, Pfizer, Takeda, and UCB Pharma.
SOURCE: Schwartz J et al. J Clin Gastroenterol. 2020 Nov 23. doi: 10.1097/MCG.0000000000001458.
Help your patients better understand their IBD treatment options by sharing AGA’s patient education, “Living with IBD,” in the AGA GI Patient Center at www.gastro.org/IBD.
FROM THE JOURNAL OF CLINICAL GASTROENTEROLOGY
Vaginal cleansing protocol curbs deep SSIs after cesarean
reported Johanna Quist-Nelson, MD, of the University of North Carolina, Chapel Hill.
“Surgical site infections after a cesarean delivery are more common if the patient is in labor or has ruptured membranes,” she said at the 2020 virtual meeting of the American College of Obstetricians and Gynecologists..
Two options to decrease the risk of SSIs after cesarean for those patients in labor or with ruptured membranes are vaginal cleansing and azithromycin, given in addition to preoperative antibiotics, Dr. Quist-Nelson said. She and her colleagues conducted a quality improvement study of the effects of a stepwise implementation of vaginal cleansing and azithromycin to reduce SSIs at cesarean delivery in this high-risk population. The data were collected from 2016 to 2019 at Thomas Jefferson University, Philadelphia.
“We aimed to decrease our SSI rate by 30% by adopting an intervention of cleansing followed by azithromycin,” she said.
The researchers added vaginal cleansing to the SSI prevention protocol in January 2017, with the addition of azithromycin in March 2018. Vaginal cleansing involved 30 seconds of anterior to posterior cleaning prior to urinary catheter placement. Azithromycin was given at a dose of 500 mg intravenously in addition to preoperative antibiotics and within an hour of cesarean delivery.
A total of 1,033 deliveries qualified for the study by being in labor or with ruptured membranes; of these 291 were performed prior to the interventions, 335 received vaginal cleansing only, and 407 received vaginal cleansing and azithromycin. The average age of the participants was 30 years; approximately 42% were Black, and 32% were White.
Cleansing protocol reduces SSIs
Overall, the rate of SSIs was 22% in the standard care group, 17% in the vaginal cleansing group, and 15% in the vaginal cleansing plus azithromycin group. When broken down by infection type, no deep SSI occurred in the vaginal cleansing or cleansing plus azithromycin group, compared with 2% of the standard care group (P = .009). In addition, endometritis, which is an organ-space SSI, was significantly lower in the cleansing group (10%) and the cleansing plus azithromycin group (11%), compared with the standard care group (16%).
The study findings were limited by factors including the use of EMRs for collection of data, and given that it is a quality improvement study, there is a potential lack of generalizability to other institutions. The study focused on patients at high risk for SSI and the use of the Plan-Do-Study-Act (PDSA) method of conducting the research, Dr. Quist-Nelson said. Compared with standard care, the implementation of vaginal cleansing reduced the SSI rate by 33%, with no significantly further change in SSI after the addition of azithromycin, she concluded.
Data sharing boosts compliance
In a question-and-answer session, Dr. Quist-Nelson noted that povidone iodine (Betadine) was chosen for vaginal cleansing because it was easily accessible at her institution, but that patients with allergies were given chlorhexidine. The cleansing itself was “primarily vaginal, not a full vulvar cleansing,” she clarified. The cleansing was performed immediately before catheter placement and included the urethra.
When asked about strategies to increase compliance, Dr. Quist-Nelson noted that sharing data was valuable, namely “reporting to our group the current compliance,” as well as sharing information by email and discussing it during multidisciplinary rounds.
The study was a quality improvement project and not a randomized trial, so the researchers were not able to tease out the impact of vaginal cleansing from the impact of azithromycin, Dr. Quist-Nelson said.
Based on her results, Dr. Quist-Nelson said she would recommend the protocol for use in patients who require cesarean delivery after being in labor or having ruptured membranes, and that “there are trials to support the use of both interventions.”
The results suggest opportunities for further randomized trials, including examination of the use of oral versus IV azithromycin, she added.
The study received no outside funding. Dr. Quist-Nelson had no financial conflicts to disclose.
reported Johanna Quist-Nelson, MD, of the University of North Carolina, Chapel Hill.
“Surgical site infections after a cesarean delivery are more common if the patient is in labor or has ruptured membranes,” she said at the 2020 virtual meeting of the American College of Obstetricians and Gynecologists..
Two options to decrease the risk of SSIs after cesarean for those patients in labor or with ruptured membranes are vaginal cleansing and azithromycin, given in addition to preoperative antibiotics, Dr. Quist-Nelson said. She and her colleagues conducted a quality improvement study of the effects of a stepwise implementation of vaginal cleansing and azithromycin to reduce SSIs at cesarean delivery in this high-risk population. The data were collected from 2016 to 2019 at Thomas Jefferson University, Philadelphia.
“We aimed to decrease our SSI rate by 30% by adopting an intervention of cleansing followed by azithromycin,” she said.
The researchers added vaginal cleansing to the SSI prevention protocol in January 2017, with the addition of azithromycin in March 2018. Vaginal cleansing involved 30 seconds of anterior to posterior cleaning prior to urinary catheter placement. Azithromycin was given at a dose of 500 mg intravenously in addition to preoperative antibiotics and within an hour of cesarean delivery.
A total of 1,033 deliveries qualified for the study by being in labor or with ruptured membranes; of these 291 were performed prior to the interventions, 335 received vaginal cleansing only, and 407 received vaginal cleansing and azithromycin. The average age of the participants was 30 years; approximately 42% were Black, and 32% were White.
Cleansing protocol reduces SSIs
Overall, the rate of SSIs was 22% in the standard care group, 17% in the vaginal cleansing group, and 15% in the vaginal cleansing plus azithromycin group. When broken down by infection type, no deep SSI occurred in the vaginal cleansing or cleansing plus azithromycin group, compared with 2% of the standard care group (P = .009). In addition, endometritis, which is an organ-space SSI, was significantly lower in the cleansing group (10%) and the cleansing plus azithromycin group (11%), compared with the standard care group (16%).
The study findings were limited by factors including the use of EMRs for collection of data, and given that it is a quality improvement study, there is a potential lack of generalizability to other institutions. The study focused on patients at high risk for SSI and the use of the Plan-Do-Study-Act (PDSA) method of conducting the research, Dr. Quist-Nelson said. Compared with standard care, the implementation of vaginal cleansing reduced the SSI rate by 33%, with no significantly further change in SSI after the addition of azithromycin, she concluded.
Data sharing boosts compliance
In a question-and-answer session, Dr. Quist-Nelson noted that povidone iodine (Betadine) was chosen for vaginal cleansing because it was easily accessible at her institution, but that patients with allergies were given chlorhexidine. The cleansing itself was “primarily vaginal, not a full vulvar cleansing,” she clarified. The cleansing was performed immediately before catheter placement and included the urethra.
When asked about strategies to increase compliance, Dr. Quist-Nelson noted that sharing data was valuable, namely “reporting to our group the current compliance,” as well as sharing information by email and discussing it during multidisciplinary rounds.
The study was a quality improvement project and not a randomized trial, so the researchers were not able to tease out the impact of vaginal cleansing from the impact of azithromycin, Dr. Quist-Nelson said.
Based on her results, Dr. Quist-Nelson said she would recommend the protocol for use in patients who require cesarean delivery after being in labor or having ruptured membranes, and that “there are trials to support the use of both interventions.”
The results suggest opportunities for further randomized trials, including examination of the use of oral versus IV azithromycin, she added.
The study received no outside funding. Dr. Quist-Nelson had no financial conflicts to disclose.
reported Johanna Quist-Nelson, MD, of the University of North Carolina, Chapel Hill.
“Surgical site infections after a cesarean delivery are more common if the patient is in labor or has ruptured membranes,” she said at the 2020 virtual meeting of the American College of Obstetricians and Gynecologists..
Two options to decrease the risk of SSIs after cesarean for those patients in labor or with ruptured membranes are vaginal cleansing and azithromycin, given in addition to preoperative antibiotics, Dr. Quist-Nelson said. She and her colleagues conducted a quality improvement study of the effects of a stepwise implementation of vaginal cleansing and azithromycin to reduce SSIs at cesarean delivery in this high-risk population. The data were collected from 2016 to 2019 at Thomas Jefferson University, Philadelphia.
“We aimed to decrease our SSI rate by 30% by adopting an intervention of cleansing followed by azithromycin,” she said.
The researchers added vaginal cleansing to the SSI prevention protocol in January 2017, with the addition of azithromycin in March 2018. Vaginal cleansing involved 30 seconds of anterior to posterior cleaning prior to urinary catheter placement. Azithromycin was given at a dose of 500 mg intravenously in addition to preoperative antibiotics and within an hour of cesarean delivery.
A total of 1,033 deliveries qualified for the study by being in labor or with ruptured membranes; of these 291 were performed prior to the interventions, 335 received vaginal cleansing only, and 407 received vaginal cleansing and azithromycin. The average age of the participants was 30 years; approximately 42% were Black, and 32% were White.
Cleansing protocol reduces SSIs
Overall, the rate of SSIs was 22% in the standard care group, 17% in the vaginal cleansing group, and 15% in the vaginal cleansing plus azithromycin group. When broken down by infection type, no deep SSI occurred in the vaginal cleansing or cleansing plus azithromycin group, compared with 2% of the standard care group (P = .009). In addition, endometritis, which is an organ-space SSI, was significantly lower in the cleansing group (10%) and the cleansing plus azithromycin group (11%), compared with the standard care group (16%).
The study findings were limited by factors including the use of EMRs for collection of data, and given that it is a quality improvement study, there is a potential lack of generalizability to other institutions. The study focused on patients at high risk for SSI and the use of the Plan-Do-Study-Act (PDSA) method of conducting the research, Dr. Quist-Nelson said. Compared with standard care, the implementation of vaginal cleansing reduced the SSI rate by 33%, with no significantly further change in SSI after the addition of azithromycin, she concluded.
Data sharing boosts compliance
In a question-and-answer session, Dr. Quist-Nelson noted that povidone iodine (Betadine) was chosen for vaginal cleansing because it was easily accessible at her institution, but that patients with allergies were given chlorhexidine. The cleansing itself was “primarily vaginal, not a full vulvar cleansing,” she clarified. The cleansing was performed immediately before catheter placement and included the urethra.
When asked about strategies to increase compliance, Dr. Quist-Nelson noted that sharing data was valuable, namely “reporting to our group the current compliance,” as well as sharing information by email and discussing it during multidisciplinary rounds.
The study was a quality improvement project and not a randomized trial, so the researchers were not able to tease out the impact of vaginal cleansing from the impact of azithromycin, Dr. Quist-Nelson said.
Based on her results, Dr. Quist-Nelson said she would recommend the protocol for use in patients who require cesarean delivery after being in labor or having ruptured membranes, and that “there are trials to support the use of both interventions.”
The results suggest opportunities for further randomized trials, including examination of the use of oral versus IV azithromycin, she added.
The study received no outside funding. Dr. Quist-Nelson had no financial conflicts to disclose.
FROM ACOG 2020
Mortality higher in older adults hospitalized for IBD
Adults older than 65 years with inflammatory bowel diseases (IBD) had significantly higher rates of inpatient mortality, compared with those younger than 65 years, independent of factors including disease severity, based on data from more than 200,000 hospital admissions.
Older adults use a disproportionate share of health care resources, but data on outcomes among hospitalized older adults with gastrointestinal illness are limited, Jeffrey Schwartz, MD, of Beth Israel Deaconess Medical Center and Harvard Medical School, both in Boston, and colleagues wrote in the Journal of Clinical Gastroenterology.
“In particular, there remains a significant concern that elderly patients are more susceptible to the development of opportunistic infections and malignancy in the setting of biological therapy, which has evolved into the standard of care for IBD over the past 10 years,” they wrote.
In their study, the researchers identified 162,800 hospital admissions for Crohn’s disease and 96,450 admissions for ulcerative colitis. Of these, 20% and 30%, respectively, were older than 65 years, which the researchers designated as the geriatric group.
In a multivariate analysis, age older than 65 years was significantly associated with increased mortality in both Crohn’s disease (odds ratio, 3.47; 95% confidence interval, 2.72-4.44; P < .001) and ulcerative colitis (OR, 2.75; 95% CI, 2.16-3.49; P < .001). The association was independent of factors included comorbidities, admission type, hospital type, inpatient surgery, and IBD subtype.
The most frequent cause of death in both groups across all ages and disease subtypes was infections (approximately 80% for all groups). The total hospital length of stay was significantly longer for geriatric patients, compared with younger patients with Crohn’s disease, in multivariate analysis (average increase, 0.19 days; P = .009). The total charges also were significantly higher among geriatric Crohn’s disease patients, compared with younger patients (average increase, $2,467; P = .012). No significant differences in hospital stay or total charges appeared between geriatric and younger patients with ulcerative colitis.
The study findings were limited by several factors such as the inclusion of older patients with IBD who were hospitalized for other reasons and by the potential for increased mortality because of comorbidities among elderly patients, the researchers noted. However, the findings support the limited data from similar previous studies and showed greater inpatient mortality for older adults with IBD, compared with hospital inpatients overall.
“Given the high prevalence of IBD patients that require inpatient admission, as well as the rapidly aging nature of the U.S. population, further studies are needed targeting geriatric patients with UC [ulcerative colitis] and CD [Crohn’s disease] to improve their overall management and quality of care to determine if this mortality risk can be reduced,” they concluded.
Tune in to risks in older adults
The study is important because the percentage of the population older than 65 years has been increasing; “at the same time, we are seeing more elderly patients being newly diagnosed with Crohn’s disease and ulcerative colitis,” said Russell D. Cohen, MD, of the University of Chicago, in an interview. “These patients are more vulnerable to complications of the diseases, such as infections, as well as complications from the medications used to treat these diseases.” However, older adults are often excluded from clinical trials and even from many observational studies in IBD, he noted.
“We have known from past studies that infections such as sepsis are a leading cause of death in our IBD patients,” said Dr. Cohen. “It is also understandable that those patients who have had complicated courses and those with other comorbidities have a higher mortality rate. However, what was surprising in the current study is that, even when the authors controlled for these factors, the geriatric patients still had two and three-quarters to three and a half times the mortality than those who were younger.”
The take-home message for clinicians is that “the geriatric patient with IBD is at a much higher rate for inpatient mortality, most commonly from infectious complications, than younger patients,” Dr. Cohen emphasized. “Quicker attention to what may seem minor but could become a potentially life-threatening infection is imperative. Caution with the use of multiple immune suppressing medications in older patients is paramount, as is timely surgical intervention in IBD patients in whom medications simply are not working.”
Focus research on infection prevention, cost burden
“More research should be directed at finding out whether these deadly infections could be prevented, perhaps by preventative ‘prophylactic’ antibiotics in the elderly patients, especially those on multiple immunosuppressive agents,” said Dr. Cohen. “In addition, research into the undue cost burden that these patients place on our health care system and counter that with better access to the newer, safer biological therapies [most of which Medicare does not cover] rather than corticosteroids.”
The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Cohen disclosed relationships with multiple companies including AbbVie, Bristol-Myers Squibb/Celgene, Eli Lilly, Gilead Sciences, Janssen, Pfizer, Takeda, and UCB Pharma.
SOURCE: Schwartz J et al. J Clin Gastroenterol. 2020 Nov 23. doi: 10.1097/MCG.0000000000001458.
Adults older than 65 years with inflammatory bowel diseases (IBD) had significantly higher rates of inpatient mortality, compared with those younger than 65 years, independent of factors including disease severity, based on data from more than 200,000 hospital admissions.
Older adults use a disproportionate share of health care resources, but data on outcomes among hospitalized older adults with gastrointestinal illness are limited, Jeffrey Schwartz, MD, of Beth Israel Deaconess Medical Center and Harvard Medical School, both in Boston, and colleagues wrote in the Journal of Clinical Gastroenterology.
“In particular, there remains a significant concern that elderly patients are more susceptible to the development of opportunistic infections and malignancy in the setting of biological therapy, which has evolved into the standard of care for IBD over the past 10 years,” they wrote.
In their study, the researchers identified 162,800 hospital admissions for Crohn’s disease and 96,450 admissions for ulcerative colitis. Of these, 20% and 30%, respectively, were older than 65 years, which the researchers designated as the geriatric group.
In a multivariate analysis, age older than 65 years was significantly associated with increased mortality in both Crohn’s disease (odds ratio, 3.47; 95% confidence interval, 2.72-4.44; P < .001) and ulcerative colitis (OR, 2.75; 95% CI, 2.16-3.49; P < .001). The association was independent of factors included comorbidities, admission type, hospital type, inpatient surgery, and IBD subtype.
The most frequent cause of death in both groups across all ages and disease subtypes was infections (approximately 80% for all groups). The total hospital length of stay was significantly longer for geriatric patients, compared with younger patients with Crohn’s disease, in multivariate analysis (average increase, 0.19 days; P = .009). The total charges also were significantly higher among geriatric Crohn’s disease patients, compared with younger patients (average increase, $2,467; P = .012). No significant differences in hospital stay or total charges appeared between geriatric and younger patients with ulcerative colitis.
The study findings were limited by several factors such as the inclusion of older patients with IBD who were hospitalized for other reasons and by the potential for increased mortality because of comorbidities among elderly patients, the researchers noted. However, the findings support the limited data from similar previous studies and showed greater inpatient mortality for older adults with IBD, compared with hospital inpatients overall.
“Given the high prevalence of IBD patients that require inpatient admission, as well as the rapidly aging nature of the U.S. population, further studies are needed targeting geriatric patients with UC [ulcerative colitis] and CD [Crohn’s disease] to improve their overall management and quality of care to determine if this mortality risk can be reduced,” they concluded.
Tune in to risks in older adults
The study is important because the percentage of the population older than 65 years has been increasing; “at the same time, we are seeing more elderly patients being newly diagnosed with Crohn’s disease and ulcerative colitis,” said Russell D. Cohen, MD, of the University of Chicago, in an interview. “These patients are more vulnerable to complications of the diseases, such as infections, as well as complications from the medications used to treat these diseases.” However, older adults are often excluded from clinical trials and even from many observational studies in IBD, he noted.
“We have known from past studies that infections such as sepsis are a leading cause of death in our IBD patients,” said Dr. Cohen. “It is also understandable that those patients who have had complicated courses and those with other comorbidities have a higher mortality rate. However, what was surprising in the current study is that, even when the authors controlled for these factors, the geriatric patients still had two and three-quarters to three and a half times the mortality than those who were younger.”
The take-home message for clinicians is that “the geriatric patient with IBD is at a much higher rate for inpatient mortality, most commonly from infectious complications, than younger patients,” Dr. Cohen emphasized. “Quicker attention to what may seem minor but could become a potentially life-threatening infection is imperative. Caution with the use of multiple immune suppressing medications in older patients is paramount, as is timely surgical intervention in IBD patients in whom medications simply are not working.”
Focus research on infection prevention, cost burden
“More research should be directed at finding out whether these deadly infections could be prevented, perhaps by preventative ‘prophylactic’ antibiotics in the elderly patients, especially those on multiple immunosuppressive agents,” said Dr. Cohen. “In addition, research into the undue cost burden that these patients place on our health care system and counter that with better access to the newer, safer biological therapies [most of which Medicare does not cover] rather than corticosteroids.”
The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Cohen disclosed relationships with multiple companies including AbbVie, Bristol-Myers Squibb/Celgene, Eli Lilly, Gilead Sciences, Janssen, Pfizer, Takeda, and UCB Pharma.
SOURCE: Schwartz J et al. J Clin Gastroenterol. 2020 Nov 23. doi: 10.1097/MCG.0000000000001458.
Adults older than 65 years with inflammatory bowel diseases (IBD) had significantly higher rates of inpatient mortality, compared with those younger than 65 years, independent of factors including disease severity, based on data from more than 200,000 hospital admissions.
Older adults use a disproportionate share of health care resources, but data on outcomes among hospitalized older adults with gastrointestinal illness are limited, Jeffrey Schwartz, MD, of Beth Israel Deaconess Medical Center and Harvard Medical School, both in Boston, and colleagues wrote in the Journal of Clinical Gastroenterology.
“In particular, there remains a significant concern that elderly patients are more susceptible to the development of opportunistic infections and malignancy in the setting of biological therapy, which has evolved into the standard of care for IBD over the past 10 years,” they wrote.
In their study, the researchers identified 162,800 hospital admissions for Crohn’s disease and 96,450 admissions for ulcerative colitis. Of these, 20% and 30%, respectively, were older than 65 years, which the researchers designated as the geriatric group.
In a multivariate analysis, age older than 65 years was significantly associated with increased mortality in both Crohn’s disease (odds ratio, 3.47; 95% confidence interval, 2.72-4.44; P < .001) and ulcerative colitis (OR, 2.75; 95% CI, 2.16-3.49; P < .001). The association was independent of factors included comorbidities, admission type, hospital type, inpatient surgery, and IBD subtype.
The most frequent cause of death in both groups across all ages and disease subtypes was infections (approximately 80% for all groups). The total hospital length of stay was significantly longer for geriatric patients, compared with younger patients with Crohn’s disease, in multivariate analysis (average increase, 0.19 days; P = .009). The total charges also were significantly higher among geriatric Crohn’s disease patients, compared with younger patients (average increase, $2,467; P = .012). No significant differences in hospital stay or total charges appeared between geriatric and younger patients with ulcerative colitis.
The study findings were limited by several factors such as the inclusion of older patients with IBD who were hospitalized for other reasons and by the potential for increased mortality because of comorbidities among elderly patients, the researchers noted. However, the findings support the limited data from similar previous studies and showed greater inpatient mortality for older adults with IBD, compared with hospital inpatients overall.
“Given the high prevalence of IBD patients that require inpatient admission, as well as the rapidly aging nature of the U.S. population, further studies are needed targeting geriatric patients with UC [ulcerative colitis] and CD [Crohn’s disease] to improve their overall management and quality of care to determine if this mortality risk can be reduced,” they concluded.
Tune in to risks in older adults
The study is important because the percentage of the population older than 65 years has been increasing; “at the same time, we are seeing more elderly patients being newly diagnosed with Crohn’s disease and ulcerative colitis,” said Russell D. Cohen, MD, of the University of Chicago, in an interview. “These patients are more vulnerable to complications of the diseases, such as infections, as well as complications from the medications used to treat these diseases.” However, older adults are often excluded from clinical trials and even from many observational studies in IBD, he noted.
“We have known from past studies that infections such as sepsis are a leading cause of death in our IBD patients,” said Dr. Cohen. “It is also understandable that those patients who have had complicated courses and those with other comorbidities have a higher mortality rate. However, what was surprising in the current study is that, even when the authors controlled for these factors, the geriatric patients still had two and three-quarters to three and a half times the mortality than those who were younger.”
The take-home message for clinicians is that “the geriatric patient with IBD is at a much higher rate for inpatient mortality, most commonly from infectious complications, than younger patients,” Dr. Cohen emphasized. “Quicker attention to what may seem minor but could become a potentially life-threatening infection is imperative. Caution with the use of multiple immune suppressing medications in older patients is paramount, as is timely surgical intervention in IBD patients in whom medications simply are not working.”
Focus research on infection prevention, cost burden
“More research should be directed at finding out whether these deadly infections could be prevented, perhaps by preventative ‘prophylactic’ antibiotics in the elderly patients, especially those on multiple immunosuppressive agents,” said Dr. Cohen. “In addition, research into the undue cost burden that these patients place on our health care system and counter that with better access to the newer, safer biological therapies [most of which Medicare does not cover] rather than corticosteroids.”
The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Cohen disclosed relationships with multiple companies including AbbVie, Bristol-Myers Squibb/Celgene, Eli Lilly, Gilead Sciences, Janssen, Pfizer, Takeda, and UCB Pharma.
SOURCE: Schwartz J et al. J Clin Gastroenterol. 2020 Nov 23. doi: 10.1097/MCG.0000000000001458.
FROM THE JOURNAL OF CLINICAL GASTROENTEROLOGY
Obesity, hypoxia predict severity in children with COVID-19
based on data from 281 patients at 8 locations.
Manifestations of COVID-19 in children include respiratory disease similar to that seen in adults, but the full spectrum of disease in children has been studied mainly in single settings or with a focus on one clinical manifestation, wrote Danielle M. Fernandes, MD, of Albert Einstein College of Medicine, New York, and colleagues.
In a study published in the Journal of Pediatrics, the researchers identified 281 children hospitalized with COVID-19 and/or multisystem inflammatory syndrome in children (MIS-C) at 8 sites in Connecticut, New Jersey, and New York. A total of 143 (51%) had respiratory disease, 69 (25%) had MIS-C, and 69 (25%) had other manifestations of illness including 32 patients with gastrointestinal problems, 21 infants with fever, 6 cases of neurologic disease, 6 cases of diabetic ketoacidosis, and 4 patients with other indications. The median age of the patients was 10 years, 60% were male, 51% were Hispanic, and 23% were non-Hispanic Black. The most common comorbidities were obesity (34%) and asthma (14%).
Independent predictors of disease severity in children found
After controlling for multiple variables, obesity and hypoxia at hospital admission were significant independent predictors of severe respiratory disease, with odds ratios of 3.39 and 4.01, respectively. In addition, lower absolute lymphocyte count (OR, 8.33 per unit decrease in 109 cells/L) and higher C-reactive protein (OR, 1.06 per unit increase in mg/dL) were significantly predictive of severe MIS-C (P = .001 and P = .017, respectively).
“The association between weight and severe respiratory COVID-19 is consistent with the adult literature; however, the mechanisms of this association require further study,” Dr. Fernandes and associates noted.
Overall, children with MIS-C were significantly more likely to be non-Hispanic Black, compared with children with respiratory disease, an 18% difference. However, neither race/ethnicity nor socioeconomic status were significant predictors of disease severity, the researchers wrote.
During the study period, 7 patients (2%) died and 114 (41%) were admitted to the ICU.
“We found a wide array of clinical manifestations in children and youth hospitalized with SARS-CoV-2,” Dr. Fernandes and associates wrote. Notably, gastrointestinal symptoms, ocular symptoms, and dermatologic symptoms have rarely been noted in adults with COVID-19, but occurred in more than 30% of the pediatric patients.
“We also found that SARS-CoV-2 can be an incidental finding in a substantial number of hospitalized pediatric patients,” the researchers said.
The findings were limited by several factors including a population of patients only from Connecticut, New Jersey, and New York, and the possibility that decisions on hospital and ICU admission may have varied by location, the researchers said. In addition, approaches may have varied in the absence of data on the optimal treatment of MIS-C.
“This study builds on the growing body of evidence showing that mortality in hospitalized pediatric patients is low, compared with adults,” Dr. Fernandes and associates said. “However, it highlights that the young population is not universally spared from morbidity, and that even previously healthy children and youth can develop severe disease requiring supportive therapy.”
Findings confirm other clinical experience
The study was important to show that, “although most children are spared severe illness from COVID-19, some children are hospitalized both with acute COVID-19 respiratory disease, with MIS-C and with a range of other complications,” Adrienne Randolph, MD, of Boston Children’s Hospital and Harvard Medical School, Boston, said in an interview.
Dr. Randolph said she was not surprised by the study findings, “as we are also seeing these types of complications at Boston Children’s Hospital where I work.”
Additional research is needed on the outcomes of these patients, “especially the longer-term sequelae of having COVID-19 or MIS-C early in life,” she emphasized.
The take-home message to clinicians from the findings at this time is to be aware that children and adolescents can become severely ill from COVID-19–related complications, said Dr. Randolph. “Some of the laboratory values on presentation appear to be associated with disease severity.”
The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Randolph disclosed funding from the Centers for Disease Control and Prevention to lead the Overcoming COVID-19 Study in U.S. Children and Adults.
SOURCE: Fernandes DM et al. J Pediatr. 2020 Nov 13. doi: 10.1016/j.jpeds.2020.11.016.
based on data from 281 patients at 8 locations.
Manifestations of COVID-19 in children include respiratory disease similar to that seen in adults, but the full spectrum of disease in children has been studied mainly in single settings or with a focus on one clinical manifestation, wrote Danielle M. Fernandes, MD, of Albert Einstein College of Medicine, New York, and colleagues.
In a study published in the Journal of Pediatrics, the researchers identified 281 children hospitalized with COVID-19 and/or multisystem inflammatory syndrome in children (MIS-C) at 8 sites in Connecticut, New Jersey, and New York. A total of 143 (51%) had respiratory disease, 69 (25%) had MIS-C, and 69 (25%) had other manifestations of illness including 32 patients with gastrointestinal problems, 21 infants with fever, 6 cases of neurologic disease, 6 cases of diabetic ketoacidosis, and 4 patients with other indications. The median age of the patients was 10 years, 60% were male, 51% were Hispanic, and 23% were non-Hispanic Black. The most common comorbidities were obesity (34%) and asthma (14%).
Independent predictors of disease severity in children found
After controlling for multiple variables, obesity and hypoxia at hospital admission were significant independent predictors of severe respiratory disease, with odds ratios of 3.39 and 4.01, respectively. In addition, lower absolute lymphocyte count (OR, 8.33 per unit decrease in 109 cells/L) and higher C-reactive protein (OR, 1.06 per unit increase in mg/dL) were significantly predictive of severe MIS-C (P = .001 and P = .017, respectively).
“The association between weight and severe respiratory COVID-19 is consistent with the adult literature; however, the mechanisms of this association require further study,” Dr. Fernandes and associates noted.
Overall, children with MIS-C were significantly more likely to be non-Hispanic Black, compared with children with respiratory disease, an 18% difference. However, neither race/ethnicity nor socioeconomic status were significant predictors of disease severity, the researchers wrote.
During the study period, 7 patients (2%) died and 114 (41%) were admitted to the ICU.
“We found a wide array of clinical manifestations in children and youth hospitalized with SARS-CoV-2,” Dr. Fernandes and associates wrote. Notably, gastrointestinal symptoms, ocular symptoms, and dermatologic symptoms have rarely been noted in adults with COVID-19, but occurred in more than 30% of the pediatric patients.
“We also found that SARS-CoV-2 can be an incidental finding in a substantial number of hospitalized pediatric patients,” the researchers said.
The findings were limited by several factors including a population of patients only from Connecticut, New Jersey, and New York, and the possibility that decisions on hospital and ICU admission may have varied by location, the researchers said. In addition, approaches may have varied in the absence of data on the optimal treatment of MIS-C.
“This study builds on the growing body of evidence showing that mortality in hospitalized pediatric patients is low, compared with adults,” Dr. Fernandes and associates said. “However, it highlights that the young population is not universally spared from morbidity, and that even previously healthy children and youth can develop severe disease requiring supportive therapy.”
Findings confirm other clinical experience
The study was important to show that, “although most children are spared severe illness from COVID-19, some children are hospitalized both with acute COVID-19 respiratory disease, with MIS-C and with a range of other complications,” Adrienne Randolph, MD, of Boston Children’s Hospital and Harvard Medical School, Boston, said in an interview.
Dr. Randolph said she was not surprised by the study findings, “as we are also seeing these types of complications at Boston Children’s Hospital where I work.”
Additional research is needed on the outcomes of these patients, “especially the longer-term sequelae of having COVID-19 or MIS-C early in life,” she emphasized.
The take-home message to clinicians from the findings at this time is to be aware that children and adolescents can become severely ill from COVID-19–related complications, said Dr. Randolph. “Some of the laboratory values on presentation appear to be associated with disease severity.”
The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Randolph disclosed funding from the Centers for Disease Control and Prevention to lead the Overcoming COVID-19 Study in U.S. Children and Adults.
SOURCE: Fernandes DM et al. J Pediatr. 2020 Nov 13. doi: 10.1016/j.jpeds.2020.11.016.
based on data from 281 patients at 8 locations.
Manifestations of COVID-19 in children include respiratory disease similar to that seen in adults, but the full spectrum of disease in children has been studied mainly in single settings or with a focus on one clinical manifestation, wrote Danielle M. Fernandes, MD, of Albert Einstein College of Medicine, New York, and colleagues.
In a study published in the Journal of Pediatrics, the researchers identified 281 children hospitalized with COVID-19 and/or multisystem inflammatory syndrome in children (MIS-C) at 8 sites in Connecticut, New Jersey, and New York. A total of 143 (51%) had respiratory disease, 69 (25%) had MIS-C, and 69 (25%) had other manifestations of illness including 32 patients with gastrointestinal problems, 21 infants with fever, 6 cases of neurologic disease, 6 cases of diabetic ketoacidosis, and 4 patients with other indications. The median age of the patients was 10 years, 60% were male, 51% were Hispanic, and 23% were non-Hispanic Black. The most common comorbidities were obesity (34%) and asthma (14%).
Independent predictors of disease severity in children found
After controlling for multiple variables, obesity and hypoxia at hospital admission were significant independent predictors of severe respiratory disease, with odds ratios of 3.39 and 4.01, respectively. In addition, lower absolute lymphocyte count (OR, 8.33 per unit decrease in 109 cells/L) and higher C-reactive protein (OR, 1.06 per unit increase in mg/dL) were significantly predictive of severe MIS-C (P = .001 and P = .017, respectively).
“The association between weight and severe respiratory COVID-19 is consistent with the adult literature; however, the mechanisms of this association require further study,” Dr. Fernandes and associates noted.
Overall, children with MIS-C were significantly more likely to be non-Hispanic Black, compared with children with respiratory disease, an 18% difference. However, neither race/ethnicity nor socioeconomic status were significant predictors of disease severity, the researchers wrote.
During the study period, 7 patients (2%) died and 114 (41%) were admitted to the ICU.
“We found a wide array of clinical manifestations in children and youth hospitalized with SARS-CoV-2,” Dr. Fernandes and associates wrote. Notably, gastrointestinal symptoms, ocular symptoms, and dermatologic symptoms have rarely been noted in adults with COVID-19, but occurred in more than 30% of the pediatric patients.
“We also found that SARS-CoV-2 can be an incidental finding in a substantial number of hospitalized pediatric patients,” the researchers said.
The findings were limited by several factors including a population of patients only from Connecticut, New Jersey, and New York, and the possibility that decisions on hospital and ICU admission may have varied by location, the researchers said. In addition, approaches may have varied in the absence of data on the optimal treatment of MIS-C.
“This study builds on the growing body of evidence showing that mortality in hospitalized pediatric patients is low, compared with adults,” Dr. Fernandes and associates said. “However, it highlights that the young population is not universally spared from morbidity, and that even previously healthy children and youth can develop severe disease requiring supportive therapy.”
Findings confirm other clinical experience
The study was important to show that, “although most children are spared severe illness from COVID-19, some children are hospitalized both with acute COVID-19 respiratory disease, with MIS-C and with a range of other complications,” Adrienne Randolph, MD, of Boston Children’s Hospital and Harvard Medical School, Boston, said in an interview.
Dr. Randolph said she was not surprised by the study findings, “as we are also seeing these types of complications at Boston Children’s Hospital where I work.”
Additional research is needed on the outcomes of these patients, “especially the longer-term sequelae of having COVID-19 or MIS-C early in life,” she emphasized.
The take-home message to clinicians from the findings at this time is to be aware that children and adolescents can become severely ill from COVID-19–related complications, said Dr. Randolph. “Some of the laboratory values on presentation appear to be associated with disease severity.”
The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Randolph disclosed funding from the Centers for Disease Control and Prevention to lead the Overcoming COVID-19 Study in U.S. Children and Adults.
SOURCE: Fernandes DM et al. J Pediatr. 2020 Nov 13. doi: 10.1016/j.jpeds.2020.11.016.
FROM THE JOURNAL OF PEDIATRICS
COVID-19 impacts women’s contraception choices
The rate of unintended pregnancies in the United States has decreased to approximately 45%, based on data published in 2016, and “for the first time in many years, this decrease affected women of all race/ethnicity, income levels, and education levels,” Eve Espey, MD, said at the 2020 virtual meeting of the American College of Obstetricians and Gynecologists.
Changes in contraceptive choices drove much of this decrease, said Dr. Espey, professor of obstetrics and gynecology at the University of New Mexico, Albuquerque.
“What is really striking is the very large increase in use of the IUD,” she noted. However, the increased use of IUDs has raised concerns about coercive tactics being used to push for IUD use in communities of color.
“The focus we should have is on reproductive autonomy and not on unintended pregnancy, a metric that is classist and racist and may value the reproduction of some groups over others,” Dr. Espey said. Previous studies have suggested that providers are biased in how they promote long-acting reversible contraception (LARC), and reports from patients suggest that women and people of color particularly may feel marginalized, not heard, and coerced, she noted.
Help patients feel empowered
Overall, the goal of contraception should be to empower women and people to make the reproductive decisions that are best for them. “My own approach to contraceptive counseling has changed over the years; I currently start by asking if the patient wants to talk about contraception,” Dr. Espey said.
The COVID-19 pandemic has impacted many women’s reproductive options and plans, she said.
A survey showed that after COVID-19, more than 40% of women reported changing their plans about childbearing, 34% wanted to get pregnant later, and 33% reported trouble getting birth control or getting an appointment with a health care provider, she said.
ACOG issued a statement in March 2020 about the provision of contraception and how contraception is an essential component of comprehensive health care. The COVID-19 ACOG guidance on contraception includes use of telehealth for services including screening new patients, offering prescriptions and refills as appropriate, and managing side effects. Providers can counsel patients on the use of emergency contraception and provide advance prescriptions for ulipristal acetate, and ideally provide a year’s worth of prescription refills to reduce pharmacy visits, although not all insurance companies allow this, Dr. Espey noted.
ACOG’s COVID-19 guidance on the use of LARCs includes preserving access when possible, and focusing on postpartum contraception as a key access point.
“The postpartum period is a very convenient time for patients who want contraceptives, including LARC,” especially since they are already in the hospital setting, Dr. Espey said. However, it is important to preserve patients’ reproductive autonomy and avoid placing barriers to LARC removal for those who request it, she emphasized.
Consider MEC categories for contraception
When advising patients about contraception, Dr. Espey noted the development of a simple app with the U.S. Medical Eligibility Criteria (MEC) as a useful tool. The app includes the four MEC categories based on the latest evidence-based guidance from the Centers for Disease Control and Prevention on contraceptive practice.
Patients in category 1 have no restriction on the use of a particular contraceptive method; category 2 means that “advantages generally outweigh the theoretical or proven risks”; in category 3, these risks usually outweigh the advantages; and category 4 indicates “unacceptable health risk if the contraceptive method is used,” according to the MEC.
“What complicates category 3 is that many patients have a condition that is associated with adverse outcomes in pregnancy,” Dr. Espey noted, “So it is even more important that category 3 options only be considered if other options are not available or not acceptable to the patient,”
For example, a patient with complicated diabetes who wants depot medroxyprogesterone acetate (DMPA) for contraception for a year must weigh the benefits with the theoretical risk of thromboembolic disease related to a higher dose progestin, and the fact that the injection is not reversible in the case of an adverse event. “Close follow-up is recommended for patients using contraception with category 3 recommendations,” Dr. Espey emphasized.
Some new elements of contraception that are ongoing in the pandemic health care setting include increased pharmacist prescribing of hormonal contraception, Dr. Espey said. Over-the-counter access to contraception is not yet an option, but a progestin-only pill will likely be the first, she added.
Although the Essure birth control implant is no longer available in the United States, new options for a contraceptive patch (Twirla [ethinyl estradiol and levonorgestrel] and Xulane [ethinyl estradiol and norelgestromin]) offer weekly contraceptive options for women with a body mass index less than 30 kg/m2.
Annovera offers more options
The newest choice on the market is Annovera, a flexible ring that delivers 150 mcg/day of segesterone acetate and 13 mcg/day of ethinyl estradiol. The ring is meant to remain in place for 21 days, with 7 days out, to repeat for a year.
During the question-and-answer session, Dr. Espey was asked whether it would be an off-label use to leave Annovera in continuously. Although this has not been studied, there is no biologically plausible reason not to leave it in for a year without taking it out. In either case, this is a patient-controlled LARC, she said.
Overall, “it remains to be seen how Annovera will do, as a potentially exciting, new, long-acting option” she said. “A major advantage is that it is controlled by the user,” she noted. However, “the price point will be very important as well.”
As for the off-label use by women with a BMI greater than 29 kg/m2, it is complicated. Two women with higher BMIs enrolled in clinical trials developed venous thromboembolisms, so an increased risk can’t be ruled out, although the good news is that BMI has not been shown to impact effectiveness of the product, she added.
IUDs appropriate for younger women
When asked for her guidelines about IUD options in the absence of head-to-head trials, Dr. Espey said that she often recommends either Mirena and Liletta. These levonorgestrel-releasing IUDS are essentially the same, can be used off label for 7 years (both are currently Food and Drug Administration approved for 6 years), and have a favorable bleeding profile. Other IUDs are marketed as having a smaller diameter designed for increased patient comfort with insertion, but she views this as less important than bleeding profile and duration given the length of time the device is in place.
Dr. Espey added that she doesn’t see age as a barrier to IUD use, and that the evidence does not support an increased risk of infertility. In fact, “we are seeing a higher demand among younger and nulliparous women.”
“We should respect the reproductive autonomy and the choices that our patients make,” Dr. Espey concluded.
Dr. Espey had no relevant financial disclosures. She is a member of the Ob.Gyn. News editorial advisory board.
The rate of unintended pregnancies in the United States has decreased to approximately 45%, based on data published in 2016, and “for the first time in many years, this decrease affected women of all race/ethnicity, income levels, and education levels,” Eve Espey, MD, said at the 2020 virtual meeting of the American College of Obstetricians and Gynecologists.
Changes in contraceptive choices drove much of this decrease, said Dr. Espey, professor of obstetrics and gynecology at the University of New Mexico, Albuquerque.
“What is really striking is the very large increase in use of the IUD,” she noted. However, the increased use of IUDs has raised concerns about coercive tactics being used to push for IUD use in communities of color.
“The focus we should have is on reproductive autonomy and not on unintended pregnancy, a metric that is classist and racist and may value the reproduction of some groups over others,” Dr. Espey said. Previous studies have suggested that providers are biased in how they promote long-acting reversible contraception (LARC), and reports from patients suggest that women and people of color particularly may feel marginalized, not heard, and coerced, she noted.
Help patients feel empowered
Overall, the goal of contraception should be to empower women and people to make the reproductive decisions that are best for them. “My own approach to contraceptive counseling has changed over the years; I currently start by asking if the patient wants to talk about contraception,” Dr. Espey said.
The COVID-19 pandemic has impacted many women’s reproductive options and plans, she said.
A survey showed that after COVID-19, more than 40% of women reported changing their plans about childbearing, 34% wanted to get pregnant later, and 33% reported trouble getting birth control or getting an appointment with a health care provider, she said.
ACOG issued a statement in March 2020 about the provision of contraception and how contraception is an essential component of comprehensive health care. The COVID-19 ACOG guidance on contraception includes use of telehealth for services including screening new patients, offering prescriptions and refills as appropriate, and managing side effects. Providers can counsel patients on the use of emergency contraception and provide advance prescriptions for ulipristal acetate, and ideally provide a year’s worth of prescription refills to reduce pharmacy visits, although not all insurance companies allow this, Dr. Espey noted.
ACOG’s COVID-19 guidance on the use of LARCs includes preserving access when possible, and focusing on postpartum contraception as a key access point.
“The postpartum period is a very convenient time for patients who want contraceptives, including LARC,” especially since they are already in the hospital setting, Dr. Espey said. However, it is important to preserve patients’ reproductive autonomy and avoid placing barriers to LARC removal for those who request it, she emphasized.
Consider MEC categories for contraception
When advising patients about contraception, Dr. Espey noted the development of a simple app with the U.S. Medical Eligibility Criteria (MEC) as a useful tool. The app includes the four MEC categories based on the latest evidence-based guidance from the Centers for Disease Control and Prevention on contraceptive practice.
Patients in category 1 have no restriction on the use of a particular contraceptive method; category 2 means that “advantages generally outweigh the theoretical or proven risks”; in category 3, these risks usually outweigh the advantages; and category 4 indicates “unacceptable health risk if the contraceptive method is used,” according to the MEC.
“What complicates category 3 is that many patients have a condition that is associated with adverse outcomes in pregnancy,” Dr. Espey noted, “So it is even more important that category 3 options only be considered if other options are not available or not acceptable to the patient,”
For example, a patient with complicated diabetes who wants depot medroxyprogesterone acetate (DMPA) for contraception for a year must weigh the benefits with the theoretical risk of thromboembolic disease related to a higher dose progestin, and the fact that the injection is not reversible in the case of an adverse event. “Close follow-up is recommended for patients using contraception with category 3 recommendations,” Dr. Espey emphasized.
Some new elements of contraception that are ongoing in the pandemic health care setting include increased pharmacist prescribing of hormonal contraception, Dr. Espey said. Over-the-counter access to contraception is not yet an option, but a progestin-only pill will likely be the first, she added.
Although the Essure birth control implant is no longer available in the United States, new options for a contraceptive patch (Twirla [ethinyl estradiol and levonorgestrel] and Xulane [ethinyl estradiol and norelgestromin]) offer weekly contraceptive options for women with a body mass index less than 30 kg/m2.
Annovera offers more options
The newest choice on the market is Annovera, a flexible ring that delivers 150 mcg/day of segesterone acetate and 13 mcg/day of ethinyl estradiol. The ring is meant to remain in place for 21 days, with 7 days out, to repeat for a year.
During the question-and-answer session, Dr. Espey was asked whether it would be an off-label use to leave Annovera in continuously. Although this has not been studied, there is no biologically plausible reason not to leave it in for a year without taking it out. In either case, this is a patient-controlled LARC, she said.
Overall, “it remains to be seen how Annovera will do, as a potentially exciting, new, long-acting option” she said. “A major advantage is that it is controlled by the user,” she noted. However, “the price point will be very important as well.”
As for the off-label use by women with a BMI greater than 29 kg/m2, it is complicated. Two women with higher BMIs enrolled in clinical trials developed venous thromboembolisms, so an increased risk can’t be ruled out, although the good news is that BMI has not been shown to impact effectiveness of the product, she added.
IUDs appropriate for younger women
When asked for her guidelines about IUD options in the absence of head-to-head trials, Dr. Espey said that she often recommends either Mirena and Liletta. These levonorgestrel-releasing IUDS are essentially the same, can be used off label for 7 years (both are currently Food and Drug Administration approved for 6 years), and have a favorable bleeding profile. Other IUDs are marketed as having a smaller diameter designed for increased patient comfort with insertion, but she views this as less important than bleeding profile and duration given the length of time the device is in place.
Dr. Espey added that she doesn’t see age as a barrier to IUD use, and that the evidence does not support an increased risk of infertility. In fact, “we are seeing a higher demand among younger and nulliparous women.”
“We should respect the reproductive autonomy and the choices that our patients make,” Dr. Espey concluded.
Dr. Espey had no relevant financial disclosures. She is a member of the Ob.Gyn. News editorial advisory board.
The rate of unintended pregnancies in the United States has decreased to approximately 45%, based on data published in 2016, and “for the first time in many years, this decrease affected women of all race/ethnicity, income levels, and education levels,” Eve Espey, MD, said at the 2020 virtual meeting of the American College of Obstetricians and Gynecologists.
Changes in contraceptive choices drove much of this decrease, said Dr. Espey, professor of obstetrics and gynecology at the University of New Mexico, Albuquerque.
“What is really striking is the very large increase in use of the IUD,” she noted. However, the increased use of IUDs has raised concerns about coercive tactics being used to push for IUD use in communities of color.
“The focus we should have is on reproductive autonomy and not on unintended pregnancy, a metric that is classist and racist and may value the reproduction of some groups over others,” Dr. Espey said. Previous studies have suggested that providers are biased in how they promote long-acting reversible contraception (LARC), and reports from patients suggest that women and people of color particularly may feel marginalized, not heard, and coerced, she noted.
Help patients feel empowered
Overall, the goal of contraception should be to empower women and people to make the reproductive decisions that are best for them. “My own approach to contraceptive counseling has changed over the years; I currently start by asking if the patient wants to talk about contraception,” Dr. Espey said.
The COVID-19 pandemic has impacted many women’s reproductive options and plans, she said.
A survey showed that after COVID-19, more than 40% of women reported changing their plans about childbearing, 34% wanted to get pregnant later, and 33% reported trouble getting birth control or getting an appointment with a health care provider, she said.
ACOG issued a statement in March 2020 about the provision of contraception and how contraception is an essential component of comprehensive health care. The COVID-19 ACOG guidance on contraception includes use of telehealth for services including screening new patients, offering prescriptions and refills as appropriate, and managing side effects. Providers can counsel patients on the use of emergency contraception and provide advance prescriptions for ulipristal acetate, and ideally provide a year’s worth of prescription refills to reduce pharmacy visits, although not all insurance companies allow this, Dr. Espey noted.
ACOG’s COVID-19 guidance on the use of LARCs includes preserving access when possible, and focusing on postpartum contraception as a key access point.
“The postpartum period is a very convenient time for patients who want contraceptives, including LARC,” especially since they are already in the hospital setting, Dr. Espey said. However, it is important to preserve patients’ reproductive autonomy and avoid placing barriers to LARC removal for those who request it, she emphasized.
Consider MEC categories for contraception
When advising patients about contraception, Dr. Espey noted the development of a simple app with the U.S. Medical Eligibility Criteria (MEC) as a useful tool. The app includes the four MEC categories based on the latest evidence-based guidance from the Centers for Disease Control and Prevention on contraceptive practice.
Patients in category 1 have no restriction on the use of a particular contraceptive method; category 2 means that “advantages generally outweigh the theoretical or proven risks”; in category 3, these risks usually outweigh the advantages; and category 4 indicates “unacceptable health risk if the contraceptive method is used,” according to the MEC.
“What complicates category 3 is that many patients have a condition that is associated with adverse outcomes in pregnancy,” Dr. Espey noted, “So it is even more important that category 3 options only be considered if other options are not available or not acceptable to the patient,”
For example, a patient with complicated diabetes who wants depot medroxyprogesterone acetate (DMPA) for contraception for a year must weigh the benefits with the theoretical risk of thromboembolic disease related to a higher dose progestin, and the fact that the injection is not reversible in the case of an adverse event. “Close follow-up is recommended for patients using contraception with category 3 recommendations,” Dr. Espey emphasized.
Some new elements of contraception that are ongoing in the pandemic health care setting include increased pharmacist prescribing of hormonal contraception, Dr. Espey said. Over-the-counter access to contraception is not yet an option, but a progestin-only pill will likely be the first, she added.
Although the Essure birth control implant is no longer available in the United States, new options for a contraceptive patch (Twirla [ethinyl estradiol and levonorgestrel] and Xulane [ethinyl estradiol and norelgestromin]) offer weekly contraceptive options for women with a body mass index less than 30 kg/m2.
Annovera offers more options
The newest choice on the market is Annovera, a flexible ring that delivers 150 mcg/day of segesterone acetate and 13 mcg/day of ethinyl estradiol. The ring is meant to remain in place for 21 days, with 7 days out, to repeat for a year.
During the question-and-answer session, Dr. Espey was asked whether it would be an off-label use to leave Annovera in continuously. Although this has not been studied, there is no biologically plausible reason not to leave it in for a year without taking it out. In either case, this is a patient-controlled LARC, she said.
Overall, “it remains to be seen how Annovera will do, as a potentially exciting, new, long-acting option” she said. “A major advantage is that it is controlled by the user,” she noted. However, “the price point will be very important as well.”
As for the off-label use by women with a BMI greater than 29 kg/m2, it is complicated. Two women with higher BMIs enrolled in clinical trials developed venous thromboembolisms, so an increased risk can’t be ruled out, although the good news is that BMI has not been shown to impact effectiveness of the product, she added.
IUDs appropriate for younger women
When asked for her guidelines about IUD options in the absence of head-to-head trials, Dr. Espey said that she often recommends either Mirena and Liletta. These levonorgestrel-releasing IUDS are essentially the same, can be used off label for 7 years (both are currently Food and Drug Administration approved for 6 years), and have a favorable bleeding profile. Other IUDs are marketed as having a smaller diameter designed for increased patient comfort with insertion, but she views this as less important than bleeding profile and duration given the length of time the device is in place.
Dr. Espey added that she doesn’t see age as a barrier to IUD use, and that the evidence does not support an increased risk of infertility. In fact, “we are seeing a higher demand among younger and nulliparous women.”
“We should respect the reproductive autonomy and the choices that our patients make,” Dr. Espey concluded.
Dr. Espey had no relevant financial disclosures. She is a member of the Ob.Gyn. News editorial advisory board.
EXPERT ANALYSIS FROM ACOG 2020
Menstrual cup use increases risk of IUD expulsion
Menstrual cup use is becoming increasingly popular as an option for menstrual hygiene among women in the United States, but little is known about the potential for IUD expulsion with menstrual cup use, Jill Long, MD, said at the 2020 virtual meeting of the American College of Obstetricians and Gynecologists.
Dr. Long cited a 2019 Internet survey of IUD users in which 11% reported menstrual cup use; reports of IUD expulsion were approximately three times higher among menstrual cup users. The results of the survey were limited by the self-reported responses and lack of data on when the expulsions occurred related to menstrual cup use.
Similar concerns about expulsion surfaced in an ongoing phase 3, randomized trial designed to support the marketing application of the Mona Lisa NT Cu380 Mini IUD, which is not currently approved in the United States.
“Nine months into the study, more expulsions were observed than expected, particularly among menstrual cup users,” said Dr. Long, medical officer and project officer for the Contraceptive Clinical Trials Network at the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The researchers then began to advise study participants to avoid menstrual cup use, and to collect data on use of menstrual hygiene products.
The preliminary study results reported by Dr. Long included 1,092 women assigned in a 4:1 ratio to receive the Mona Lisa NT Cu380 Mini and ParaGard, an IUD approved in the United States. Participants had follow-up visits at 6 weeks and at 3, 6, 12, 24, and 36 months after placement to verify the IUD position.
At 34 months, the overall rate of IUD expulsion was 9%. Of 277 women who reported menstrual cup use, the expulsion rate was 18%, compared with a 6% expulsion rates among the 704 women who reported tampon use.
Patient behavior persists despite advisory
Overall IUD expulsion was not significantly different among patients enrolled before and after the advisory against menstrual cup use (9.8% vs. 8.8%, respectively). In addition, menstrual cup use did not decrease after the implementation of the advisory (24% preadvisory vs. 28% post advisory).
The expulsion rates between menstrual cup users and nonusers were significantly different at both 12 months (14% vs. 5%) and 24 months (21% vs. 6%).
In addition, the researchers created a category of accidental self-removal, defined as the percent of expulsions occurring at the time the menstrual hygiene product was removed. Accidental self-removal was significantly higher among menstrual cup users, compared with tampon users (43% vs. 10%).
Study limitations included study blinding with regard to IUD type, parity, and age, so the impact of these factors on expulsion remains unclear, Dr. Long said. In addition, data on menstrual hygiene product use was collected retrospectively for the first 9 months, and no data were available on the impact on expulsion of combined use of menstrual cups and tampons.
Despite the apparent lack of impact of counseling, “women should be informed of the increased risk of expulsion if they choose to use menstrual cups concurrently with copper IUDs,” Dr. Long concluded.
More data to come from further analysis
During a question-and-answer session following the presentation, Dr. Long was asked whether suction might contribute to expulsion. “We advised subjects to break the seal on the menstrual cup prior to removal, but we did not see a decrease in expulsion rates with menstrual cup use after this advisory,” she said.
“The type of menstrual cup may be a factor,” she added. “We still need to analyze the data by the type of menstrual cup used as different cups have different degrees of suction.”
When asked about the potential role of coital activity on expulsion, Dr. Long said that the researchers had not yet reviewed coital activity logs to compare expulsion data with the timing of sexual activity.
Any increased pregnancy rates among menstrual cup users are “unlikely, but we don’t know for sure,” she added.
The current study also did not evaluate quantitative differences in bleeding, and participants are using bleeding diaries, Dr. Long noted. She added that participants are able to report problems with bleeding to the study sites, and that these are captured as adverse events.
The study was supported by a partnership between NICHD and FHI 360, a nonprofit human development organization based in North Carolina, with FHI 360 funding from the Bill and Melinda Gates Foundation. Dr. Long had no financial conflicts to disclose.
Menstrual cup use is becoming increasingly popular as an option for menstrual hygiene among women in the United States, but little is known about the potential for IUD expulsion with menstrual cup use, Jill Long, MD, said at the 2020 virtual meeting of the American College of Obstetricians and Gynecologists.
Dr. Long cited a 2019 Internet survey of IUD users in which 11% reported menstrual cup use; reports of IUD expulsion were approximately three times higher among menstrual cup users. The results of the survey were limited by the self-reported responses and lack of data on when the expulsions occurred related to menstrual cup use.
Similar concerns about expulsion surfaced in an ongoing phase 3, randomized trial designed to support the marketing application of the Mona Lisa NT Cu380 Mini IUD, which is not currently approved in the United States.
“Nine months into the study, more expulsions were observed than expected, particularly among menstrual cup users,” said Dr. Long, medical officer and project officer for the Contraceptive Clinical Trials Network at the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The researchers then began to advise study participants to avoid menstrual cup use, and to collect data on use of menstrual hygiene products.
The preliminary study results reported by Dr. Long included 1,092 women assigned in a 4:1 ratio to receive the Mona Lisa NT Cu380 Mini and ParaGard, an IUD approved in the United States. Participants had follow-up visits at 6 weeks and at 3, 6, 12, 24, and 36 months after placement to verify the IUD position.
At 34 months, the overall rate of IUD expulsion was 9%. Of 277 women who reported menstrual cup use, the expulsion rate was 18%, compared with a 6% expulsion rates among the 704 women who reported tampon use.
Patient behavior persists despite advisory
Overall IUD expulsion was not significantly different among patients enrolled before and after the advisory against menstrual cup use (9.8% vs. 8.8%, respectively). In addition, menstrual cup use did not decrease after the implementation of the advisory (24% preadvisory vs. 28% post advisory).
The expulsion rates between menstrual cup users and nonusers were significantly different at both 12 months (14% vs. 5%) and 24 months (21% vs. 6%).
In addition, the researchers created a category of accidental self-removal, defined as the percent of expulsions occurring at the time the menstrual hygiene product was removed. Accidental self-removal was significantly higher among menstrual cup users, compared with tampon users (43% vs. 10%).
Study limitations included study blinding with regard to IUD type, parity, and age, so the impact of these factors on expulsion remains unclear, Dr. Long said. In addition, data on menstrual hygiene product use was collected retrospectively for the first 9 months, and no data were available on the impact on expulsion of combined use of menstrual cups and tampons.
Despite the apparent lack of impact of counseling, “women should be informed of the increased risk of expulsion if they choose to use menstrual cups concurrently with copper IUDs,” Dr. Long concluded.
More data to come from further analysis
During a question-and-answer session following the presentation, Dr. Long was asked whether suction might contribute to expulsion. “We advised subjects to break the seal on the menstrual cup prior to removal, but we did not see a decrease in expulsion rates with menstrual cup use after this advisory,” she said.
“The type of menstrual cup may be a factor,” she added. “We still need to analyze the data by the type of menstrual cup used as different cups have different degrees of suction.”
When asked about the potential role of coital activity on expulsion, Dr. Long said that the researchers had not yet reviewed coital activity logs to compare expulsion data with the timing of sexual activity.
Any increased pregnancy rates among menstrual cup users are “unlikely, but we don’t know for sure,” she added.
The current study also did not evaluate quantitative differences in bleeding, and participants are using bleeding diaries, Dr. Long noted. She added that participants are able to report problems with bleeding to the study sites, and that these are captured as adverse events.
The study was supported by a partnership between NICHD and FHI 360, a nonprofit human development organization based in North Carolina, with FHI 360 funding from the Bill and Melinda Gates Foundation. Dr. Long had no financial conflicts to disclose.
Menstrual cup use is becoming increasingly popular as an option for menstrual hygiene among women in the United States, but little is known about the potential for IUD expulsion with menstrual cup use, Jill Long, MD, said at the 2020 virtual meeting of the American College of Obstetricians and Gynecologists.
Dr. Long cited a 2019 Internet survey of IUD users in which 11% reported menstrual cup use; reports of IUD expulsion were approximately three times higher among menstrual cup users. The results of the survey were limited by the self-reported responses and lack of data on when the expulsions occurred related to menstrual cup use.
Similar concerns about expulsion surfaced in an ongoing phase 3, randomized trial designed to support the marketing application of the Mona Lisa NT Cu380 Mini IUD, which is not currently approved in the United States.
“Nine months into the study, more expulsions were observed than expected, particularly among menstrual cup users,” said Dr. Long, medical officer and project officer for the Contraceptive Clinical Trials Network at the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The researchers then began to advise study participants to avoid menstrual cup use, and to collect data on use of menstrual hygiene products.
The preliminary study results reported by Dr. Long included 1,092 women assigned in a 4:1 ratio to receive the Mona Lisa NT Cu380 Mini and ParaGard, an IUD approved in the United States. Participants had follow-up visits at 6 weeks and at 3, 6, 12, 24, and 36 months after placement to verify the IUD position.
At 34 months, the overall rate of IUD expulsion was 9%. Of 277 women who reported menstrual cup use, the expulsion rate was 18%, compared with a 6% expulsion rates among the 704 women who reported tampon use.
Patient behavior persists despite advisory
Overall IUD expulsion was not significantly different among patients enrolled before and after the advisory against menstrual cup use (9.8% vs. 8.8%, respectively). In addition, menstrual cup use did not decrease after the implementation of the advisory (24% preadvisory vs. 28% post advisory).
The expulsion rates between menstrual cup users and nonusers were significantly different at both 12 months (14% vs. 5%) and 24 months (21% vs. 6%).
In addition, the researchers created a category of accidental self-removal, defined as the percent of expulsions occurring at the time the menstrual hygiene product was removed. Accidental self-removal was significantly higher among menstrual cup users, compared with tampon users (43% vs. 10%).
Study limitations included study blinding with regard to IUD type, parity, and age, so the impact of these factors on expulsion remains unclear, Dr. Long said. In addition, data on menstrual hygiene product use was collected retrospectively for the first 9 months, and no data were available on the impact on expulsion of combined use of menstrual cups and tampons.
Despite the apparent lack of impact of counseling, “women should be informed of the increased risk of expulsion if they choose to use menstrual cups concurrently with copper IUDs,” Dr. Long concluded.
More data to come from further analysis
During a question-and-answer session following the presentation, Dr. Long was asked whether suction might contribute to expulsion. “We advised subjects to break the seal on the menstrual cup prior to removal, but we did not see a decrease in expulsion rates with menstrual cup use after this advisory,” she said.
“The type of menstrual cup may be a factor,” she added. “We still need to analyze the data by the type of menstrual cup used as different cups have different degrees of suction.”
When asked about the potential role of coital activity on expulsion, Dr. Long said that the researchers had not yet reviewed coital activity logs to compare expulsion data with the timing of sexual activity.
Any increased pregnancy rates among menstrual cup users are “unlikely, but we don’t know for sure,” she added.
The current study also did not evaluate quantitative differences in bleeding, and participants are using bleeding diaries, Dr. Long noted. She added that participants are able to report problems with bleeding to the study sites, and that these are captured as adverse events.
The study was supported by a partnership between NICHD and FHI 360, a nonprofit human development organization based in North Carolina, with FHI 360 funding from the Bill and Melinda Gates Foundation. Dr. Long had no financial conflicts to disclose.
FROM ACOG 2020